Every finding on record at Maybrook Hills Rehabilitation and Healthcare Cente

Based on review of policies, clinical records, observations and staff interviews, it was determined that the facility failed to implement interventions in a resident's care plan to prevent a wandering resident from entering other's rooms for six of 19 residents reviewed (Residents 13, 14, 15, 16, 17, 18).Findings include: The facility's policy regarding care plans, dated June 10, 2026, revealed that the resident's care plan will address resident goals, actual and potential problems, needs, strengths and individual preferences of the resident. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated June 15, 2026, revealed that the resident was severely cognitively intact, ambulated without assistance, and had wandering behaviors. The resident's care plan, most recently updated 6/26/26, revealed that she wanders and that she would not significantly intrude on the privacy or activity of others. Observations of Resident 19 on June 30, 2026, revealed that the resident was walking the halls of the [NAME] 1 floor and wandering aimlessly. A quarterly MDS assessment for Resident 13, dated May 9, 2026, indicated that the resident was severely cognitively impaired, required assistance for daily care needs, and had diagnoses that included anxiety. The resident's care plan, dated November 17, 2025, revealed that she is to have a stop sign on her room door to maintain privacy and that staff will observe placement of stop sign during rounds. Observations of Resident 13 in room [ROOM NUMBER] on June 30, 2026, at 1:00 p.m. revealed that she was laying in her bed in her room and the stop sign at her doorway was not engaged. A quarterly MDS assessment for Resident 14, dated March 27, 2026, revealed that the resident was cognitively intact. The resident's care plan, dated June 10, 2025, revealed that she was to have a stop sign on her door to maintain privacy and that staff would observe the placement of the stop sign during rounds. Observations of Resident 14 in room [ROOM NUMBER] on June 30, 2026, at 1:11 p.m. revealed that she was sitting at the side of her bed and that the stop sign was not engaged on her doorway. A quarterly MDS assessment for Resident 15, dated May 29, 2026, revealed that the resident was cognitively intact and required assistance from staff for all her daily care needs. The resident's care plan, dated April 18, 2024, revealed that the resident is to have a stop sign at her doorway. Observations of Resident 15 in room [ROOM NUMBER] on June 30, 2026, at 1:11 p.m. revealed that the resident was laying in her bed and her stop sign was not engaged on her doorway. A quarterly MDS assessment for Resident 16, dated March 27, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated June 10, 2025, revealed that she was to have a stop sign at her door to maintain privacy and that staff would observe placement of the stop sign during rounds. Observations of Resident 16 in room [ROOM NUMBER] on June 30, 2026, at 1:11 p.m. revealed that she was lying in her bed and that the stop sign was not engaged on her door. A quarterly MDS assessment for Resident 17, dated May 31, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated October 15, 2025, revealed that the resident was to have a stop sign at her door to maintain privacy and that staff would observe placement of stop sign during rounds. Observations of Resident 17 in room [ROOM NUMBER] on June 30, 2026, at 1:13 p.m. revealed that she was laying in her bed and the stop sign was not engaged on her door. A quarterly MDS assessment for Resident 18, dated May 3, 2026, revealed that the resident was severely cognitively impaired and required assistance from staff for her daily care needs. The resident's care plan, dated August 27, 2025, revealed that the resident was to have a stop sign on her door to maintain privacy and that staff would observe placement of stop sign during rounds. Observations of Resident 18 in room [ROOM NUMBER] on June 30, 2026, at 1:13 p.m. revealed that she was lying in her bed and the stop sign was not engaged on her door. Interview with Nurse Aide 1 and Nurse Aide 2 on June 30, 2026, at 1:10 p.m. revealed that they were agency nurse aides and that they believed the resident's stop signs only had to be up at certain times of the day and that when they charted regarding the stop sign they were signing off that the stop sign was at the door, not that it was engaged at the resident's door. Interview with Licensed Practical Nurse 3 on June 30, 2026, at 1:20 p.m. revealed that the residents stop signs should be engaged in order to prevent Resident 19, or other wandering residents, into their rooms. She walked around the halls and placed the stop signs across from the residents' rooms. Interview with the Director of Nursing on June 30, 2026, at 3:10 p.m. revealed that he put the stop signs in their proper place earlier this day, but that staff or residents may have taken them down since that time. He stated that they should be in place in order to prevent a wandering resident from entering their rooms. He further stated it may not be the best intervention since other residents tend to tear them down. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 15 of 65 residents reviewed (Residents 10, 22, 43, 71, 72, 75, 77, 83, 108, 112, 115, 124, 150, 190, 199).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days.A quarterly MDS assessment for Resident 10 had an ARD of May 2, 2025. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days.A quarterly MDS assessment for Resident 22 had an ARD of June 29, 2025, but it was not completed (Section Z0500B) until July 14, 2025.A quarterly MDS assessment for Resident 43 had an ARD of July 8, 2025, but it was not completed (Section Z0500B) until July 23, 2025.A quarterly MDS assessment for Resident 71 had an ARD of June 26, 2025, but it was not completed (Section Z0500B) until July 11, 2025. A quarterly MDS assessment for Resident 71 had an ARD of July 15, 2025, but it was not completed (Section Z0500B) until July 30, 2025.A quarterly MDS assessment for Resident 72 had an ARD of July 2, 2025, but it was not completed (Section Z0500B) until July 21, 2025.A quarterly MDS assessment for Resident 75 had an ARD of May 5, 2025, but it was not completed (Section Z0500B) until May 21, 2025. A quarterly MDS assessment for Resident 75 had an ARD of May 15, 2025, but it was not completed (Section Z0500B) until May 30, 2025.A quarterly MDS assessment for Resident 77 had an ARD of July 5, 2025, but it was not completed (Section Z0500B) until July 23, 2025.A quarterly MDS assessment for Resident 83 had an ARD of Jun 30, 2025, but it was not completed (Section Z0500B) until July 16, 2025.A quarterly MDS assessment for Resident 108 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 16, 2025.A quarterly MDS assessment for Resident 112 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 15, 2025.A quarterly MDS assessment for Resident 115 had an ARD of June 11, 2025, but it was not completed (Section Z0500B) until June 30, 2025.A quarterly MDS assessment for Resident 124 had an ARD of June 18, 2025, but it was not completed (Section Z0500B) until July 7, 2025.A quarterly MDS assessment for Resident 150 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 15, 2025.A quarterly MDS assessment for Resident 190 had an ARD of June 29, 2025, but it was not completed (Section Z0500B) until July 14, 2025.A quarterly MDS assessment for Resident 199 had an ARD of June 18, 2025, but it was not completed (Section Z0500B) until July 7, 2025.Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2025 at 8:32 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 11 of 65 residents reviewed (Residents 1, 9, 30, 39, 51, 85, 108, 115, 180, 222, 238). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that for admission MDS assessments, the assessment completion date, and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days and there must be an MDS every 92 days. A comprehensive MDS assessment for Resident 1 revealed that the ARD was June 26, 2025. The MDS assessment was dated as completed on July 18, 2023, which was nine days late.A comprehensive MDS assessment for Resident 9 revealed that the ARD was July 8, 2025. The MDS assessment was dated as completed on July 22, 2023, which was 1 day late.A comprehensive MDS assessment for Resident 30 revealed that the ARD was May 6, 2025. The MDS assessment was dated as completed on May 21, 2023, which was 2 days late.A comprehensive MDS assessment for Resident 39 revealed that the ARD was June 29, 2025. The MDS assessment was dated as completed on July 18, 2023, which was 6 days late.A comprehensive MDS assessment for Resident 51 revealed that the ARD was May 19, 2025. The MDS assessment was dated as completed on June 3, 2023, which was 2 days late.A comprehensive MDS assessment for Resident 85 revealed that the ARD was June 24, 2025. The MDS assessment was dated as completed on July 17, 2023, which was 10 days late.A comprehensive MDS assessment for Resident 108 revealed that the ARD was July 4, 2025. The MDS assessment was dated as completed on July 22, 2023, which was 5 days late.A comprehensive MDS assessment for Resident 115 revealed that the ARD was April 19, 2025. The MDS assessment was dated as completed on May 6, 2023, which was 4 days late.A comprehensive MDS assessment for Resident 180 revealed that the ARD was June 10, 2025. The MDS assessment was dated as completed on July 8, 2023, which was 15 days late.A comprehensive MDS assessment for Resident 222 revealed that the ARD was June 20, 2025. The MDS assessment was dated as completed on July 11, 2023, which was 8 days late.A comprehensive MDS assessment for Resident 238 revealed that the ARD was March 7, 2025. The MDS assessment was dated as completed on April 4, 2023, which was 15 days late.Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2025 at 8:32 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument, clinical records, and the Minimum Data Set validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 3 of 65 residents reviewed (Residents 26, 83, 218). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). The MDS assessment validation report from iQIES (a federal government website for the Centers for Medicare and Medicaid), dated May 1, 2025 - August 1, 2023, revealed that the following MDS assessments were submitted late:Resident 26 had a quarterly MDS assessment with a completion date of January 21, 2025, however, was not submitted until July 25, 2025. Resident 83 had a quarterly MDS assessment with a completion date of May 11, 2025, however, was not submitted until June 2, 2025.Resident 218 had a quarterly MDS assessment with a completion date of June 21, 2025, however, was not submitted until July 16, 2025. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2025 at 8:32 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 65 residents reviewed (Residents 3, 5, 8, 75, 112, 186). Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0350A (insulin) was to be coded with the number of days that insulin injections were received during the seven-day assessment period, Section N0415C1 (antidepressant medication) was to be checked if the resident received an antidepressant medication during the seven-day assessment period, Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day assessment period, Section N0415G1 (diuretic medication) was to be checked if the resident received an diuretic medication during the seven-day assessment period, Section N0415H1 (opioid medication) was to be checked if the resident received an opioid medication during the seven-day assessment period, and Section N0415K1 (anticonvulsant medication) was to be checked if the resident received an anticonvulsant medication during the seven-day assessment period.Physician's orders for Resident 3 dated July 2, 2025, included an order for the resident to receive 75 milligrams (mg) of Venlafaxine HCl daily for depression. The resident's Medication Administration Record (MAR) for July 2025 revealed that the resident received Venlafaxine daily from July 3 through 31, 2025.A significant change MDS assessment for Resident 3, dated July 24, 2025, revealed that Section N0415C1 was not checked, indicating that the resident did not receive any antidepressant medications during the seven days of the assessment period. Physician's orders for Resident 5 dated December 5, 2022, included an order for the resident to receive 10 mg of Escitalopram daily for depression. The resident's MAR for June 2025 revealed that the resident received Escitalopram daily from June 1 through 30, 2025.A significant change MDS assessment for Resident 5, dated June 11, 2025, revealed that Section N0415C1 was not checked, indicating that the resident did not receive any antidepressant medications during the seven days of the assessment period. Physician's orders for Resident 8 dated July 30, 2024 and May 7, 2025, included orders for the resident to receive 500 mg of Keppra two times a day for adjustment disorder and 8 units of Insulin Glargine subcutaneously (beneath the skin) daily for diabetes mellitus. The resident's MAR for June 2025 revealed that the resident received Keppra two times a day and Insulin Glargine daily from June 1 through 30, 2025.A quarterly MDS assessment for Resident 8, dated June 6, 2025, revealed that Section N0350A and N0415FK1 was not checked, indicating that the resident did not receive any inulin or anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 75 dated October 7, 2024, included orders for the resident to receive 7.5 mg of Mirtazapine (antidepressant) at bedtime for an appetite stimulant, 40 mg of Lasix (diuretic) daily for edema (swelling), 200mg of Gabapentin three times a day for neuropathy (nerve pain), and 50 mg of Tramadol every six hours as needed for moderate to severe pain. The resident's MAR for May 2025 revealed that the resident received Mirtazapin, Lasix, and Gabapentin May 1 through 31, 2025, and received Tramadol as needed may 2 through 31, 2025.A quarterly MDS assessment for Resident 75, dated May 15, 2025, revealed that Sections N0415C1, N0415G1, N0415H1, and N0415K1 were not checked, indicating that the resident did not receive any antidepressant, diuretic, opioid, and anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 112 dated July 8, 2025, included an order for the resident to receive 50 mg of Tramadol every eight hours as needed for moderate to severe pain. The resident's MAR for July 2025 revealed that the resident received Tramadol as needed on July 11, 14, 15, and 16, 2025. A quarterly MDS assessment for Resident 112, dated July 17, 2025, revealed that Section N0415H1 was not checked, indicating that the resident did not receive any opioid medications during the seven days of the assessment period. Physician's orders for Resident 186 dated June 9, 2025, included an order for the resident to have Bacitracin-Polymixin B ointment applied to her right third finger topically every shift for wound care until it was healed. The resident's MAR for July 2025 revealed that the resident had Bacitracin-Polymixin B applied to her right third finger July 1 through 9, 2025.A quarterly MDS assessment for Resident 186, dated July 5, 2025, revealed that Section N0415F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period. An interview with the Registered Nurse Assessment Coordinator on August 6, 2025, at 11:30 a.m. confirmed that assessments for Residents 3, 5, 8, 75, 112, and 186 were coded incorrectly.28 Pa. Code 211.5(f) Medical records.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 65 residents reviewed (Residents 51, 72, 180). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated May 20, 2025, indicated that the resident was cognitively impaired, was incontinent of bowel, and that she required extensive assistance from staff for daily care needs. Physician's order for Resident 51, dated May 19, 2025, included an order for the resident to receive 8.6 mg Senna Oral, give 4 tablets as needed for constipation if no bowel movement in three days. Physician's order, dated May 19, 2025, was for the resident to receive 10 milligrams (mg) of Bisacodyl Suppository (treats constipation) as needed for constipation if no bowel movement in four days. Review of Resident 51's task record, dated July 2025, revealed that the resident had no bowel movement from July 11-17, 2025 (7 days). Review of Resident 51's Medication Administration Record (MAR), dated July, 2025, revealed no documented evidence that the resident was medicated for constipation until July 16, 2025 (on the 6th day). Review of Resident 51's task record, dated July 2025, revealed that the resident had no bowel movement from July 18-24, 2025. Review of Resident 51's MAR, dated July 2025, revealed no documented evidence that the resident was medicated for constipation until July 23, 2025 (on the 6th day).Interview with Director of Nursing on August 7, 2025 at 11:59 a.m. confirmed that staff were not medicating Resident 51 for constipation per physician's orders and they should have been.A quarterly MDS assessment for Resident 72, dated July 2, 2025, revealed that the resident was cognitively impaired and had diagnoses that included hypertension.Physician's orders for Resident 72, dated June 14, 2025 included an order for the resident to receive 40 mg Propranolol extended release capsule once daily and to hold if the heart rate was less than 60 or the systolic blood pressure (top number) was less than 100.A review of Resident 72's MAR, dated July 2025, revealed that the staff were not assessing the resident's heart rate or blood pressure prior to administering the Propranolol. Interview with the Director of Nursing on August 7, 2025 at 1:34 p.m. revealed that the staff should have been assessing Resident 72's heart rate and blood pressure and documenting the results prior to administering the propranolol and they were not.A comprehensive MDS assessment for Resident 180, dated June 17, 2025, revealed that the resident was cognitively intact and had diagnoses that included renal insufficiency and received dialysis (process to clean the blood of toxins when the kidneys fail).Physician's orders for Resident 180, dated June 10, 2025, included an order for the resident to receive 5 mg Midodrine (treats low blood pressure) and to hold if the systolic blood pressure (SBP) is greater than 130. A review of Resident 180's MAR, dated July and August 2025, revealed that the resident received Midodrine on July 3 with a BP of 140/82, July 6 with a BP of 132/74, July 8 with a BP of 136/70, July 9 with a BP of 132/72, July 18 with a BP of 130/74, July 22 with a BP of 136/84, July 31 with a BP of 132/82, August 1 at 8:00 a.m. with a BP of 134/74 and 3:00 p.m. with a BP of 134/74.Interview with the Director of Nursing on August 7, 2025 at 1:48 p.m. revealed that Resident 180's Midodrine should have been held on the above dates and it was not.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 65 residents reviewed (Resident 83).Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 83, dated July 24, 2025, revealed that the resident was cognitively intact, required substantial assistance from staff with daily care tasks. Physician's orders for Resident 83, dated February 23, 2023, included an order for the resident to receive 500 milligram (mg) of amoxicillin (antibiotic) by mouth daily for prophylaxis for urinary tract infection (UTI) and an order with a start date of January 24, 2023, for one gram (gm) of Methenamine Hippurate (antibiotic) by mouth every morning and at bedtime for UTI prevention due to a history of urinary tract infections with sepsis. There was no documented evidence that a care plan was developed to address Resident 83's individual care and treatment needs related to her use of antibiotic medications. Interview with the Director of Nursing on August 7, 2025, at 2:55 p.m. confirmed that a care plan to address the care needs related to Resident 83's need for antibiotic medication use was not developed and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 65 residents reviewed (Resident 5). Findings include:CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.The facility's policy regarding EBP, dated January 13, 2025, indicated that the facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is currently targeted by CDC may be considered epidemiologically important. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 11, 2025, revealed that the resident was cognitively impaired and was at risk for developing pressure sores.Physician's orders for Resident 5, dated July 30, 2025, included orders for the resident to have 0.125% Dakin's Solution (antiseptic used for cleaning wounds and preventing infection) applied to the pressure ulcer on her left heel topically every day and evening shift.A wound note, dated July 31, 2025, revealed the resident had an unstageable pressure ulcer (wound bed cannot be visualized) on her left lateral heel that measured 6.8 x 8.4 x 0.2 centimeters (cm) and was covered 70% by eschar (a layer of dead tissue, that forms on the skin's surface, often as a scab-like covering over a wound or burn).A wound note, dated August 5, 2025, revealed the resident had an unstageable pressure ulcer on her left lateral foot that measured 1.2 x 1.5 x 0.0 centimeters (cm) and was covered 100% by eschar , and had an unstageable pressure ulcer on her left heel that measured 6.2 x 8.1 x 0.2 cm and was covered 70% by eschar.Observations of Resident 5 on August 4, 2025, at 12:00 p.m., revealed that the resident was in her room, and there was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room. There was no documented evidence that EBP was ordered and care planned for Resident 5 until August 6, 2025.Interview with the Nursing Home Administrator on August 7, 2025, at 4:31 p.m. confirmed that Resident 5's EBP was missed and she should have been in place due to the resident having pressure ulcers.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date an opened multidose vial of tuberculin solution (used to detect tuberculosis infection) in one of two medication storage area refrigerators reviewed (Unit D2). The facility's policy regarding medication storage, dated July 17, 2025, indicated that it is the policy of this facility to ensure all medications housed on their premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Manufacturer's instructions for Aplisol solution, dated November 2013, indicated that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.Observations of the facility's medication storage area refrigerator on D2 unit, on August 5, 2025, at 1:45 p.m. revealed an opened and undated vial of Aplisol solution for TB skin testing (to test for tuberculosis).Interview with Licensed Practical Nurse 1 at the time of the observation confirmed that the vial of Aplisol solution was not dated when it was opened and that it should have been.Interview with the Director of Nursing on August 5, 2025, at 3:51 p.m. confirmed that the vial of Aplisol solution should have been dated when opened. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 11 residents reviewed (Resident 2). Findings include: The facility's policy regarding as needed (prn) pain medications, dated May 8, 2025, revealed that prn medications would be administered according to the physician-ordered parameters. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 14, 2025, revealed that the resident was cognitively intact, understood and able to understand others, required supervision with daily care needs, and had diagnoses that included right arm fracture, osteoporosis and a pathological fracture of the lumbar spine. Physician's orders for Resident 2, dated April 9, 2025, included an order for the resident to have acetaminophen (Tylenol) 325 mg, two tablets by mouth every six hours as needed for mild pain with a level of (1-3), and oxycodone 5 mg, one tablet by mouth every six hours as needed for moderate to severe pain, at a level of (4-10). Review of the Medication Administration Record (MAR) for Resident 2, dated June 2025, revealed that on June 8 and 13 oxycodone was given for a pain level of 3, when the pain parameter for oxycodone was a pain level 4-10, and on June 15 Tylenol was given for a pain level of 5, when the pain parameter for Tylenol was pain level 1-3. Interview with the Director of Nursing on June 24, 2025, at 13:29 p.m. confirmed that Resident 2's pain medications were not given as per physician-ordered parameters, and they should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of five residents reviewed (Resident 1). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated May 8, 2024, indicated that EBP's would be indicated for residents with wounds or indwelling medical devices, and infection or colonization with an MDRO. Healthcare personnel were to wear appropriate PPE, including gloves and gowns, when providing care to residents requiring EBP's. The facility's pharmacy policy regarding medication administration, dated May 8, 2024, indicated that staff were not to touch tablets or capsules with their fingers. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 26, 2025, indicated that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), received insulin injections, and had diagnoses that included diabetes and neurogenic bladder (bladder lacks control due to nerve or muscle problems). A physician's order and care plan for Resident 1, dated February 19, 2025, included an order for the resident to have a urinary (foley) catheter (an indwelling catheter) and EBP's for the use of the indwelling catheter. The physician's orders also included orders for the resident to receive 27 units of Insulin Glargine subcutaneously (beneath the skin) one time a day for diabetes, 4 percent Lidocaine External Patch to be applied to the lower back topically one time a day for pain, and 0.4 milligrams/hour Nitroglycerin Transdermal Patch to be applied one time a day for angina (chest pain). Observations of medication pass on March 5, 2025, at 9:40 a.m. and 10:04 a.m. revealed that Licensed Practical Nurse 1, while not wearing gloves, spilled a cup of prepared medications onto the top of the medication cart, picked them up and put them back into the cup, and administered them to Resident 1. She continued to feel Resident 1's lower back and applied the Lidocaine patch, cleaned the resident's abdomen with alcohol and administered his Insulin Glargine, and removed the Nitroglycerin patch from his right upper chest. During the medication pass Licensed Practical Nurse 1 dropped the Lisinopril pill onto the floor and returned to the medication cart to prepare another dose. While preparing the dose of Lisinopril, without gloves on, she spilled the pill onto the top of the medication cart and picked it up with her fingers, put it back into the medication cup and administered it to the resident. She then applied the Nitroglycerin patch to the resident's left upper chest. Licensed Practical Nurse 1 did not wear any PPE during the administration of medications to Resident 1. Interview with Licensed Practical Nurse 1 on March 5, 2025, at 10:12 a.m. revealed that she did not think that Resident 1 was on EBP and that she never wears gloves when administering insulin pens or applying medicated patches, and confirmed that she did not use gloves when touching the resident's spilled medication, since her hands had been washed prior. Interview with the Director of Nursing on March 5, 2025, at 1:55 p.m. confirmed that Resident 1 was on EBP, and that Licensed Practical Nurse 1 should have been wearing a gown and gloves while providing direct care to the resident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for handling linen while providing care for two of 11 residents reviewed (Residents 10, 11). Findings include: The facility's infection control policy concerning handling of linen, dated May 8, 2024, revealed that staff is to handle soiled linen using standard precautions, such as wearing gloves. Observations on November 18, 2024, at 10:17 a.m. revealed that Nurse Aide 1 exited the room of Resident 11 carrying soiled laundry with her bare hands and placed them in the dirty linen bin in the hallway. Interview with Nurse Aide 1 on November 18, 2024, at 10:18 a.m. confirmed that she should wear gloves while handling soiled laundry. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 2, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs. Observations on November 18, 2024, at 10:43 a.m. revealed that Nurse Aide 2 and Nurse Aide 3 were providing a bed bath to Resident 10 and threw a soiled gown, a soiled brief, and soiled bed linen on the floor while providing the care. Interview with Nurse Aide 2 and Nurse Aide 3 on November 8, 2023, at 10:44 a.m. confirmed that they should not throw soiled gowns, briefs and bed linens on the floor while providing care and that the soiled items should be placed in bags and taken to the dirty linen bins. Interview with the Nursing Home Administrator on November 18, 2024, at 1:05 p.m. confirmed that gloves should be worn when carrying soiled laundry out of resident rooms; soiled gowns, briefs and bed linens should not be thrown on the floor; and staff should place all laundry in bags and it should be taken to the dirty utility room. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for eight of 57 residents reviewed (Residents 1, 3, 143, 148, 171, 182, 192, 194). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415F was to be coded (1) if an antibiotic medication was administered while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 1, dated April 28, 2023, included an order for the resident to receive 1 gram of Hiprex (an antibiotic) twice a day for recurrent urinary tract infections. Review of the Medication Administration Record (MAR) for Resident 1, dated August 2024, revealed that the resident was administered 1 gram of Hiprex from August 1 through 28, 2024. An annual MDS assessment for Resident 1, dated August 10, 2024, revealed that Section N0415 was not coded (1), indicating that the resident did not receive an antibiotic during the seven-day assessment period. Physician's orders for Resident 192, dated May 31, 2024, included an order for the resident to receive 300 mg of Cefdinir (an antibiotic) twice a day for a urinary tract infection. Review of the MAR for Resident 192, dated June 2024, revealed that the resident was administered 300 mg of Cefdinir from June 1 through 7, 2024. A quarterly MDS assessment for Resident 192, dated June 10, 2024, revealed that Section N0415 was not coded (1), indicating that the resident did not receive an antibiotic during the seven-day assessment period. The RAI User's Manual, dated October 2023, revealed that if a wander/elopement alarm was used, then Section P0200E was to be coded as (0) not used, (1) used less than daily, or (2) used daily. Physician's orders for Resident 3, dated April 4, 2024, included orders for the resident to use a wanderguard (alarm that sounds when approaching exits) and to check for proper function every evening and to check for placement every shift. The resident's Treatment Administration Record (TAR) for August 2024 revealed that a wander/elopement alarm was used from August 1 through 25, 2024. However, an annual MDS assessment for Resident 3, dated August 3, 2024, revealed that Section P0200E was coded with a (0), indicating that the resident did not use a wander/elopement alarm. The RAI User's Manual, dated October 2023, revealed that Section O0110G1b (non-invasive mechanical ventilator) was to be checked if a CPAP/BIPAP device (respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle) was used while a resident within the last 14 days and Section O0110J1b was to be checked if the resident was receiving dialysis treatment while a resident within the last 14 days. Physician's orders for Resident 143, dated March 16, 2024, included an order for the resident to use a BIPAP (bilevel positive airway pressure) at bedtime and physician orders, dated May 1, 2024, included an order for the resident to receive dialysis three times a week. Review of the TAR for Resident 143, dated June 2024, revealed that the resident used a BIPAP device from June 1 through 30, 2024. Dialysis progress notes revealed Resident 143 received dialysis on June 14, 17, 19 and 21, 2024. An annual MDS for Resident 143, dated June 22, 2024, revealed that Section O0110G1b was not checked, indicating that the resident did not use a BIPAP device within the last 14 days while a resident and Section O0110J1b was not checked, indicating that the resident did not receive dialysis treatment within the last 14 days while a resident. Physician's orders for Resident 182, dated June 25, 2024, included an order for the resident to use a CPAP (continuous positive airway pressure) at bedtime for sleep apnea (disorder that causes breathing to stop or become shallow during sleep). An admission MDS assessment for Resident 182, dated June 30, 2024, revealed that Section O0110G1b was not checked, indicating that the resident did not use a CPAP device within the last 14 days while a resident. Review of the MAR for Resident 182, dated June 2024, revealed that the resident used a CPAP device from June 25 through 30, 2024. The RAI User's Manual, dated October 2023, revealed that Section N0415 (high risk drug classes) A (antipsychotic) was to be coded (1) if an antipsychotic (drugs used to treat psychosis-related conditions and symptoms) medication was administered while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 148, dated November 30, 2023, included for the resident to receive 15 milligrams (mg) of olanzapine (an antipsychotic) one time a day for schizophrenia (mental illness that affects how a person thinks, feels, and behaves). Review of the MAR for Resident 148, dated August 2024, revealed that the resident was administered 15 mg of olanzapine all seven days of the seven-day assessment period. A quarterly MDS for Resident 148, dated August 14, 2024, revealed that Section N0415A was not coded (1), indicating that the resident did not receive an antipsychotic during the seven-day assessment period. The RAI User's Manual, dated October 2023, revealed that the intent of Section O Special treatments, Procedures, and Programs was to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Section O0110 K1 (Hospice Care) was to be checked if the services were received while as a resident. A social services note for Resident 171, dated January 31, 2024, revealed that the resident was admitted to hospice care with a terminal diagnosis of chronic obstructive pulmonary disease (COPD - a progressive lung disease that causes breathing problems and restricted airflow). Physician's orders for Resident 171, dated February 1, 2024, included an order for the resident to be admitted to hospice. A quarterly MDS assessment for Resident 171, dated March 2, 2024, revealed that Section O0110 K1 (Hospice Care) was not checked, indicating that the resident did not receive hospice care while a resident. The RAI User's Manual, dated October 2023, revealed that Section O0110C1b (oxygen) was to be checked if oxygen was used while a resident within the last 14 days. Physician's orders for Resident 194, dated July 1, 2024, included an order for the resident to receive 2 liters per minute of oxygen. An admission MDS assessment for Resident 194, dated July 5, 2024, revealed that Section O0110C1b was not checked, indicating that the resident did not use oxygen within the last 14 days while a resident. Review of the MAR for Resident 194, dated July 2024, revealed that the resident used oxygen from July 1 through 31, 2024. Interview with the Nursing Home Administrator on August 28, 2024, at 10:23 a.m. confirmed that the MDS assessments on the dates mentioned above were coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records.

