Every finding on record at Masonic Village at Warminster

Based on facility policy review, facility documentation review, and staff interview, it was determined that the facility failed to maintain complete and accurate reconciliation records to ensure the prevention of diversion of controlled substances on one of three medication carts. (East Unit) Findings include:Review of the facility policy entitled, Controlled Medication Orders, last reviewed March 17, 2026, revealed that when coming on duty, going off duty, taking over or releasing a medication cart, two licensed nurses will do a complete controlled medication count. Both nurses were to sign the controlled medication count sheet. Signatures confirmed that the count was done thoroughly and that the licensed nurse verified the count was accurate. In an interview on August 20, 2026, at 9:10 a.m., the Director of Nursing stated that the nurse coming on duty and nurse going off duty were to count all controlled substances and other medications with the risk of abuse or diversion at the change of each shift and document on a Controlled Medication Count sheet that the count on the resident accountability card was accurate. The nurse coming on duty was responsible for the cart. This shift-to-shift count was to be completed at the same time by both nurses. Following shift to shift count, both nurses were to sign the Medication Count sheet. Any discrepancies of the controlled substances were to be reported to the registered nurse designated as in charge of the facility and/or the Director of Nursing promptly. Review of the Medication Count Sheet for the East Unit medication cart from July 1 through 31, 2026, and August 1 through 19, 2026, revealed a lack of documentation to support that two nurses verified the controlled medication count as evidenced by the following number of missing licensed nursing signatures:Coming on duty at 6:00 a.m., six of 50 days reviewed.Coming on duty at 2:00 p.m., 14 of 50 days reviewed.Coming on duty at 10:00 p.m., 12 of 50 days reviewed.Going off duty at 6:00 a.m., nine of 50 days reviewed.Going off duty at 2:00 p.m., five of 50 days reviewed.Going off duty at 10:00 p.m., 14 of 50 days reviewed. In an interview on August 20, 2026, at 9:30 a.m., the Director of Nursing confirmed that the signatures were not available for the identified dates and times and should have been. 28 Pa. Code 211.9(j.1)(5) Pharmacy services.28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for one of five newly hired employees. (Employee 2)Findings include:A review of the facility policy entitled, Abuse Prevention, dated May 3, 2026, revealed that the facility was to conduct screenings for all potential hires. This included reference checks and license/registration verification. Employee 2 (E2) had been working in the facility as a licensed practical nurse since June 10, 2026, and a reference check was not completed until July 8, 2026. Further review of the personnel file revealed there was no evidence that the facility submitted an inquiry to the state licensure board to obtain current verification, prior to E2 working in the facility. In an interview on August 20, 2026, at 10:19 a.m., the Administrator confirmed there was no documented evidence that a reference check was completed and that the facility submitted an inquiry to the state licensure board for license/registry verification prior to the start of E2's employment.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include:Observation of the dumpster area on August 18, 2026, at 11:15 a.m., revealed that on the ground, there were more than 15 used plastic gloves, several crushed plastic lids and straws, a piece of cardboard, and used paper towels. There was a torn plastic bag holding debris that was sticking out of the drain hole of the dumpster. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to accommodate resident food allergies for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included dementia and depression. On October 3, 2024, it was noted in the resident's ongoing plan of care and admission documentation that she was allergic to pineapple. The Minimum Data Set assessment dated [DATE], revealed the resident had severe cognitive impairment and required set-up assistance from staff for feeding. The posted menu for December 21, 2025, listed Hawaiian Ham (ham with pineapple sauce) for the main entree. Review of facility investigation documents dated December 21, 2025, confirmed that on December 21, 2025, the resident was served the ham with pineapple sauce and that she ingested some of it. In further review of facility documentation, the pineapple allergy was noted on Resident 1's meal ticket. In an interview on December 30, 2025, at 1:57 p.m., the Director of Nursing confirmed that staff should have followed the food allergy that was listed on the meal ticket for Resident 1 and they should not have served the pineapple sauce.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b) Management.

