Every finding on record at Misericordia Nursing & Rehabilitation Center

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the comprehensive resident assessments were completed in the required timeframe for two of 15 resident records reviewed (Residents 16 and 20). Findings Include:Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, revised October 2024, revealed Discharge Assessment-return not anticipated are to be completed no later than the discharge date + 14 calendar days. Further review revealed admission (comprehensive) assessment should be completed no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days).Review of Resident 16's census information, provided by the facility, revealed that Resident 16 was discharged from the facility on May 8, 2025.Review of Resident 16's Minimum Data Set (MDS- an assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) information on September 15, 2025, at 1:30 PM, revealed that a discharge MDS had not yet been completed.During an interview with the Nursing Home Administrator (NHA) on September 16, 2025, at 9:45 AM, it was revealed that Resident 16's discharge MDS was not completed in the required 14-day window because of a dating error in their system, and now that the problem was identified it would be corrected.Review of Resident 20's census information, provided by the facility, revealed that Resident 20 was admitted to the facility on [DATE].Review of Resident 20's MDS information on September 17, 2025, at 1:00 PM, revealed that a comprehensive admission assessment had not yet been completed for Resident 20. Interview with the NHA on September 18, 2025, at 9:30 AM, revealed that Resident 20's comprehensive admission assessment should have been completed within 14 days of the Resident's admission28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interviews, the facility failed to review and revise the resident plan of care for two of 14 residents reviewed (Residents 1 and 24). Findings include: Review of Resident 1's clinical record revealed diagnoses that included anxiety (an emotion characterized by fear, tension, and worry about real or perceived threats) and dementia (mental decline severe enough to interfere with daily life, caused by various brain diseases and injuries).Review of Resident 1's plan of care revealed a care plan under the problem category: Psychotropic Drug Use, Resident receives PRN (as needed) antianxiety medication related to anxiety and hospice care.Review of current physician orders for Resident 1 failed to reveal any current orders for any antianxiety medications.An interview with the Director of Nursing (DON) on September 18, 2025, at 12:15 PM, revealed that Resident 1 had previously used antianxiety medication and it was discontinued in June 2025.Review of resident 24's clinical record documented she was admitted to the facility on [DATE]. Diagnoses included: dementia with behavioral disturbances, Alzheimer's disease (a progressive neurodegenerative disorder that primarily destroys memory and other important mental functions), and depression (feelings of severe despondency and dejection). Review of Resident 24's physician orders included: Lexapro (medication used to treat depression and anxiety) 20 mg in AM, started March 12, 2025; mirtazapine (medication use to treat depression) 7.5 mg at nighttime, started August 14, 2025; and olanzapine (antipsychotic medication used bipolar disorder) 5 mg once daily for dementia with behavioral disturbances, started April 14, 20205. Review of Resident 24's care plan prior to September 17th, 2025, failed to document the use of an antidepressant or antipsychotic medication. Review of Resident 24's quarterly Minimum Data Set (MDS - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated June 12, 2025, documented use of routine antipsychotic and antidepressant medications. During an interview with the DON on September 18, 2025, at 11:00 AM, it was revealed that Resident 24 should have a care plan for the antidepressant and antipsychotic medications. 28 Pa. Code 211.12(d)(5) Nursing services

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure residents receive appropriate urinary catheter care and services to prevent urinary tract infections for one of two residents reviewed for catheter care (Resident 29). Findings include: Review of facility policy, titled Catheter Care- Daily, last reviewed October 12, 2023, read, in part, Objective: To prevent infection of residents with foley catheters. Ensure foley catheter is secured to leg with leg strap or tape. Assist resident to position of comfort and cover. Review of Resident 29's clinical record revealed diagnoses that included chronic kidney disease, stage 4 (a condition characterized by a gradual loss of kidney function), obstructive and reflux uropathy (occurs when urine can't flow normally through your urinary tract due to a blockage), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 29's physician orders revealed an order for Suprapubic Catheter 18Fr to bedside drainage system with dignity cover, with a start date of March 4, 2024. Observation of Resident 29 on August 5, 2024, at 12:22 PM, revealed he was eating lunch in the dining room. His catheter bag was on the right side of his chair and was visible without a dignity cover. Observation of Resident 29 on August 6, 2024, at 9:40 AM, revealed he was in a common area watching television. His catheter bag was underneath his chair, touching the floor, and was visible without a dignity cover. Observation of Resident 29 on August 6, 2024, at 12:35 PM, revealed he was eating lunch in the dining room. His catheter bag was underneath his chair, touching the floor, and was visible without a dignity cover. Interview with the Director of Nursing on August 7, 2024, at 9:53 AM, revealed she would expect Resident 29's catheter bag to have a dignity cover and not to touch the floor. 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services

