Every finding on record at Morrisons Cove Home

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 5 residents reviewed (Resident 1). This deficiency is being cited as past non-compliance.Findings include: A facility policy for glucose monitoring dated January 27, 2026, indicated that glucose meter checks are obtained per physician's order or as needed if resident is displaying signs and symptoms of hypoglycemia or hyperglycemia. Resident 1's clinical record revealed that the resident was admitted on [DATE], with a diagnosis of Diabetes. Physician's orders for Resident 1, dated June 17, 2026, included orders for the resident to receive insulin lispro (a rapid acting insulin that lowers blood sugar in 10-15 minutes) 100 unit/milliliter, inject per sliding scale if blood sugar is 141-180 milligrams/deciliter (mg/dL)= 2 units, 181-220 mg/dL = 4 units, 221-260 mg/dL= 6 units, 261-300 mg/dL = 8 units, 301-340 mg/dL = 12 units before meals. Current manufacturer's instructions for inulin lispro100 unit/milliliter indicate to inject medication 5-10 minutes prior to eating. The facility's meal delivery schedule for South Hall revealed that dinner trays were to arrive at 5:00 p.m. daily. A review of the Medication Administration Record (MAR) for Resident 1 on June 22, 2026, revealed that LPN 1 checked the resident's blood glucose at 3:57 p.m., it was 149 mg/dL and she administered 2 units of insulin lispro (63 minutes before the scheduled dinner meal). A review of Resident 1's meal intake for dinner at 5:00 p.m. on June 22, 2026, revealed the resident ate zero percent of the meal. A nursing note for Resident 1 dated June 22, 2026, at 8:30 p.m. revealed that the resident was found unresponsive in his room and 911 was called. The resident's blood sugar was rechecked by EMS at 8:45 p.m. and was 47mg/dL. An incident report for Resident 1, dated June 24, 2026, confirmed that dinner trays were not provided on June 22, 2026, until 5:00 p.m., and that LPN 1 did not recheck the resident's blood sugar. An interview with the Director of Nursing on July 20, 2026, confirmed that LPN 1 did not administer the insulin at the appropriate time per manufacturer's instructions. Following the incident on June 22, 2026, the facility's corrective actions included: 1. On June 22, 2026, at 8:30 p.m. the resident was assessed, the Medical Director and the Resident Representative were notified. EMS was notified and the resident was evaluated and sent to the Emergency Room. On June 23, 2026, LPN1 was educated on site for medication and hypoglycemia and subsequently terminated as a result of the incident. 2. Education records, dated June 23, 2026, revealed that all of the facility's nursing staff received education regarding the facility's hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) policy and manufacturer's instructions for insulin. 4. The Director of Nursing or designee will audit treatments to ensure that resident's on sliding scale insulin is administered per policy and protocol for five days a week for one week, and then three days a week for one week and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F760 on July 23, 2026. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to follow hospital discharge orders and failed to follow dietary recommendations for one of 30 residents reviewed (Resident 69).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 69, dated December 17, 2025, indicated that the resident was cognitively impaired, required substantial assistance to dependent with most care needs, required setup assistance with eating, was incontinent of bowel and bladder, received insulin, and had diagnoses that included a urinary tract infection (UTI) in the last 30 days, Extended-spectrum beta-lactamase (ESBL-infections resistant to common antibiotics), bacteremia (bacteria in the bloodstream), diabetes, hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), orthostatic hypotension (low blood pressure when standing quickly), and Alzheimer's dementia. Discharge instructions for Resident 69, dated December 10, 2025, indicated that the following medications and diet were to be continued following discharge from the Veterans Affairs Medical Center (VAMC): Insulin Aspart (a rapid acting insulin used to control high blood sugars) per sliding scale coverage (SSC-extra insulin doses are given based on blood sugar readings) ac (before meals) and hs (at bedtime); Metoprolol Succinate (an extended release medication used to treat hypertension, chronic heart failure, and angina) 12.5 milligrams (mg) daily with parameters to hold if heart rate (HR) is less than 60 beats per minute (bpm) or systolic blood pressure (SBP-top number of the blood pressure reading) is less than 100 millimeters of mercury (mmHg); Levofloxacin (an antibiotic) 750 mg every 48 hours with the next/last dose due to be given on December 12, 2025, to complete a one week treatment for ESBL UTI and bacteremia; and a consistent carbohydrate diet (helps manage blood sugar, diabetes, or insulin imbalances). Physician's orders for Resident 69, dated December 10, 2025, revealed that the resident was to receive Insulin Aspart per SSC every morning before breakfast and at bedtime and inject one unit subcutaneously (injection of medication into the fat layer of the skin) one time a day before lunch and one time a day for diabetes before dinner. Physician's orders for Resident 69, dated December 11, 2025, revealed that the resident was to receive Insulin Aspart per SSC every morning before breakfast and at bedtime. Review of the physician's orders revealed that this order was discontinued on December 11, 2025, due to the administration of one unit of Insulin Aspart twice daily not being indicated per the hospital discharge orders. Physician's orders for Resident 69, dated December 17, 2025, revealed that the resident was to receiveInsulin Lispro (a rapid acting insulin used to control high blood sugars) per SSC every morning before breakfast and at bedtime. Review of the resident's Medication Administration Record (MAR) for December 2025, revealed that there was no documented evidence that the resident's blood sugars were monitored between December 11, 2025, and December 16, 2025, until the order was resumed on December 17, 2025. Physician's orders for Resident 69, dated December 10, 2025, revealed that the resident was to receive 12.5 mg of Metoprolol Tartrate (an immediate release medication used to treat hypertension, angina, and acute heart attack) daily for high blood pressure with parameters to hold if HR is less than 60 bpm or SBP is less than 100 mmHg. A progress note for Resident 69, dated December 19, 2025, at 6:54 p.m. indicated that the resident returned from his cardiology appointment with recommendation to use metoprolol succinate vs tartrate. A cardiology progress note for Resident 69, dated December 19, 2025, indicated that his metoprolol should be succinate with the same hold parameters. Physician's orders for Resident 69, dated December 19, 2025, revealed that the resident was to receive 12.5 mg of Metoprolol Succinate ER (Extended Release) daily for hypertension with parameters to hold if HR is less than 60 bpm or SBP is less than 100 mmHg. Review of the resident's clinical record revealed no documented evidence that his blood pressure and heart rate was being checked as ordered prior to the administration of the Metoprolol Succinate ER. Physician's orders for Resident 69, dated December 10, 2025, revealed that the resident was to receive 750 mg of Levofloxacin one time only until December 13, 2025, for ESBL Bacteremia to complete the last dose/one week treatment course that begun at the VAMC. Review of the resident's MAR for December 2025, revealed that the resident received a 750 mg tablet of Levofloxacin on December 10, 2025; however, he was to receive his last dose of 750 mg of Levofloxacin on December 12, 2025, per the discharge instructions. Physician's orders for Resident 69, dated December 10, 2025, revealed that the resident was ordered a cardiac heart healthy diet. A dietary note for Resident 69, dated December 12, 2025, at 1:32 p.m. indicated that the resident was admitted with diet order of cardiac/heart healthy diet. The cardiac/heart healthy diet is restrictive given advanced age and diagnosis of Alzheimer's and recommended to discontinue his cardiac/heart healthy diet, change his diet to consistent carbohydrate (CHO) diet instead due to his diagnosis of diabetes, and add glucerna supplement three times daily. If meal intakes do not improve during his stay, may need to consider further diet liberalization. A progress note for Resident 69, dated December 12, 2025, at 2:10 p.m. revealed that the Certified Registered Nurse Practitioner (CRNP) was notified of the diet recommendations and agreed with order as written to add Glucerna supplement three times daily. A progress note for Resident 69, dated December 19, 2025, at 6:33 p.m. revealed that the physician was made aware of the dietician's request for the resident's diet to be liberalized to regular and was in agreement with suggestion. A dietary note for Resident 69, dated December 23, 2025, at 7:57 a.m. indicated that the resident's current diet order was a cardiac/heart healthy diet. Recommendations were made to clarify the diet order to be consistent CHO diet. Physician's orders for Resident 69, dated December 23, 2025, revealed that the resident was ordered a consistent carbohydrate diet. A communication note for Resident 69, dated December 17, 2025, at 1:20 p.m. indicated that the daughter called in very irate with multiple questions concerning her father's care. The daughter requested the physician call her related to her father's care, and she had questions related to his diet and appetite. The residents discharge medication list, progress notes from the hospital and the dietary progress note was reviewed with the daughter. Interview with the Director of Nursing on February 12, 2026, at 12:50 p.m. confirmed that Resident 69's insulin, metoprolol, levofloxacin and diet were not ordered as per the hospital discharge instructions, his blood pressure and heart rate were not being checked as ordered prior to the administration of the metoprolol succinate, and confirmed that his diet was not changed as recommended by the dietician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications and treatments were provided as ordered by the physician for three of 30 residents reviewed (Resident 5, 30, 57).Findings include:The facility's policy for administering medications dated January 27,2026, indicated that medications and treatments are administered in a safe and accurate manner per physician orders and administered by licensed staff that has completed facility's medication administration training program.