Based on clinical record review, facility policy review, incident report review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 12 sampled residents. (Resident 14) Findings include: Review of the facility policy entitled, Abuse Prevention, dated June 15, 2022, revealed that procedures were in place to assure adequate review of all incidents, accidents, and suspicious bruising or injuries of unknown origin. Occurrences were reviewed for trends or patterns that might constitute abuse. An investigation was to begin immediately by interviewing the resident who was suspected of being abused and any witnesses. Clinical record review revealed that Resident 14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assistance from staff for activities of daily living. On August 13, 2022, a nurse noted that staff observed an abrasion to the resident's ribs on the right side of her body, as well as petechiae (small red or purple spots caused by bleeding into the skin) to the resident's right hip. It was noted that the resident was unable to describe how this injury occurred due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the incident report dated August 13, 2022, confirmed that the resident had an abrasion to the right lateral ribs and petechiae to her right hip and that the resident was unable to give a description of how the injury happened. There was no evidence that the facility conducted a thorough investigation that included interviews with all witnesses of the injury identified on August 13, 2022, to rule out abuse. In an interview on August 25, 2022, at 10:14 a.m., the Director of Nursing confirmed that there was no evidence that the facility conducted a thorough investigation of the injury of unknown origin identified on August 13, 2022. 28 Pa. Code 201.29(i) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of consultant pharmacist reports, and staff interview, it was determined that the facility failed to document the rationale for the continued use of an as needed (PRN) anti-anxiety medication for one of 12 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety. The physician ordered an anti-anxiety medication ([MEDICATION(S)]) every 12 hours PRN for anxiety January 19, 2022, through June 15, 2022, and June 15, 2022, through July 19, 2022. Review of Resident 1's medication administration record revealed that staff adminstered the PRN anti-anxiety medication on April 2 and 10, May 6 and 25, and June 29, 2022. On April 14, 2022, a consultant pharmacist completed a review and requested documentation of the rationale for the continued use of the PRN anti-anxiety medication beyond 14 days and that a specific duration be documented in the physician order. On May 10, 2022, the physician signed the pharmacist's recommendation and indicated he was in agreement with the request. On May 10, 2022, the consultant pharmacist again requested justification for the continued use of the PRN anti-anxiety medication. On June 20, 2022, the physician again acknowledged the pharmacist's recommendation and indicated he was in agreement however no further action was taken. There was no evidence that the order for the PRN anti-anxiety medication was adjusted with a specific duration or that the physician provided rationale for the ongoing use of the PRN anti-anxiety medication beyond 14 days, following the pharmacist's recommendations on April 14, 2022, and May 10, 2022. In an interview on August 25, 2022, at 11:40 a.m., the Director of Nursing confirmed that the order for the PRN anti-anxiety medication was not revised and that there was no evidence that the physician provided rationale for its continued use past 14 days from the original order dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to serve and store food items in a safe and sanitary manner in the main dining room and nursing unit pantry. Findings include: During the lunch observation on August 23, 2022, at 12:01 p.m., in the main resident dining room, Resident 10 was seated at a table and the nurse aide (NA 2) was setting up her lunch. After touching multiple items, including a soda can, and not performing hand hygiene, NA 2 used her ungloved fingers to hold back ice while pouring water from a glass into another container. She then opened the can of gingerale, poured it into the glass of ice, placed a straw, and presented it to Resident 10. Resident 10 was observed drinking the beverage. Observation on August 23, 2022, at 1:11 pm., in the East corridor pantry revealed an open container of applesauce in the resident refrigerator. The date on the facility label indicated that it was opened February 20, 2022, and the manufacturer's expiration date on the container was May 28, 2022. 28 Pa. Code 211.6(c)(f) Dietary services.

