Every finding on record at Moravian Hall Square Health and Wellness Center

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of two sampled residents who required adaptive equipment with meals. (Resident 42)Findings include: Clinical record review revealed that Resident 42 had diagnoses that included fracture of the third and fourth metacarpal bones (in the hand), chronic pain syndrome, and osteoarthritis. Review of the care plan revealed that the resident was at risk for nutrition problems with an intervention for adaptive equipment while eating. The intervention was for staff to provide built-up left angled utensils, a divided plate, and a cup with a lid and straw for all meals. A physician's order dated February 3, 2026, directed staff to provide built-up left angled utensils, a divided plate, and a cup with a lid and straw for all meals. On March 11, 2026, from 8:15 a.m. through 8:25 a.m., Resident 42 was observed in her room with her meal and without built-up left angled utensils or a divided plate. On March 11, 2026, from 12:10 p.m. through 12:35 p.m., Resident 42 was observed in the dining room with her meal and without built-up left angled utensils, a divided plate, or a cup with a lid and straw. In an interview on March 12, 2026, at 11:45 a.m., the Director of Physical Therapy confirmed that the resident should have received the built-up left angled utensils, divided plate, and a cup with lid and straw at all meals. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure resident safety and prevent an avoidable accident related to a fall for one of four sampled residents which resulted in actual harm of a laceration (a traumatic wound caused by sharp objects or blunt trauma) to the head and a skin tear (a wound caused by blunt force, friction, and/or shear). (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia (a group of symptoms affecting memory, thinking, language, and behavior) and anxiety (condition that involves excessive and persistent worrying that interferes with daily life). The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated April 3, 2025, indicated that the resident was cognitively impaired, with a BIMs score (brief interview for mental status tool that is used to get a quick snapshot of how well one is functioning cognitively) of four (zero to seven indicates severe cognitive impairment). The assessment indicated that the resident had physical (hitting, kicking, etc.) and verbal (screaming, cursing, etc.) behavioral symptoms directed towards others. The care plan identified that Resident 1 had a mood and behavior problem related to dementia as evidenced by verbally aggressive behaviors and interventions included for staff to attempt redirection in a calm manner when he was agitated and to ensure resident safety. In addtion, the care plan noted that Resident 1 was at risk for falls related to confusion. On May 27, 2025, a nurse noted that the resident's behaviors began to escalate. The resident started tapping on the medication cart, grabbed the narcotic book (a record-keeping system to track the use of controlled substances such as narcotics) and attempted to throw it. The nurse backed up, grabbed the Dinamap (a device on wheels, designed for precise and reliable measurements of vital signs, including blood pressure, pulse, temperature, and oxygen saturation) and placed it in front of the resident. The resident grabbed the Dinamap and started shaking it. The nurse let go; the cart moved and the resident lost his balance, fell backwards, and hit his head on the closed doors. The nurse noted that the resident appeared to lose consciousness for three to five seconds, and sustained a laceration to the head and a skin tear to the right hand, resulting in a transfer to the hospital. The resident received five staples to close the wound to the back of the head and three Steri-Strips (thin, sticky bandages applied to small cuts or wounds to help them stay closed as they heal) to the right hand. According to facility documentation of the investigation, the nurse used the Dinamap to place in front of the resident, introducing a safety risk to Resident 1 resulting in an avoidable accident related to a fall. In an interview on June 23, 2025, at 1:00 p.m., the Director of Nursing confirmed the facility failed to prevent Resident 1 from an avoidable accident related to a fall, resulting in injury and transfer to the hospital. 483.25(d) Accidents. Previously cited 2/27/25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 15 sampled residents. (Residents 47, 57) Findings include: Clinical record review revealed that Resident 47 had a diagnosis of diabetes. Section N of the MDS assessment dated [DATE], indicated that Resident 47 was injected with insulin once during the seven-day review period. Review of Resident 47's clinical record revealed that Resident 47 did not have a physician's order for and was not administered insulin during the seven-day review period, as inaccurately identified on the MDS assessment. Clinical record review revealed that Resident 57 was admitted to the facility on [DATE], for short term rehabilitation. A nursing note dated February 4, 2025, indicated the resident was discharged back to her home in a personal care setting with memory support. The MDS assessment dated [DATE], indicated the resident discharged to a long term care hospital. In an interview on April 3, 2025, at 9:11 a.m., the Nursing Home Administrator confirmed that Resident 47's and 57's MDS assessments were inaccurate.