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 19, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had a diagnosis of osteomyelitis (infection of the bone and bone marrow).Physician's orders for Resident 5, dated November 19, 2025, included orders for 1 gram of Vancomycin (an antibiotic) to be administered intravenously two times a day for osteomyelitis.Review of Resident 5's Medication Administration Record (MAR) for December 2025 revealed no documented evidence that 1 gram of Vancomycin was administered to Resident 5, December 3 at 8:00 a.m., December 6, at 6:00 a.m., December 13, at 6:00 p.m. and December 23, 2025, at 6:00 a.m. as ordered by the physician.An interview with the Director of Nursing on February 10, 2026, at 3:30 p.m. confirmed that 1 gram of Vancomycin was not administered to Resident 5 on the above mentioned daysA Quarterly MDS assessment for Resident 30, dated December 6, 2025, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.Physician's orders for Resident 30, dated August 30, 2025, included an order for the resident to receive 2 step PPD on admission administer 1 step PPD on admission, read results and document results under immunizations, administer 2nd step PPD 14 days after first step is read, read 2nd step PPD and document under immunizationsA review of Resident 30's MAR for September and October 2025, revealed that a 1 step PPD was administered on September 16 during the day shift and was read on September 18, 2025 during the day shift. There was no documented evidence that a 2nd step PPD was administered 14 days after the first step was read.An interview with the Director of Nursing on February 11, at 1:35 p.m. confirmed that a 2nd step PPD was not administered to Resident 30 and it should have been.A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated October 20, 2025, revealed that the resident was cognitively impaired, was understood and was able to understand others, required partial assistance with daily care needs, and had diagnoses that included heart failure.Physician's orders for Resident 57, dated October 2, 2025, included an order for the resident to have compression pump to bilateral lower extremities (both legs) 60mmHG, 1 time per day, 60 minutes a day.Review of the Treatment Administration Record (TAR) for Resident 57, dated October 2025 through January 2026 revealed that there was no documented evidence that compression pumps were applied on October 4, 2025, October, 14, 2025, October 18, 2025, October 27, 2025, November 11, 2025m November 14, 2025, November 21, 2025 November 25, 2025, November 26, 2025, December 23, 2025, January 2, 2025, January 5, 2025, January 7, 2025, and January 13, 2025.Interview with the Director of Nursing on February 12, 2026, at 9:29 a.m. confirmed that there was no documented evidence that Resident 57's compression pumps were applied on the above date and times and there should have been.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care and maintenance of intravenous catheters and failed to ensure that intravenous catheters were flushed according to facility policy for one of 30 residents reviewed (Resident 5). Findings include:The facility's policy regarding flushing peripheral catheter (a thin, flexible tube that is inserted into a vein to administer fluids, blood, or medications), dated January 27, 2026, indicated that peripheral intravenous (IV) catheters will be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications. Staff was to use the push-pause technique to instill the normal saline. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 19, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had a diagnosis of osteomyelitis (infection of the bone and bone marrow).Physician's orders for Resident 5, dated November 19, 2025, included orders for 1 gram of Vancomycin (an antibiotic) to be administered intravenously two times a day for osteomyelitis.Physician's orders for Resident 5, dated November 21, 2025, included orders to place PICC or Midline catheter (a thin, flexible tube that is inserted into an upper arm vein to administer fluids or medications) for blood draws as well as administration of medication. Review of Resident 5's Medication Administration Records (MAR's) for November and December 2025 revealed no documented evidence that Resident 5's midline catheter was flushed before and after the administration of the antibiotic.Interview with the Director of Nursing on February 11, 2026, at 2:11 p.m. confirmed that there was no documented evidence that Resident 5's midline catheter was flushed before and after the administration of the antibiotic.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the facility's nursing staff and failed to have a contract with the Dialysis facility for one of 30 residents reviewed (Resident 9). Findings include:An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 14, 2025, revealed that the resident was understood and could understand, and had diagnoses that included end-stage renal disease (the last stage of chronic kidney disease, where the kidneys are only functioning at 10 to 15 percent of their normal capacity). The resident's care plan, dated May 23, 2024, revealed that the resident received dialysis on Monday, Wednesday, and Friday. Review of the clinical record for Resident 9 revealed that there was no documented evidence of routine collaboration of care and communication between the long-term care facility and the dialysis center, when the resident received dialysis services, and there was no documented evidence of a contract with US Renal the dialysis facility. Interview with the Director of Nursing on February 11, 2026, at 1:46 p.m. confirmed that there was no documented evidence of communication between the dialysis facility and the facility because the facility does not send any paperwork back, and the facility does not have a contract with the dialysis center. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 30 residents reviewed (Residents 6, 10). Findings Include: The facility's policy regarding the use of psychotropic medications, dated January 27, 2026, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated January 15,2026, revealed that the resident was cognitively intact, received antianxiety and antidepression medications ( psychotropic medications), and had diagnoses that included dementia. Physician's orders for Resident 6, dated February 5, 2026, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every 6 hours as needed.There was no documented evidence in Resident 6's clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the Ativan. Interview with the Director of Nursing on February 12, 2026, at 11:53 a.m. confirmed that there was no documented evidence in Resident 6's clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the as needed Ativan.A Quarterly MDS for Resident 10 dated February 1, 2026, revealed that the resident was cognitively impaired, was receiving an antipsychotic, antianxiety and an antidepressant medication, and had diagnoses that included anxiety and depression.Physician's orders for Resident 10 dated May 14, 2025, included an order for the resident to receive 12.5mg Trazodone ( an antianxiety medication) twice a day.Physician's orders for Resident 10 dated May 28, 2025, included an order for the resident to receive 25mg trazodone twice a day.There was no documented evidence in Resident 10's clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the Trazodone or increasing the dose of Trazodone.Interview with the Director of Nursing on February 12, 2026, at 11:53 a.m. confirmed that there was no documented evidence in Resident 10's clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the Trazodone or increasing the dose of Trazodone. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and/or the resident's responsible party regarding the reason for transfer to the hospital for five of 33 residents reviewed (Residents 1, 29, 35, 54, 59). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 30, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others. A nursing note for Resident 1, dated July 18, 2024, at 2:30 p.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital. A nursing note for Resident 1, dated November 20, 2024, at 9:23 a.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital. A nursing note for Resident 1, dated November 23, 2024, at 6:23 a.m., revealed that Resident 1 was admitted with congestive heart failure (CHF). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS assessment for Resident 29 revealed that the resident was sometimes understood and could sometimes understand others. A nursing note for Resident 29, dated January 14, 2025, at 4:56 p.m., revealed that the writer was called to the resident's room at 4:46 p.m. due to a fall. The resident was lying on the floor face down parallel to his bed. The resident was yelling get me up! The resident had a small skin tear present on his left second finger; however, the resident did yell out in pain while leaning him forward. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate. A nursing note for Resident 29, dated January 15, 2025, at 3:07 p.m., revealed that the resident was going to be admitted to the hospital for 24-hour observation with diagnosis of altered mental status. There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. An admission MDS for Resident 35, dated May 8, 2024, revealed that the resident was sometimes understood and could sometimes understand others. A nursing note for Resident 35, dated July 31, 2024, at 8:06 a.m., revealed that the resident was resting in bed with his eyes closed. The resident was not easily arousable to verbal stimuli and staff had to use physical stimuli to awaken the resident. The resident was not verbal that a.m. and slightly confused, and was only oriented to self. The resident's right pupil was sluggish during the assessment. A nursing note at 9:12 a.m. revealed that the physician was aware, and orders were received to send the resident for a CT scan. A nursing note at 9:50 a.m. revealed that the resident was sent to the hospital for further evaluation. A nursing note at 2:25 p.m. revealed that the resident will be admitted for acute head injury with bleeding. There was no documented evidence that a written notice of Resident 35's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. Interview with the Director of Nursing on January 23, 2025, at 1:40 p.m. confirmed that there was no documented evidence that a written notice of Resident 29 and Resident 35's transfers to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the residents and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS for Resident 54, dated September 24, 2024, revealed that the resident was usually understood, could usually understand others, and was severly cognitively impaired. A quarterly MDS for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood and could sometimes understand others. A nursing note for Resident 54, dated December 6, 2024, at 7:57 p.m., revealed that the writer was called to the nursing desk due to a fall. The resident was witnessed to have fallen on his face from the wheelchair. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate. A nursing note for Resident 54, dated December 25, 2024, at 3:57 p.m. revealed that the writer was called to the the resident's room due to a change in condition. The resident was not acting right and was leaning to the right side. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluated. There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS assessment for Resident 59, dated December 26, 2024, revealed that the resident was moderately cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, and had diagnoses that included diabetes and heart disease. A nursing note for Resident 59, dated April 16, 2024, at 12:50 p.m., revealed that the resident had a fall and complained of pain in her forehead, knee, and left arm. The physician was notified, and the resident was sent to the hospital for an evaluation and was admitted . There was no documented evidence that a written notice of Resident 59's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital and/or the reason for hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of policies, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in resident care needs for four of 33 residents reviewed (Residents 8, 26, 53, 66). Findings include: The facility's policy regarding care plans, dated November 7, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia. A nursing note for Resident 8, dated June 21, 2024, revealed that the nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had used Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, use toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine. Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove creams kept at the bedside. As of January 22, 2025, there was no documented evidence that Resident 8's care plan was revised/updated to include that bedside creams should be removed. Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items. Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's care plan was not revised/updated to include that bedside creams should be removed. An admission MDS assessment for Resident 26, dated December 9, 2024, indicated that the resident was cognitively impaired, and that she was medicated with an anticoagulant (blood thinner). Physician's orders for Resident 26, dated December 3, 2024, included an order for the resident to receive 20 milligrams (mg) of Xarelto (blood thinner) daily until January 1, 2025, at which time the medication would be discontinued. Resident 26's care plan, dated December 9, 2024, revealed that the resident was medicated with a blood thinner. There was no documented evidence that Resident 26's care plan was updated to reflect the discontinuation of the blood thinner. An interview with the Director of Nursing on January 24, 2025, at 9:13 a.m. confirmed that Resident 26's care plan was not updated after the discontinuation of the blood thinner and it should have been. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, indicated that the resident was severely cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had a catheter related to the diagnosis of neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged resulting in difficulty urinating or incontinence). Clinical notes for Resident 53, dated June 3, 2024, indicated that while performing a.m. care the aide noted a tear of the penis meatus (opening for urine) with scant bleeding. A physician's order for Resident 53, dated June 4, 2024, included an order to cleanse the penis with soap and water, pat dry and apply bacitracin every shift for skin tear to the meatus (opening for urine). A current care plan indicated treatment to the residents skin tear was ongoing; however, physician orders indicated that the treatments were discontinued on November 6, 2024. Interview with the Director of Nursing on January 22, 2024, at 9:51 a.m. confirmed that Resident 53's care plan should have been updated to reflect that the treatments to the resident's penis were discontinued, and it was not. A quarterly MDS assessment for Resident 66, dated September 13, 2024, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had heart failure and hypertension (high blood pressure). A care plan dated July 5, 2024, revealed that Resident 66 was at risk for falls due to deconditioning, gait and balance problems, weakness and non-compliance with transfers and ambulation. A fall investigation for Resident 66, dated October 30, 2024, revealed that the resident had a fall from a high bed. The immediate intervention was to remove the bed remote out of reach from the resident. There was no documented evidence to indicate that the fall care plan was updated to reflect that the bed remote should be kept out of his reach. Interview with the Director of Nursing on January 22, 2025, at 9:51 a.m. confirmed that Resident 66's care plan should have been updated to reflect that the bed remote control should not be in reach, and it was not. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care and maintenance of intravenous catheters, failed to ensure that intravenous catheters were flushed according to facility policy, and failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for one of 33 residents reviewed (Resident 29). Findings include: The facility's policy regarding flushing peripheral catheter (a thin, flexible tube that is inserted into a vein to administer fluids, blood, or medications), dated November 7, 2024, indicated that peripheral intravenous (IV) catheters will be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications. Staff was to use the push-pause technique to instill the normal saline. Physician's orders for Resident 29, dated November 15, 2024, included an order for the resident to receive one gram (gm) of Meropenem (used to treat infections caused by bacteria) intravenously every six hours for a urinary tract infection for seven days. Physician's orders for Resident 29, dated November 15, 2024, and discontinued on November 24, 2024, included an order for the resident to receive a 10 milliliter (ml) normal saline flush every shift for IV maintenance until the completion of his antibiotic. Resident 29's Medication Administration Records (MAR's) for November 2024 revealed that there was no document evidence that staff administered the 10 ml normal saline flush during the dayshift on November 24, 2024, or during the evening shift on November 15, and 22, 2024. Resident 29's MAR's for November 2024 revealed that staff administered the IV Meropenem on November 15, 2024, at 8:00 p.m.; on November 16 through 21, 2024, at 2:00 a.m., 8:00 a.m., 2:00 p.m. and 8:00 p.m.; and on November 22, 2024, at 2:00 a.m., 8:00 a.m., and 2:00 p.m However, there was no documented evidence that staff flushed the resident's IV catheter with normal sterile saline solution before and after the administration of the Meropenem. A nursing note for Resident 29, dated November 27, 2024, revealed that the resident's IV catheter was removed at this time. However, there was no documented evidence that Resident 29's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed. Interview with the Director of Nursing on January 23, 2025, at 3:05 p.m. confirmed that there was no documented evidence that Resident 29's IV catheter was flushed with the 10 ml of normal saline during the dayshift on November 24, 2024, and during the evening shift on November 15, and 22, 2024; that there was no documented evidence that the resident's IV catheter was flushed with normal sterile saline solution before and after the administration of the Meropenem; and that there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 8). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia. A care plan, dated June 14, 2024, revealed that the resident was at risk for falls related to gait/balance problems, as well as a history of non-compliance with transfers and ambulation. The resident was an assist of one staff with a gait belt and a wheeled walker for her transfers. Nursing notes for Resident 8, dated June 15, 16, and 17, 2025, revealed that the resident had been observed self-ambulating and that despite much education to the resident by staff on the importance of ringing her call bell and waiting for staff assistance, the resident's non-compliance with self-transfers continues. A nursing note for Resident 8, dated June 26, 2024, revealed that the writer was called to the resident's room due to a fall. The resident had tried to self-ambulate to the bathroom and fell inside of the bathroom. There was no documented evidence that any new interventions to prevent the resident from self-transferring without staff assistance were initiated prior to Resident 8's fall on June 26, 2024. Interview with the Nursing Home Administrator and the Director of Rehabilitation on January 22, 2025, at 1:12 p.m. revealed that Resident 8 was on therapy case load for strengthening and balance training in attempts to get the resident back to being independent at that time. On June 11, 2024, the resident's transfer status was changed from being independent to being a one assist. The Nursing Home Administrator confirmed that the resident was educated by staff when they observed the resident self-transferring; however, there were no new and/or revised interventions to prevent the resident from self-transferring without staff assistance initiated prior to Resident 8's fall on June 26, 2024. A nursing note for Resident 8, dated June 21, 2024, revealed that a nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had taken Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) and was using it on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, used toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine. Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove bedside creams. As of January 22, 2025, there was no documented evidence that Resident 8's care plan was revised/updated to include that bedside creams should be removed. Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items. Interview with Nurse Aide 2 on January 22, 2025, at 2:44 p.m. confirmed that there were two tubes of Calmoseptine in Resident 8's plastic bin in her bathroom. She indicated that this morning the resident rang her call bell and when she responded to the call bell, she found that the resident had self-transferred to the bathroom. Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's Calmoseptine should not have been in the resident's room. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 33 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated December 5, 2024, revealed that the resident was cognitively intact and had diagnoses which included PTSD. A care plan for the resident, dated September 11, 2024, revealed that the resident had a potential for mood problems related to his PTSD. An interview with Resident 62 on January 22, 2025, at 10:38 a.m. revealed that he was a war veteran and that he had a terrible motor vehicle accident. He stated that he had some trauma from both of those life events. However, there was no documented evidence that the facility completed an assessment for a history of trauma for Resident 62 to identify specific triggers that could re-traumatize the resident. Interview with the Nursing Home Administrator on January 22, 2025, at 2:09 p.m. confirmed that there was no documented evidence of an assessment for a history of trauma being completed for Resident 62. 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 54). Findings include: The facility's policy for controlled substances, dated November 7, 2024, revealed that facility staff should document the time and day of administration, amount administered, and remaining quantity. Each dose of a medication shall be initialed on the Medication Administration Record (MAR) after the medication was actually administered. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood, and could sometimes understand others, required assistance with all care needs, and had diagnosis that included depression. Physician's orders for Resident 54, dated December 4, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a narcotic anxiety medication) every six hours as needed for restlessness for 14 days. Physician's orders for Resident 54, dated December 28, 2024, included an order for the resident to receive 0.5 mg of Ativan every six hours as needed for restlessness and anxiety for 30 days. Review of the December 2024 and January 2025 controlled drug records for Resident 54 revealed that 0.5 mg of Ativan was signed out on December 9, 2024, at 4:30 a.m.; December 11, 2024, at 11:00 p.m.,; and January 11, 2025, at 10:00 p.m. However, there was no documented evidence in Resident 54's clinical record, including the MAR, that the signed-out dose of the controlled medication was administered to the resident on the above-mentioned date and time. Interview with the Director of Nursing on January 24, 2025, at 12:15 p.m. confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of controlled medications mentioned above were administered to Resident 54. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending January 4, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 24, 2025, identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records. The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending January 4, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans. The facility's plan of correction for a deficiency regarding the pharmacy procedures, services, and records, cited during the survey ending January 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding pharmacy procedures, services, and records. Refer to F657 and F755. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed during wound care for one of 33 residents reviewed (Resident 53). Findings include: The facility's policy regarding wound care and hand washing/hand hygiene, dated November 7, 2024, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, revealed that the resident was severely cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, received hospice, had diagnoses that included multiple sclerosis and sacral wounds, and had a Stage 4 pressure ulcer (skin breakdown from pressure that exposes fat under the skin). Physician's orders, dated October 29, 2024, included an order to wash around the wound bed with water and antibacterial soap, pat dry, cleanse wound with a four by four (gauze sized four inches by four inches) soaked in 0.25 percent acetic acid solution, apply A and D ointment (a thick skin protective) to the peri wound, loosely pack wound bed and undermining with Aquacel Ag (a type of wound dressing that contains ionic silver), and cover with an abdominal pad and secure. Observations of Resident 53's wound care on January 23, 2025, at 11:15 a.m. revealed that Licensed Practical Nurse 3 washed her hands and put on a gown and gloves prior to placing a barrier on the bed and cleaning around the wound on the resident's sacrum with water and antibacterial soap. She then patted the area dry, cleaned the sacral wound with 0.25 percent acetic acid solution, patted dry, disposed of the barrier, removed her gloves, washed and dried her hands and donned new gloves, applied A and D ointment on the periphery of the wound, applied Aquacel Ag using a large Q-tip to press the dressing into the wound, and covered the wound with an abdominal pad and secured with tape. Licensed Practical Nurse 3 then touched the resident's skin below the dressing area, adjusted the resident's pillow and protective heal boots, and then used the bed controls to reposition the bed. Licensed Practical Nurse 3 then gathered the supplies, placed items into the garbage, removed her gloves, and washed her hands. Licensed Practical Nurse 3 did not remove her gloves and wash her hands after providing wound care and before adjusting Resident 53's pillow, protective heel boots, and bed controls. Interview with Licensed Practical Nurse 3 on January 23, 2025, at 11:36 a.m. confirmed that she did not remove her gloves and wash her hands after Resident 53's wound care and prior to providing care to the resident. Interview with the Director of Nursing on January 23, 2025, at 1:35 p.m. confirmed that Licensed Practical Nurse 3 should have removed her gloves and washed her hands prior to adjusting the pillow, protective heel boots, and bed controls, as that was considered moving from a dirty to a clean task. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for one of 33 residents reviewed (Resident 59). Findings include: A nursing note for Resident 59, dated March 16, 2024, indicated that the resident was transferred to the hospital and was being admitted after a change in condition. There was no documented evidence that the resident and/or the resident's representative were provided with written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) at the time of the transfer to the hospital. Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that there was no documented evidence that a written notice of the facility's bed hold policy was provided to Resident 59 and/or the resident's representative at the time of the resident's transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for two of 33 residents reviewed (Residents 53, 61). Findings include: The facility's policy titled admissions, dated November 7, 2024, revealed that the policy objective was to provide a safe, clean and homelike environment for residents within 72 hours of admission. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, revealed that the resident was severely cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, and had diagnoses that included sacral wounds and multiple sclerosis. Observations in Resident 53's room on January 24, 2025, at 1:00 p.m. revealed that an area on the dry wall behind the resident's bed, measuring approximately seven inches long by ten inches wide, with multiple scratches, gouges and nicks in it, and the paint was coming off in several areas. Interview with the Maintenance Director on January 24, 2025, at 1:10 p.m. confirmed that the dry wall in Resident 53's room was not homelike and needed repaired and painted. An admission MDS assessment for Resident 61, dated November 14, 2024, revealed that the resident was cognitively intact, had clear speech, was understood and could understand, required assistance with daily care needs, and had diagnoses that included depression and diabetes. A review of Resident 61's clinical record revealed that the resident was moved to a private room on October 1, 2024. Observations in Residents 61's room on January 21, 2025, at 12:06 p.m. and January 23, 2025, at 1:48 p.m. revealed an area of dry wall behind the resident's bed that measured approximately three inches wide by five feet long, with multiple scratches, gouges and nicks where the brown layer of dry wall was exposed and the paint was coming off. Interview with Nurse Aide 1 on January 23, 2025, indicated that the previous resident had padding on the wall for safety and the damage may be from when they removed the padding from the wall. Interview with the Maintenance Director on January 23, 2025, at 2:40 p.m. confirmed that the dry wall in Resident 61's room was not homelike and needed repaired and painted. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified about a resident ingesting perfume for one of four residents reviewed (Resident 2). Findings include: The facility's policy for Accident and Incident Investigation Procedures and Reporting, dated July 17, 2024, indicated that any incident (an unexpected, unintended event that causes or has the potential to cause bodily harm) will be reported immediately to the nursing supervisor on duty. The resident will be assessed, and the physician will be notified. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 20, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for her daily care needs, and had diagnoses of vascular dementia with behavioral disturbance. A nursing note for Resident 2, dated August 5, 2024, revealed that the resident was at the nurse's station and grabbed a tiny bottle of perfume that was placed at the nurses station by another resident. The nurse was preparing medications and noticed the resident grab the bottle of perfume and place it to her lips. The nurse grabbed the bottle of perfume from the resident immediately, noting that there was a tiny drop on the resident's lips and also presumed that a tiny sip was ingested by the resident. The nurse offered the resident a drink of water, but the resident refused. The registered nurse assessment indicated no gagging, nausea or vomiting, and vital signs were within the resident's normal limits. An attempt was made to contact the resident's guardian with no answer, and a message was left for a return call. There was no documented evidence in Resident 2's clinical record to indicate that the physician was notified about the ingestion of perfume on August 5, 2024. An interview with the Director of Nursing on September 11, 2024, at 12:29 p.m. confirmed that the physician was not notified about Resident 2 ingesting perfume on August 5, 2024, and should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings. Findings include: Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director or designee did not attend any meetings from April 2023 through December 2023. Interview with the Nursing Home Administrator on January 4, 2024, at 3:48 p.m. confirmed that there was no documented evidence that the Medical Director or designee attended any meetings in the last three quarterly meetings reviewed. Meetings were scheduled on days that the Medical Director rounded in the facility, but there was no documented evidence that his signature was obtained. 28 Pa. Code 201.18(e)(1)(2)(3) Management.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a criminal background check prior to hire for one of one temporary nurse aides (Temporary Nurse Aide 1). Findings include: The facility's policy regarding criminal background checks, dated August 18, 2023, indicated that the employee would be screened for a history of abuse using the state police criminal background check procedure. Results of the criminal background check must be available within 30 days from the hire date. The personnel file for Temporary Nurse Aide 1 revealed that she was hired on October 10, 2023, but as of January 4, 2024, there was no evidence that a criminal background check was completed. Interview with the Nursing Home Administrator on January 4, 2024, at 3:02 p.m. confirmed that there was no documented evidence that Temporary Nurse Aide 1 had a criminal background check. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for two of five residents reviewed (Residents 29, 279). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days. An annual comprehensive MDS assessment for Resident 29, with an ARD of November 21, 2023, was due to be completed by December 4, 2023, but was not signed as completed until December 5, 2023, which was one day from the ARD until completion. The RAI User's Manual, dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admitted plus 13 calendar days). An admission MDS assessment for Resident 279 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was incomplete as of January 4, 2024, which was 19 days after admission. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 4, 2024, at 4:05 and 4:37 p.m. confirmed that the above comprehensive and admission MDS assessments were not completed in the required time frame. 28 Pa. Code 211.5(f) Medical records.