Based on observation, facility documentation review and staff interview, it was determined that the facility failed to store and prepare food in accordance with professional standards of food service safety. Findings include: Review of a facility document for the cleaning and maintenance of the ice machine in the kitchen revealed that when the ice machine is dirty it can be corrected by cleaning and sanitizing the ice machine. The sanitizing section revealed that sanitizer is used for removal of algae or slime. Observation in the dietary department on (MONTH) 25, 2019, at 10:01 a.m. during the initial tour of the main kitchen with the Food Service Director (FSD) revealed the ice machine had brown slime discolorations in the ice storage area of the machine, rubber gaskets for the fridge box and freezer box were cracked and brown substances were observed on the seals, the freezer box door had ice stuck around the rubber gaskets, the freezer box contained a large unlabeled undated brown bag containing an unknown substance, an ice pop with open packaging, the refrigerator contained an open and undated scrambled egg mix carton, a cake was open, unlabeled and undated and three apples were stored in a container marked as nectar thick liquid. Further observation in the dietary department with the Food Service Director (FSD) on (MONTH) 25, 2019, at 10:31 a.m. revealed a large container of white sugar with a plastic cup sitting in the sugar. Grouting between floor tiles had accumulations of loose black substances. The floor of the loading dock room was covered in black powders, debris, dust, plastic wrapping waste and had one cardboard box stacked directly on the floor. In the dry storage room, a bag of broken up Graham crackers was dated as prepared (MONTH) 22, 2019 but had no expiration date. The floor outside the walk-in fridge and freezer boxes had a one square foot puddle of a pink-tinged liquid which was noted to have an unpleasant smell. Further observation in the dietary department with the Food Service Director (FSD) on (MONTH) 25, 2019, at 11:01 a.m. revealed an ice cream box in the food serving area with two ice cream containers without lids and the ice cream open to the circulating freezer air, the rubber gaskets were covered in dried ice cream, dust and other particulates with an approximately one foot length of a black discolorations. The cold food holding unit in this area had a prepared salad that was undated, three bags of ham slices that expired on (MONTH) 20, 2019, three bags of turkey slices that expired (MONTH) 30, 2019, a partially consumed gallon of milk that expired (MONTH) 22, 2019, expired royal cherry tomatoes and expired fruit preserve in a jar. All findings in the dietary department on (MONTH) 25, 2019, were confirmed by the Food Service Director (FSD) at the times listed. Further, the FSD stated that the crunched-up Graham crackers should have been dated with an expiration date and because they were not, this meant they were expired. Observation in the activity department on (MONTH) 25, 2019, at 12:59 p.m. with Employee E5, Registered Nurse (RN), revealed a resident nourishment refrigerator and freezer unit. In the freezer was an unlabeled and undated high protein drink with a straw piercing the top and frozen drink through the straw tubing, and a partially consumed vanilla bean ice cream that expired on (MONTH) 11, 2019, an undated unlabeled partially consumed ice cream cup. The freezer compartment drawers were contaminated with brown substances throughout. All findings in the activity department on (MONTH) 25, 2019, were confirmed by Employee E5, Registered Nurse (RN), at the time listed. Further observation in the dietary department on (MONTH) 27, 2019, at 8:51 a.m. of the main kitchen with the Food Service Director (FSD) revealed the ice machine had brown slime discolorations in the ice storage area of the machine. The facility failed to store and prepare food in accordance with professional standards of food service safety. 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited [DATE] 28 Pa. Code 207.4 Ice containers and storage

Based on observation, medical record review and staff interview, it was determined that the facility failed to provide special eating equipment and utensils for one resident for one out of 15 residents reviewed (Resident R15). Findings include: Review of Resident R15's clinical record revealed the [DIAGNOSES REDACTED]. Review of Resident R15's care plan for nutrition identified the resident with a history of weight loss related to dementia, depression, anxiety, [MEDICAL CONDITION], and tremors. The a goal noted was for the resident to tolerate an oral diet. Further review of the resident's care plan noted mechanical soft, ground diet (all) (for Resident R15), provide divided dish, weighted utensils and two handled mug at meals to aide in self-feeding. Observation of Resident R15 on (MONTH) 25, 2019, at 12:33 p.m. revealed the resident had a regular plastic cup, a regular set of metal cutlery and regular round white plate with a low lip. The resident was observed using a regular spoon, pushing food up and over the edge of the plate while trying to load her spoon with food. The resident was observed to have a noticeable tremor and when she did load her spoon with food, much of the food wobbled off her spoon into her lap before she put food in her mouth. Further observation of Resident R15 on (MONTH) 27, 2019, at 12:28 p.m. revealed Resident R15 eating lunch with one Styrofoam cup stacked inside a second Styrofoam cup, a regular set of metal cutlery and a regular round white plate with a low lip. Interview with Employee E3, Registered Nurse (RN), on (MONTH) 27, 2019, at 12:30 p.m. revealed confirmation that Resident R15 was supposed to have a scoop plate for all meals, weighted cutlery and a double handled-mug. Interview with the Director of Nursing on (MONTH) 27, 2019, at 1:45 p.m. revealed confirmation that Resident R15 was on a list of residents who require assistive devices for meals. The facility failed to provide special eating equipment and utensils during meals. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/03/18, 07/17/17 28 Pa. Code 201.18(b)(1) Management Previously cited 07/07/17 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(b)(3) Management Previously cited 08/03/18 28 Pa. Code 211.6(c) Dietary services Previously cited 08/03/18 28 Pa. Code 211.12(a) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 07/07/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 08/03/18, 07/17/17

