Every finding on record at Moravian Village of Bethlehem

Based on facility policy review, clinical record review, and staff interview, it was determined the facility failed to ensure that one of four sampled residents was free of a significant medication error (Resident 1).Findings include: Review of facility policy entitled General Dose Preparation and Medication Administration, last reviewed January 27, 2026, revealed that prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including confirming that the Medication Administration Record (MAR) reflected the most recent medication order. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia, heart failure, and diabetes. A physician's order dated July 23, 2026, directed staff to administer torsemide (a diuretic) for weight gain greater than two pounds (lbs.) in 24 hours. On July 25, 2026, the resident weighed 153.6 lbs. On July 26, 2026, the resident weighed 156 lbs., which reflected a 2.4 lb. weight gain. On July 27, 2026, the resident weighed 160.2 lbs., which reflected a 4.2 lb. weight gain. A review of the MAR for July 2026, revealed that there was no evidence that staff administered the torsemide for the resident's weight gain on July 26 or 27, 2026. In an interview on August 21, 2026, at 1:08 p.m., the Director of Nursing confirmed that there was no documented evidence that staff administered the torsemide as ordered. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to provide the resident and the resident's representative(s) with a written notice of transfer(s), which included the reasons for the moves, the effective date of the transfer, a statement of the residents' appeal rights, and the Ombudsman information. Additionally, the facility failed to provide written notice of duration of the bed-hold policy, and copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for three out of three residents who were transferred out of the facility. (Residents 3, 10, and 50)Findings include: Clinical record review revealed that Resident 3 was transferred to the hospital on February 15, 2026, after a significant change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital, the bed-hold policy, and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 10 was transferred to the hospital on June 4 and June 10, 2026, after significant changes in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital, the bed-hold policy, and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 50 was transferred to the hospital on May 11, 2026, and June 19, 2026, after significant changes in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital, the bed-hold policy, and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on July 1, 2026, at 12:05 p.m., the Administrator confirmed that the notification of transfers and bed-hold policy were not sent for these residents and resident representatives and that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 10 sampled residents. (Residents 4 and 5) Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed January 27, 2026, revealed that a resident may exercise the right to self-administer medications when determined that the practice was safe. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: resident safety to self-administer medications, location of medication administration, who would be responsible for storage, and documentation of medication administration. If the resident indicated a desire to self-administer his or her medications, the Interdisciplinary Team would complete the Self-Administration of Medications UDA (User Defined Assessment) to determine a resident's ability to safely self-administer medications. The care plan would document interventions to support self-administration of medications by the residents. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], and had diagnoses that included chronic heart failure, persistent lower extremity edema, and bullous pemphigoid (a chronic autoimmune skin condition). Review of the Minimum Data Set (MDS) assessment, dated May 29, 2026, revealed that Resident 4 was alert and oriented. Observation on June 30, 2026, at 11:35 a.m., and 2:27 p.m., and on July 1, 2026, at 8:08 a.m. and 11:45 a.m., revealed a prescribed tube of a topical corticosteroid medication, used to treat the skin condition (clobetasol 0.05%), was on the resident's tray table. In an interview on July 1, 2026, at 11:45 a.m., the resident stated that he was permitted to administer the medication by himself. There was no documentation to support that the interdisciplinary team had assessed the resident to self-administer medications. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], and had diagnoses that included diabetes, polyneuropathy (a nerve disease caused by damage to multiple nerves), and osteomyelitis. Review of the MDS assessment, dated April 20, 2026, revealed that Resident 5 was alert and oriented. Observations on July 1, 2026, at 8:10 a.m., 8:58 a.m., and 10:27 a.m., revealed a prescribed topical medication for pain (diclofenac 1%) was on the resident's tray table. In an interview on July 1, 2026, at 8:58 a.m., the resident stated that she was permitted to administer the medication by herself. There was no documentation to support that the interdisciplinary team had assessed the resident to self-administer medications. In an interview on July 1, 2026, at 12:43 p.m., the Director of Nursing confirmed that Residents 4 and 5 did not have a physician's order to self-administer medications, and the residents were not assessed to self-administer the medication. 