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual residents' needs as identified in the comprehensive assessment for two of 15 sampled residents. (Residents 20, 56) Findings include: Clinical record review revealed that Resident 20 had diagnoses that included legal blindness, hearing loss, difficulty walking, and an enlarged prostate. The Minimum Data Set (MDS) assessment dated [DATE], noted the resident had vision difficulties, communication issues due to his impaired hearing, and continence issues. The MDS Care Area Assessment (CAA) summary noted that the resident's vision, communication, and urinary incontinence issues were to be addressed in the care plan. There was no evidence that interventions to address Resident's 20's vision, communication, and urinary incontinence were addressed in the care plan. Clinical record review revealed that Resident 56 had diagnoses that included difficulty walking and heart failure. Resident 56's admission bowel and bladder assessment dated [DATE], indicated that the resident was occasionally incontinent. The MDS CAA summary dated March 20, 2025, noted that the resident's incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 56's urinary incontinence was included in the current care plan. In an interview on April 3, 2025, at 9:13 a.m., the Assistant Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the care plans. 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 ensure that assessed safety interventions with transfers was implemented for one of four residents sampled. (Resident R1) Findings include: Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included a closed fracture of the left tibia/fibula, anemia and osteopenia. On January 25, 2025, the physical therapist and physician directed staff to transfer the resident with the assist of two staff members with any transfer from the bed to the wheelchair. A note by a nurse on February 4, 2025, following an orthopedic planned followup, revealed that the resident was transferred by one staff member from her bed to the wheelchair. The resident experienced discomfort after the transfer. In an interview on February 27, 2025, at 10:30 a.m., the Nursing Home Administrator confirmed that the nursing assistant did not follow the resident's plan of care. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to inform a resident and (or) responsible party, in advance, of a treatment and (or) treatment options prior to receiving a vaccine for one of three sampled residents. (Resident 1) Review of the facility policy entitled, Covid-19 Vaccine Policy, dated January 4, 2025, revealed that before receiving any Covid-19 vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the vaccine and obtain consent. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included dementia and muscle weakness. The Minimum Data Set assessment dated [DATE], indicated the resident had memory loss and required extensive assistance with activities of daily living. On September 17, 2024, the physician ordered for staff to administer an as needed Covid-19 vaccination in the event of an outbreak. On November 7, 2024, staff administered the Covid-19 vaccine. There was no documentation to support that the resident or the resident's responsible party was provided with information and education regarding the benefits and potential side effects of the vaccine or that consent was obtained prior to the administration of the Covid-19 vaccine. In an interview on January 17, 2025, at 1:30 p.m., the Director of Nursing confirmed that the resident and the resident's representative were not provided with informed consent prior to receiving the Covid-19 vaccine. 28. Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 16 sampled residents. (Resident 32) Findings include: Clinical record review revealed that Resident 32 was admitted to the facility on [DATE], and had diagnoses that included polyosteoarthritis and muscle weakness. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated February 18, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 32's urinary incontinence were included in the current care plan. In an interview on March 21, 2024, at 9:21 a.m., the Corporate Compliance Officer confirmed there was no documented evidence that the identified care area (urinary incontinence) was addressed in Resident 32's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, staff interview, and resident interview, it was determined that the facility failed to implement interventions to prevent pressure ulcers for one of three sampled residents with pressure sores. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included generalized muscle weakness, arthritis of the right knee, and a pressure ulcer of the left heel. The Minimum Data Set assessment dated [DATE], indicated that the resident was oriented and required staff assistance with activities of daily living, including dressing. The care plan identified that the resident had the potential for skin breakdown related to immobility. Review of the consulting wound physician's report dated April 13, 2023, revealed that orders included that Resident 9 keep wearing Prevalon boots (boots with a cushioned bottom to prevent pressure) on both feet. Nursing documentation dated April 14, 2023, also noted that the resident was to wear Prevalon boots on both feet. Resident 9 was observed on April 19, 2023, at 2:11 p.m., and April 20, 2023, at 1:40 p.m. seated in the wheelchair wearing a pressure relieving boot on the left foot and only a sock on the right foot. Both feet were placed on and in contact with a wheelchair foot rest. In an interview on April 20, 2023, at 1:40 p.m., Resident 9 reported that staff do not always apply the boot for the right foot and that it was available in the closet. The resident denied refusing to wear the right boot. During an interview on April 20, 2023, at 1:47 p.m., the nurse aide (NA 1) reported that the resident had an order to wear a pressure relieving boot on the left foot only and stated that the resident had only one boot available. Observation on April 20, 2023, at 1:50 p.m., revealed that a second pressure relieving boot was in Resident 9's closet. 