Based on observation, review of the clinical record and interview with staff, it was determined that the facility did not develop a comprehensive person-centered care plan with measurable objectives and goals related to anticoagulant use and the use of oxygen therapy for two of 16 records reviewed (Resident R41 and R242 ). Findings include: Review of Resident R41's clinical record revealed the resident was admitted to the facility on (MONTH) 12, 2019, with a [DIAGNOSES REDACTED]. Review of Resident R41's clinical record revealed the resident was ordered on (MONTH) 20, 2019, Jantoven (anticoagulant that can treat and prevent blood clots and may cause excessive bleeding) 3 milligrams every day. Further, review of Resident R41's clinical record revealed no documented evidence a comprehensive care plan had been developed for the use of the anticogulant medication Jantoven. Interview on (MONTH) 27, 2019, at 8:47 a.m. with the Director of Nursing, where she confirmed the resident was ordered Jantoven and she confirmed that a comprehensive care plan had not been developed for the use of Jantoven. The facility failed to develop a comprehensive care plan for the use of an anticoagulant. Review of Resident R242's clinical record revealed the resident was admitted to the facility with a [DIAGNOSES REDACTED]. Observation on (MONTH) 25, 2019, at 10:15 a.m. revealed the resident was receiving oxygen via a nasal cannula. Review of Resident R242's clinical record revealed no comprehensive care plan had been developed for the resident's oxygen use. Interview on (MONTH) 27, 2019, at 8:47 a.m. with the Director of Nursing, where she confirmed the resident was receiving oxygen via nasal cannula and she confirmed that a comprehensive care plan had not been developed for the use of the oxygen. The facility failed to develop a comprehensive care plan for the use of oxygen therapy. 28 Pa. Code 211.11(d) Resident care plan

Based on observation, documentation review and staff interview, it was determined that the facility failed to mainitain and post at the beginning of each shift the nurse staffing information in a prominent place readily accessible place to residents and visitors. Findings include: Observations on (MONTH) 25, 2019, at 9:20 a.m., (MONTH) 26, 2019, at 11:00 a.m. and (MONTH) 27, 2019, at 11:28 a.m. revealed the nurse staffing sheets posted was for (MONTH) 1, 2019. The nurse staffing sheet for the days of the observations was located at the nursing and not in a prominent place readily accessible to residents and visitors view. Interview with the Nursing Home Administrator on (MONTH) 27, 2019, at 11:29 a.m. revealed confirmation that the nurse staffing sheets were not in a prominent location that was readily accessible to resident and visitors. The facility failed to post at the beginning of each shift the nurse staffing information in a prominent place readily accessible to residents and visitors. 28 Pa. Code 211.12(k) Nursing services

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary food service operations in a manner to prevent the potential spread of food borne illness in the facility's main kitchen and main dining room. Findings included: A review of facility documentation entitled Cleaning Assignment Chart, for the facility's main kitchen revealed the following: Job B day shift is to sweep the kitchen floor completely and under counters and check the equipment pull list to see what equipment to pull that day, daily from 1:00 - 2:00 PM. Job A night shift is to sweep the kitchen, making sure to get under all counters daily from 6:10 - 7:30 PM Job B night shift is to scrub or mop the kitchen floor with Job A from 6:30 - 7:30 PM. Observation of the main kitchen on (MONTH) 31, (YEAR), at 11:30 AM revealed dirt and debris including pieces of plastic ware, spray bottle, salt shaker, shelving tags, and dried food under equipment and along the wall edges throughout the kitchen, walk in cooler, and dry storage area. Further observation also revealed an ice scoop used to dispense ice from the kitchen bulk ice machine located in the bin filled with clean ice. A concurrent observation in the facility's main dining room revealed a bulk container of thickener (a powdered product used to alter the consistency of food and beverages), half full sitting on a table where two residents were seated. A plastic scoop used to dispense the product was located inside the container. An interview with Employee 3, food service director, on (MONTH) 31, (YEAR), at 12:25 PM confirmed the floors should be swept and mopped under equipment throughout the kitchen, cooler, and dry storage area daily, and the scoops should not be stored in the bin of ice or container of thickener. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 1, (YEAR), at 2:00 PM. 28 Pa. Code 211.6 (c) Dietary services