Based on review of facility policy, observations, staff interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for five of 16 resident records reviewed (Residents 13, 24, 33, 102, and 202). Findings Include: Review of facility policy, titled Care Plans, Comprehensive Person-Center, not dated, read, in part, comprehensive person-centered care plans describe services to be furnished to attain or maintain resident highest practicable physical, mental, and psychosocial wellbeing. Review of Resident 13's clinical record on October 10, 2023, at approximately 10:55 AM, revealed diagnoses that included retention of urine (a condition in which you are unable to empty all the urine from your bladder) and bulbous urethral stricture (narrowing of the urethra tube that transports urine out of the body, impeding the body's ability to pass urine). Observation of Resident 13 on October 10, 2023, at 10:34 AM, revealed the Resident lying in bed with a catheter inserted and hanging on his bed frame. Review of Resident 13's physician orders revealed an order for a foley catheter, written on September 12, 2023. Review of Resident 13's comprehensive plan of care revealed Resident 13 did not have a care plan developed or implemented that addressed the foley catheter. During an interview with the Nursing Home Administrator (NHA) on October 12, 2023, at approximately 10:50 AM, it was revealed that it was the facility's expectation that Resident 13's comprehensive plan of care would include the foley catheter. Review of Resident 24's clinical record revealed diagnoses that included congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement). Review of Resident 24's October 2023 physician orders included oxygen at 2 Liters/Minute (rate of oxygen flow) on in HS (hour of sleep - at bedtime) and remove in AM, with a start date May 23, 2023. Review of Resident 24's interdisciplinary plan of care revealed none developed to address the Resident's use of oxygen. During an interview with the NHA on October 11, 2023, at 11:20 AM, it was revealed that the oxygen wasn't documented on the care plan and it should've been on the care plan. Review of Resident 33's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and atrial fibrillation (a common type of irregular heart rhythm). Review of Resident 33's physician orders revealed an order for the medication Eliquis (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke in people with nonvascular atrial fibrillation) 5 mg (milligrams) twice a day. Review of Resident 33's interdisciplinary plan of care revealed none developed to address the Resident's use of the anticoagulant medication. Review of Resident 102's clinical record revealed diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and difficulty in walking. Review of Resident 102's physcian orders revealed an order for the continous use of oxygen on day, evening and night shifts. Review of Resident 102's interdisciplinary plan of care revealed none developed to address the use of oxygen. An interview with the NHA on October 11, 2023, at 11:20 AM, confirmed the anticoagulant medication care plan for Resident 33 and the oxygen care plan for Resident 102 were not developed and would be added to their care plans. Review of Resident 202's clinical record revealed diagnoses that included acute respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]). Observation of Resident 202 on October 10, 2023, at 10:34 AM, revealed the Resident sitting in their wheelchair in their room. There was an oxygen concentrator sitting beside Resident 202's bed. Immediate interview with Resident 202 revealed that they use supplemental oxygen at night, while in bed. Review of Resident 202's current physician's orders on October 10, 2023, revealed current physician's orders for continuous supplemental oxygen at 2 liters per minute to be applied at bedtime and removed in the morning, and an order for Eliquis (anticoagulant medication) 5 mg two times daily. Review of Resident 202's care plan on October 10, 2023, failed to reveal any care planning for the Resident's use of a supplemental oxygen or anticoagulant medication. During a staff interview with the NHA on October 11, 2023, at 11:20 AM, revealed that Resident 202 did not have a care plan for her supplemental oxygen use or anticoagulant use, but that they would be added. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen and for one of one kitchenette. Findings include: Review of facility policy, titled Food Storage, revised August 2019, read, in part, ready-to-eat foods must be labeled with a use by date. Thickened liquids, once opened, user must add use by information; product to be used within five days after opening. Observation in the dry storeroom on October 10, 2023, at 9:35 AM, revealed one bag of spaghetti was open with contents partially removed and was not date marked with an open date. During an interview on October 10, 2023, at 9:35 AM, with Employee 1 (Director of Food Service), it was revealed that the spaghetti should've been date marked when it was opened. Observation in the main kitchen on October 10, 2023, at 9:45 AM, revealed a white scoop was inside a bag of bulk sugar that was inside a bulk bin. During an interview with Employee 1 on October 10, 2023, at 9:45 AM, it was revealed that the scoop shouldn't be stored in the bag of sugar. Observation on October 10, 2023, at 9:56 AM, in the cupboard in the main kitchen revealed three packages of chicken gravy mix were open with contents partially removed and not date marked. During an interview with Employee 1 on October 10, 2023, at 9:56 AM, it was revealed that the gravy mix should be dated once opened. Observation in the [NAME] Field kitchenette on October 10, 2023, at 10:06 AM, in the refrigerator, revealed: one 46 ounce container of mildly thickened orange juice and on 46 ounce container of mildly thickened cranberry juice that were opened with contents partially removed and not date marked with an opened date. During an interview with Employee 1 on October 10, 2023, at 10:06 AM, it was revealed that the aforementioned thickened juices should be date marked when opened. Observation in the [NAME] Field kitchenette on October 10, 2023, at 10:07 AM, in the freezer, revealed there was one sleeve of frozen waffles and one sleeve of frozen French toast that was not date marked. During an interview with Employee 1 on October 10, 2023, at 10:76 AM, it was revealed that the sleeve of waffles and French toast should be date marked with the received date when removed from the original case. During an interview with the Nursing Home Administrator on October 12, 2023, at 10:38 AM, it was revealed that the aforementioned items should be date marked per the Food Storage policy. 28 Pa code 211.6(f) - Dietary Services