Based on review facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices for cleaning durable medical equipment for two of 57 residents reviewed (Residents 47, 133), and for providing care for five of 57 residents reviewed (Residents 101, 152, 163, 184, 204). Findings include: Observations during the medication administration on August 27, 2024, at 8:37 a.m. revealed that Licensed Practical Nurse 5 obtained Resident 47's blood pressure prior to preparing the resident's medications. After Licensed Practical Nurse 5 administered Resident 47 her medications, she then went to Resident 133's room. Without cleaning the blood pressure cuff, she then obtained Resident 133's blood pressure prior to preparing his medications for administration. Interview with Licensed Practical Nurse 5 on August 27, 2024, at 9:03 a.m. confirmed that the blood pressure cuff should have been cleaned prior to obtaining Resident 133's blood pressure. Interview with the Assistant Director of Nursing on August 27, 2024, at 2:41 p.m. confirmed that the blood pressure cuff should have been cleaned between residents. The facility's policy concerning handling of linen, dated May 8, 2024, revealed that staff is to handle soiled linen to minimize the risk of infection and illness by using standard precautions, such as wearing gloves. CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 152, dated August 2, 2024, revealed that he was understood, could understand, was cognitively intact, was dependent on staff for care, and had a urinary catheter (a soft flexible plastic tube inserted in the bladder to drain urine). A care plan for Resident 152, dated July 28, 2024, indicated that the resident had a catheter with an intervention to monitor for signs and symptoms of infection. Physician's orders for Resident 152, dated July 28, 2024, included an order for Foley catheter care to be completed every shift. Observations and interview with Resident 152 on August 25, 2024, at 1:30 p.m. revealed that he was admitted to the facility because he had an urinary tract infection and needed antibiotics. He was sitting in his wheelchair and there was a urine collection bag secured under his wheelchair. There was no visible signage of EBP around or near the doorway, no personal protection equipment (PPE) available outside of the room, and no designated receptacle for PPE removal. Interview with Licensed Practical Nurse Manager 14 on August 25, 2024, at 2:31 p.m. confirmed that Resident 152 should have appropriate signs posted outside of the room and necessary items for residents with EBP. Interview with the Licensed Practical Nurse Manager and Infection Preventionist 15 on August 28, 2024, at 9:43 a.m. confirmed that Resident 152 should have appropriate signs posted outside of the room and necessary items for residents with EBP. The facility's policy regarding EBP, dated May 8, 2024, indicated that gloves and a gown are used during high contact resident care which includes indwelling medical devices, such as a feeding tube or tracheostomy. Observations on August 27, 2024, at 9:19 a.m. revealed that Nurse Aide 16 exited the room of Resident's 101 and 163 carrying soiled linen with her bare hands and placed them in the dirty linen bin in the hallway. Interview with Nurse Aide 16 on August 27, 2024, at 9:20 a.m. confirmed that she should wear gloves while handling soiled laundry. Interview with the Nursing Home Administrator on August 26, 2024, at 2:49 p.m. confirmed that staff should be wearing gloves when handling soiled linen and place it in linen bins to be taken to the dirty utility room. A admission quarterly MDS assessment for Resident 184, dated June 21, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for daily care needs, and had a feeding tube (a soft flexible plastic tube inserted in the gastrointestinal tract to provide nutrition) and a tracheostomy (a surgical opening through the neck into the trachea). A care plan for Resident 184 regarding enhanced barrier precautions, dated June 20, 2024, revealed that the resident had EBP related to a feeding tube and tracheostomy. Observations on August 28, 2024, at 1:38 p.m. revealed that Nurse Aide 17 was providing incontinence care to Resident 184 without PPE. Interview with Nurse Aide 17 on August 28, 2024, at 1:40 p.m. confirmed that she should wear gloves and a gown while providing incontinence care for residents with EBP. Interview with the Nursing Home Administrator on August 28, 2024, at 3:48 p.m. confirmed that staff should be wearing a gown and gloves when providing care for residents with EBP. An admission MDS assessment for Resident 204, dated August 2, 2024, revealed that the resident was understood, could understand, was cognitively impaired, was dependent on staff for eating, and had a feeding tube (a soft flexible plastic tube inserted in the gastrointestinal tract to provide nutrition). A care plan for Resident 204, dated June 20, 2024, indicated the resident had EBP for a percutaneous endoscopic gastrostomy tube (PEG - type of feeding tube). Physician's orders for Resident 204, dated June 22, 2024, included an order for the resident to be administered a bolus of 237 milliliters (ml) of Jevity 1.5 calorie six times a day for enteral feedings. Observations on August 27, 2024, at 2:53 p.m. revealed that Licensed Practical Nurse 18 was providing a bolus feeding to Resident 204 only wearing gloves. Interview with Licensed Practical Nurse 18 on August 28, 2024, at 3:40 p.m. confirmed that she should have worn a gown while providing a feeding tube feedings for residents with EBP. Interview with the Licensed Practical Nurse Manager and Infection Preventionist 15 on August 28, 2024, at 9:43 a.m. confirmed that staff should be wearing a gown when providing care for residents with EBP. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that enteral feedings (feeding through a tube inserted directly into the stomach) were administered in accordance with physician's orders and failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for two of 57 residents reviewed (Residents 20, 56). A facility policy for tube feeding, dated May 8, 2024, revealed that it is the policy and procedure to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for administering tube feeding includes to check for residual (the amount of gastric fluid in the stomach between feedings) by pulling back no more than 150 cubic centimeters (cc). Note the amount of residual if any. Return the gastric contents back into the stomach and clamp the gastric tube. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated August 3, 2024, revealed that the resident was usually understood, could usually understand others, and had a feeding tube. A care plan for the resident, dated July 18, 2022, revealed that the resident was at risk for malnutrition due to need for tube feeding, thickened fluids, mechanically altered diet, and poor intake at times. Staff was to provide the resident with her tube feed as ordered. The resident was to receive Jevity 1.5 (a type of nutritional tube feeding) if she consumed less than 50 percent of her meal. Physician's orders for Resident 20, dated November 24, 2023, included an order for the resident to receive 237 milliliters (ml) of Jevity 1.5 if the resident ate less than 50 percent of each meal. Review of the Medication Administration Record (MAR) for Resident 20, dated July and August 2024, revealed that staff did not administer the 237 ml of Jevity 1.5 to the resident on July 6, 2024, at 1:00 p.m. after consuming 0 to 25 percent of her meal; staff administered the 237 ml of Jevity 1.5 on July 14, 2024, at 1:00 p.m. after consuming 76 to 100 percent of her meal; July 23, 2024, at 6:00 p.m. after consuming 51 to 75 percent of her meal; August 7, 2024, at 6:00 p.m. after consuming 51 to 75 percent of her meal; and on August 8, 2024, at 8:00 a.m. after consuming 76 to 100 percent of her meal. Interview with the Assistant Director of Nursing on August 28, 2024, at 12:50 p.m. confirmed that Resident 20 was not receiving her tube feedings as ordered by the physician A quarterly MDS for Resident 56, dated May 15, 2024, revealed that the resident was cognitively impaired, was dependent on staff for eating and personal hygiene needs, had diagnoses that included dementia, and had a feeding tube. Physician's orders for Resident 56, dated July 3, 2024, included an order for the resident to receive a 240-milliliter (ml) bolus (a method of tube feeding that involves delivering large amounts of formula over a short period of time) of Isosource 1.5 (a type of nutritional tube feeding) through her feeding tube after meals if she consumed less than 50 percent of her meal by mouth. A care plan for Resident 56, dated June 7, 2022, indicated that the resident needed assistance in maintaining or improving her nutritional status. Staff were to check residual and positioning of her feeding tube prior to administering a bolus of 250 ml of Isosource 1.5 if she consumed less than 50 percent of each meal daily. Review of meal intake records for Resident 56, dated July 2024 and August 2024, revealed that on July 5, 2024, at 9:00 a.m. and 1:00 p.m.; July 6, 2024, at 9:00 a.m. and 1:00 p.m.; July 7, 2024, at 9:00 a.m. and 6:00 p.m.; July 8, 2024, at 9:00 a.m.; August 4, 2024, at 1:00 p.m.; August 17, 2024, at 1:00 p.m.; and August 18, 2024, at 1:00 p.m., the resident consumed less than 50 percent of her meal. Review of the Medication Administration Record (MAR) for Resident 56, dated July and August 2024, revealed no documented evidence that the resident was provided a 240 ml bolus of Isosource 1.5 on the above-mentioned dates and times when the resident consumed less than 50 percent of her meal by mouth. Review of meal intake records for Resident 56, dated July and August 2024 revealed that on July 12, 2024, at 6:00 p.m.; July 15, 2024, at 1:00 p.m.; July 18, 2024, at 6:00 p.m.; July 19, 2024, at 6:00 p.m.; August 3, 2024, at 1:00 p.m.; and August 4, 2024, at 9:00 a.m. revealed that the resident consumed greater than 50 percent of her meal. Review of the MAR for July and August revealed that the resident was provided a 240 ml bolus of Isosource 1.5 on these dates and times. There was no documented evidence that staff were checking residual and documenting the amounts of residual prior to administering the tube feeding per facility policy. Interview with the Assistant Director of Nursing on August 28, 2024, at 2:47 p.m. confirmed that Resident 56 was not receiving her tube feedings as ordered by the physician and that staff were not checking and documenting residual per the facility's policy and the resident's care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for four of 57 residents reviewed (Residents 33, 147, 157, 159). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 33, with an ARD of June 12, 2024, was due to be completed by June 26, 2024, but was not signed as completed until June 27, 2024, which was 15 days from the ARD until completion. A quarterly MDS assessment for Resident 147, with an ARD of June 12, 2024, was due to be completed by June 26, 2024, but was not signed as completed until June 27, 2024, which was 15 days from the ARD until completion. A quarterly MDS assessment for Resident 157, with an ARD of June 8, 2024, was due to be completed by June 22, 2024, but was not signed as completed until June 27, 2024, which was 19 days from the ARD until completion. A quarterly MDS assessment for Resident 159, with an ARD of June 6, 2024, was due to be completed by June 20, 2024, but was not signed as completed until June 23, 2024, which was 17 days from the ARD until completion. An interview with the Nursing Home Administrator on August 27, 2024, at 9:53 a.m. confirmed that quarterly MDS assessments were not completed on time. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for four of 57 residents reviewed (Residents 32, 128, 204, 225). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days. An admission MDS assessment for Resident 32 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 2, 2024, which was 15 days after admission. An admission MDS assessment for Resident 128 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on July 22, 2024, which was 18 days after admission. An admission MDS assessment for Resident 204 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on July 9, 2024, which was 21 days after admission. An admission MDS assessment for Resident 225 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 27, 2024 which was 19 days after admission. An interview with Nursing Home Administrator on August 27, 2024, at 9:53 a.m. confirmed that MDS assessments were not completed timely. An interview with Assistant Director of Nursing on August 28, 2024, at 1:30 and 2:27 p.m. confirmed that Residents 32, 128, 204, and 225's comprehensive admission MDS assessments were completed late. 28 Pa. Code 211.5(f) Clinical Records.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for two of 57 residents reviewed (Residents 2, 143). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 26, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included heart failure (a serious condition that occurs when the heart cannot pump enough blood and oxygen to the body's organs). A care plan for the resident, dated June 3, 2024, revealed that the resident was on an as needed diuretic (a drug that increases urine production, which helps the body get rid of extra salt and fluid) related to edema (swelling caused by fluid trapped in the body's tissues). Staff was to administer her medications as ordered. Physician's orders for Resident 2, dated June 1, 2024, included an order for staff to weigh the resident daily, and if the resident's weight was up two pounds or five pounds in one week staff was to administer 40 milligrams (mg) of Lasix (used to treat edema due to heart failure) along with 20 milliequivalent (mEq) of Potassium (a mineral that your body needs to work properly) A review of Resident 143's Medication Administration Record (MAR) for July 2024 revealed that the resident's weight on July 10, 2024, was 182.8 pounds; on July 11, 2024, the resident's weight was 186.4 pounds (3.6 pound increase); on July 28, 2024, the resident's weight was 181.8 pounds; and on July 29, 2024, the resident's weight was 185.2 pounds (3.4 pound increase). However, there was no documented evidence that staff had administered the Lasix and Potassium as ordered. Physician's orders for Resident 2, dated May 22, 2024, included an order for the resident to receive two 5-mg tablets of Midodrine (a medication that treats low blood pressure) every eight hours for hypotension (low blood pressure) and was to be held if the systolic blood pressure (the top number in a blood pressure reading) was greater than 130 millimeters of mercury (MmHg). A review of Resident 143's MAR for July and August 2024 revealed that staff administered the two 5-mg tablets of Midodrine when the resident's blood pressure was 136/82 MmHg at 6:00 a.m. on July 15, 2024; 134/78 MmHg at 2:00 p.m. on July 23, 2024; 132/72 MmHg at 10:00 p.m. on July 12, 2024; 132/76 MmHg at 10:00 pm. on July 16, 2024; 132/84 MmHg at 10:00 p.m. on July 22, 2024; 132/80 MmHg at 6:00 a.m. on August 13, 2024; and 136/80 MmHg at 10:00 p.m. on August 20, 2024. Interview with the Assistant Director of Nursing on August 27, 2024, at 12:33 p.m. confirmed that Resident 2 did not receive the Lasix and Potassium as ordered on the above dates, and also confirmed that the resident received the Midodrine on the above dates and that staff should have held the medication as ordered. An annual MDS for Resident 143, dated June 22, 2024, revealed the resident was cognitively intact and had diagnoses of diabetes and renal failure. Physician's orders, dated May 1, 2024, included an order for the resident to receive dialysis three times a week. Physician's orders for Resident 143, dated December 28, 2023, included orders for the resident to receive 36 units of Insulin Aspart (fast acting insulin) subcutaneously (SQ-beneath the skin) with meals for diabetes; orders dated January 16, 2024 for the resident to receive two tablets of 800 milligrams (mg) of Renvela (used to control phosphorous levels) with meals for dialysis; and orders dated February 6, 2024, for the resident to receive 36 units Insulin Glargine SQ one time a day with lunch. A review of Resident 143's MAR for August 2024 revealed that the resident did not receive 36 units of Insulin Aspart, 1600 mg of Renvela, and 36 units of Insulin Glargine on August 2 at 12:46 p.m., August 19 at 2:56 p.m., and August 21, 2024, at 12:47 p.m. due to being at dialysis. Interview with the Assistant Director of Nursing on August 28, 2024, at 12:52 p.m. confirmed that Resident 143 did not receive Insulin Aspart, Renvela, and Insulin Glargine on the mentioned dates and times due to being at dialysis, and that the medications should have been administered upon his return. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on interviews with residents and staff, as well as observations, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as eating in the dining room with other residents, for nine of 57 residents reviewed (Residents 70, 72, 79, 125, 149, 151, 157, 162, 164). Findings include: Interview with Resident 72 on August 25, 2024, at 11:21 a.m. revealed that she likes to eat in the main dining room but has been unable to do so because the air conditioner is broken and the facility said that it would be too hot in there to have the dining room open. She indicated that the facility is waiting on a part to come to fix the air conditioner. During an group interview with Residents 70, 72, 79, 125, 149, 151, 157, 162, and 164 on August 26, 2024, at 2:04 p.m. the residents reported that they would like to eat in the main dining room, but they were told that they are unable to do so because the air conditioner is broken and the facility said that it would be too hot in there to have the dining room open. They indicated that the facility is waiting on a part to come to fix the air conditioner. The dietary's meal cart order, dated July 11, 2012, revealed that the main dining room's cart was to be delivered to the main dining room for the lunch meal at 12:12 p.m. An email, dated April 5, 2024, sent to the facility's ownership/management team by the Nursing Home Administrator revealed a Weekly Nursing Home Administrator report, dated March 29, 2024, to April 5, 2024. I forgot to include in my report that we have started soft opening of the main dining room and S2 unit dining room this week on Tuesdays and Thursdays. It has been a huge hit, and we will continue twice weekly throughout this month, then it will move to daily next month. This is for lunch only. Observations on August 25, 26, 27, and 28, 2024, during the lunch meal revealed that there were no residents eating in the main dining room during the meal and the doors were closed and locked. Interview with the Nursing Home Administrator on August 28, 2024, at 11:35 a.m. revealed that they had started with residents eating in the main dining room on Tuesdays and Thursdays, and shortly after that the air conditioning units went down. With the high temperatures outside it was decided to close the main dining room until they got quotes from vendors to decide if they were going with replacement parts or buying new units. Interview with the Maintenance Director on August 28, 2024, at 12:57 p.m. confirmed that he was advised by staff that the air conditioning units were not working in the main dining room. He indicated that on August 5, 2024, he had a vendor come to the facility to look at the air conditioning units. He received a quote on fixing the air conditioning units on August 23, 2024. He indicated that he is currently waiting for a quote to see if replacing the air conditioning units would be more cost effective than just repairing them. He indicated that they did not attempt any other interventions to try and keep the dining room open so that the residents could still eat in the main dining room and that it was decided to just close the main dining room down. Interview with the Nursing Home Administrator on August 28, 2024, at 2:33 p.m. confirmed that they did not monitor temperatures in the main dining room, they just closed it on the side of caution. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage, or failed to provide 48-hour advanced notice, for two 57 residents reviewed (Residents 201, 228). Findings include: Resident 201's medical record revealed that he began Medicare A services on March 1, 2024, and his last covered day was April 22, 2024. The medical record indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The facility had no documented evidence that the resident was issued a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, or an Advance Beneficiary Notice (ABN) as required. A verbal notification was provided to the resident's responsible party on May 1, 2024, which was not 48 hours in advance. The ABN notice provided to the resident's responsible party did not include the items and services that are/are not covered under Medicaid or by the facility's per diem rate and did not include the cost of those items and services. Resident 228's medical record revealed that he began Medicare A services on February 7, 2024, and his last covered day was April 1, 2024. The medical record indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form and an Advance Beneficiary Notice (ABN) were signed on March 29, 2024; however, the ABN notice provided to the resident did not include the items and services that are/are not covered under Medicaid or by the facility's per diem rate and did not include the cost of those items and services. Interview with the Nursing Home Administrator on August 26, 2024, at 2:22 p.m. confirmed that Resident 201 was not issued a SNF Beneficiary Protection Notification Review form or an ABN timely and that the ABN forms for Residents 201 and 228 were not completed accurately and should have been. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of six residents reviewed (Resident 1). Findings include: The facility's abuse policy, dated June 1, 2021, indicated that every resident has the right to be free from mistreatment, neglect, abuse, exploitation, and misappropriation of property. This is a Zero Tolerance policy and will be strictly enforced. A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 20, 2022, indicated that the resident was cognitively intact, had physical and verbal behaviors one to three days of the seven-day look-back period, required the assistance of staff with transfers, it was very important for her to choose her own bedtime and to take care of her personal belongings, and had diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life). Facility investigation documents, dated April 29, 2022, revealed that on April 28, 2022, at approximately 7:30 p.m. Resident 1 was interacting with other residents and staff on her unit and was propelling herself down the hallway to look out the glass window on the door to the activity/dining room. At that time Nurse Aide 1 stepped in front of Resident 1 blocking her path and sat down on the floor preventing the resident from continuing towards the door. The resident attempted to propel her wheelchair around Nurse Aide 1 but was stopped when Nurse Aide 1 put her left hand on top of the resident's hand preventing her from moving while placing her right hand on the wheel and brake of the chair to keep it from moving. The resident became visibly upset and was observed crying as Nurse Aide 1 informed Resident 1 that she must turn around and go to bed (it was 7:30 p.m.). The resident continued to resist, and Nurse Aide 1 went to the rear of the resident's wheelchair, lifted the front of the wheelchair slightly into the air, while the resident kicked her legs back and forth and cried. Licensed Practical Nurse 2 then came over and told Resident 1 that she needed to go to bed, and assisted Nurse Aide 1 to force Resident 1 to get into her room. Nurse Aide 1 and Licensed Practical Nurse 2 held down Resident 1's arm and pushed her wheelchair down the hall without using leg rests and forced her into her room. They placed Resident 1 in her room and put a stop sign barrier across her door. Licensed Practical Nurse 2 then stood in Resident 1's doorway to prevent her from exiting her room. Nurse Aide 1 then pushed Resident 1's wheelchair backwards into her room and placed her into bed. An interview with Resident 1 on April 29, 2022, at 5:30 p.m. revealed that staff made her go to her room when she just wanted to look out the door. She further stated that she put her feet over the edge of her bed and put herself on the floor of her room because she did not want to be in bed. Resident 1 was tearful during the interview and stated that two girls were mean to her and made her go to her room when she just wanted to look out the door. A witness statement by Housekeeper 3, dated April 29, 2022, revealed that Resident 1's hands gripped the wheelchair wheels so tightly that they could not move them and that Nurse Aide 1 and Licensed Practical Nurse 2 pried her hands from the chair while yelling at her the entire way to her room. A witness statement by Housekeeper 4, dated April 29, 2022, revealed that Resident 1 was near the nurse's station and Licensed Practical