Every finding on record at Menno Haven Rehabilitation Center

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for five of 22 residents reviewed (Residents 7, 11, 23, 32, 50). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated June 9, 2026, revealed that the resident was cognitively impaired and that his COVID vaccination was not up to date. Review of Resident 7's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. A comprehensive MDS assessment for Resident 11, dated June 29, 2026, revealed that the resident was cognitively intact, was admitted to the facility on [DATE], and that her COVID-19 vaccination was not up to date. Review of Resident 11's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. A comprehensive MDS assessment for Resident 23, dated May 26, 2026, revealed that the resident was cognitively intact and that his COVID vaccination was not up to date. Review of Resident 23's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccination. A comprehensive MDS assessment for Resident 32, dated May 21, 2026, revealed that the resident was cognitively intact, was admitted to the facility on [DATE], and that her COVID-19 vaccination was not up to date. Review of Resident 32's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. Resident 50's clinical record indicated that he was admitted on [DATE]. There was no documented evidence that he was offered the COVID-19 vaccination. Review of Resident 50's clinical record revealed no immunization or declination information documented related to the COVID-19 vaccine. Interview with the Infection Control Nurse on July 8, 2026, at 1:39 p.m. revealed that Residents 7, 11, 23, 32, and 50 were not offered the COVID-19 vaccination. She stated that the pharmacist advised her not to offer the COVID vaccination outside of the COVID season because the new formula is released in October and a person must wait three months after receiving a COVID-19 vaccination prior to receiving another one. Interview with the Nursing Home Administrator on July 8, 2026, at 9:32 a.m. revealed that they do not offer the COVID-19 vaccination at this time because their pharmacist advised them not to do so. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.Findings include: The facility's current policy regarding food temperatures, dated January 8, 2025, indicated that a tray line point of service standard for cold food must be held at a temperature of 31-41 degrees Fahrenheit (F) and hot food between 155-170 degrees F. A delivery standard for cold food must be served at a temperature between 33-50 degrees F and hot food at 135-155 degrees F. Interview with Resident 38 on August 11, 2025, at 11:30 a.m. included that the resident stated, the food is always cold when I get it. Interview with Resident 35 on August 11, 2025, at 12:10 p.m. included that the resident stated, the food just doesn't seem to stay hot. Interview with Resident 37 on August 11, 2025, at 12:30 p.m. included that the resident stated, the food would taste much better if it wasn't always cold. The menu for Wednesday (undated) revealed that the lunch meal included cold Italian couscous salad, macaroni and cheese, stewed tomatoes, dinner roll and a glazed blueberry lemon cake. The food production log, dated August 13, 2025 revealed that at 11:15 a.m. the temperature of the macaroni and cheese was 184 degrees F and the stewed tomatoes was 168 degrees F. Observations in the main kitchen service area on August 13, 2025, revealed that the Coastal Way cart left the main kitchen at 12:40 p.m. and arrived on the Coastal Way unit. Trays were passed to the residents in their rooms and the last resident was served at 12:42 p.m. At 12:42 p.m. the temperature of the macaroni and cheese was 126.3 degrees F, and the temperature of the stewed tomatoes was 130.8 degrees F. The macaroni and cheese and stewed tomatoes were lukewarm and did not taste appetizing. Interview with [NAME] 1 on August 13, 2025 at the time of the observation confirmed that the macaroni and cheese and stewed tomatoes should have been hotter. 28 Pa. Code 211.6(b) Dietary Services.

Based on policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a physician's order was obtained to provide specialized respiratory treatment for one of 25 residents reviewed (Resident 45).Findings include:The facility policy for non-invasive ventilation (CPAP- continuous positive airway pressure used to provide patent airway during periods of sleep apnea (breathing repeatedly stops and starts during sleep), dated January 8, 2025, revealed that the facility was to obtain an order for the use of the CPAP device and settings from the practitioner.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 45, dated July 30, 2025, revealed that the resident was cognitively intact and used non-invasive ventilation. A care plan for the resident, dated July 23, 2025, revealed that the resident was to use CPAP per the physician's order. A nursing note, dated July 29, 2025, at 1:55 p.m. revealed that Resident 45 used CPAP at bedtime.There was no documented evidence that a physician's order was obtained to use the CPAP machine at bedtime. Interview with the Director of Nursing on August 12, 2025, at 1:15 p.m. confirmed that there was no documented evidence that there was a physician's order for Resident 45 to use CPAP.