Based on observations, facility policy review, clinical record review and staff interview, it was determined that the facility failed to ensure the resident environment remains free of accident hazards for one of seventeen resident records reviewed (Resident 5) and failed to maintain an environment that was free of accident hazards during medication administration on one of two nursing units (Fayfield Place). Findings Include: Review of Resident 5's October 2021 physician orders revealed diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling. An observation of Resident 5's bed, on October 12, 2021, at 9:39 revealed bilateral enabler bars attached to the bed. Review of the facility's form titled Evaluation for Use of Enabler Bar/Assist Rail in Bed, dated August 3, 2021, revealed a recommendation reading Enabler bar/assist rail not indicated at this time. An interview with the Director of Nursing, on October 13, 2021, at 1:08 PM revealed Resident 5's enabler bars should have been removed from the bed based on the evaluation dated August 3, 2021. The interview also revealed the enabler bars were currently no longer attached to the bed. Review of facility policy titled Administering Medications with a review date of October 2020, revealed During administration of medications, the medication cart will be kept closed and locked, with all medications & information secured, when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on October 13, 2021, at 9:00 AM revealed an unattended, unlocked medication cart located in the hallway of Fayfield Place. A few minutes later, Licensed Practical Nurse (LPN) 1 was observed walking down the hall and then approached the medication cart to continue with medication administration. On October 13, 2021, at approximately 9:15 AM, LPN 1 was observed preparing and then administering medications to Resident 23. LPN 1 did not lock the medication cart prior to entering Resident 23's room. The medication cart was left unattended and out of LPN 1's sight during Resident 23's medication administration. On October 13, 2021, at approximately 9:43 AM, LPN 1 was observed preparing medications for Resident 6. LPN 1 walked down the hallway to the TV room on Fayfield Place where Resident 6 was located. LPN 1 left the medication cart unlocked, unattended, and out of her sight. A few minutes later, when LPN 1 and surveyor went back to the medication cart to continue with medication administration, the medication cart was observed to be locked. LPN 1 noted that the cart was locked and stated that someone must have walked passed the cart and locked it. LPN 1 stated she was bad at remembering to lock the cart. On October 14, 2021, at 11:45 AM the Nursing Home Administrator stated that the facility policy should be followed and medication carts should be locked when unattended. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation, review of facility policy, and resident and staff interviews it was determined that the facility failed to provide food and beverage that are palatable, and at a safe and appetizing temperature for one of one meal observed on the Fayfield unit. Findings include: During the initial pool process on October 12, 2021, several residents who ate meals in their room had concerns with food not being served at a palatable temperature. Review of facility policy Food Preparation and Service, version 2.1 without a date, documented that proper hot and cold temperatures are maintained during food service. Temperatures of foods held in steam table are monitored throughout the meal by food and nutrition service staff. A test tray was completed on October 13, 2021, on the Fayfield unit. Test tray temperatures were taken by Cook 1 and Dietary Aide 1 on October 13, 2021, at approximately 12:08 PM behind the nursing station, and revealed the following: Beef Brisket was 113 degrees Fahrenheit, tender and very tasty, not palatable temperature Lima Beans were 109 degrees Fahrenheit, not palatable for texture or temperature Baked Potato was 109 degrees Fahrenheit, palatable Rice Pudding was 54 degrees Fahrenheit, palatable Ice Tea was 51 degrees Fahrenheit, palatable Orange Juice was 48 degrees Fahrenheit, palatable Coffee was 111 degrees Fahrenheit, not palatable for temperature. During an interview with the Food Service Director1 (FSD 1) on October 13, 2021, at approximately 1:00 PM it was revealed that he would have expected the beef, lima beans, and coffee would've been served at a higher temperature. 28 Pa code 211.6(b)(d) - Dietary Services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide resident choice for one of 14 residents reviewed (Resident 29). Findings Include: Review of Resident 29's clinical record revealed [DIAGNOSES REDACTED]. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet). Review of Resident 29's current physician orders [REDACTED]. Surveyor observation on (MONTH) 22, 2019, at 12:15 p.m. revealed Resident 29's family member, who is not the Power of Attorney (POA), feeding Resident 29 yogurt and a banana. At that time, a staff member asked Resident 29's family member if Resident 29 wanted her lunch and the family member stated no. A staff member proceeded to bring Resident 29's plate of lunch to her and Resident 29's family member became upset because she didn't want Resident 29 to have anything to eat. The Food Service Director (FSD) attempted to explain to Resident 29's family member that the facility needed to serve Resident 29 what was on her meal ticket but the family member was angry and stated she wanted the ticket changed. Surveyor observation revealed that nobody acknowledged Resident 29 or asked her if she wanted her lunch. Review of Resident 29's meal ticket, dated (MONTH) 22, 2019, revealed that Resident 29 was to have fruit juice, pureed oriental mixed vegetables, tea, milk, and custard and that she