Based on observation and staff interview, it was determined that the facility failed to provide adequate maintenance and housekeeping services to maintain equipment clean and free of disrepair for five of 12 residents reviewed (Residents 14, 35, 40, 10, and 11). Findings include: An observation of Resident 14 on (MONTH) 31, (YEAR), at 12:25 PM revealed the resident eating lunch in the main dining room, sitting in a wheelchair. The wheels, spokes, and metal bars on the wheelchair contained a large amount of dirt and dust. An observation of Resident 35 on (MONTH) 31, (YEAR), at 12:25 PM revealed the resident eating lunch in the main dining room, sitting in a wheelchair. A large amount of dust was identified on the wheels and wheel spokes and metal bars under the chair. Dried food was also on the side metal bar of the chair. An observation of Resident 40 on (MONTH) 31, (YEAR), at 12:25 PM revealed the resident eating lunch in the main dining room, sitting in a wheelchair. The wheels, spokes and metal bars under the chair contained a large amount of dust and dirt. An observation of Resident 10 on (MONTH) 31, (YEAR), at 1:42 PM revealed the resident sitting in her wheelchair sleeping at an activity. The wheels and spokes of her wheelchair as well as the metal bars underneath the wheelchair contained a large amount of dust and dirt. The vinyl of the seat cushion was torn, and the foot cushion contained rips and tears. An observation of Resident 11 on (MONTH) 31, (YEAR), at 12:30 PM revealed the resident eating lunch in the main dining room, sitting in a wheelchair. The vinyl covering to the chair was torn, exposing the frame on both rear sides of the chair. The above findings were discussed with the Nursing Home Administrator and Director of Nursing on (MONTH) 1, (YEAR), at 2:00 PM. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2 (a) Administrator's responsibility

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that medications were appropriately labeled and stored in one of two medication carts reviewed (E Wing, Resident 4). Findings include: The facility's policy entitled, Storage of Medication and Supplies, last reviewed (MONTH) 1, (YEAR), revealed that the pharmacy dispenses medications in containers that meet legal requirements, including standards set forth by the United States Pharmacopeia. Medications are kept in these containers. Nursing staff are not to transfer medications from one container to another. Observation of the medication pass on (MONTH) 2, (YEAR), at 8:50 AM revealed Employee 2, registered nurse, approached the E Wing medication cart, accessed the cart, and removed a medication cup containing unlabeled medication. The medication cup contained two halved tablets. Resident 4 came out of the main dining room into the hallway where the medication cart was, and Employee 2 administered the tablets to Resident 4. Concurrent interview with Employee 2 revealed the employee recently prepared the medications to administer to Resident 4 by removing them from the labeled package from pharmacy and placed them in a medication cup and returned them to the medication cart until Resident 4 was ready to take them. Interview with the Director of Nursing on (MONTH) 3, (YEAR), at 11:00 AM confirmed that the practice of pre-pouring medications is not the facility's policy or acceptable nursing practice. 28 Pa. Code 211.9(h) Pharmacy services

Based on clinical record review and resident and staff interview it was determined the facility failed to ensure pain management was provided to residents consistent with professional standards of practice for one of four residents reviewed (Resident 22). Findings Include: In an interview with Resident 22 on (MONTH) 31, (YEAR), at 3:39 PM the resident indicated that she always has pain and that she receives medicine for the pain. Clinical record review for Resident 22 revealed a physician's orders [REDACTED]. Further review revealed another physician's orders [REDACTED].#3 tablet 300 mg - 30 mg tablet to be administered one tablet by mouth every six hours as needed for pain. There was no evidence to indicate any parameter of pain level on a pain scale as to which as needed pain medication staff was to administer. Review of Resident 22's Medication Administration Record [REDACTED]. Staff administered the 300 mg - 30 mg tablet of [MEDICATION NAME] with [MEDICATION NAME] 14 times during the month with no documented pain level for 13 of the 14 times the medication was administered. In an interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 2, (YEAR), at 5:00 PM it was confirmed that Resident 22 did have two orders for as needed pain medication with no indication of pain level parameters for staff to determine which medication to administer to the resident. It was also confirmed that there was no documentation of the resident's pain level for 13 of the 14 times the medication was administered. 28 Pa. Code 211.12 (d) (5) Nursing services Previously cited 7/7/17 28 Pa Code 211.12 (d) (1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessment discharge tracking records to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of the event for one of one residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 revealed the resident was admitted to the facility on (MONTH) 19, (YEAR), and discharged to personal care on (MONTH) 29, (YEAR). There was no documented evidence that the discharge Minimum Data Set (MDS, assessment tool completed at specific intervals to determine care needs) tracking records (federally-mandated electronic records) were submitted for Resident 1. Interview with Employee 1, Registered Nurse Assessment Coordinator 1 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on (MONTH) 2, (YEAR), at 4:27 PM confirmed that a discharge MDS should have been submitted for Resident 1 but was not submitted as required.