Nurse 2 tried to take the resident back to her room and pried her hands from her wheelchair and yelled at her the whole way to her room. A written statement from Nurse Aide 1, dated April 30, 2022, at 11:33 a.m. revealed that Licensed Practical Nurse 2 told her to put Resident 1 in her room and the resident was resisting. Therefore, Nurse Aide 1 and Licensed Practical Nurse 2 worked together to put Resident 1 in her room, even though she was screaming and did not want to be in there. Nurse Aide 1 stated that Resident 1 was yelling that she wanted to go to the hospital. Nurse Aide 1 said that about an hour later they attempted to transfer Resident 1 into her bed and she was still upset and was physically aggressive to the staff at that time. Nurse Aide 1 confirmed that she had been educated regarding resident rights and the right to be free from abuse and stated yes, most definitely, I know that I was following what my Licensed Practical Nurse told me to do. A written statement from Licensed Practical Nurse 2, dated April 30, 2022, at 12:13 p.m. revealed that she was told that on the evening of the incident Resident 1 was attempting to hit and kick another resident and that Nurse Aide 1 was trying to calm her down. She stated that Resident 1 was attempting to go into an activity room where the floor was being waxed and Nurse Aide 1 attempted to stop her. When Nurse Aide 1 was unable to redirect the resident she grabbed her hands to move the wheelchair around. She further stated that she did grab both of Resident 1's hands to get the wheelchair turned around and then took her to her room. She indicated that Resident 1 bit her arm while she was trying to help Nurse Aide 1 get her into her bed. Interview with the Director of Nursing on June 9, 2022, at 12:42 p.m. confirmed that Nurse Aide 1 and Licensed Practical Nurse 2 were terminated for forcing Resident 1 into her room and into her bed when she did not want to be in there. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for eight of 23 residents reviewed (Residents 1, 3, 4, 5, 6, 7, 8, 9). The facility's failure created a situation in which four of these residents (Residents 3, 5, 6, 8) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents. Findings include: Pennsylvania Health Alert Network (PAHAN) - 609, Core Infection Prevention and Control Measures for Long-term Care Facilities, dated December 1, 2021, revealed that nursing homes must follow Centers for Medicare and Medicaid Services (CMS) core principles of COVID-19 infection prevention (e.g., in QSO-20-39-NH). These are consistent with principles provided by the Centers for Disease Control and Prevention (CDC) and the Department of Health. For additional information to outline the facility's response to a new suspected, probable, or confirmed case of COVID-19 in a facility staff or resident, or when a resident has been exposed to COVID-19, refer to guidance provided in PA-HAN-610 or its successor. Core prevention measures for COVID-19 in long-term care facilities in Pennsylvania include: Identify a COVID-19 care unit dedicated to monitoring and care for residents with confirmed [CONDITION(S)]-COV-2 infection. Determine the location of the COVID Care Unit and create a staffing plan. Doing this before residents or Healthcare Professional (HCP) with [CONDITION(S)]-CoV-2 infection are identified in the facility will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Facilities that have already identified cases of [CONDITION(S)]-CoV-2 infection among residents but have not developed a COVID Care Unit should work to create one unless the proportion of residents with [CONDITION(S)]-CoV-2 infection makes this impossible (e.g., the majority of residents in the facility are already infected). The location of the COVID Care Unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. The COVID Care Unit should have dedicated entrance and exit points such that HCP not working in that unit do not need to pass through. Identify HCP who will be assigned to work only on the COVID Care Unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID Care Unit and other units during the same shift. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Ideally, environmental services (EVS) should be dedicated to this unit, but to the extent possible, EVS should avoid working on both the COVID Care Unit and other units during the same shift. To the extent possible, HCP dedicated to the COVID Care Unit (e.g., NAs and nurses) will also be performing cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant (e.g., wipe) from List N into the room and wipe down high-touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room. HCP working on the COVID Care Unit should have access to a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Ensure HCP practice source control measures and physical distancing in the break room and other common areas (i.e., other than while eating, HCP wear a respirator or source control and sit at least 6 feet apart while on break). Ensure that high-touch surfaces in staff break rooms and work areas are frequently cleaned and disinfected (e.g., each shift). PAHAN - 610, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities (LTCF), dated December 1, 2021, revealed that close contact is someone who was within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period during their infectious period. The infectious period begins from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection date of the positive test). Isolation for residents: The term isolation refers to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, HCP, or visitors. Isolation in LTCF residents includes: Use of standard and transmission-based precautions for COVID-19; a private room with a private bathroom or with another resident with laboratory confirmed COVID-19, preferably in a COVID Care Unit; and restrict the resident to their room with the door closed. In some circumstances (e.g., memory care units) keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway; follow visitation guidance as outlined in QSO-20-39-NH; restrict residents to medically-necessary outings during the isolation period; monitor by assessing symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam at least three times a day; and follow the guidance in PA-HAN-554 to determine duration of isolation for residents. To implement Zone-based guidance in your facility, refer to guidance in PA-HAN-570. For all other outbreak response approaches where a mixture of quarantine and non-quarantine for residents might occur on a single unit, Transmission-Based Precautions, room restrictions, and other quarantine measures must be assigned to the care of each individual resident. PAHAN -570, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-Term Care Facilities, dated May 10, 2021, revealed that residents needed to be cohorted to separate units in three zones, based on test results: 1. COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. 2. Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. 3. Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. Staff should be designated by zone as much as possible to minimize risk to exposed (Yellow) and non-exposed (Green) residents. Guidance from the Centers for Disease Control (CDC - a national public health agency), dated April 30, 2020, included that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. The facility's policy regarding COVID-19, dated June 1, 2021, revealed that all residents confirmed or assumed positive will be placed in transmission-based precautions (Droplet) for a minimum of 10 days and may be extended based on symptoms. When Red Zone is at maximum capacity, positive residents will shelter-in-place. Any exposed resident/roommate will remain in place and be tested according to CDC latest guidance. These rooms will be marked red zone for staff to identify COVID positive rooms. The facility's policy regarding COVID cohorting, dated June 1, 2021, revealed that the purpose was to minimize interaction of infectious residents from non-infectious residents as much as possible during their admissions process. Cohorting refers to the grouping of residents with the same condition in the same location (room, wing, or building). For the purpose of this policy the term cohorting refers to separating admissions based on vaccination status and/or confirmed COVID-19. All suspected and/or positive COVID-19 residents are admitted or transferred to a specific area/floor that is separated from COVID-19 negative residents. Positive COVID-19 residents will be cohorted accordingly using appropriate transmission-based precautions in the dedicated Red Zone. A COVID-19 test result for Resident 1, dated January 14, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 3, dated January 14, 2022, revealed that the resident was negative. Daily census information revealed that Residents 1 and 3 were roommates at the time that Resident 1 had a positive test result on January 14, 2022, and there was no documented evidence that either resident was moved following Resident 1's positive test result. A COVID-19 test result for Resident 4, dated January 19, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 5, dated January 19, 2022, revealed that the resident was negative. Daily census information revealed that Residents 4 and 5 were roommates at the time that Resident 4 had a positive test result on January 19, 2022, and there was no documented evidence that either resident was moved following Resident 4's positive test result. A COVID-19 test result for Resident 7, dated January 18, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 6, dated January 18, 2022, revealed that the resident was negative. Daily census information revealed that Residents 6 and 7 were roommates at the time that Resident 7 had a positive test result on January 18, 2022, and there was no documented evidence that either resident was moved following Resident 7's positive test result. A COVID-19 test result for Resident 9, dated January 19, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 8, dated January 19, 2022, revealed that the resident was negative. Daily census information revealed that Residents 8 and 9 were roommates at the time that Resident 9 had a positive test result on January 19, 2022, and there was no documented evidence that either resident was moved following Resident 9's positive test result. Observations of Residents 4 and 5 on January 19, 2022, at 5:17 p.m. revealed that they resided in the same room that was identified as a Red Zone with no type of barrier between them. Observations of Residents 1 and 3 on January 19, 2022, at 5:19 p.m. revealed that they resided in the same room that was identified as a Red Zone with no type of barrier between them. Observations of Residents 6 and 7 on January 19, 2022, at 9:15 p.m. revealed that they resided in the same room that was identified as a Red Zone with no type of barrier between them. Observations of Residents 8 and 9 on January 19, 2022, at 9:22 p.m. revealed that they resided in the same room that was identified as a Red Zone with no type of barrier between them. Interview with the Nursing Home Administrator and the Infection Preventionist on January 19, 2022, at 7:57 p.m. revealed that because the residents that tested negative for COVID-19 had already been exposed to their COVID-19 positive roommates, they felt that if they moved the COVID-19 positive residents and/or COVID-19 negative residents out of their current rooms it would potentially expose more of the facility's residents to COVID-19, so it was decided to shelter the COVID-19 positive and COVID-19 negative residents in place. Interview with Pennsylvania Department of Health Epidemiology Research Associate 1 on Janaury 20, 2022, at 9:04 a.m. revealed that the guidance has not changed regarding cohorting of residents and that the facility's practice does not appear to be in alignment with the current guidance. The only situation this kind of cohorting may be acceptable that she could think of is if the positive residents were in a Red Zone (instead of Yellow Zone) and the negative residents had COVID-19 recently and recovered, but the facility did not have anywhere to move the resident out of the Red Zone. This