is to get yogurt and applesauce with all meals. During an interview with the Nursing Home Administrator (NHA) on (MONTH) 23, 2019, at 9:40 a.m. she stated that Resident 29's family member is only at the facility for lunch. The NHA stated that the family member calls the puree food slop and doesn't want Resident 29 to have meat, so she will give her yogurt for protein. The NHA stated that Resident 29 will eat the meals she is served when the family member is not present. Surveyor observation on (MONTH) 23, 2019, at 12:11 p.m. revealed Resident 29's family member feeding her peaches and yogurt. At 12:27 p.m., Resident 29's family member was offered orange sherbet for Resident 29 but the family member declined. The staff member did not offer it directly to Resident 29 or ask Resident 29 if she wanted any sherbet. Surveyor observation in the dining room at that time failed to reveal that the staff offered Resident 29 her meal. Review of Resident 29's meal ticket for lunch on (MONTH) 23, 2019, revealed that Resident 29 was to get pureed lasagna with meat sauce, pureed seasoned green peas and pureed bread. Review of Resident 29's progress note dated (MONTH) 16, (YEAR), revealed that Resident 29 was having lunch in the dining room, being assisted by a nurse aide (NA). Resident 29's family member arrived in the dining room and threw Resident 29's plate across the table and said You're not eating this s***! The family member then proceeded to get a banana and applesauce to assist Resident 29 with eating. Review of Resident 29's progress note dated (MONTH) 19, (YEAR), at 11:56 a.m. revealed that Resident 29's family member was very upset because she missed the care plan meeting for Resident 29. Staff explained to the family member that she was not the medical POA. The family member stated she wants her wishes followed and she does not want (Resident 29) to have meat as 'she came here to die'. Explained that Resident (29) has the right to choose for herself and she is able to verbalize her response. Staff discussed with the family member the need for Resident 29 to have protein for wound healing and the family member stated She doesn't need protein. She came here to die. Review of Resident 29's progress note, dated (MONTH) 28, (YEAR), revealed Resident 29's family member was yelling at kitchen staff at start of lunch because resident was served pureed food per her diet order. Family member yelled 'She don't eat this slop, she eats what I say'. During staff interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on (MONTH) 23, 2019, at 2:50 p.m. they stated that there have been multiple conversations with Resident 29's family member regarding the food. The DON stated that a while back they had a winter picnic with hot dogs and baked beans. The DON asked Resident 29 if she wanted that and she said yes. The DON stated that if the family member was present at that time, Resident 29 would not have been given the hot dog and baked beans. He stated that Resident 29 is able to say what she wants and say yes and no but the family member dictates what Resident 29 gets to eat. At that time, the NHA stated that the facility makes sure Resident 29 gets protein, such as yogurt and that Resident 29 eats breakfast and supper, when the family member is not present. 28 Pa. Code 201.29(j) Resident Rights

Based on observation, clinical record review, as well staff and resident interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for six of 17 residents reviewed (Residents 8, 9, 21, 23, 25, and 39). Findings include: Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Surveyor observation on (MONTH) 22, 2019, at 10:09 a.m. revealed that Resident 8 had a catheter. Review of Resident 8's current physician orders [REDACTED]. Review of Resident 8's current care plan revealed that Resident 8 is incontinent of bowel and bladder. Further review of Resident 8's care plan failed to reveal that Resident 8 has a Foley catheter. On (MONTH) 24, 2019, at approximately 1:00 p.m. the facility provided the surveyor with an updated care plan for Resident 8's catheter, with a start date of (MONTH) 24, 2019. Review of Resident 9's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 9's (MONTH) 2019, Physician orders [REDACTED]. Review of Resident 9's care plan on (MONTH) 24, 2019, at approximately 9:00 a.m. revealed Resident requires an indwelling urinary catheter related to [MEDICAL CONDITION], with a start date of (MONTH) 15, (YEAR). Interview with the Nursing Home Administrator on (MONTH) 24, 2019, at approximately 10:57 a.m. revealed that Resident 9 was admitted with a catheter and it was discontinued on (MONTH) 23, (YEAR), it was also revealed that the care plan should have been updated when the indwelling catheter was discontinued. Review of Resident 21's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 21's clinical record on (MONTH) 22, 2019, at 2:45 p.m. revealed a care plan for Potential for skin breakdown R/T: incontinence, limited mobility, L side weakness, R shoulder pain, [DIAGNOSES REDACTED], this care plan had a problem start date of (MONTH) 28, (YEAR), a long-term goal target date of (MONTH) 28, (YEAR), and a last reviewed/revised date of (MONTH) 28, (YEAR). Further review of Resident 21's clinical record revealed quarterly assessments were completed on (MONTH) 12, (YEAR), and (MONTH) 5, (YEAR), and the care plan was not reviewed or revised after either one. Review of Resident 23's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 23's clinical record on (MONTH) 22, 2019, at 2:55 p.m. revealed a care plan for resident requires an indwelling urinary catheter R/T [MEDICAL CONDITION], Dx [MEDICAL CONDITION], this care plan had a problem start date of (MONTH) 28, (YEAR), a long-term goal target date of (MONTH) 28, (YEAR), and a last reviewed/revised date of (MONTH) 28, (YEAR). Further review of Resident 23's clinical record on (MONTH) 22, 2019 at 2:55 p.m. revealed a care plan for potential for alteration in comfort/pain due to: stage 4 sacral ulcer, [MEDICAL CONDITION], this care plan had a problem start date of (MONTH) 28, (YEAR), a long-term goal target date of (MONTH) 28, (YEAR), and a last reviewed/revised date of (MONTH) 