Based on a review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to have adequate supervision and interventions in place to prevent elopement for six of six residents reviewed (Residents 1, 2, 3, 4, 5 and 6) who were identified as wanderers and at risk for elopement. The facility's failure created a situation which placed the residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. It was determined that the facility failed to monitor the temperature of hot liquids that were served to residents, resulting in a second degree burn for one resident (Resident 1) who was served coffee without a lid and it spilled. Findings include: The facility's policy regarding the Wanderguard system (an electronic monitoring system, specifically designed for cognitively impaired patients, that allows them to have the freedom to move about within the safety of the facility), dated April 9, 2021, revealed that it is the policy of the facility to provide a safe environment for residents who may be at risk for wandering from the unit without direct supervision. It is the purpose of the Wanderguard system to alert staff when a resident is exiting the unit and/or remind the resident through an alarm that he/she should have supervision. At any time that a resident is thought to be at risk for exiting their unit without supervision staff will apply a Wanderguard bracelet or anklet, the band must be loose enough not to interfere with circulation and not so loose that it will slip off. When the alarm sounds, alerting staff that a resident is attempting to exit the unit, the resident is to be redirected back onto the unit or accompanied off the unit with supervision. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 25, 2022, and a quarterly MDS assessment, dated May 25, 2022, revealed that the resident had diagnoses that included Alzheimer's disease, she could understand and was understood, had severe cognitive impairment, exhibited wandering behaviors on four to six days during the review period, required limited assistance from staff for her daily care tasks, and a Wanderguard/elopement alarm was used daily during the review period. A care plan for Resident 2, dated February 18, 2022, and revised March 21, 2022, revealed that the resident has an ADL self-care performance deficit and that she has been a walker in the community for years. She is very agile and fast with her movements and ambulation. Resident 2 is an elopement risk/wanderer related to being disoriented to place. She has impaired safety awareness and a history of attempts to leave the facility unattended. She wanders aimlessly, looking for her husband and trying to leave the unit. Staff was to disguise exits, cover door knobs and handles, distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. Wanderguard was to be worn for safety and exit seeking. Physician's orders for Resident 2, dated February 18, 2022, included an order for the resident to have a Wanderguard for safety and exit seeking. A Wandering Risk Scale for Resident 2 on admission, dated February 18, 2022, revealed that she was at a high risk to wander. A quarterly Wandering Risk Scale for Resident 2, dated May 13, 2022, revealed that she was at a high risk to wander. A progress note for Resident 2, dated February 18, 2022, revealed that the resident was admitted to the facility from personal care. She is reported to have episodes of wandering and trying to leave the personal care often and needed redirected. She was a resident there with her husband. A progress note for Resident 2, dated February 18, 2022, at 7:00 p.m. revealed that the resident is very focused on returning to her apartment and her spouse at personal care. A progress note for Resident 2, dated February 19, 2022, revealed that the writer spoke with the resident regarding how she is feeling with being in a new environment, and she stated Well, I feel fine. She is upbeat and positive but does express anxiety regarding her purse, wallet, and phone numbers that she does not have in her room with her. She stated that she cannot find them anywhere and that it is making her anxious. The personal care staff where she was admitted from stated that they are not aware of any of those items being left in her apartment and that the resident is most likely planning to leave and that is why she is looking for those items. The staff were alerted to the potential of the resident attempting to leave. A progress note for Resident 2, dated March 5, 2022, revealed that the resident was tearful at times during this morning shift, wandering around unit looking for the door to get out, and stated she needs to get out of here. A progress note for Resident 2, dated March 7, 2022, revealed that the resident was very restless this morning shift, very anxious and tearful, going to the doors on the unit and attempting to open them to get out to go to Willliamsburg. A progress note for Resident 2, dated March 8, 2022, revealed that the writer was notified by the licensed practical nurse that the Wanderguard alarm had sounded. Staff responded and observed the resident in the stairwell on the landing between floors. The resident was redirected and returned to nursing unit. A progress note for Resident 2, dated March 17, 2022, revealed that the resident has made several attempts to get onto the elevator to leave. A progress note for Resident 2, dated March 19, 2022, revealed that the resident was attempting to leave unit after she came back up from a visit with her daughter. The resident was pacing around unit stating to let her go, why am I here, and to just let me the hell out. The resident was pushing on the back doors trying to get out. A progress note for Resident 2, dated March 21, 2022, revealed that the resident was restless at times, set the door alarm off numerous times, and was ambulating in the hallway and attempting to go into other residents' rooms. A progress note for Resident 2, dated April 4, 2022, revealed that the resident was having increased anxiety this morning shift, pacing around the unit stating I don't know what to do, I don't know what I'm doing, and I need to get out of here. The resident attempted to get on the elevator. The resident was able to be redirected away from the elevator and continues pacing around unit. A progress note for Resident 2, dated April 6, 2022, revealed that the resident was having increased anxiety since the beginning of this morning shift, attempting to get on the elevator, and trying to put in numbers on the key pad by the elevator when the alarm sounds. The resident was continuously looking for the door to get out, was unable to be redirected, and continues getting agitated with staff and tearful at times. The resident was asking staff to open the window in the TV lounge so she can jump out. The resident was pacing up and down the halls on unit at this time. A progress note for Resident 2, dated April 8, 2022, revealed that the resident was moved to the South floor unit (a secured unit with a Wanderguard system) at 1:30 p.m. A progress note at 9:43 p.m. revealed that the resident was wandering all shift in the hallway, in and out of rooms, and exit seeking. Progress notes for Resident 2, dated April 10, 11, 12, 15, 26, and 27, 2022, and May 7, 2022, revealed that the resident had been wandering on the unit and exit seeking. A progress note for Resident 2, dated May 24, 2022, revealed that the South unit east door alarm sounded and staff went to check the door. There were no residents seen around the interior door or between the doors. The alarm to open the exterior door was silenced and no one was seen outside the building. Staff in the building were instructed to locate the resident because she had a history of wandering. A door-to-door search was started. The resident was last seen on the monitor at the nurses station around 9:05 p.m. sitting with another resident in the south lounge. The resident was unable to be located on the unit, the registered nurse was made aware, and the elopment process started. The facility investigation documents, dated May 24, 2022, revealed that at approximately 9:20 p.m. the exit door alarm at the end of South unit odd hall alarmed. Staff checked the area between the doors and outside; however, there was no one noted. Nursing staff confirmed that all but two residents were present on the unit. Resident 2 and another resident were unable to be located. At 9:41 p.m. the residents were located approximately 0.25 miles away from the facility. Resident 2 was placed on 15-minute checks. A progress note for Resident 2, dated June 13, 2022, revealed that the Interdisciplinary Team and floor nursing staff noted that the resident has not been making exit seeking attempts or statements about wanting or trying to exit the facility. Will discontinue the 15-minute checks and continue with Wanderguard. A progress note for Resident 2, dated July 6, 2022, revealed that the resident was noted to be tearful this shift and had multiple episodes of wandering. The resident continues to leave room without assistance or use of call bell after putting her in bed. The door chime and Wanderguard were intact. A progress note for Resident 2, dated July 14, 2022, revealed that her COVID antigen test results were positive. The resident was transferred to the BDN (COVID positive) unit (a non-secured unit without a Wanderguard system) for isolation. A progress note for Resident 2, dated July 15, 2022, revealed that the resident was sitting in her wheelchair at the nurses station, awake and alert with usual confusion noted. A progress note for Resident 2, dated July 16, 2022, at 3:04 a.m. revealed that the resident was sitting in her wheelchair at the nurse's station eating a snack. She was in bed for the majority of shift until about ten minutes ago and refused to go back to bed at this time. The facility's investigative documents, as well as a progress note for Resident 2, dated July 16, 2022, at 7:38 p.m. revealed that Registered Nurse 1 went into room 96 to help the licensed practical nurse do a toilet transfer with another resident. Registered Nurse 1 and Licensed Practical Nurse 2 were in room 96 for approximately three minutes. When Registered Nurse 1 came out of room 96, she noticed that Resident 2 was not sitting in her wheelchair at the nurse's station as she was prior to assisting with the toilet transfer. At this time, the unit search began and the resident was unable to be located on the unit. The Registered Nurse Supervisor was notified. A perimeter search was started immediately per facility protocol. The resident was wearing a light blue top with a black zip-up jacket over it, black slacks, light blue socks and green sketchers rubber sole sneakers. A progress note at 9:30 p.m. revealed that the resident was safely brought back to unit at this time, accompanied by the registered nurse supervisor. A full head-to-toe assessment was completed. The resident was awake and alert with baseline confusion noted. The resident denied any pain or discomfort and was able to move all extremities without difficulty. No abnormalities of extremities were noted, and no injuries were noted at this time. The resident is currently sitting in room with licensed practical nurse completing 1:1 direct supervision to maintain safety of resident. A progress note at 10:10 p.m. revealed that the resident's daughter called back. It was explained to the daughter that her mom exited the facility through a hallway door that was located near Central High School and was returned by local police after a nurse on foot discovered from bystanders the direction that the resident was going and relayed it to the officer. Her mom was very upset for about 20 minutes and was comforted by staff. An Emergency Medical Services (EMS) referral was made by the officer as a precaution, who cleared the resident after an assessment. The resident was then given a head-to-toe assessment, which was negative