would reduce the risk of transmission to other residents in the Yellow Zone. On January 19, 2022, at 8:51 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The facility submitted and implemented an immediate action plan that included ensuring that each resident's most recent COVID-19 test result was reviewed. Residents who tested positive were moved out of the rooms where they were previously residing with residents who tested negative to an existing designated Red Zone or to a new additional Red Zone that was created. Residents were placed in the Red and Yellow Zones according to their most recent COVID-19 test results. The facility developed an infection control education plan for all current and future staff, including agency staff, and staff who were currently off work related to testing positive for COVID-19. The education included cohorting positive and negative residents in the proper infection control zones. The Immediate Jeopardy was lifted on January 21, 2022, at 2:00 p.m. when it was confirmed that the facility moved all residents into the correct infection control zones in accordance with their COVID-19 test results, educated the majority of staff, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, investigative reports and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and the facility's policy for transporting residents for one of six residents reviewed (Resident 1), resulting in a fracture for the resident. Findings include: The facility's policy regarding abuse prevention, dated June 1, 2021, indicated that each resident had the right to be free from mistreatment, neglect, and misappropriation of property, and no one was to subject residents to abuse, including facility staff, other residents, consultants, volunteers, other agencies serving the resident, family members, legal guardians, friends, or other individuals. The facility's policy regarding wheelchair transport, dated June 1, 2021, indicated that bilateral (right and left) leg rests (a supportive surface on a wheelchair for the legs and feet to rest on) were to be used to prevent injury when any resident was being tranported in a wheelchair by any staff, families or volunteers. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 13, 2021, revealed that the resident was alert and oriented, was dependent for transfers, did not ambulate (walk), and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated October 9, 2019, included that she required assistance with daily care tasks and was to use leg rests on her specialty wheelchair for transport only. A nursing notes for Resident 1, dated July 22, 2021, at 2:45 p.m. revealed that Licensed Practical Nurse 1 was made aware that the resident's foot got caught under her wheelchair while being transported to the nursing unit after an appointment. A nursing note dated July 22, 2021, at 6:23 p.m. revealed that Resident 1 was administered 650 milligrams (mg) of acetaminophen (used to treat mild to moderate pain) for complaints of left leg pain. A nursing note dated July 22, 2021, at 9:00 p.m. revealed that Registered Nurse 2 assessed Resident 1, and the resident told her that her left leg slid off the foot rest and got caught underneath the leg rest. The resident complained of pain to her left leg from her knee to her foot, had trace [CONDITION(S)] (minor swelling) to the left ankle, and shouted and grimaced in pain with range of motion (movements of the joints in different direction) to the left lower leg. The physician was notified and an x-ray was ordered. Information submitted by the facility, dated July 23, 2021, revealed that the transport nurse aide returned from an appointment with Resident 1 and transported her in a wheelchair with only one (the right) leg rest on the wheelchair, and the resident's foot caught under her wheelchair while she was being tranported back to her unit. At 6:23 p.m. the resident complained of pain from her left knee to her foot. An x-ray was obtained and revealed a fracture of the left distal fibular malleolus (ankle). Investigative documents for Resident 1, dated July 23, 2021, revealed that on July 22, 2021, Transport Nurse Aide 3 transported the resident to her appointment using one leg rest (right) and told the resident to hold her (left) foot up on the other (right) rest. When she was returning Resident 1, her left foot dropped while in the hallway and her foot snagged on the floor. She was slowly pushed to her room and the licensed practical nurse was told about the incident. The facility's investigation determined that Transport Nurse Aide 3 was educated regarding transporting residents on June 25, 2020, and violated the facility's policy when she transported Resident 1 in a wheelchair using one leg rest on July 22, 2021. Interview with the Nursing Home Administrator on July 27, 2021, at 12:52 p.m. confirmed that Transport Nurse Aide 3 did not use two leg rests on Resident 1's wheelchair while transporting her on July 22, 2021, and two leg rests should have been used during the transport. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for two of 11 residents reviewed (Residents R3 and R4) and in actual harm to Resident R4. Findings include: physician's orders [REDACTED]. A nursing note for Resident R4 dated March 24, 2016, and written by Licensed Practical Nurse 1, revealed that at 3:10 a.m. the resident had a medium, yellow liquid emesis (she vomited). While being suctioned, the nurse noted that the resident was not acting like herself, was unable to state where she was, and that her pupils were pin point and fixed. The resident's oxygen saturation level (percentage of oxygen in the blood) was 78-85 percent (normal levels are above 92 percent). The note indicated that the resident had requested pain medication at approximately 2:45 a.m., and 5 mg of the [MEDICATION NAME] solution was administered according to the directions on the bottle's (pharmacy) label, which were that 5 ml was equal to 5 mg. After the change in the resident's condition was noted at 3:10 a.m., it was determined that the bottle of [MEDICATION NAME] was labeled (by the manufacturer) as 100 mg/5 ml, which meant that the resident was administered 100 mg of [MEDICATION NAME] (20 times the prescribed dose). Emergency Medical Services (EMS) were called, and upon arrival at the facility they administered [MEDICATION NAME] (a medication to reverse the effects of narcotics) to the resident. An interview with Licensed Practical Nurse 1 on April 6, 2016, at 7:10 a.m., confirmed that she administered 5 ml of [MEDICATION NAME] solution to Resident R4 based on the pharmacy label on the bottle, which indicted that 5 mg was equal to 5 ml. She confirmed that she did not verify the concentration of the solution until after it was noted that the resident's condition declined. She confirmed that the manufacturer's label on the medication bottle indicated that 100 mg was equal to 5 ml. Interview with Pharmacist 2 on April 6, 2016, at 9:50 a.m., confirmed that the pharmacy supplied the wrong concentration of [MEDICATION NAME] to the facility for Resident R4, and the bottle had an incorrect pharmacy label. He verified that the concentration supplied was 100 mg/5 ml, which equaled 20 mg/ml. He confirmed that the pharmacy's label on the bottle indicated that 5 mg was equal to 5 ml. Interview with the Director of Nursing on April 6, 2016, at 12:15 p.m., confirmed that the incorrect dose of [MEDICATION NAME] was admininstered to Resident R4. She confirmed that the concentration of the [MEDICATION NAME] was indicated on the manufacturer's label on the front of the bottle, and that Licensed Practical Nurse 1 did not follow the 5 rights (a nursing standard for the administration of medications that includes ensuring that the resident receives the right medication and the right dose) of medication administration because she did not verify the concentration of the [MEDICATION NAME] solution prior to administering it to Resident R4. physician's orders [REDACTED]. The facility's investigation, dated January 20, 2016, indicated that the resident was found to have a 50 mcg/hr [MEDICATION NAME] on her right arm instead of the prescribed 25 mcg/hr patch. Interviews with the Director of Nursing and the Nursing Home Administrator on April 6, 2016, at 12:15 p.m., revealed that a Licensed Practical Nurse took a 50 mcg/hr [MEDICATION NAME] from a box of patches on the medication cart that belonged to another resident and placed the patch on Resident R3, who was ordered a 25 mcg/hr patch. 28 Pa Code 211.12(d)(1) Nursing services. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 1/28/16, 12/30/15, 10/29/15.

Based on review of clinical records and professional standards for normal blood glucose levels, as well as resident and staff interviews, it was determined that the facility failed to ensure that the residents had the right to be free from neglect, resulting from a failure to administer prescribed medications to 34 of 66 residents reviewed, thus placing these residents in an Immediate Jeopardy situation, due to the danger of significant adverse consequences (Residents R1-R34). Findings include: The Medication Administration Records (MAR) for 34 residents on the Stouffer 2 Nursing Unit revealed that the residents did not receive medications as ordered by their physicians at 6:00 a.m. and 6:30 a.m., on May 10, 2015. Recommendations of The American Diabetes Association, dated 2015, revealed that a normal fasting blood sugar level is 70-130 milligrams per deciliter (mg/dL) and is less than 180 mg/dL after meals. Resident R1's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. Subsequently, the MAR indicated [REDACTED]. An interview with Resident R1 on May 15, 2015, at 2:15 p.m., revealed that she felt very sick and almost passed out on the morning of May 10, 2015, and told the nurse that it was because she did not receive her medications and insulin. An interview with Licensed Practical Nurse (LPN) 3 on May 15, 2015, at 12:50 p.m., confirmed that Resident R1 complained of being sick on the morning of May 10, 2015, because she did not receive her insulin or other medications that morning. Resident R2's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. In addition, the resident was to receive 15 units of routine Humalog insulin subcutaneously and 1,000 milligrams (mg) of [MEDICATION NAME] HCl (an oral antidiabetic) every day at 6:00 a.m., and 30 units of [MEDICATION NAME] (a long acting insulin given once a day) subcutaneously every day at 6:30 a.m. The MAR indicated [REDACTED]. Subsequently, the MAR indicated [REDACTED]. Resident R21's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. Subsequently, the MAR indicated [REDACTED]. Resident R16's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. In addition, the resident was to receive 5 units of routine Humalog insulin subcutaneously, 500 mg of [MEDICATION NAME] and 40 mg of pantoprazole (used to treat GERD) at 6:00 a.m., every day. The MAR indicated [REDACTED]. Subsequently, the resident's blood sugar on May 10, 2015, at 11:00 a.m., was 258 mg/dL. Resident R33's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. In addition, the resident was to receive 2 units of Humalog insulin subcutaneously, 30 mg of [MEDICATION NAME] HCl (a heart medication), and 20 mg of [MEDICATION NAME] DR (used to treat GERD) at 6:00 a.m., every day. The MAR indicated [REDACTED]. Subsequently, the resident's blood sugar on May 10, 2015, at 12:00 p.m., was 346 mg/dL. Resident R25's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. of Dexilant DR (used to treat GERD) at 6:00 a.m., every day. The MAR indicated [REDACTED]. Resident R9's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Resident R19's MAR, dated May 2015, revealed that the resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. Medication Administration Records, dated May 2015, for Residents R3 and R17 revealed that both residents had [DIAGNOSES REDACTED]. The residents' MAR's revealed no documented evidence that the staff completed the blood sugar tests at 6:00 a.m., on May 10, 2015, and as a result no insulin was given. Subsequently, the MAR's revealed that on May 10, 2015, Resident R3's blood sugar at 12:00 p.m. was 128 mg/dL and Resident R17's blood sugar at 4:00 p.m. was 202 