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident or resident representative in writing of a transfer to the hospital for six of seven residents reviewed (Residents 41, 11, 3, 29, 43, and 14). Findings include: Clinical record review revealed that Resident 41 was transferred to an acute care hospital on (MONTH) 21, (YEAR) and (MONTH) 1, (YEAR). Further clinical record review revealed that no written notification was provided to Resident 41 or Resident 41's responsible party regarding the transfers that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Clinical record review revealed that Resident 11 was transferred to an acute care hospital on (MONTH) 22, (YEAR), (MONTH) 9, (YEAR), (MONTH) 29, (YEAR), and (MONTH) 5, (YEAR). Further clinical record review revealed that no written notification was provided to Resident 11's responsible party regarding the transfers that included the required contents as listed above. Clinical record review for Resident 14 revealed she was transferred to an acute care hospital on (MONTH) 14, (YEAR), where she was admitted . There was no documented evidence that written notification was provided to Resident 14 or Resident 14's responsible party regarding the transfers that included the required contents as listed above. Interview with the Nursing Home Administrator on (MONTH) 1, (YEAR), at 11:45 AM revealed that the facility did not provide residents or their responsible parties with the required written notice of transfer. Clinical record review revealed that Resident 3 was transferred to the emergency roiagnom on (MONTH) 24, (YEAR), for an evaluation after a fall, and again on (MONTH) 3, (YEAR), for [MEDICAL CONDITION] (low blood pressure). Further clinical record review revealed that no written notification was provided to Resident 3, or the resident's responsible party regarding the transfers that included the required contents as listed above. Closed clinical record review for Resident 43 revealed the resident was transferred to the hospital on (MONTH) 5, (YEAR), for complaints of pain and coffee ground emesis, and later died at the hospital. Further clinical record review revealed that no written notification was provided to Resident 43, or the resident's responsible party regarding the transfer that included the required contents as listed above. Clinical record review for Resident 29 revealed the resident was transferred to the hospital on (MONTH) 7, (YEAR), for small urine output, and again on (MONTH) 6, (YEAR), for an evaluation due to not eating, and elevated temperature. Further clinical record review revealed that no written notification was provided to Resident 29 regarding the transfers that included the required contents as listed above. In an interview with the Nursing Home Administrator on (MONTH) 1, (YEAR), at 11:45 AM she indicated that the facility has not implemented any procedures to notify the resident or the resident's responsible party in writing regarding the notice of transfer and the required components when the residents are sent out of the facility to the emergency room or hospital. 28 Pa. Code 201.29(a) Resident rights Previously cited [DATE] 28 Pa. Code 201.14 (a) Responsibility of license Previously cited [DATE]

Based on review of a clinical record, hospice contract and interview with staff, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice provider and the facility for one of 13 residents reviewed (Resident R30). Findings include: Review of the clinical record for Resident R30, revealed that the resident was admitted to the facility on [DATE], with the diagnoses, including but not limited to, [MEDICAL CONDITION], (progressive, [MEDICAL CONDITION] brain disorder causing confusion, impaired memory, judgement and reasoning), kidney failure, and legally blind. Further review of Resident R30's clinical record revealed at the time of admission to the facility, October 31, 2016, Resident R30, was receiving hospice services (end of life care). Review of Resident R30's clinical record revealed a signed agreement between the hospice provider, Resident R30's designated responsible party, and the facility, for provision of hospice care services. Further review of the hospice agreement indicated that Resident R30, would receive services from a hospice, Certified Nurses Aide, seven times a week, once to twice a week visits from a hospice Licensed Nurse, visits as needed by a hospice Social Worker and Chaplain. Review of the Hospice contract dated, October 31, 2016, section, 3.3.9, Documentation of Services, indicated, Both parties shall maintain appropriate documentation of services provided under this Agreement in accordance with applicable state and federal law and regulations and Accreditation Standards. Patient medical records and documentation maintained by each Party shall be available for review and inspection by the other Party as necessary for the proper evaluation, screening, and provision of services to Patients under this Agreement. Interview with the Director of Nursing, on July 6, 2017, at 2:20 p.m. revealed being unaware of the names of the hospice staff providing care to Resident R30, and had no current schedule available for the hospice staff who were caring for Resident R30. Director of Nursing also indicated that the facility did not have any documentation available for review related to hospice care services provided to Resident R30, since admission to the facility, on October 31, 2016. The facility failed to ensure that adequate communication was maintained between the contracted hospice provider and the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 PA. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and staff interviews it was determined that the facility failed to have survey results easily accessible to residents and visitors throughout the facility. Findings include: During the initial tour of the facility on July 5, 2017, survey results were observed posted behind a locked glass enclosure adjacent to the nursing station. The survey results could not be accessed by residents or visitors without the assistance of staff due to the glass enclosure being locked. An interview with employee E1, facility administrator, on July 7, 2017, at 1:00 p.m. confirmed that survey results were placed in a binder that was stored in a drawer of a desk, located in the front lobby. There was no signage posted in the lobby indicating the location of the binder containing the survey results. The facility failed to display the survey results in a location where the residents could retrieve them independently. 28 Pa. Code:201.29(a) Resident rights.