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 develop a comprehensive care plan that addressed each resident's needs as identified in the comprehensive assessment for one of 10 sampled residents. (Resident 8)Findings include:Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], and had diagnoses that included depression and anxiety. The Minimum Data Set Care Area Assessment summary dated June 11, 2026, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records for June 2026, revealed the resident received two antidepressants (venlafaxine and trazadone) and one antianxiety medication (buspirone), which were classified as psychotropic drugs, during the review period. There was no documented evidence that interventions to address Resident 8's psychotropic drug use were included in the current care plan. In an interview on July 1, 2026, at 12:44 p.m., the Director of Nursing confirmed there was no documented evidence that psychotropic drug use was addressed in Resident's 8 current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for one of 10 sampled residents. (Resident 18)Findings include: Clinical record review revealed that Resident 18 had diagnoses that included polyosteoarthritis and polyneuropathy. A Minimum Data Set assessment dated [DATE], revealed that Resident 18 required partial to moderate assistance with hygiene and self-care and had no cognitive impairment. Review of the ongoing care plan revealed that staff were to assist the resident with activities of daily living and were to clean and manicure fingernails as needed. Review of bathing documentation revealed that Resident 18 was last bathed by staff on June 29, 2026. On June 30, 2026, at 11:10 a.m., the resident was observed in her room. Her nails were long, yellow, uneven, and dirty. She stated in an interview at that time that she would like her nails cleaned and that she would not refuse nail care on her bath day since her nails were dirty. On July 1, 2026, at 9:48 a.m., the resident was observed in her bed. Her nails remained long, yellow, uneven, and dirt was observed underneath them. There was no evidence that staff offered or provided the resident with nail care and there were no documented refusals. In an interview on July 1, 2026, at 10:51 a.m., the Director of Nursing confirmed that nail care is to be done on bathing days and as needed. 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 implement a physician's order for one of 10 sampled residents. (Resident 5)Findings include: Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], and had diagnoses that included diabetes and osteomyelitis. Review of the Minimum Data Set assessment, dated April 20, 2026, revealed that Resident 5 was alert and oriented and received insulin injections to treat her diabetes. A physician's order dated April 29, 2026, directed staff to monitor Resident 5's blood glucose levels by conducting blood glucose level checks before meals and at bedtime. In an interview on June 30, 2026, at 11:00 a.m., Resident 5 stated that staff often checked her blood sugar levels after she had completed her meals, her readings were high, and she got insulin coverage for her post meal blood glucose. Observations on July 1, 2026, from 8:20 a.m. to 8:29 a.m., revealed that Resident 5 was in her room with her meal tray. She had eaten 100 percent of her breakfast meal that consisted of eggs, toast, and coffee. In an interview at that time, Resident 5 stated that she had not yet had her blood glucose level checked by staff that morning. Staff did not check the resident's blood glucose level until 8:30 a.m., after she had eaten her breakfast meal. In an interview on July 1, 2026, at 12:46 p.m., the Director of Nursing confirmed the resident's blood sugar checks should have been done prior to eating per the physician's order. CFR 483.25 Quality of Care Previously cited 06/18/2025 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of 10 sampled residents. (Resident 26)Findings include: Clinical record review revealed that Resident 26 had diagnoses that included Parkinson's disease (a progressive neurological disorder that primarily affects movement), polyneuropathy (a nerve disease caused by damage to multiple nerves), and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated May 25, 2026, revealed that Resident 26 was alert and oriented. A physician order dated May 25, 2023, directed staff to provide an adaptive cup to the resident in her room. A physician order dated July 16, 2025, directed staff to provide a one or two-handled adaptive cup with a straw. Review of a nutrition assessment, dated November 26, 2025, revealed Resident 26 required set up with assistance as needed for self-feeding, including an adaptive cup. Review of the care plan revealed that the resident required assistance with activities of daily living, was at risk for nutrition problems, with interventions to include an adaptive cup. On June 30, 2026, at 10:35 a.m., and July 1, 2026, at 8:46 a.m. and 1:06 p.m., the resident was observed sitting in her wheelchair, with the tray table in front of her and with a Styrofoam cup of water with a straw. On July 1, 2026, at 1:06 p.m., Resident 26 stated that she prefers to use a two-handled adaptive cup in her room for drinking water. She stated she struggles using the Styrofoam cup and has spilled water all over herself. In an interview on July 1, 2026, at 1:23 p.m., the Director of Nursing confirmed that the resident should have been provided with the adaptive cup in her room. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of manufacturer instructions, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of three sampled residents reviewed for their drug regimen. (Resident 1)Findings include: According to the manufacturer's instructions, the buprenorphine patch should be changed at the same time of day, one week (exactly seven days) after the patch was applied. After removing and disposing of the patch, the date and time of removal should be recorded.Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included multiple acute thoracic vertebra fractures, multiple right rib fractures, and severe kyphosis (excessive forward curve of the spine). Review of the hospital after visit summary dated March 10, 2026, revealed a buprenorphine patch (an opioid) was to be discontinued after the current patch was completed. On March 23, 2026, the resident was transferred to the hospital for a change in condition. Upon transfer, the nurse observed the buprenorphine patch on the resident's upper arm. The facility failed to identify, monitor the effects, or timely remove the buprenorphine patch that remained on the resident for 13 days.In an interview on April 9, 2026, at 2:00 p.m., the Director of Nursing confirmed that the buprenorphine patch order was not identified until March 23, 2026, and staff should have removed the patch at an earlier date.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 ensure that physician prescribed medications were provided for one of four sampled residents. (Resident CR 1) Findings include:Clinical record review revealed that Resident CR 1 was admitted to the facility with diagnoses that included atrial fibrillation (irregular heartbeat). On December 30, 2025, the physician ordered staff to administer an anti-arrythmia medication (propafenone 225 milligrams) three times a day. Review of the Medication Administration Record (MAR) for January 2026 revealed that three doses of the medication were not administered on January 15, 2026. In an interview on March 12, 2026, at 1:21 p.m., the Director of Nursing confirmed that the medication was not administered and not provided timely by the pharmacy. 28 Pa. Code 211.9(d) Pharmacy services.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 ensure that clinical record documentation was complete and accurate for one of four sampled residents. (Resident CR 1)Findings include:Resident CR 1 was admitted to the facility with diagnoses that include atrial fibrillation. The plan care plan included interventions that directed staff to provide showers twice a week. Review of the facility ADL (Activities of Daily Living) Verification Worksheet revealed that from January 21, 2026, through February 5, 2026, there was a lack of documentation to support that showers were offered or provided twice weekly to the resident on four occasions.In an interview on March 12, 2026, at 1:14 p.m., the Director of Nursing was unable to provide documentation that showers were provided to Resident CR 1 as identified. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview, and resident interview, it was determined that the facility failed to implement physician's orders for one of 14 sampled residents. (Resident 36) Findings include: Clinical record review revealed that Resident 36 had diagnoses that included a broken right ankle and diabetes. A physician's order dated April 30, 2025, directed staff to apply an anti-embolic stocking (a special sock to prevent blood clots) to the left leg daily and remove every night due to swelling. Observation on June 16, 2025, at 12:30 p.m. revealed that Resident 36 did not have the anti-embolic stocking applied to her left leg, and multiple observations on June 17, 2025 between 10:00 a.m. and 12:50 p.m., revealed that the stocking was not applied to Resident 36's left leg. Review of the Treatment Administration Record (TAR) for June 2025 revealed nurses' initials indicated that the anti-embolic stocking was applied in the morning and removed at bedtime on June 16, 2025 and June 17, 2025. In an interview on June 16, 2025 at 12:30 p.m., the resident stated that she has never had a stocking applied to her left leg. In an interview on June 18, 2025 at 11:45 a.m., the Director of Nursing (DON) confirmed that the order for the anti-embolic stocking to the left leg was an error and that the nurses should not have indicated that it was applied. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of a change in condition for one of 14 sampled residents. (Resident 34) Findings include: Review of facility policy entitled, Change in a Resident's Condition or Status, last reviewed January 30, 2023, revealed that the facility would promptly notify the resident's physician of changes in medical condition or status. Notification was to be made within 24 hours of a change occurring in the resident's medical condition or status. Clinical record review revealed that Resident 34 had diagnoses that included dislocation of left hip, anxiety, and depression. Review of a physical therapy evaluation dated October 20, 2022, revealed that the resident had pain and there was a length discrepancy to the left leg. Review of an x-ray report dated October 21, 2022, revealed that the resident had a dislocation to the left hip. Review of an undated staff statement revealed that the x-ray results were available and at the nursing unit for review on the evening of October 21, 2022. Review of a staff statement dated October 23, 2022, revealed that the x-ray results were reviewed with the certified nurse practitioner (CRNP) at 3:00 p.m., on October 23, 2022, and the resident was transferred to the hospital on the same date. There was no evidence that the CRNP was notified of the results of the x-ray report until October 23, 2022, more than 24 hours after the facility received the results. In an interview on June 14, 2023, at 12:51 p.m., the Assistant Director of Nursing confirmed that there was no evidence that the CRNP was notified of the x-ray results until October 23, 2022, and staff should have notified the CRNP within 24 hours. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the trash compactor area during a facility tour on June 13, 2023, beginning at 9:55 a.m., revealed debris that included aerosol cans, gloves, plastic bottles, and paper items were scattered on the grass on the side of the compactor. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review, it was determined that the facility failed to ensure that adaptive equipment to promote safety was provided for one of six residents sampled. (Resident R2) Findings include: Clinical record review revealed that Resident R2 had diagnoses that included dementia with behaviors that included care resistance and impulsiveness. An occupational therapy assesment of February 17, 2023, revealed that the resident had difficulty with self feeding and would often spill both food items and beverages. A Kennedy cup (a device with handles, a lid and straw) was ordered to assist with safe meal completion. The Minimum Data Set (MDS) assessment of March 1, 2023, revealed that the resident required staff assistance with meals. The care plan also noted the need for the Kennedy cup for beverages at meal time. A note by a nurse on April 21, 2023 at 12:00 p.m., revealed that the resident was at the dining table in preparation for the noon meal. The meal tray was placed in front of him as well as his beverages. The resident impulsively reached for his cup with coffee. The cup and beverage fell on to his lap. The resident sustained a reddened area requiring a cold compress. Staff had not provided the adaptive cup for the meal resulting in the resident spilling the beverage on himself. 28 Pa. Code 211.12(d)(1)(5) nursing services.

Based on facility policy review, review of incident reports, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 16 sampled residents (Resident 4) Findings include: Review of the facility policy entitled Abuse Investigations, dated January 31, 2022, revealed that all reports of resident abuse, neglect and injuries of unknown source were to be promptly and thoroughly investigated by facility management. The investigation was to include interviews from staff members on all shifts who had contact with the resident during the period of the alleged incident. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance with activities of daily living. Review of the current care plan identified the resident was at risk for impaired skin integrity. On May 2, 2022, a nurse noted that the resident was observed with a new bruise to the right side of her chin and right lower lip (appeared as a linear) shape and that the cause of the bruise was unknown/unwitnessed. Review of the incident report dated May 2, 2022, revealed that the resident had a new alteration in skin integrity. There was no documented evidence that staff members from all shifts who had contact with the resident duing the period of the alleged incident had been interviewed in order to rule out abuse. In an interview on June 30, 2022, at 10:09 a.m., RN1 stated that the facility had not obtained written witness statements and that there was no documented evidence that staff members who had contact with the resident had been interviewed to rule out abuse as per facility policy. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and review of incident reports, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of four sampled residents who were at risk for falls. (Resident 36) Findings include: Clinical record review revealed that Resident 36 was admitted to the facility on [DATE], and had diagnoses that included dementia, [CONDITION(S)], and spinal stenosis. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, and required a one person assist for transfers The assessment further indicated that she was not steady moving from a seated to a standing position, she was not steady walking and had a history of falls. Review of the current care plan identified the resident was at risk for falls. Review of a fall risk evaluation dated March 31, 2022, revealed that the resident had a history of falls, she was disoriented, occasionally incontinent and had poor safety awareness due to taking risks. Review of a second fall risk evaluation dated June 23, 2022, revealed that the resident was disoriented, was frequently incontinent, lacked safety awareness, and had problems walking even with a device. Review of nursing documentation and incident reports revealed that Resident 36 had fallen 13 times between February 26, 2022, through June 