for any injury. The daughter asked how she was able to exit, given that she wears a Wanderguard. It was explained that three of the four patient areas in the facility have the Wanderguard system installed, but the BDN unit does not. that her mom has not displayed any exit-seeking behaviors for past six weeks, and that 1:1 line of sight observation of her mom would be provided until she returns to the South Unit (a secured unit with a Wanderguard system). Census information for Resident 2, dated July 22, 2022, revealed that the resident was moved from the BDN unit (a non-secured unit without a Wanderguard system) back to the South unit (a secured unit with a Wanderguard system). A witness statement completed by Registered Nurse 1, dated July 16, 2022, revealed that she went in to a room to help Licensed Practical Nurse 2 transfer another resident. She was in room 96 for approximately three minutes, then went back to the nurse's station to work on the 8:00 p.m. medication pass. When she came out she noticed that Resident 2 was not sitting in her wheelchair at the nurse's station as she was prior to helping in room 96. She alerted Licensed Practical Nurse 2, who alerted the registered nurse supervisor. A perimeter search was started as per facility protocol. A witness statement completed by Licensed Practical Nurse 2, dated July 16, 2022, revealed that she was providing care for another resident and needed Registered Nurse 1 to assist. Registered Nurse 1 and Licensed Practical Nurse 2 were in the resident's bathroom for approximately two to three minutes. The resident was uncooperative with care and was a two-person assist for transfers. Once the resident was safely in her wheelchair, Registered Nurse 1 left to check the other residents. Registered Nurse 1 yelled into the room that Resident 2 could not be located on the unit. The registered nurse supervisor was called and a search of the building and outside was immediately initiated per facility protocol. A statement completed by the Nursing Home Administrator, dated July 16, 2022, revealed that she was notified of Resident 2's elopement at 7:56 p.m. by the registered nurse supervisor. At 8:25 p.m. she arrived at the front entrance. Law enforcement was present with Resident 2, informed that the resident was without obvious injury, but EMS had been contacted to confirm that she was without injury. At 8:45 p.m. law enforcement escorted the Nursing Home Adminstrator from the port of exit (ground level exit door) to the location where Resident 2 was found. The total distance was 1.1 miles. An EMS transfer of care form for Resident 2, undated, revealed that a dementia patient escaped and fell a few times, was gone 30 minutes, and normally has a confused mental state. Interview with the Nursing Home Adminstrator on July 29, 2022, at 9:08 a.m. revealed that during the facility's morning meeting on July 13, 2022, it was determined that an alarm was needed on the BDN unit (a non-secured unit without a Wanderguard system) due to an increase in the population from the facility's South unit (a secured unit with a Wanderguard system). A Daily Interdisciplinary Team Meeting, dated July 13, 2022, revealed that a barrier/alarm was needed for wandering residents on the BDN unit. A maintenance request form, dated July 13, 2022, revealed that a Mr. Chime (DA4D-a passive infrared motion detector that senses the infrared energy emitted by a person or object crossing through its field of view) was installed on the double smoke doors (made to stop smoke from spreading into fire escape routes) on the BDN unit. Manufacturer's directions for the Mr. Chime, undated, revealed that before permanently mounting the unit, temporarily tape the mounting bracket in place with ordinary adhesive tape, then slide the switch on the DA4D to on. Walk through the protected area and the DA4D should chime, then cease. After the DA4D has been tested and aligned, then permanently install it. Turning the DA4D to Data Code #1 the alert will be a ding [NAME]. Data Code #3 the alert will chirp. Observations on the BDN unit on July 29, 2022, at 8:56 a.m. revealed that the unit currently had no residents. There were double smoke doors that were closed with an alarm mounted on the top of the door jam. The alarm ding [NAME] sounded when walking towards the door and ceased once through the door. After walking through the smoke doors there was a short hallway that led to double glass doors that exited to the outside and had an alarm mounted to the top of the door jam. Interview with the Chief Executive Officer on July 29, 2022, at 9:20 a.m. revealed that as long as he has been there the double glass doors on the BDN unit were never alarmed and that this unit was never meant for residents identified as wanderers. He indicated that the doors were not locked because that was how staff entered the facility when they were working on the BDN unit when it was the Red Zone (COVID care unit). Interview with the Maintenance Director on July 29, 2022, at 10:05 a.m. revealed that the double glass doors that exit to the outside had been alarmed when the BDN unit was part of the facility's personal care a long time ago. He indicated that the alarm above the doors had been deactivated a long time ago. It was brought up in morning meeting that an alarm was needed, and the Mr. Chime alarm was suggested. Interview with Registered Nurse 1 on July 29, 2022, at 10:25 a.m. revealed that she went in to assist Licensed Practical Nurse 2 with another resident and Resident 2 was sitting in her wheelchair in the hallway across from the nurse's station. She indicated that they had the resident's bathroom door shut for privacy. The window air conditioner unit was on in the room and they were talking with the resident. They heard no alarms while they were in the room. Registered Nurse 1 indicated that she was in the room approximately three minutes and when she came out of the room she noticed that Resident 2 was not in her wheelchair. She checked the rooms beyond the double smoke doors. When she went through the double smoke doors the alarm did chime. There were no alarms sounding when she came out of the room. When she did not see Resident 2 in any of the rooms she went back and told Licensed Practical Nurse 2 that Resident 2 was missing. She checked the other rooms and then called the registered nurse supervisor. She indicated that she was not sure if she might have jinxed them, because she was speaking with a coworker the evening before and said that she was surprised how well Resident 2 was doing since she had eloped from the facility once before. Interview with Licensed Practical Nurse 2 on July 29, 2022, at 12:28 p.m. revealed that she was going into room 96 to toilet the resident and that Registered Nurse 1 had to come in to assist her with the resident because she was an assist of two. Prior to going into room 96 she saw Resident 2 in her wheelchair in the hallway across from the nurse's station. The bathroom door was closed, the air conditioner in the room was on, and the resident was yelling and slightly uncooperative with the care. She indicated that they did not hear any alarms while they were in room 96. Once they got to a point to where she could take care of the resident, Registered Nurse 1 said that she better leave so she could check the other residents. After leaving she came back and said that Resident 2 was missing. A quarterly MDS assessment for Resident 1, dated June 3, 2022, indicated that the resident was confused, walked with limited assistance from staff, used a wheelchair, had a wander alarm, and had diagnoses that included a stroke, Alzheimer's, and dementia. Physician's orders, dated April 30, 2021, included an order for the resident to have a Wanderguard applied to his wheelchair every shift for elopement behaviors. A care plan, dated May 4, 2021, revealed that the resident was an elopement/wander risk related to impaired safety awareness (trying to exit unit without staff) and was to use a wanderguard. A wandering risk scale for Resident 1, dated June 5, 2022, revealed that the resident was at high risk for wandering. A nursing note for Resident 1, dated June 13, 2022, at 10:17 p.m. revealed that the resident was moved to the COVID unit. A nursing note for Resident 1, dated June 13, 2022, at 10:33 p.m. revealed that the resident was noted to be wandering in his wheelchair and attempting to exit seek. Census information revealed that the resident returned to the South unit (secured unit) on July 21, 2022. A quarterly MDS assessment for Resident 3, dated June 17, 2022, indicated that the resident was confused, walked with supervision from staff, had a wander alarm, and had diagnoses that included a stroke and dementia. Physician's orders for Resident 3, dated February 11, 2022, included an order for the resident to have a Wanderguard for safety. A care plan, dated February 23, 2021, revealed that the resident had impaired safety awareness and a history of wandering/elopement, and was to use a Wanderguard. A wandering risk scale for Resident 3, dated June 24, 2022, revealed that the resident was at high risk for wandering. A nursing note, dated July 14, 2022, at 1:22 p.m. revealed that the resident tested positive for COVID-19 and was moved to the COVID unit. A nursing note, dated July 21, 2022, at 5:31 a.m. revealed that the resident was wandering in other resident's rooms. Census information revealed that the resident returned to the South unit on July 22, 2022. A quarterly MDS assessment for Resident 4, dated May 6, 2022, indicated that the resident was confused, had wandering behaviors, walked with limited assistance from staff, had a wander alarm, and had diagnoses that included Alzheimer's and dementia. Physician's orders for Resident 4, dated November 7, 2020, included an order for the resident to have a Wanderguard for safety. A care plan, dated June 17, 2020, revealed that the resident was an elopement/wander risk related to history of attempts to leave the facility unattended and wanting to go home, and was to use a Wanderguard. A wandering risk scale for Resident 4, dated May 7, 2022, revealed that the resident was at high risk for wandering. A nursing note for Resident 4, dated July 9, 2022, at 9:30 p.m. revealed that the resident tested positive for COVID-19 and was moved to the COVID unit. A nursing note, dated July 17, 2022, at 8:30 a.m. revealed the resident was moved back to the South unit. A quarterly MDS assessment for Resident 5, dated April 20, 2022, indicated that the resident was confused, had wandering behaviors, walked with limited assistance from staff, had a wander alarm, and had diagnoses that included dementia. Physician's orders for Resident 5, dated February 21, 2021, included an order for the resident to have a Wanderguard for safety. A care plan, dated November 13, 2020, revealed that the resident was an elopement/wander risk related to impaired safety awareness, cognitive deficits, and comments made about going home, and going towards the exits. A wandering risk scale for Resident 5, dated June 3, 2022, revealed that the resident was at high risk for wandering. A nursing note for Resident 5, dated July 9, 2022, at 9:30 p.m. revealed that the resident was moved to the COVID unit due to testing positive for COVID-19. A nursing note, dated July 17, 2022, at 9:08 a.m. revealed that the resident was moved back to the South unit. An annual MDS assessment for Resident 6, dated May 24, 2022, indicated that the resident was confused, walked with extensive assistance from staff, used a wheelchair, had a wander alarm, and had diagnoses that included dementia. Current physician's orders for Resident 6 included an order for the resident to have a Wanderguard to her wheelchair at all times. A care plan, revised December 15, 2021, revealed that the resident was an elopement/wander risk. She frequently self propels her wheelchair around the unit looking