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 provide services to restore bladder function as much as possible for one of 15 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection and anxiety. The Minimum Data Set assessment dated [DATE], indicated that she was incontinent of urine and required extensive assistance from staff to use the toilet. According to a Continence Assessment, dated February 7, 2023, the resident was considered a candidate for a toileting program. The care plan identified that the resident had a problem with incontinence, however there was no documented intervention to restore bladder function such as a toileting program. In an interview on April 20, 2023, at 10:30 a.m., the Quality Assurance Coordinator stated that a toileting program was never initiated for Resident 2. 28 PA Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, and review of incident/accident reports, it was determined that the facility failed to ensure that hot liquids were served to residents at a safe temperature for one of 15 sampled residents. (Resident 2) Findings include: Review of the facility policy entitled, Hot Beverage Policy, implemented May 27, 2021, revealed that the temperature of hot beverages would be recorded by a designated staff member at the start of meal service. The temperature of hot liquids would not exceed 155 degrees Fahrenheit to prevent burns and scalding. Clinical record review revealed that Resident 2 had diagnoses that included spinal stenosis and anxiety. A Minimum Data Set assessment dated [DATE], identified that the resident needed only staff setup assistance to eat meals. A nurse noted on March 26, 2023, at 2:38 p.m. that Resident 2 spilt hot chocolate on herself during lunch. Follow-up documentation revealed that the resident's skin was assessed after the incident and had reddened areas to her chest and abdomen. Review of the facility's investigation into the incident revealed that the temperature of the hot chocolate was not taken by dietary staff prior to service to ensure a safe temperature. 28 Pa. Code: 201:18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for two of 13 sampled residents. (Resident 43, 204) Findings include: Clinical record review revealed that Resident 43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired and required extensive assistance with dressing and personal hygiene. Review of a physician's order dated October 19, 2019, revealed that the resident was to have a palm guard placed on each hand after his morning hygiene and it was to be left on during daytime hours. On May 11, 2022, at 9:55 a.m., 12:16 p.m., 12:29 p.m., and 1:00 p.m., the resident was observed to be fully dressed and did not have his palm guards in place. The two palm guards were observed on top of the resident's bedside cabinet. In an interview on May 11, 2022, at 9:25 a.m. the Director of Nursing confirmed that the resident should have had the palm guards in place. Clinical record review revealed that Resident 204 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order dated April 28, 2022, revealed that staff was to weigh the resident daily for 30 days and to call the physician if there was an increase or decrease greater than three pounds from the admission weight. Resident 204's documented admission weight on April 29, 2022, was 119 pounds. On May 3, 2022, the resident's weight was 112 pounds, reflecting a seven pound weight loss. On May 4, 2022, the resident's weight was 110.5 pounds, reflecting a 8.5 pound weight loss. On May 7, 2022, the resident's weight was 111.2 pounds, reflecting a 7.8 pound weight loss. On May 8, 2022, the resident's weight was 110.3 pounds, reflecting a 8.7 pound weight loss. On May 9, 2022, the resident's weight was 107.2 pounds, reflecting an 11.8 pound weight loss. There was no documented evidence that the physician was contacted regarding the weight loss in accordance with the order. Additionally staff failed to document weights on May 5, 2022 and May 6, 2022. In an interview on May 12, 2022, at 9:41 a.m., the Director of Nursing stated there was no documentation to support that nursing had notified the physician of the weight changes and that the two daily weights were not done and should have been done. 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 ensure pain management included non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 14 sampled residents. (Residents 6, 37) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records revealed that the resident was given the as needed pain medication 21 times in May 2021, and four times in June, 2021. There was a lack of documentation to support that non-pharmacological interventions were provided prior to or in conjunction with the as needed medication in an attempt to alleviate the resident's pain. Clinical record review revealed that Resident 37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication administration records revealed that the resident was given the as needed pain medication 22 times in May 2021, and four times in June 2021. There was a lack of documentation to support that non-pharmacological interventions were provided prior to or in conjunction with the as needed medication in an attempt to alleviate the resident's pain. During an interview on June 4, 2021, at 11:55 a.m., the Director of Nursing confirmed that there was no documentation to support that non-pharmacological interventions had been provided for Resident 6 and Resident 37 prior to or in conjunction with the administration of as needed pain medication. 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 provide services to increase range of motion and/or to prevent a further decrease in range of motion for one of five sampled residents with limited range of motion. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory problems, required staff assistance for care, and had functional limitation in range of motion of both lower extremities. A physical therapy discharge summary signed by the therapist on April 7, 2021, noted that at the time of discharge staff was performing range of motion of both lower extremities and a restorative nursing/functional maintenance program was recommended to prevent decline. Prognosis to maintain the current level of functioning was noted as excellent with consistent staff support. There was no evidence to support that the resident was provided with a restorative nursing program for range of motion. During an interview on June 4, 2021, at 10:10 a.m., the therapy director confirmed that Resident 6 was not provided with the recommended restorative range of motion program. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide written notification to the resident and the resident's representative regarding transfer and the reasons for transfer for four of four sampled residents who were transferred to the hospital. (Residents 21, 31, 35, 50) Findings Include: Clinical record review revealed that Resident 21 was transferred and admitted to the hospital on September 19, 2020, after a change in mental status. There was no evidence to support that the resident or the resident's responsible party was provided with written notification regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 31 was transferred and admitted to the hospital on March 14, 2021 and April 2, 2021, after a change in condition. There was no documented evidence that the resident or the resident's responsible party was provided written notification regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 35 was transferred and admitted to the hospital on April 26, 2021, after a change in mental status. There was no evidence to support that the resident or the resident's responsible party was provided with written notification regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 50 was transferred and admitted to the hospital on March 7, 2021, after a change in condition. There was no documented evidence that the resident or the resident's responsible party was provided written notification regarding the resident's transfer to the hospital. In an interview on June 4, 2021, at 08:50 a.m., the Administrator confirmed that residents and/or residents' representatives were not notified in writing of transfers to the hospital.

Based on review of facility policy, clinical record review, review of facility generated investigations and staff interview, it was determined that the facility failed to adequately supervise a resident who was at risk for wandering to prevent elopement for one of one sampled resident at risk for elopement. (Resident 7) Findings include: Review of the facility's policy entitled Resident Elopement, dated (MONTH) 2019, revealed that the facility was responsible to ensure the safety and security of all residents and to ensure a safe and secure environment for all residents. Clinical record review revealed that Resident 7 had [DIAGNOSES REDACTED]. Review of an elopement/wandering risk assessment dated (MONTH) 23, 2019, revealed that the resident was at risk for elopement due to a history of wandering, [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 5, 2019, indicated that the resident had memory impairment, required assistance from staff for activities of daily living, and was not steady with his balance and was only able to stabilize with staff assistance. In addition, the assessment indicated that the resident utilized a wheelchair and had a history of [REDACTED]. Review of a facility investigation dated (MONTH) 27, 2019, revealed that at 6:15 p.m., staff heard a weak alarm sounding and realized that it was the stairwell door on the[NAME]nursing unit in stairwell #10. When staff went through the door, they found the resident seated at a step of the stairwell landing with his wheelchair behind him. The investigation indicated that the resident stated I stood up out of my wheelchair and held on to the railing. The investigation further indicated that the locks on the door to both stairwells #9 and #10 were not functioning. There were no witnesses to the resident leaving the nursing unit. Review of a second facility investigation dated (MONTH) 4, 2019, revealed that at 8:30 p.m., a staff member again heard a weak alarm sounding and discovered it was coming from stairwell #10. The door was closed and when the staff member went through the door, Resident 7 was found on the landing of the stairwell in his wheelchair. The investigation further revealed that staff were unable to ascertain how the resident was able to get through the door. In an interview on (MONTH) 26, 2019, at 2:00 p.m., the Director of Nursing stated that the resident had exited the same stairwell located on the[NAME]nursing unit without staff knowledge. The facility failed to provide adequate supervision in order to prevent two elopements off of the nursing unit where the same resident was able to exit from the same stairwell on two occassions within a one week period of time. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/4/18

Based on clinical record review and staff interview it was determined that the facility failed to notify the resident and the residents' representative(s) of the transfer and the reasons for transfer in writing for five out of five sampled residents who were transferred to the hospital. (Residents 37, 38, 41, 53, 105) Findings include: Clinical record review revealed that Resident 37 was transferred and admitted to the hospital on (MONTH) 3, 2019, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 38 was transferred and admitted to the hospital on (MONTH) 16, 2019, Ocotber 14, 2019, and (MONTH) 15, 2019, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 41 was transferred and admitted to the hospital on (MONTH) 1, 2019, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 53 was transferred and admitted to the hospital on (MONTH) 2, 2019, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 105 was transferred and admitted to the hospital on (MONTH) 16, 2019, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. In an interview on (MONTH) 26 at 2:05 p.m., the Administrator confirmed that the aforementioned residents and/or resident's representatives were not notified in writing of the transfer to the hospital.