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as interviews with residents, family members, and staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of 25 residents reviewed (Resident 35).Findings include: The facility's policy regarding hand hygiene, dated January 8, 2025, indicated that all team members will be trained and complete hand hygiene competencies at regular in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections upon hire and no less than annually. Staff are to use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap at times that include before and after handling clean or soiled dressings, gauze pads, etc., after removing gloves, and before and after entering isolation precautions settings. The use of gloves does not replace hand washing/hand hygiene. The facility's Wound Care Observation Checklist for Infection Control, completed by Registered Nurse 2 on June 10, 2025, revealed that best practices for infection control during wound dressing changes indicated that hand hygiene is to be performed properly before preparing a clean field. A clean field is prepared when the surface is wiped with antiseptic wipes following manufacturer's guidelines, a surface barrier is applied (e.g., chux (absorbent pads, often used to protect surfaces like beds, chairs, and furniture from fluids )pads) and supplies are placed on the surface barrier in aseptic manner Hand hygiene is performed before starting the procedure, a barrier is positioned under the wound, the old dressing is removed and discarded, the dirty gloves are removed and discarded, and hand hygiene is applied before accessing the clean supplies, and clean gloves are donned. Gloves are removed and hand hygiene is performed properly after dressing change is complete. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated August 2, 2025, indicated that the resident was understood and usually able to understand others, required assistance for daily care needs, had diagnoses that included after care for fracture of the right lower leg, and had a skin tear. Physicians' orders for Resident 35 dated August 8, 2025, included an order to cleanse the skin tear on the right lower extremity with normal saline and apply xeroform gauze then cover with gauze pads and wrap with Kerlix, may place abdominal pad to back of leg for additional padding every day shift. Physician's orders for Resident 35 dated August 10, 2025, included an order to cleanse the skin tear on the left shin with normal saline and apply xeroform gauze then cover with gauze pads and wrap with Kerlix every day shift. Observations on August 13, 2025, at 2:42 p.m. revealed that Registered Nurse 2 took wound care supplies into Resident 35's room, placed them on her dresser in the room and donned a gown and gloves. She removed Resident 35's left lower extremity dressing, removed her gloves, used alcohol-based hand rub and reapplied gloves. She moved the dressing supplies from the dresser and placed the gauze pads, and xeroform (medicated petrolatum gauze dressing,) dressings unopened onto the floor in Resident 35's room, opened the supplies from the floor to cleanse the resident's skin tear. She then picked up the Xeroform dressing package from the floor and cut a piece off and applied it the resident's leg, added a gauze pad and padding to the back of her leg and wrapped kerlix around the leg. She removed her gloves and applied tape to the dressing. Registered Nurse 2 then proceeded to take the CAM (Controlled Ankle Motion boot - used to immobilize and support the ankle after an injury) boot off the resident's right leg, applied gloves and removed the old dressing. She then removed her gloves, applied new gloves, opened the gauze sponge packaging that she had laying on the floor and cleansed the skin tear with saline, removed her gloves, went to her treatment cart to get more gauze pads, used hand sanitizer, and applied new gloves. She then cleansed the skin tear some more, removed her gloves, and applied clean gloves, used skin prep to the area surrounding the skin tear, removed her gloves, donned clean gloves, used the package of Xeroform that was on the floor and applied xeroform to two areas, and removed her gloves. She then repositioned the resident's leg, applied new gloves, applied gauze pad, wrapped the leg with kerlix, taped the dressing, applied pads to top and back of the resident's leg and reapplied the CAM boot. Registered Nurse 2 then removed her gloves and gown and washed her hands and cleansed her scissors and removed the garbage from the room to the soiled utility room and used hand sanitizer. There was no observation that a clean field for wound care dressings was used, that a barrier was positioned under the resident's wound, or that hand hygiene was performed every time the nurse removed her gloves. Interview with Registered Nurse 2 on August 13, 2025, at 3:28 p.m. revealed that she thought she probably should have performed hand hygiene between glove changes. Interview with the Director of Nursing on August 13, 2025, at 3:52 p.m. revealed that Registered Nurse 2 should have performed hand hygiene each time she removed her gloves, and that placing dressing supplies on the resident's floor is probably not best practice, even though the dressings were unopened while on the floor and remained uncontaminated when opened. 