for her dad and had impaired safety awareness. A wandering risk scale for Resident 6, dated May 6, 2022, revealed that the resident was at high risk for wandering. A nursing note for Resident 6, dated July 12, 2022, at 7:52 a.m. revealed that the resident was moved to the COVID unit due to testing positive for COVID-19. A nursing note, dated July 26, 2022, at 10:00 a.m. revealed the resident was moved back to the South unit. A progress note for Resident 2, dated July 16, 2022, revealed that the resident was placed on 1:1 direct supervision. A Daily Interdisciplinary Team Meeting, dated July 22, 2022, revealed that education was provided to the unit managers and nurse supervisors regarding the monitoring on residents who are at risk for elopement on the BDN unit. A message posted to the facility's electronic medical record system, dated July 22, 2022, revealed that monitoring residents who are at risk for elopement on BDN unit will be as follows: If there is a two-person assist and assigned staff are in the room, staff from BDN must call the registered nurse supervisor to monitor the door if no one is assigned. On July 29, 2022, at 2:25 p.m. the Nursing Home Adminstrator was given the Immediate Jeopardy template and informed that the health and safety of Residents 1, 2, 3, 4, 5 and 6 was placed in Immediate Jeopardy due to the failure to ensure that supervision and adequate interventions were in place to prevent elopements while on an unsecured unit. Interview with the Nursing Home Adminstrator on July 29, 2022, at 2:45 p.m. revealed that she presented education to staff during the morning meeting on July 22, 2022, as well as had the education placed onto the electronic medical record system that when staff are assigned to the BDN unit they need to call the supervisor whenever they need to leave the unit or both have to go into a room to care for a resident. She began audits on July 22, 2022, and completed one prior to the unit's closing on July 26, 2022, when all of the residents had recovered from COVID. An immediate action plan was submitted and contained the following: Upon return of Resident 2 to the facility, the resident was placed on a one to one staffing pattern. The facility directed that when the BDN unit was being utilized as a COVID unit, all residents upon transfer into the unit, would be assessed for their wandering risk. Nursing staff assigned to the BDN (COVID) unit will coordinate their assignments to ensure a staff member is available to monitor the exit doors at all times. This may require the supervisor to report to the BDN (COVID) unit when all staff are working at the bedside. On July 22, 2022, during morning meeting, education was provided to department managers and a notice was placed in the electronic medical record system to alert all nursing staff. This notice was removed from the electronic medical record system on July 29, 2022. On July 22, 2022, a memo was issued to the registered nurse supervisors related to wandering risk assessments when utilizing the BDN (COVID) unit. On July 22, 2022, an auditing process was initiated to confirm compliance with the BDN unit as a COVID unit. The Immediate Jeopardy was lifted on July 29, 2022, at 5:02 p.m. when it was confirmed that the unsecured unit was closed and that all residents who were at risk for wandering or elopement were secure. A quarterly MDS assessment for Resident 1, dated June 3, 2022, indicated that the resident was confused, required supervision from staff with eating after his meal was set up, and had diagnoses that included a stroke, Alzheimer's, and dementia. An incident note for Resident 1, dated June 21, 2022, at 10:13 a.m. revealed that at 10:00 a.m. the housekeeping staff yelled for the registered nurse after witnessing the resident spill his coffee that he just received from activities. The registered nurse noted a dark pink area measuring 15.0 x 10.0 centimeters (cm). A nursing note for Resident 1, dated June 22, 2022, at 6:16 a.m. revealed that the resident had a burn on his left upper thigh that measured 9.0 x 3.5 cm with blistering noted. A facility investigation report for Resident 1, dated June 21, 2022, revealed that the activities staff served coffee and cookies in the hallway by the nurse's station and the resident spilled the coffee onto his left thigh. There was a dark to medium colored pink area to the upper thigh measuring approximately 10.0 x 15.0 cm. There was no documented evidence of the temperature of the coffee at that time. A witness statement from Activity Staff 3, undated, confirmed that she gave Resident 1 a cup of coffee without a lid and told the resident to be careful because the coffee was hot. Interview with the Director of Nursing on July 29, 2022, at 3:24 p.m. and 4:21 p.m. revealed that the facility's practice was to not serve anything above 165 degrees Farhenheit and that there was no documented evidence that Activity Staff 3 took the temperature of the coffee before serving it to Resident 1. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review facility investigation reports, staff education materials and records, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide care using adequate assistance devices to prevent accidents for one of five residents reviewed (Resident 1), resulting in the resident experiencing a fall and fractures. Findings include: The facility's education materials for nurse aides, provided to each nursing staff member upon hire and annually, indicated that staff were to always use a gait belt with each transfer. Education records for Nurse Aide 1 revealed that she signed that she received education regarding the facility's gait/transfer belt use policy on June 19, 2020, and education regarding the facility's abuse policy and fall prevention policy on June 19, 2020. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 2, 2020, revealed that the resident was cognitively impaired, required the extensive assistance of two staff for transfers and toileting, and was only able to stabilize herself with staff assistance. The resident's care plan, updated July 2, 2020, revealed that she required one staff member, a gait belt, and a wheeled walker for transfers. Resident 1's Kardex (a document that contains information regarding her care), undated, indicated that she was to have a gait belt in use with all transfers and assisted ambulation (walking). An incident note for Resident 1, dated August 10, 2020, revealed that the resident was sitting on her recliner chair when Nurse Aide 1 attempted to stand her and transfer her into her wheelchair. The resident fell to the floor, landing on her knees. X-ray reports, dated August 10, 2020, revealed that Resident 1 had a non-displaced fracture of the left distal fibula (bone in the lower leg). The facility's investigation documents included a written statement by the Director of Nursing, dated August 10, 2020, which indicated that Nurse Aide 1 did not use a gait belt when transferring Resident 1. An interview with the Director of Nursing on August 20, 2020, at 9:30 a.m. confirmed that Nurse Aide 1 did not use a gait belt when transferring Resident 1 and she should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, agency training records, information submitted by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of one residents reviewed (Resident 1), which resulted in a [MEDICAL CONDITION] for the resident. Findings include: The facility's policy regarding abuse and neglect, dated (MONTH) 5, 2019, indicated that neglect was defined as the failure to provide goods or services necessary to avoid physical harm. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 14, 2019, indicated that the resident was cognitively impaired and required the extensive assistance of two persons for transfers. physician's orders [REDACTED]. persons and a manual turner (a device used to assist the resident to stand, be turned, and to transfer). Resident 1's care profile (information included in the facility's electronic documentation system as a guide to resident care for nurse aides), updated (MONTH) 9, 2019, indicated that the resident transferred with the assistance of two persons and a manual turner. Information submitted by the facility, and incident investigation information, dated (MONTH) 19, 2019, indicated that Nurse Aide 1, who was employed by an agency, was working independently with Resident 1 to transfer the resident from the toilet to a wheelchair. As the resident was being seated on the chair, she began sliding off the edge of the seat. Nurse Aide 1 attempted to stop the resident from sliding but was unable to and lowered the resident to the floor. The resident was transferred to the hospital for an evaluation of left hip pain, had an x-ray of the left hip, and returned to the facility. A hospital x-ray report for Resident 1, dated (MONTH) 19, 2019, indicated that the possibility of a non-displaced subcapital [MEDICAL CONDITION] hip could not be excluded and to consider further evaluation. A CT scan (computer-aided diagnostic imaging) dated (MONTH) 21, 2019, revealed that the resident had a left [MEDICAL CONDITION]. The investigation report concluded that Nurse Aide 1 failed to transfer Resident 1 with the assistance of two staff and the use of a manual turner, and the resident fell during the transfer. Nurse aide documentation for Resident 1, dated (MONTH) 16-19, 2019, reflected that Nurse Aide 1 documented that on (MONTH) 16, 2019, at 7:37 p.m., the resident was transferred with the assistance of one; on (MONTH) 17, 2019, at 7:17 p.m. the resident was transferred with the assistance of two; and on (MONTH) 19, 2019, at 9:22 a.m. the resident was transferred with the assistance of two. A written statement from Nurse Aide 1, dated (MONTH) 19, 2019, indicated that she did not ask how Resident 1 transferred because it was her first daylight shift and another nurse aide, who did not work on the resident's unit, told her that the resident was a one assist. There was no documented evidence in Nurse Aide 1's statement that she consulted Resident 1's care plan or the charge nurse for direction regarding the resident's transfer status. Agency training records, dated (MONTH) 20, 2019, revealed that Nurse Aide 1 completed competencies (skills testing to demonstrate the knowledge and ability to perform a skill or task) on accident prevention, resident transfers and body mechanics, and mechanical lift transfers. Facility training records, dated (MONTH) 16, 2019, revealed that Nurse Aide 1 received training regarding the facility's abuse policy. Interview with the Director of Nursing on (MONTH) 29, 2019, at 3:40 p.m. confirmed that Nurse Aide 1 was educated by the agency that employed her regarding accident prevention and resident transfers, and that she transferred Resident 1 by herself and without the use of the manual turner, although she documented on (MONTH) 17 and 19, 2019, that the resident required the assistance of two to transfer. The Director of Nursing indicated that if the nurse aide was unsure of the resident's transfer status, she should have consulted the charge nurse or the resident's care plan instead of other staff who were not assigned to care for the resident. Interview with Nurse Aide 1 on (MONTH) 6, 2019, at 1:30 p.m. revealed that on (MONTH) 19, 2019, she transferred Resident 1 from the toilet to her wheelchair without the assistance of another staff and the manual turner. The resident slid off the wheelchair and had to be lowered to the floor. The nurse aide indicated that she was aware to check the care plan and/or to check with the charge nurse regarding transfer status, but checked with other staff who were not assigned to the resident. 42 CFR 483.12(a)(1) Free from Abuse and Neglect. Previously cited 7/18/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/18/19, 6/20/19, 5/17/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited cited 7/18/19, 6/20/19, 5/17/18.