Based on observations, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to maintain consistent infection control practices for wound care for two of 13 residents reviewed (Resident R31, Resident R12). Review of Resident R31's physician orders [REDACTED]. Review of a wound care specialist evaluations dated May 25, 2016 to June 1, 2016 revealed assessments and treatments for a left posterior (behind) leg venous (a wound caused by poor circulation/ PVD) ulcer with measurements performed on June 1, 2016 of 1.1 centimeters (cm.) long by 1.7 cm. wide and .05 cm. deep. Observations of the left leg venous ulcer treatment and dressing change on June 2, 2016 at 10:25 a.m. revealed Employee E3, a licensed nurse, cut the old dressing off with a pair of domestic scissors (similar to kitchen scissors) that were dull at the point of cutting, which tugged at the old dressing, causing pressure on the ulcer. The tips of the scissors were sharp. The soiled dressing had a small to moderate amount of yellow, brown, and bloody drainage. The soiled dressings were placed in the resident's bedside trash can. The scissors were not cleaned, but used to cut the new medicated dressing which was applied directly on the ulcer, and the scissors were used to cut the king (gauze wrap) that was wrapped around the resident's leg to keep the medicated dressing secure. Employee E3 proceeded to write the date, time and initials on the new dressing after it was on the resident. Interview with Employee E3 on June 2, 2016 at 11:00 a.m. confirmed that the scissors should have been cleaned after cutting away the soiled dressings, and because it was bloody, should have been placed in a red (infectious) biohazard bag and placed in a biohazard container in the soiled utility room. Employee E3 agreed that it was not respectful to write on the resident. There was no facility policy for standards of infection control practices for wound care dressings available at this time. Interview with Employee E2 the Director of Nursing (DON), on June 2, 2016 at 2:00 p.m. revealed that the type of scissors used should have been nursing scissors, which has a protected edge and tip, and should have been cleansed after each use, and that the soiled dressing should have been placed in a red biohazard bag and discarded in the biohazard trash in the soiled utility room. Review of Resident R12's clinical record revealed [DIAGNOSES REDACTED]. Review of wound care specialist evaluation revealed the sacral ulcer measurements on June 1, 2016 to be 2. 5 cm. long and 1.6 cm. wide, and 0.3 cm. deep. This pressure ulcer was evaluated at a Stage IV (ulcer involving loss of skin layers, exposing muscle and/or bone). Observation of Resident R12's sacral and gluteal pressure ulcer treatments on June 2, 2016 at 11:00 a.m. by Employee E3, a licensed nurse, revealed cleansing of the sacral wound and gluteal ulcers without changing gloves, and without washing hands. Also, Employee E3 failed to change gloves and wash hands before proceeding to the clean treatment. Also, Employee E3 wrote the time, date and initials on the new dressing while on the resident. Interview with Employee E2, the DON, on June 3, 2016 at 11:00 a.m. confirmed that Employee E3 should have considered each ulcer treatment separately. Also, Employee E2 confirmed that Employee E3 should have changed gloves, washed hands after the cleansing of the sacral wound, and changed gloves, washed hands after the cleansing of the gluteal wound. The facility failed to maintain consistent infection control practices for wound care. 28 Pa. Code: 211.12 (1)(2)(5) Nursing services. Previously cited 7/2/2015.