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 develop a comprehensive care plan that included specific and individualized interventions to address the care needs for two of 16 residents reviewed (Residents 17, 29). Findings include: The facility's policy regarding comprehensive care plans, dated June 12, 2024, indicated that the interdisciplinary team, in conjunction with the guest and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each guest. The comprehensive, person-centered care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the guest's highest practicable physical, mental, and psychological well-being. An admission MDS assessment for Resident 17, dated July 4, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated June 28, 2024, and resolved on July 3, 2024, revealed that the resident used continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while sleeping) related to obstructive sleep apnea (when breathing is interrupted during sleep). Physician's orders for Resident 17, dated July 17, 2024, included an order for staff to apply the resident's CPAP in the p.m. and remove the resident's CPAP in the a.m. There was no documented evidence that an individualized care plan was developed and implemented again related to Resident 17's CPAP. Interview with the Nursing Home Administrator on August 7, 2024, at 10:15 a.m. revealed that Resident 17's care plan was resolved because he was not using the CPAP, and then his wife talked him into using the CPAP again. He confirmed that a care plan should have been developed regarding the resident's CPAP. An admission MDS assessment for Resident 29, dated July 21, 2024, revealed that the resident was understood and could understand others. A nursing note for Resident 29, dated July 22, 2024, revealed that the writer found Halls cough drops in the resident's room. The resident insisted on having cough drops at his bedside and can appropriately administer the medication. A new order was obtained for the cough drops, and that he may have them at his bedside Physician's orders for Resident 29, dated July 22, 2024, included an order for the resident to receive cough drops mouth/throat lozenges as needed for cough and may do unsupervised self-administration. There was no documented evidence that an individualized care plan was developed and implemented related to Resident 29's ability to self-administer the cough drops or have the cough drops at his bedside. Interview with Nursing Home Administrator on August 6, 2024, at 2:15 p.m. confirmed that Resident 29's care plan was not developed until today for the self-administration of the cough drops and to have the cough drops at his bedside. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was thawed as per facility policy and that food stored in the kitchen was labeled, dated and secured. Findings include: The facility's policies regarding thawing frozen foods and food storage, dated June 12, 2024, revealed that food should never be thawed at room temperature and any food that has been opened must be labeled, dated and secured in such a way that the food item is air tight. Observations in the kitchen on August 5, 2024, at 10:23 a.m. revealed that there was a total of 38 hot dogs thawing on the counter at room temperature. Observations in the walk-in cooler on August 5, 2024, at 10:27 revealed that there was approximately one cup of sage in a plastic bag that was undated and unsecured. Observations in the meat cooler on August 5, 2024, at 10:30 a.m. revealed that there was one piping bag (a kitchen tool in the shape of a cone used for decorating cakes, pies and pastries) full of whip cream that was undated and unsecured. Observations in dry storage on August 5, 2024, at 10:34 a.m. revealed that there was approximately three pounds of dry spaghetti secured in plastic wrap but undated. Interview with the Director of Dietary and the Executive Director of Culinary on August 5, 2024, at 10:45 a.m. confirmed that food should not be thawing on the counter at room temperature and all food items in the kitchen should be labeled, dated and secured. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of 16 residents reviewed (Residents 11, 26, 29). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated June 11, 2024, revealed that the resident was understood, could understand others, and had diagnoses that included a hip fracture. A care plan for the resident, dated July 5, 2024, revealed that the resident was on a Restorative Nursing Program for active range of motion, and the resident was to perform 15 ankle pumps (bend foot up and down at the ankle joint) and 15 ankle rolls (roll ankle to the right in a circular motion, and then to the left in a circular motion) two times per day. Review of nurse aide documentation for Resident 11, dated July and August 2024, revealed that staff documented the 15 ankle pumps and the 15 ankle rolls as Not Applicable (NA) during the day shift on July 24, 25, 26, 28, and August 1, 2, and 6, 2024. An admission MDS assessment for Resident 26, dated June 25, 2024, revealed that the resident was usually understood, could understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly known as a stroke). A care plan for the resident, dated June 11, 2024, revealed that the resident was on a Restorative Nurse Program for active range of motion, and the resident was to perform 15 ankle pumps (bend foot up and down at the ankle joint) and 15 ankle rolls (roll ankle to the right in a circular motion, and then to the left in a circular motion) two times per day. Review of nurse aide documentation for Resident 26, dated June, July, and August 2024, revealed that staff documented the 15 ankle pumps and the 15 ankle rolls as NA during the day shift on June 22, 23, and 28, 2024, and was left blank on June 26, and 29, and August 2, 2024. Review of nurse aide documentation for Resident 26, dated June, July, and August 2024, revealed that staff documented the 15 ankle pumps and the 15 ankle rolls as NA during the night shift on June 20-25, 27-30; July 1, 3, 5, 6, 7, 10, 11, 14, 17, 18, 19, 22, 24, 26, 27, 28, 30 and 31; and August 2, 3, 4, 2024, and was left blank on June 26, and July 8, 13, 15, 21, and 23, 2024. An admission MDS assessment for Resident 29, dated July 21, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included a hip fracture. A care plan for the resident, dated July 16, 2024, revealed that the resident was on a Restorative Nurse Program for active range of motion, and the resident was to perform 15 ankle pumps (bend foot up and down at the ankle joint) and 15 ankle rolls (roll ankle to the right in a circular motion, and then to the left in a circular motion) two times per day. Review of nurse aide documentation for Resident 29, dated July and August 2024, revealed that staff documented the 15 ankle pumps, and the 15 ankle rolls as NA during the night shift on July 17, 19, 26, 27, 28, 30 and 31, and August 2, 2024, and was left blank on July 23, 2024. Interview with the Nursing Home Administrator on August 7, 2024, at 8:55 a.m. regarding Residents 11, 26 and 29 confirmed that staff should be documenting that the resident received, did not receive, or refused, and that staff should not be documenting NA or leaving blank spaces. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, clinical records, and observations, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for one of 16 residents reviewed (Resident 50). Findings include: The facility's policy regarding baseline care plans (includes the minimum healthcare information necessary to properly care for a resident), dated June 12, 2024, indicated that the baseline care plan will be developed within 48 hours of a guest's admission, include the minimum healthcare information necessary to properly care for the guest including, but not limited to: initial goals based on admission orders, physician's orders, dietary orders, therapy orders, and social services. The admitting nurse or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information, physician's orders, and discussion with the guest and the guest's representative. Interventions shall be initiated that address the guest's current needs. A nursing note for Resident 50, dated August 2, 2024, indicated that the resident was admitted to the facility that day. Physician's orders for Resident 50, dated August 2, 2024, included an order for the resident to have an indwelling urinary catheter (a medical device that drains urine from the bladder), provide indwelling urinary catheter care every day and night shift, change the indwelling urinary catheter drainage bag every two weeks on Friday, change the indwelling urinary catheter every 28 days, and irrigate the indwelling urinary catheter with 60 milliliters (ml) of sterile water as needed for blockage. Physician's orders for Resident 50, dated August 2, 2024, included an order for the resident to be on Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission of resistant organisms). Observations of Resident 50 on August 5, 2024, at 2:11 p.m. and on August 6, 2024, at 2:35 p.m. revealed that the resident had an Enhanced Barrier precaution sign on her doorway indicating that the resident was on Enhanced Barrier Precautions, and she was in her room sitting her wheelchair with a indwelling urinary catheter drainage bag hanging from underneath her wheelchair. There was no documented evidence that Resident 50's baseline care plan, dated August 2, 2024, included information about the resident's care needs related to the indwelling urinary catheter and Enhanced Barrier Precautions. Interview with the Nursing Home Administrator on August 7, 2024, at 10:15 a.m. confirmed that there was no documented evidence that a baseline care plan was developed and implemented related to Resident 50's indwelling urinary catheter and Enhanced Barrier Precautions. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician orders were followed for one of 16 residents reviewed (Resident 11). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 11, 2024, revealed that the resident was cognitively intact, depended on assistance from staff for daily care needs, and received a diuretic (a medication that increases urine output). A care plan, dated July 5, 2024, indicated that the resident was to receive diuretic per physician's orders. Physician's orders for Resident 11, dated July 29, 2024, included an order for the resident to receive 2 milligrams (mg) of Bumex (a diuretic) every 24 hours as needed for edema (swelling), if the resident has a 2-pound weight increase in one day. A review of Resident 11's Treatment Administration Record (TAR) for July and August 2024 revealed that the resident's weight on July 30 was 202 pounds, July 31 was 204 pounds, and August 1 was 216.8 pounds. A review of Resident 11's Medication Administration Record (MAR) for July and August 2024 revealed that the resident did not receive Bumex on July 31 for a 2-pound weight gain or on August 1 for a 12.8-pound weight gain. Interview with RN Clinical Manager 1 on August 6, 2024, at 15:28 p.m. confirmed that Resident 11 did not receive Bumex as ordered and should have on the above dates. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending September 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending August 7, 2024, identified repeated deficiencies related to quality of care and sanitary food preparation and storage. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding proper food preparation and storage, cited during the survey ending September 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining proper food preparation and storage. Refer to F684, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 16 residents reviewed (Resident 11). Findings include: The facility's policy regarding notification of changes, dated June 12, 2024, revealed that the physician was to be notified with any changes in a resident's condition. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated July 11, 2024, indicated that the resident was understood and could understand, was cognitively intact, required substantial assistance for care, was receiving a diuretic medication (a drug that causes increased urine output), and had diagnoses that included end-stage kidney disease. A care plan for Resident 11, dated July 5, 2024, revealed that the resident was on a diuretic for high blood pressure and required daily monitoring for effectiveness. Physician's orders for Resident 11, dated July 12, 2024, included an order for the resident to have daily weights taken. Review of Resident 11's clinical record revealed that on July 31, 2024, the resident weighed 204 pounds, and on August 1, 2024, the resident weighed 216.8 pounds (a 12.8-pound increase). There was no documented evidence that the physician was notified of Resident 11's weight gain of 12.8 pounds in one day. Interview with RN Clinical Manager 1 on August 6, 2024, at 3:28 p.m. confirmed that there was no documented evidence that Resident 11's physician was notified about the 12.8 pound weight gain, and that it should have been addressed. 28 Pa. Code 211.12(d)(3) Nursing Services.

Based on the review of the facility policies, as well as obervations and staff interviews, it was determined that the facility failed to ensure that food stored in the walk-in freezer was properly dated and labeled. Findings include: The facility's policy for food storage, dated July 12, 2023, indicated that all products were to be labeled and dated with the receiving date. All open items will have an open date and will be resealed to prevent contamination. Observations of the dietary walk-in freezer on September 5, 2023, at 11:14 a.m. revealed undated and/or unlabeled items that were not in their original delivery box, including a bin of chicken breasts (8 cases -multiple breasts in separate clear plastic bags), beef brisket in a clear sealed bag, one angel food cake in a tied plastic bag, multiple single serving macaroni and cheese in a plastic bin, two packages of sandwich buns in a plastic bag, and a partial loaf of gluten-free bread. Interview with the Executive Chef on September 5, 2023, at 11:30 a.m. confirmed that all items should have been dated and/or labeled. 28 Pa. Code 211.6(f) Dietary services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to physician's orders for one of 19 residents reviewed (Resident 42). Findings include: The facility's policy regarding flushing intravenous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated July 12, 2023, indicated that central venous access catheters would be flushed after each infusion to clear infused medications. The facility's policy regarding medication administration, dated July 12, 2023, revealed that medications were to be administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards. Staff were to sign the Medication Administration Record (MAR) after the medication was administered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated August 27, 2023, indicated that the resident was cognitively intact, received an antibiotic, and received