29, 2022. Most of the falls occurred in her room. Six of the falls were between 5:00 p.m., and 11:00 p.m., four of the falls were between 12:00 a.m., and 2:00 a.m. On February 26, 2022, a nurse noted that the resident was extremely confused and had gotten out of bed several times. Review of an incident report dated February 26, 2022, at 8:00 p.m., revealed that the resident had been found on the floor in her room. On April 15, 2022, a nurse noted that the resident had gotten up repeatedly from her bed and was combative with staff. Review of incident reports dated April 16, 2022, and April 26, 2022, revealed that the resident had additional falls. A nurse noted on April 26, 2022, that the resident had been exit seeking, was confused and had been pacing the hallway. Review of incident reports revealed that the resident fell again on May 24, 2022, and May 29, 2022. On June 8, 2022, a nurse noted that the resident gets up unassisted in her room. Review of incident reports dated June 8, 11, 13, 23, and 24, 2022, revealed that the resident had fallen five more times. Review of an incident report dated June 29, 2022, revealed that at 12:30 a.m., the resident had an unwitnessed fall in her room requiring a hospital evaluation. There was no documented evidence that the facility had evaluated the need for increased supervision in order to prevent falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to assess and document the status of a pressure ulcer per facility policy for one of three sampled residents. (Resident 22) Findings include: Review of the facility policy entitled Pressure Ulcer Prevention and Management of Skin Integrity dated January 31, 2022, revealed that skin integrity and/or conditions affecting the resident's skin must be documented at least once every seven days, the pressure of skin breakdown/abnormal skin appearance will be documented weekly, and interventions and progress toward outcome will have documentation at least weekly. Clinical record review revealed that Resident 22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairments, and required extensive assistance with activities of daily living including bed mobility, transferring, and personal hygiene. Review of a nurse's note dated May 30, 2022, revealed the resident developed areas to his buttocks, classified as deep tissue pressure injuries. There was no documented evidence that Resident 22's pressure ulcers were assessed and documented per facility policy after June 6, 2022 until June 27, 2022. In an interview on June 30, 2022 at 10:02 a.m., the Director of Nursing confirmed there is no documentation of weekly pressure ulcer assessment and documentation per facility policy. 28 Pa Code 211.12 (d)(1)(5) Nursing services. 28 Pa. Code 211.5(f) Clinical records.

Based on observation and staff interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on August 3, 2021, at 9:29 a.m. revealed the following items in the walk in refrigerator: A container of prepared marinara sauce with a use by date of July 28 A container of prepared chicken and vegetable soup with a use by date of August 2 A container of prepared mashed potatoes with a use by date of July 31 A container of blueberry yogurt with a use by date of August 1 Strawberries noted in three different containers with white mold on the surface of the fruit A pan of cooked ground chicken with a production date of July 23 During the observation period, the production manager stated that prepared food items should be discarded within three days of the production date. Observation of the food preparation area revealed a bulk container of breadcrumbs and thickener powder that was not dated upon transfer from the original containers, a bulk bin of flour that was not labeled or dated when transferred from the original container, and a bulk bin of sugar with a use by date of June 26. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.6 (c) Dietary services

Based on clinical record review and resident interview, it was determined that the facility failed to offer bathing in accordance with the resident's choice for one of 14 sampled residents (Resident 28). Findings include: Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident expressed that it was very important to choose the type of bathing he received. A quarterly MDS assessment dated [DATE], indicated that the resident had no cognitive impairment, and required assistance for bathing. In an interview with Resident 28 on August 03, 2021, at 11:28 a.m. the resident stated that he is only getting bed baths and he would like to get a shower. There was no documented evidence in the clinical record that Resident 28 was offered a shower since July 2020. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide services to prevent a decline in range of motion for one of four sampled residents with limited range of motion (Resident 28). Findings include: Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment, required extensive assistance for dressing, and had limitation to his range of motion. On January 16, 2020, a physician ordered that staff apply a soft wrist splint to the resident's left wrist every shift. On all days of the survey, Resident 28 was observed with no left wrist splint in place. In an interview conducted on August 04, 2021, at 11:58 a.m. the resident stated that staff does not offer the splint to him. 28 Pa. Code 211.12(d)(1)(5) Nursing services