mg/dL. Medication Administration Records, dated May 2015, for Residents R3, R6, R8, R14, R20, and R27, revealed that each of the residents had a [DIAGNOSES REDACTED]. The MAR's revealed no documented evidence that the staff administered the oral diabetic medications to the residents at 6:00 a.m., on May 10, 2015. Medication Administration Records, dated May 2015, for Residents R18, R22, R23, R29, R32, and R34, revealed that each of the residents had a [DIAGNOSES REDACTED]. The MAR's revealed no documented evidence that the staff administered the [MEDICAL CONDITION] medications to the residents at 6:00 a.m., on May 10, 2015. Medication Administration Records, dated May 2015, for Residents R15, R24, R32, and R34, revealed that each of the residents had a respiratory diagnosis. The physician's orders [REDACTED]. The MAR's revealed no documented evidence that the staff administered the respiratory medications to the residents at 6:00 a.m., on May 10, 2015. Medication Administration Records, dated May 2015, for Residents R4, R5, R6, R7, R8, R10, R11, R12, R13, R14, R15, R17, R22, R26, R27, R28, R29, R30, R32, and R34, revealed that each of the residents had a [DIAGNOSES REDACTED]. at 6:00 a.m., every day. The MAR's revealed no documented evidence that the staff administered the stomach medications to the residents at 6:00 a.m., on May 10, 2015. Medication Administration Records, dated May 2015, for Residents R23 and R31 revealed that both residents had a [DIAGNOSES REDACTED]. The MAR's revealed no documented evidence that the staff administered the artificial tears to the residents at 6:00 a.m., on May 10, 2015. Interview with Registered Nurse 1 (RN 1) on May 15, 2015, at 12:00 p.m., revealed that due to staff call-offs for the 11:00 p.m. to 7:00 a.m., shift on May 10, 2015, she was responsible for passing medications on the Stouffer 2 Nursing Unit in addition to her regular duties as the Registered Nurse (RN) Supervisor. She indicated that she was not physically able to complete her responsibilities as the RN Supervisor and to complete the medication pass. Registered Nurse 1 confirmed that she did not administer the above medications to Residents R1-R34, and she informed the oncoming nurses (LPN 3 and RN 2) that the 6:00 a.m. and 6:30 a.m., medications were not administered to most of the residents on the Stouffer 2 Nursing Unit. Registered Nurse 1 also indicated that she was too busy to notify her Director of Nursing or the residents' attending physicians that the medications were not administered. Interview with LPN 3 on May 15, 2015, at 12:50 p.m., confirmed that she was informed by RN 1 that the 6:00 a.m. medications were not administered on May 10, 2015. LPN 3 also confirmed that she did not report the missed medications to anyone. Interview with RN 2 on May 16, 2015, at 7:55 a.m., confirmed that she was informed by RN 1 that the 6:00 a.m. medications were not administered on May 10, 2015. Registered Nurse 2 also confirmed that she did not notify the Director of Nursing or the residents' attending physicians about the situation. Interview with the Director of Nursing on May 15, 2015, at 2:00 p.m., confirmed that she was not aware that medications were not administered on May 10, 2015, until she arrived at the facility on Monday, May 11, 2015. On Friday, May 15, 2015, she was unable to provide information to show that an analysis of the situation and its cause(s) had been completed or that any actions to prevent the situation from occurring again had been initiated. The Director of Nursing indicated that she had not yet interviewed the nurse responsible for not passing the medications on May 10, 2015. On May 15, 2015, at 2:30 p.m., the Nursing Home Administrator was informed that Immediate Jeopardy was identified due to the lack of action to complete medication administration by the responsible RN and the oncoming LPN and RN, the lack of response to analyze and correct the situation by the facility's administration, and the risk posed to residents who did not receive medications, including diabetic residents who did not receive insulin. Adequate scheduled nursing staffing was ensured for May 15, 2015, through May 20, 2015. A back-up plan was initiated by the facility involving mandatory nursing hours provided by administrative nursing staff in the event of call-offs that could not be replaced after efforts to do so. On Saturday, May 16 and Sunday, May 17, 2015, the facility experienced numerous call-offs by nursing staff and were forced to use their back-up plan of administrative nursing staff to cover vacant nursing care shifts or partial shifts. The Immediate Jeopardy was removed during an on-site visit on May 18, 2015, at 10:30 a.m. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3) Management. 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 4/7/15, 11/7/14, 10/22/14. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 5/2/15, 4/23/15, 4/7/15, 1/30/15, 11/7/14, 10/22/14, 8/22/14, 2/7/14, 1/9/14, 12/12/13.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the necessary care to prevent constipation for two of 30 residents reviewed (Residents R1, R14) and failed to follow physician orders [REDACTED]. Findings include: The facility's policy and procedure regarding bowel protocol, dated 6/1/13, indicated that to ensure residents had proper bowel elimination, staff were to follow the physician orders [REDACTED]. A comprehensive assessment dated [DATE] for Resident R1 revealed that the resident was dependent for activities of daily living, could not walk, had a gastrostomy tube for nutrition (a tube placed directly into the stomach), and had a [DIAGNOSES REDACTED]. The resident's plan of care regarding pain, dated 7/28/13, indicated that due to narcotic medication use, staff were to observe for any complications such as constipation and intervene appropriately. Physician orders [REDACTED]. Resident R1's bowel records for October and November 2013 revealed that he did not have a documented bowel movement from 10/14/13 to 10/17/13 (four days). Medication administration records for this time period revealed that Milk of Magnesia was not administered on the third day as ordered by the physician, and the [MEDICATION NAME] suppository was administered on 10/18/13 (day five) instead of on the fourth day as ordered. The bowel records revealed that the resident did not have a documented bowel movement from 10/20/13 to 10/26/13 (seven days). The Medication Administration Record [REDACTED]. The bowel movement records revealed that the resident did not have a documented bowel movement from 11/6/13 to 11/10/13 (five days). The Medication Administration Record [REDACTED]. The bowel movement records revealed that the resident did not have a documented bowel movement from 11/12/13 to 11/15/13 (four days). The Medication Administration Record [REDACTED]. The bowel movement records revealed that the resident did not have a documented bowel movement from 11/17/13 to 11/22/13 (six days). The medication administration records for this time period revealed that Milk of Magnesia was administered on days three and five, and a [MEDICATION NAME] suppository was not administered as ordered. There was no documented evidence that the physician was notified regarding the resident's ongoing episodes of constipation, and no evidence that an individualized plan of care related to constipation was ever developed. A hospital CAT scan report dated 11/23/13 revealed that the resident had a rectal fecal impaction and proctitis (the formation of a firm mass of feces in the rectum with inflammation of the rectum and anus). Interview with Registered Nurse 7 on 12/10/13 at 12:50 p.m. revealed that she was unaware that Resident R1 had problems with constipation. Interview with Registered Nurse 14 on 12/11/13 at 3:00 p.m. confirmed that physician orders [REDACTED]. Physician orders [REDACTED]. Bowel movement records for October and November 2013 revealed that Resident R14 had no documented bowel movements from 10/17/13 to 10/20/13 (four days). The Medication Administration Record [REDACTED]. The bowel records revealed that the resident did not have a documented bowel movement from 10/27/13 to 10/29/13 (three days), from 10/31/13 to 11/2/13 (three days), and 11/22/13 to 11/24/13 (three days). The medication administration records for these time periods revealed that Milk of Magnesia was not administered. Interview with Licensed Practical Nurse 2 on 12/13/13 at 2:15 p.m. confirmed that physician orders [REDACTED]. Physician orders [REDACTED]. Medication administration records for September 2013 revealed that staff administered [MEDICATION NAME] on 9/20/13 at 4:00 p.m. and 8:00 p.m., four hours apart instead of six hours apart as ordered by the physician. Medication administration records for November 2013 revealed that staff administered [MEDICATION NAME] on 11/7/13 at 12:00 p.m. and 3:45 p.m., 3 hours and 45 minutes apart instead six hours apart as ordered. Interview with the Director of Nursing on 12/12/13 at 8:50 a.m. confirmed that the medication administration records indicated that [MEDICATION NAME] was not administered as ordered by the physician. 42 CFR 483.25 Provide Care and Services for Highest Well Being Previously cited 10/22/13, 11/8/12. 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 10/22/13. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/22/13, 11/8/12.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: The facility's policy and procedure regarding bowel protocol, dated 6/1/13, indicated that to ensure residents had proper bowel elimination, staff were to follow the physician orders [REDACTED]. A comprehensive assessment, dated 12/17/13, for Resident R1 revealed that the resident was dependent for activities of daily living, could not walk, had a gastrostomy tube for nutrition (a tube placed directly into the stomach), had a [DIAGNOSES REDACTED]. The resident's plan of care, dated 12/12/13, indicated that staff were to monitor the resident's bowel movements closely and were to administered routine medications to address the resident's constipation. Physician orders, dated 1/31/14, revealed that if the resident did not have a bowel movement in two days, staff were to administer three doses of prune juice; if the prune juice was not effective, staff were to administer Milk of Magnesia (a laxative) at bedtime; and if the resident did not have a bowel movement within 24 hours of receiving Milk of Magnesia, staff were to administer a [MEDICATION NAME] suppository (a rectal laxative) at bedtime. Resident R1's bowel records for January and February 2014 revealed that he did not have a documented bowel movement from 1/28/14 to 2/1/14 (five days). Medication administration records for this time period revealed that staff administered only two doses of prune juice on 1/30/14 instead of three as ordered by the physician. The prune juice was not effective so Milk of Magnesia was administered but was not effective. There was no documented evidence that a suppository was then administered as ordered by the physician. The bowel records revealed that the resident did not have a documented bowel movement from 2/4/14 to 2/7/14 (three days). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Physician orders, dated 12/15/13, for Resident R8 revealed that staff were to administer a bran mixture and three doses of prune juice if the resident did not have a bowel movement in two days. If the bran mixture and prune juice were not effective, then staff were to administer Milk of Magnesia at bedtime. If the Milk of Magnesia was not effective within 24 hours, then staff were to administer a [MEDICATION NAME] suppository at bedtime. Bowel movement records for February 2014 revealed that Resident R8 had no documented bowel movements from 2/1/14 to 2/5/14 (five days). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. One dose of prune juice was administered on the morning of the fourth day and Milk of Magnesia was administered at bedtime on the fourth day. Interviews with Registered Nurse 4 and Registered Nurse 5 on 2/7/14 at 1:18 p.m. and 1:00 p.m. confirmed that the physician orders [REDACTED]. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 12/12/13. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 1/9/14, 12/12/13.