Based on review of employee personnel files and staff interview, it was determined that the facility failed to complete a performance review at least once every 12 months and provide individualized in-service education accordingly to five of five sampled nurse aides. (Employee 1, 2, 3, 4, 5) Findings include: A review of the employee files and training records of nurse aides (Employees 1, 2, 3, 4, and 5) revealed no documented evidence that the facility completed a performance review of these nurse aides the last 12 months. Review of the facility nurse aide training records revealed that Employees 1, 2, 3, 4, and 5 were not provided regular in-service education based on the outcome of an annual performance review during the last 12 months of their employment. An interview with the Director of Nursing on (MONTH) 27, 2019, at 1:00 PM, confirmed that there was no documented evidence that the aforementioned nurse aides received a performance review in the past 12 months. 28 Pa. Code 211.12 (c) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide alternatives and obtain informed consent for utilization of bed rails with residents or their representatives for three of 15 sampled residents. (Resident 39, 47, 54) Findings include: Clinical record review revealed that Resident 39 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed (MONTH) 30, (YEAR), revealed that the resident had severe memory impairment and received extensive assistance of two or more staff members for bed mobility and did not transfer. Observations during tour from (MONTH) 2, (YEAR), through (MONTH) 3, (YEAR), revealed Resident 39 in bed with two bilateral quarter bed rails in the up position at the top of the bed. Clinical record review revealed that Resident 47 had [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 13, (YEAR), revealed that the resident had memory impairment and received extensive assistance of two or more staff members for bed mobility and occasional transfers. Observations on (MONTH) 2, (YEAR), at 9:43 a.m. and (MONTH) 3, (YEAR), at 8:50 a.m., revealed Resident 47 in bed with two bilateral quarter bed rails in the up position at the top of the bed. Clinical record review revealed that Resident 54 had [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 20, (YEAR), revealed that the resident had severe memory impairment and received extensive assistance of two or more staff members for bed mobility and transfers. On (MONTH) 24, (YEAR), clinical documentation revealed that a bed rail assessment had been completed but there was no documented evidence that alternatives had been attempted, considered, or discussed with the resident representative prior to bed rail consent. Observations on (MONTH) 2, (YEAR), at 9:48 a.m. and (MONTH) 3, (YEAR), at 10:22 a.m., revealed Resident 54 in bed with two bilateral quarter bed rails in the up position at the top of the bed. In an interview on (MONTH) 4, (YEAR), at 1:14 p.m., the Director of Nursing stated that the facility had not obtained informed consent and had not provided alternative attempts or consideration to the residents or resident's representatives prior to bed rail usage. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/28/17

Based on clinical record review and staff interview it was determined that the facility failed to implement physician's orders for two of 14 sampled residents. (Residents R20, R52) Findings include: Clinical record review revealed that Resident R20 had [DIAGNOSES REDACTED]. On July 15, 2017, a physician ordered that staff weigh the resident daily and notify the physician if the resident gained three or more pounds in one day or 5 or more pounds in five days. Review of the weight record revealed that the resident gained four pounds between September 15 and 17, 2017, and a gained four pounds between August 10 and 15, 2017. There was no documented evidence that the physician was notified of the weight gains as per physician's orders. Clinical record review revealed that Resident R52 had [DIAGNOSES REDACTED]. Since December 16, 2015, the physician ordered that staff weigh the resident three times a week, and notify the physician if the resident gained three or more pounds. Review of the weight record revealed that the resident gained four pounds between July 24 and 28, 2017. There was no documented evidence that the physician was notified of the weight gain as per physician's orders. In an interview on September 28, 2017, at 9:00 a.m., the Director of Nursing confirmed that there was no documented evidence that physician's orders regarding weight gain were followed for the two aforementioned residents. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/14/16

Based on clinical record review and staff interview, it was determined that the facility failed to offer nonpharmacological interventions prior to the administration of an as needed antianxiety medication for one of seven sampled residents who were on antianxiety medication. (Resident R51) Findings include: Clinical record review revealed that Resident R51 had [DIAGNOSES REDACTED]. Review of the Medication Administration Records (MARs) revealed that staff administered the PRN [MEDICATION NAME] 13 times in June 2017, 14 times in July 2017, and four times in August 2017. There was no documented evidence that staff attempted nonpharmacological interventions prior to the administration of the PRN [MEDICATION NAME]. In an interview on September 28, 2017, at 9:10 a.m., the Director of Nursing confirmed that there was no consistent documented evidence to support that staff offered nonpharmacological interventions prior to the administration of the PRN antianxiety medication. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/14/16