28, (YEAR). Further review of Resident 23's clinical record revealed quarterly assessment completed on (MONTH) 12, (YEAR) and annual assessment completed on (MONTH) 5, (YEAR), and the care plan was not reviewed or revised after either one. Interview with Nursing Home Administrator on (MONTH) 24, 2019, at 11:15 a.m. revealed that she would have expected the care plans to be reviewed and revised, at minimum, after each assessment. Review of Resident 25's (MONTH) 2019, physician orders [REDACTED]. An observation on (MONTH) 22, 2019, at 10:11 AM in Resident 25's room, revealed bilateral enabler devices attached to her bed. Review of the facility's document titled Facility Order, dated (MONTH) 20, (YEAR), reads Two UPPER Siderails, Assist Rails, Grab Bars or Enablers, assigned to Resident 25. Review of Resident 25's interdisciplinary plan of care, addressing her potential for falls, revealed none developed to address the bilateral bars attached to her bed. An interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) 1, on (MONTH) 23, 2019, at 1:32 PM confirmed she could not locate Resident 25's enablers on the interdisciplinary plan of care. Review of Resident 39's clinical record revealed [DIAGNOSES REDACTED]. Surveyor observation on (MONTH) 22, 2019, at 12:29 p.m. revealed Resident 39 with a catheter. Review of Resident 39's current physician orders [REDACTED].>Review of Resident 39's current care plan revealed that Resident experiences bladder incontinence. Further review of the care plan failed to reveal any mention of the Foley catheter. As of (MONTH) 24, 2019, at 1:00 p.m. no additional information was provided by the facility. 42 CFR 483.21(b) Comprehensive Care Plans Previously cited 3/2/17, 1/10/17, 4/12/16 28 Pa. Code 211.11(d)(e) Resident care plan Previously cited 3/2/17, 1/10/17, 2/11/16 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/2/17, 1/10/17, 2/11/16, 3/26/15

Based on record review, and interview, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of Resident 9's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 9's physician orders [REDACTED]. medication used to treat constipation) 17 grams(a unit of measure) if no Bowel Movement after 6 shifts, mix in 4 - 8 ounces (a unit of measure) of fluid for constipation as needed, start date (MONTH) 27, (YEAR); [MEDICATION NAME] suppository (a medication used to treat constipation), 10mg (a unit of measure) rectal if no bowel movement after 7 shifts, perform rectal check and give suppository, gastrointestinal assessment must be documented in progress notes every 72 hours as needed, start date (MONTH) 27, (YEAR); and Fleet Enema (a medication used to treat constipation) 19-7 grams/18 milliliters (a unit of measure) rectal if no results after 8 shifts and having been given [MEDICATION NAME] Suppository with no results, then give Fleets enema, gastrointestinal assessment must be documented in progress notes, if no results after fleets enema at end of 8th shift call doctor for further orders, start date (MONTH) 27, (YEAR). Review of Resident 9's point of care history of control with bowel function revealed Resident 9 didn't have a bowel movement on the following days and number of shifts, and the as needed [MEDICATION NAME] was not given per physician order: January 3, 2019 at 9:18 p.m. through (MONTH) 7, 2019 at 6:38 a.m. (12 shifts); January 18, 2019, 2:19 a.m. through (MONTH) 21, 2019, at 4:02 a.m.(8 shifts); November 16, (YEAR) at 7:59 p.m. through (MONTH) 19, (YEAR) at 2:06 a.m. (8 shifts); November 28, (YEAR) at 9:52 p.m. through (MONTH) 1, (YEAR) at 1:46 a.m.(10 Shifts) and; October 20, (YEAR) at 9:27 p.m. through (MONTH) 24, (YEAR) at 1:55 a.m. (11 shifts). Review of Resident 9's Medication Administration History (record of medications that were administered) for (MONTH) 2019 revealed that: [MEDICATION NAME] ordered to be given every other day was given day shift on (MONTH) 18th, 20th, 22 nd, and 24th; [MEDICATION NAME] ordered to be given as need for no bowel movement in 6 shifts was given day shift on (MONTH) 7th, 11th, 14th, 16th; and as needed suppository was given day shift (MONTH) 24th. Review of Resident 9's Medication Administration History (record of medications that were administered) for (MONTH) (YEAR) revealed that: [MEDICATION NAME] ordered to be given as need for no bowel movement in 6 shifts was given day shift on (MONTH) 4th, 12th, 18th, 21st, and 24th. Review of Resident 9's Medication Administration History (record of medications that were administered) for (MONTH) (YEAR) revealed that: [MEDICATION NAME] ordered to be given as need for no bowel movement in 6 shifts was given day shift on (MONTH) 1st, 5th, 7th, 11th, 14th, 16th, 19th, and 26th; as needed [MEDICATION NAME] suppository was given (MONTH) 12th; and as needed Fleets enema was given (MONTH) 2nd. Review of Resident 9's Medication Administration History (record of medications that were administered) for (MONTH) (YEAR) revealed that: [MEDICATION NAME] ordered to be given as need for no bowel movement in 6 shifts was given day shift on (MONTH) 3rd, 11th, 18th, 24th, and 25th, and evening shift on the 19th; [MEDICATION NAME] suppository given 24th on evening shift, and Fleet enema given on night shift/morning of the 25th. During an interview with the Nursing Home Administrator on (MONTH) 24, 2019, at approximately 2:15 p.m. revealed that the bowel protocol should have been followed unless resident refused. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews it was determined that the facility failed to store food in accordance with professional standards for food service safety in the main facility kitchen and in the downstairs dry storage room. Findings include: During entrance tour of the facility main kitchen on (MONTH) 22, 2019, at 9:12 a.m., while accompanied with Dietary Manager (DTM) 1, there was observed in the walk-in freezer a plastic zip bag with a small amount of chicken breast and also turkey breast approximately one pound wrapped in foil with neither item displaying a label for identification of product or dates placed in freezer and/or to use by. Also observed was a package of ham loaf labeled with a use by date of (MONTH) 28, (YEAR); a plastic bag with bulk hamburger and one with bulk ground turkey of approximately three to four pounds each without label for product identification and/or placement in freezer or use by dates and a plastic zip bag of bratwurst approximately two pounds without labeling to identify date placed in freezer and/or use by date. In the walk-in refrigerator was observed a beef loin approximately seven pounds and bag of bacon approximately three pounds without labeling to identify date placed in refrigerator and/or use by date. In dry cupboard in kitchen was observed a case box bottom from syrup product which contained one packet of Ken's dressing (individual use) and individual 13 serving containers of syrup and four individual containers of jelly. DTM 1 identified that the syrup in the box was not original to the box. Review of the products revealed no use by dates on them. Also revealed in this pantry was a closed plastic container storing rice. It was noted that a piece of the original packaging bag for the rice was being used as the label for writing the open date of the rice package. Also observed in this cupboard was small packet of pudding mix and a plastic bag containing an opened bag of Tri-colored spirelli in it with no received and/or use by dates. During an observation during this tour also revealed in the reach-in meat/vegetable freezer a plastic bag of meatballs with no received/opened dates and/or use by dates. Observation in the reach-in refrigerator revealed four, approximately one pound packages, and one log, five pounds, of American cheese without received and/or use by dates. During same entrance tour it was observed in downstairs dry storage area at 10:18 a.m. the facility ice cream chest freezer . It was observed that the freezer presented with no built-in temperature device on the outside surface nor was there present any type temperature device on the inside. It was also observed that there was significant ice build-up in the bottom of the freezer and significant frosting on the inner sides. In addition it was observed that there was icing on the inside lid and that the insulating material on the inside lid was exposed. Also observed in the dry storage area was a five pound bag of breadcrumbs with a use by date of (MONTH) 3, (YEAR), and a five pound bag of ziti in a plastic zip bag and an out of case box sleeve of oatmeal cookies with no received and/or use by dates. During interview with DTM 1 while progressing through entrance tour, DTM 1 confirmed that the unidentified and/or undated food products should have had labeling to identify product and/or receive and/or use dates. Review of facility Food Receiving and Storage Policy with revision date of (MONTH) 2008, revealed All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date)). Review of this policy revealed no guidelines for dating/labeling of dry food storage products. During an interview with the Nursing Home Administrator (NHA) on (MONTH) 22, 2019, at approximately 3:00 p.m. the NHA revealed the expectation that food items should be properly stored. During an interview with the NHA on (MONTH) 23, 2019, at approximately 3:00 p.m. the NHA revealed that the facility will be acquiring information to replace the dry storage chest freezer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. code 201.18(b)(3) Management

Based on surveyor observation and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for two of four residents observed in the dining room (Residents 8 and 20). Findings Include: Surveyor observation on (MONTH) 22, 2019, at 12:20 p.m. revealed Residents 8, 20, 37 and 42, all sitting at a table in the dining room. Resident 37 and Resident 42 were being assisted with eating their lunch meal by a staff member. Resident 8 and Resident 20 were sitting at the table, still waiting to be served lunch. At 12:25 p.m., Resident 20 was served her lunch and she required no assistance with eating. At 12:26 p.m., Resident 8 was served and received assistance with eating. During an interview with the Nursing Home Administrator on (MONTH) 24, 2019, at 11:30 a.m. she stated that the dining room gets busy at lunchtime and it is hard to serve everyone at once. 28 Pa. Code 201.29(j) Resident Rights

Based on clinical record review and staff interview, it was determined that the facility failed to develop a baseline care plan for each resident within 48 hours of resident's admission for two of 16 residents reviewed (Resident 29 and 36). Findings include: Review of Resident 29's clinical record revealed [DIAGNOSES REDACTED]. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet). Further review of Resident 29's clinical record revealed that she was admitted to the facility on (MONTH) 27, (YEAR). Review of Resident 29's baseline care plan revealed a date of (MONTH) 4, (YEAR). As of (MONTH) 24, 2019, at 1:00 p.m. the facility was unable to provide surveyor with a baseline care plan for Resident 29 completed within 48 hours of Resident 29's admission to the facility. Review of the clinical record for Resident 36 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident 36 was admitted to the facility on (MONTH) 20, (YEAR), with a pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). Review of the current care plan revealed that on (MONTH) 2, 2019, a care plan was developed that addressed the pressure ulcer. During an interview with the Director of Nursing on (MONTH) 23, 2019, at 3:05 p.m. he confirmed that the care plan was developed on (MONTH) 2, 2109. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on surveyor observations, clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for two of 14 residents reviewed (Residents 8 and 39). Findings Include: Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 8's current care plan revealed an approach for Resident 8 to have a multipodus boot (helps in the healing and prevention of heel and toe ulcers and safeguards against foot drop) to the right foot when out of bed. Review of Resident 8's NursingAssistant Care Plan/ Cardex revealed blue boots on feet with gray foam position aid. Surveyor observation on (MONTH) 22, 2019, at 10:07 a.m. revealed Resident 8 in the activity room in her chair with a blue boot to the left foot and gray foam under the left foot. Resident 8 did not have any boot on her right foot. Surveyor observation on (MONTH) 23, 2019, at 12:01 p.m. revealed Resident 8 had a blue boot to her left foot with gray foam underneath but nothing was on or under her right foot. During an interview with the Director of Nursing on (MONTH) 24, 2019, at 11:37 a.m. he stated that the care plan and orders did not match for the boots. He stated it has been updated. No additional information was provided to the surveyor in regards to the correct use of the boots. Review of Resident 39's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 39's current care plan revealed that Resident 39 (MONTH) not have knife at meals. Fork and spoon only. Review of Resident 39's meal tickets, dated (MONTH) 22 and (MONTH) 23, 2019, revealed (MONTH) not have a knife. Fork and spoon only. Surveyor observation on (MONTH) 22, 2019, at 12:14 p.m. revealed Resident 39 sitting in the dining room, eating lunch, and had a knife. Surveyor observation on (MONTH) 23, 2019, at 12:13 p.m. revealed Resident 39 had a knife with her lunch. Surveyor observed Nurse Aide (NA) 1 pick up Resident 39's knife, cut Resident 39's lasagna, and then place the knife back on Resident 39's plate and walk away. During an interview with the Nursing Home Administrator (NHA) on (MONTH) 23, 2019, at 2:37 p.m. she stated that if Resident 39 was care planned to not have a knife, she should not have had a knife. During an additional interview with the NHA on (MONTH) 24, 2019, at 9:11 a.m. she stated that Resident 39 was trying to cut her wanderguard off with a knife and that is why she was care planned to not have one. 28 Pa. Code 211.11 (d) Resident care plan

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards in regards to pressure ulcers for two of four residents reviewed (Residents 8 and 29). Findings Include: Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. During staff interview on (MONTH) 22, (YEAR), at approximately 1:00 p.m. the Director of Nursing and Licensed Practical Nurse (LPN) 1 stated that Resident 8 and Resident 29 did not currently have a pressure ulcer. LPN 1 stated that she was taught that once an area is called a skin tear, excoriation, etcetera, it cannot be reclassified to a pressure ulcer. It will stay named a skin tear, excoriation, etcetera, until it is healed. Review of Resident 8's facility form Skin Condition Report revealed weekly skin assessments done by LPN 1, for a skin tear (a wound caused by shear, friction, and/or [MEDICATION NAME] force resulting in separation of skin layers) to the right buttock. Review of Resident 8's Registered Nurse (RN) progress note dated (MONTH) 22, 2019, at 3:04 p.m. revealed that Resident 8 had a skin tear injury back in (MONTH) of (YEAR) to her right buttock. Over time, it has deteriorated .Upon observation this morning, this wound should be reclassified as a Stage IV (full -thickness skin and tissue loss) area. While the initial injury was a skin tear, pressure to the area from the ischial tuberosity (the part of pelvis that supports a person while sitting) most likely contributed to the significant deterioration so it is more correctly classified as a pressure injury. Review of Resident 29's clinical record revealed [DIAGNOSES REDACTED]. It can be caused by factors such as: unknown medical problems, chronic disease, medication interactions, physical decline, poor appetite, or poor diet). Review of Resident 29's facility form Skin Condition Report revealed weekly skin assessments done by LPN 1 for excoriation (a place where your skin is scraped or abraded) to the left buttock. Review of Resident 29's RN progress note, dated (MONTH) 22, 2019, at 6:16 p.m. revealed Participated in wound rounds this morning. (Resident) has an area to her left buttock that originally presented as an excoriation on 6/27/18. Over time, pressure contributed to challenges of healing so that the area is more correctly staged as a pressure injury at this time. During an interview with the Director of Nursing on (MONTH) 23, 2019, at 1:20 p.m. he stated that LPN 1 did not reclassify wounds. He stated that if a wound presented as a skin tear or an excoriation, that is what it would be called until it healed. At that time, the Director of Nursing stated that Resident 8's skin tear and Resident 29's excoriation should have been reclassified as a pressure ulcer prior to (MONTH) 22, 2019. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of three closed records reviewed (Resident 26). Findings Include: Review of the Review of the clinical record for Resident 26 revealed [DIAGNOSES REDACTED]. Resident 26 was discharged to home on (MONTH) 3, 2019. Review of Resident 26's discharge summary, dated (MONTH) 3, 2019 revealed that Resident 26's pre-discharge medications were not included as part of the discharge summary. During an interview with the Nursing Home Administrator on (MONTH) 24, 2019, at 12:55 p.m. she acknowledged that the pre-discharge medications were not reconciled on the discharge summary. 28 Pa. Code 201.25 Discharge policy 28 Pa. Code 211.5(d)(f) Clinical records

Based on clinical record review and staff interview it was determined that the facility failed to inform the physician of significant weight loss for one of 14 residents reviewed (Resident 9). Findings include: Review of Resident 9's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 9's (MONTH) 2019, Physician orders [REDACTED]. 