intravenous therapy (IV therapy - medications administered directly into a vein). Physician's orders for Resident 42, dated August 21, 2023, included an order for the resident to receive 3000 milligrams of Ampicillin-Sulbactam Sodium Intravenous Solution (an antibiotic) intravenously (IV - administered directly into a vein) every six hours for 23 days for bacteriuria (bacteria in the urine) and to use the SASH method (flush with 0.9 percent normal saline (sterile salt water solution), administer antibiotic, flush with 0.9 percent saline and flush with 50 units of heparin (blood thinner)) when administering an antibiotic. Staff were to check the resident's PICC line (peripherally inserted central catheter) site for signs and symptoms of infection/infiltration every day and night shift. Resident 42's MAR's for August and September 2023 revealed that the resident received IV Ampicillin-Sulbactam every six hours from August 21 through September 6, 2023; however, there was no documented evidence that staff flushed the resident's IV catheter with the SASH method every six hours with the administration of Ampicillin-Sulbactam. The MAR's indicated that the SASH method was administered one time on the day shift and one time on the night shift. Interview with the Director of Nursing on September 7, 2023, at 8:45 a.m. confirmed that there was no documented evidence that Residents 42's IV catheter was flushed with the SASH method with every administration of IV antibiotics. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete wound treatments as ordered by the physician for one of 19 residents reviewed (Resident 17). Findings include: An admission Minimum Data Set (MDS) assessment for Resident 17, dated August 17, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance for daily care tasks, and had a venous or arterial ulcer (ulcer caused by poor circulation). Physician's orders for Resident 17, dated August 15 and 29, 2023, included orders for the resident's right ankle to be cleansed with normal saline solution (sterile water), Opticell Ag (absorbent anti-bacterial dressing) applied, and covered with optifoam (foam dressing) three times a week. A care plan, dated August 14, 2023, indicated that wound care was to be provided as ordered. Review of Resident 17's Treatment Administration Records (TAR's) for August and September 2023 revealed that there was no documented evidence that the treatment to the resident's right ankle was completed three times a week as ordered on August 18 and 30, 2023. Interview with the Director of Nursing on September 7, 2023, at 11:57 a.m. confirmed that Resident 17's treatment to the right ankle was not completed as ordered on August 18 and 30, 2023. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 19 residents reviewed (Residents 1, 24). Findings include: The facility's policy regarding medication management, dated August 22, 2022, indicated that accurate accountability of the inventory of all controlled drugs would be maintained at all times. When a controlled substance was administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): date and time of administration, amount administered, remaining quantity, and the initials of the nurse administering the dose, completed after the medication was actually administered. Physician's orders for Resident 1, dated August 16 and 27, 2022, included orders for the resident to receive 5 milligrams (mg) of [MEDICATION(S)] (a controlled medication used to treat pain) every four hours as needed for moderate pain. Resident 1's controlled drug accountability records for August 2022 revealed that staff signed out doses of [MEDICATION(S)] for administration to the resident on August 26 at 7:00 p.m., August 28 at 2:00 a.m., and August 28 at 6:30 p.m.; however, there was no documented evidence in the MAR that the [MEDICATION(S)] was actually administered to the resident on the dates and times listed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated August 16, 2022, revealed that the resident was usually understood and could usually understand, was alert and oriented, required extensive assistance from two staff for care, had diagnoses that included fractures and arthritis, had pain frequently and received an opioid (narcotic pain medication). Physician's orders for Resident 24, dated August 9, 2022, included orders for the resident to receive 5 milligrams (mg) of [MEDICATION(S)] (a controlled medication used to treat pain) every six hours as needed for moderate pain. Resident 24's controlled drug accountability records for August 2022 revealed that staff signed out a dose of [MEDICATION(S)] for administration to the resident on August 11, at 4:42 p.m.; however, there was no documented evidence in the MAR that the [MEDICATION(S)] was actually administered to the resident on the date and time listed. Interview with the Director of Nursing on August 30, 2022, at 3:52 p.m. revealed that she could not locate any documentation that the [MEDICATION(S)] was administered after it was signed out on the above listed dates and times for Residents 1 and 24. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of Centers for Medicare and Medicaid Service memos, information submitted by the facility and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents, their representatives, and families were informed by 5:00 p.m. the next calendar day following subsequent occurrences of a confirmed COVID-19 infection for four of 19 residents reviewed (Residents 1, 5, 17, 31). Findings include: The Centers for Medicare and Medicaid Services (CMS), QSO-20-29-NH memo, dated May 6, 2020, indicated that facilities must inform residents, their representatives, and families of those residing in facility by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must not include personally identifiable information, must include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered, and include any cumulative updates for residents, their representatives, and families at least weekly or by 5:00 p.m. the next calendar day following the subsequent occurrence of either, each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. The facility's record of COVID-19 positive staff tests revealed that at least one staff tested positive on August 21, 2022. The facility's record of COVID-19 positive resident tests revealed that at least one resident tested positive on August 22, 2022. An entry tracking MDS for Resident 32, dated August 15, 2022, revealed that the resident was admitted to the facility on this date. A nursing note for Resident 32, dated August 22, 2022, at 1:46 p.m. revealed that the resident tested positive for COVID-19. The resident and her daughter were notified; however, there was no documented evidence that Residents 1 and 5, who resided on the same wing as Resident 32, their representatives and families were notified by 5:00 p.m. the next calendar day following Resident 32's confirmed COVID-19 infection. Interview with the Infection Preventionist on August 30, 2022, at 4:22 p.m. confirmed that there was no documented evidence that Residents 1 and 5, their representatives, and families were informed by 5:00 p.m. the next calendar day following the above occurrences of confirmed COVID-19 infections. An admission MDS assessment for Resident 17, dated August 9, 2022, revealed that the resident was understood, understands, was cognitively intact, and required extensive assistance from staff for her daily care tasks. There was no documented evidence in Resident 17's clinical record that the resident, their representatives, and families were informed by 5:00 p.m. the next calendar day following the above occurrences of confirmed COVID-19 infections. An admission MDS assessment for Resident 31, dated June 1, 2022, revealed that the resident was understood, understands, was cognitively intact, and required extensive assistance from staff for his daily care tasks. There was no documented evidence in Resident 31's clinical record that the resident, their representatives, and families were informed by 5:00 p.m. the next calendar day following the above occurrences of confirmed COVID-19 infections. Interview with the Infection Preventionist on August 30, 2022, at 1:34 p.m. confirmed that there was no documented evidence that Residents 17 and 31, their representatives, and families were informed by 5:00 p.m. the next calendar day following the above occurrences of confirmed COVID-19 infections. She indicated that because the employee only worked on the 100 unit and the resident that was positive was on the 100 unit. She only notified the residents, their representatives, and families on the 100 unit and did not notify the residents, their representatives, and families on the 200 unit. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that professional standards of practice were followed for the care of long-term intravenous catheters for one of 17 residents reviewed (Resident 15). Findings include: The facility's policy regarding intravenous catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated May 20, 2021, revealed that the catheter was to be flushed with 5 milliliters (ml) of normal saline (salt water solution) before and after the infusion (of medication). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 15's Medication Administration Records (MAR's) for September 2021 revealed that staff administered [MEDICATION(S)] six times and [MEDICATION(S)] six times. There was no documented evidence that Resident 15's IV catheter was flushed before and after medication administration. An interview with the Director of Nursing on September 10, 2021, at 1:49 p.m. confirmed that the nurse should flush the intravenous catheter before and after medication administration; however, there was no documented evidence that this occurred for Resident 15. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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 ensure that comprehensive Minimum Data Set assessments were completed in the required time frame for four of 17 residents reviewed (Residents 10, 23, 24, 25). 