6 hours as needed for nausea with vomiting, start date of (MONTH) 14, (YEAR). Resident 9's weight variance report revealed the following weight history: January 13, 2019 = 142.7 lb (pounds - a unit of measure) (an 8 lb loss over the past month = 5% ) January 1, 2019 = 143.8 lb (a 7 lb loss over the past 30 days = 4.8% ) December 3, (YEAR) = 151 lb November 2, (YEAR) = 155 lb October 2, (YEAR) = 160.8 lb September 3, (YEAR) = 161 lb August 1,2018 = 161 lb July 6, (YEAR) = 157 lb Per Registered Dietitian's note dated (MONTH) 15, 2019, it was revealed that Resident 9 had a 5% significant weight loss from (MONTH) (YEAR) to (MONTH) 2019. It was also revealed that Resident 9 meal consumption is 25-50%, and that he is eating a small amount of food and consuming mainly liquids due to becoming nauseated and having emesis on (MONTH) 13th and 15th. Further review of Resident 9's progress notes revealed Resident 9 was nauseated and/or had emesis on the following days: (MONTH) 19th, 16th, 15th; (MONTH) 30th, 29th, 8th, 5th, 2nd; and (MONTH) 28th, 14th, 4th, and 1st. Review of Speech Therapy screen completed for Resident 9 on (MONTH) 14, (YEAR), due to recent emesis with meals, revealed that: resident stated he is tolerating chewing/swallowing without difficulty, has occasional emesis when nauseated, nursing staff educated on history of [MEDICAL CONDITION] dilatation (stretching/widening of the esophagus) and possible follow up, Resident 9 and his wife are against any alteration is diet as they don't feel it is a swallowing issue. During an interview with the Nursing Home Administrator on (MONTH) 24, 2019, at approximately 1:00 p.m. it was revealed that there is no documentation the Physician is aware that Resident 9 has had incurred a significant weight loss over the past 30 days. It was also revealed that on (MONTH) 14, 2019, Resident 9's wife completed an application for the use of a public transportation service which would enable Resident 9 to see an out of facility medical provider to assess the need for and/or complete an [MEDICAL CONDITION] dilatation. The application was faxed to the public transportation company on (MONTH) 15, 2019. An e-mail received from the Nursing Home Administrator on (MONTH) 24, 2019, at approximately 6: 25 p.m. revealed that Resident 9 has an appointment for an out of facility [MEDICATION NAME] consult on (MONTH) 25, 2019, at 11:30 a.m. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to discard expired biologicals for one of one medication rooms observed (Fayfield medication room). Findings Include: Review of facility policy titled, Insulin Injections, effective (MONTH) 1, (YEAR), with a revision date of (MONTH) 11, (YEAR), Section 6 revealed a chart indicating that [MEDICATION NAME] (a medication of diabetes) should be discarded 28 days after opening. Review of [MEDICATION NAME] (medication used to determine the presence of [MEDICATION NAME] bacteria) medication information sheet on FDA.gov revealed on page 5, Dosage and Administration section that Vials in use for more than 30 days should be discarded. Observation of the Fayfield medication room on (MONTH) 23, 2019, at 1:06 p.m. revealed one open vial of [MEDICATION NAME] with an open date of (MONTH) 20, (YEAR). Further observation of Fayfield medication room on (MONTH) 23, 2019, at 1:06 p.m. revealed one open vial of [MEDICATION NAME] with an open date of (MONTH) 30, (YEAR). Further observation of the Fayfield medication room on (MONTH) 23, 2019, at 1:06 p.m. revealed 98 3cc syringes with an expiration date of (MONTH) (YEAR). During a staff interview on (MONTH) 23, 2019, at 2:20 p.m. the Director of Nursing revealed that he would expect that the expired medications and supplies would have been disposed of properly or stored separately from other medications until disposed of per the facility policy. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1)(i) Pharmacy services. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the office of the state ombudsman of facility-initiated transfers for two of 17 residents reviewed (Residents 51 and 52). Findings include: Review of Resident 51's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 51's clinical record revealed a transfer to the hospital on (MONTH) 14, (YEAR), where she was admitted with acute [MEDICATION NAME] (inflammation of the gallbladder). Further review of Resident 51's clinical record revealed that no letter was provided to the resident/resident representative regarding the transfer with included the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, a statement of the resident's appeal rights, and contact and address information of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator on (MONTH) 24, 2019, at 12:30 p.m. revealed that she could not find any documented letter containing the above-mentioned contents was provided to the resident or resident representative. Review of Resident 52's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 52's clinical record revealed a transfer to the hospital on (MONTH) 4, (YEAR), where she was admitted with a [MEDICAL CONDITION] (the condition of low sodium levels in the blood). Further review of Resident 52's clinical record revealed that no letter was provided to the resident/resident representative regarding the transfer with included the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, a statement of the resident's appeal rights, and contact and address information of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator on (MONTH) 24, 2019, at 12:30 p.m. revealed that she could not find any documented letter containing the above-mentioned contents was provided to the resident or resident representative. 28 Pa. Code 201.29(h) Resident Rights 28 Pa. Code 201.14 (a) Responsibility of License

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure the comprehensive plan of care is reviewed and revised to meet the physical, mental, and psychosocial needs of one of 15 residents reviewed (Resident 14). Findings include: Review of Resident 14's clinical record on (MONTH) 20, (YEAR), at approximately 1:30 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 14's physician orders [REDACTED]. Review of the physician order [REDACTED]. Review of Resident 14's comprehensive plan of care revealed no care plan that addressed the use of an anti-anxiety medication. Review of facility policy titled, Care Plans, last revised (MONTH) (YEAR), revealed it stated, The Resident Care Plan shall be reviewed, evaluated and updated by professionals involved in the care of the resident at least every ninety days and when changes occur. During a staff interview on (MONTH) 22, (YEAR), at approximately 11:30 a.m. Director of Nursing revealed that there should have been a care plan to address Resident 14's use of an anti-anxiety medication. 28 Pa code 211.11(d) Resident care plan 28 Pa code 211.12(d)(1)(3)(5) Nursing services