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 2019, 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 admitted plus 13 calendar days. A comprehensive admission MDS assessment for Resident 10 revealed that she was admitted on [DATE], and the MDS was signed as completed on July 30, 2021, which was 14 days after admission. A comprehensive admission MDS assessment for Resident 23 revealed that she was admitted on [DATE], and the MDS was signed as completed on June 23, 2021, which was 20 days after admission. A comprehensive admission MDS assessment for Resident 24 revealed that he was admitted on [DATE], and the MDS was signed as completed on July 11, 2021, which was 17 days after admission. A comprehensive admission MDS assessment for Resident 25 revealed that he was admitted on [DATE], and the MDS was signed as completed on August 20, 2021, which was 18 days after admission. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on September 10, 2021, at 1:03 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frame. 28 Pa. Code 211.5(f) Clinical records.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise residents' care plans with individualized interventions to address current care needs for three of 17 residents reviewed (Residents 5, 15, 22). Findings The facility's policy regarding care plans, dated May 20, 2021, indicated that care plans would be ongoing and revised as information about the resident and the resident's condition changed. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's care plan, dated July 26, 2021, included that that the resident needed IV medications through a midline catheter (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications) for a hip infection. A nursing note, dated August 24, 2021, at 7:53 a.m. revealed that Resident 5's midline catheter was removed from the left upper arm. A nursing note, dated August 26, 2021, at 5:50 p.m. revealed that a peripheral IV (small hollow tube that is inserted into a vein) was inserted into the resident's right forearm. There was no documented evidence that Resident 5's care plan was updated to include the use of a peripheral IV. Interview with the Director of Nursing on September 10, 2021, at 1:51 p.m. confirmed that there was no documented evidence that Resident 5's care plan was updated when the midline catheter was removed and a peripheral IV catheter was initiated. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated August 27, 2021, indicated that the resident's antibiotic therapy was complete and the PICC line was removed. A nursing note dated September 5, 2021, indicated that the resident received a peripheral intravenous catheter for fluids and that she had an IV inserted into her left arm. The resident's care plan, initiated August 18, 2021, indicated that she had a PICC line. There was no documented evidence that Resident 15's care plan was reviewed and updated to reflect that she no longer had a PICC line and that she currently had an IV catheter in her forearm. An interview with the Director of Nursing on September 10, 2021, at 10:58 a.m. confirmed that Resident 15's care plan was not updated to reflect her current IV status and it should have been. Resident 22's care plan, dated August 13, 2021, revealed that the resident was at risk for skin breakdown and was to use a pressure-redistribution mattress. Observations on September 22, 2021, at 11:08 a.m. revealed that Resident 22 was in bed, and the bed was equipped with an air mattress. There was no documented evidence that Resident 22's care plan was revised to include the use of the air mattress versus a pressure-redistribution mattress. Interview with the Director of Nursing on September 10, 2021, at 3:15 p.m. confirmed that Resident 22's care plan should have been revised to include the use of the air mattress, and the intervention to use a pressure-redistribution mattress should have been removed. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that care was provided to residents in accordance with professional standards of practice, by failing to monitor if a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated August 10, 2021, indicated that the resident was cognitively intact, required extensive assistance from staff for daily care activities, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's intake and output records for August and September 2021 revealed that staff were not accounting for the resident's fluid intake daily, and her exact fluid intake amount was not known. Observations of and an interview with Resident 8 on September 9, 2021, at 11:22 a.m. revealed that the resident had two large cups full of water and one large cup full of lemonade, and that she was actively drinking during the interview. She stated that she was aware that she was supposed to watch her fluid intake, but that she was not sure exactly how much she could have on a daily basis. She stated that she believed she could drink all of the fluids that she was given because the staff would not give her fluids if she was not permitted to have them. An interview with the Director of Nursing on September 10, 2021, at 1:10 p.m. confirmed that the facility staff were not keeping track of Resident 8's fluid intake, and that they should be monitoring so they could determine if the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.12(d)(5) Nursing services.