Based on review of facility policies, information submitted by the facility, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of one residents reviewed (Resident 1), resulting in corporal punishment, mental abuse and verbal abuse, with psychosocial harm for the resident. Findings include: The facility's abuse policy, dated (MONTH) 2, 2019, indicated that abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that residents would be kept free of and protected from any form of physical, verbal, mental or sexual abuse by any employee or agent of the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 1, 2019, indicated that the resident was confused, had clear speech, was usually understood and could sometimes understand others, had a history of [REDACTED]. Resident 1's care plan, dated (MONTH) 14, 2019, indicated that she had a history of [REDACTED]. Facility investigation documents, dated (MONTH) 24, 2019, indicated that Nurse Aides 1 and 2 were working together to provide a whirlpool bath for Resident 1, and Nurse Aide 1 placed a blanket over the resident's head, stating it was to prevent the resident from hitting them. Nurse Aide 2 questioned the appropriateness of the blanket being placed over the resident's head. Nurse Aide 1 also placed medical gloves on the resident's hands. Neither of these interventions were included in the resident's care plan for combativeness toward staff during care. The resident was transported by the staff to the tub and the bath was initiated. The resident was reported to be combative and poked Nurse Aide 1 in the eye, at which point Nurse Aide 1 referred to the resident as a psycho. Nurse Aide 2 stated that as the resident was being lifted out of the tub, Nurse Aide 1 used the spray hose and directed the water at the resident's mouth and continued this action two to three more times. The investigation indicated that the facility viewed the actions of Nurse Aide 1 as gross misconduct and terminated her employment. Review of orientation and training records revealed that Nurse Aide 1 was hired on (MONTH) 8, (YEAR), and received training regarding resident rights and resident abuse, including prevention, recognition, investigating, and reporting, several times and most recently on (MONTH) 23, 2019. A written statement from the Medical Records Coordinator, dated (MONTH) 24, 2019, indicated that on that date she was walking through the nursing unit and heard Resident 1 yelling in the whirlpool room, and then heard Nurse Aide 1 yell back, Ouch, you psycho! A written statement from Nurse Aide 1, dated (MONTH) 24, 2019, indicated that on that date, she and Nurse Aide 2 were bathing Resident 1, and the resident poked her in the eye. She indicated that the resident had soap around her mouth and neck and she used the spray hose to spray it off. The resident did not seem to like the hose, and she jokingly used the spray hose near the resident's mouth two or three more times when the resident spit on them. A written statement from Nurse Aide 2, dated (MONTH) 24, 2019, indicated that on that date, she helped Nurse Aide 1 get Resident 1 ready for a whirlpool tub bath, and when they put the resident in the whirlpool chair Nurse Aide 1 placed a blanket over her head and said it was to keep the resident from hitting them. Nurse Aide 2 indicated that after getting the resident into the whirlpool the resident was spitting at them, and Nurse Aide 1 used the hose and sprayed water in the resident's mouth several times, until the resident started coughing from it, and Nurse Aide 1 also called the resident a psycho during the bath. Interview with Nurse Aide 1 on (MONTH) 16, 2019, at 2:30 p.m. revealed that she was aware that Resident 1 was not alert and oriented and was always combative with care. She stated that during the tub bath on (MONTH) 24, 2019, she used the spray hose to spray soap off the resident's neck and mouth, and she was not going to admit to anything. Interview with the Director of Nursing on (MONTH) 16, 2019, at 3:25 p.m. revealed that Nurse Aide 1 should have followed Resident 1's care plan and stopped providing care when Resident 1 became combative. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/20/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/20/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/20/19, 5/17/18. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/20/19. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/20/19, 5/17/18, 5/18/17.

Based on review of facility policies, investigation reports, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received adequate supervision to prevent falls for one of 46 residents reviewed (Resident 86), resulting in a fall with a fracture for the resident; failed to ensure resident safety during transportation in a wheelchair for two of 46 residents reviewed (Residents 45, 76); and failed to ensure that call bells were within reach for one of 46 residents reviewed (Resident 62) who had limited mobility and a history of falls. Findings include: The facility's undated policy regarding pressure and tab alerts (a device that sounds when a resident attempts to get up unassisted) revealed that when a resident was ordered an alarm to prevent falls, then the resident should not be left alone when using the toilet. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 86, dated (MONTH) 28, (YEAR), revealed that the resident could understand and be understood, and required limited assistance from one staff for bed mobility, transfers, ambulation (walking) in and out of the room, and toilet use. Initial physical and occupational therapy evaluations for Resident 86, dated (MONTH) 22, (YEAR), revealed that the resident had mild deconditioning following a hospital stay, required minimum assistance for gait and transfers, had decreased safety awareness which limited her ability to independently and safely complete mobility skills, and was at risk for falls. The resident's care plan, dated (MONTH) 25, (YEAR), revealed that she had a self-care deficit and was at risk for falls, and staff were to encourage her to use the bell to call for assistance and were to anticipate and meet the resident's needs. physician's orders [REDACTED]. belt (a heavy-duty fabric belt placed around the resident's waist and used by staff to help the resident sit, stand or walk); that staff were to ensure that the resident's call light was within reach and encourage the resident to use it for assistance; and that the resident needed prompt response to all requests for assistance. Nursing notes for Resident 86, dated (MONTH) 16, (YEAR), revealed that at 6:40 p.m. a nurse found the resident lying on her right side by her recliner with her feet facing toward her bathroom. The resident stated she was having pain in the right lower leg, and the right leg was noted to be externally rotated with a hematoma (a collection of blood outside the blood vessels) forming to the right anterior (outer surface) lower leg. A new physician's orders [REDACTED]. At 10:25 p.m., the hospital notified the facility that the resident was admitted with a [MEDICAL CONDITION] lower leg. A nursing note, dated (MONTH) 17, (YEAR), revealed that the facility was informed that the resident was to have surgery for [REDACTED]. A witness statement completed by Nurse Aide 6, dated (MONTH) 17, (YEAR), revealed that she was with Resident 86 five minutes prior to the incident. The resident was in the bathroom, she gave the resident her call bell, and then she left the resident unattended while using the toilet. Interview with Nurse Aide 7 on (MONTH) 18, 2019, at 3:42 p.m. revealed that if a resident was ordered a pressure alarm and was capable of ambulating, staff will place a gait belt and assist the resident into the bathroom, then stay with the resident until he/she is done. The nurse aide indicated that this has been the process for the entire time she has worked at the facility, which was [AGE] years. Interview with the Staff Development Coordinator on (MONTH) 18, 2019, at 3:55 p.m. revealed that if a resident is ordered an alarm, then staff are to assist the resident into the bathroom and are not to leave the resident unattended. Interview with the Director of Nursing on (MONTH) 19, 2019, at 9:20 a.m. confirmed that Nurse Aide 6 failed to follow the facility's policy and should not have left Resident 86 alone in the bathroom. A quarterly MDS assessment for Resident 45, dated (MONTH) 16, 2019, revealed that the resident was cognitively intact and required extensive assistance from staff for care. The resident's care plan, dated (MONTH) 10, (YEAR), indicated that she had a self-care deficit due to limited mobility and a history of falls. Observations of Resident 45 on (MONTH) 17, 2019, at 10:47 a.m. revealed that she was in her wheelchair being pushed by Nurse Aide 5. The wheelchair did not have leg rests in place and the resident was holding her legs up off the floor during the transport. There was no documented evidence that an assessment was completed to determine if it was safe to transport Resident 45 in a wheelchair without leg rests. An interview with Nurse Aide 5 on (MONTH) 17, 2019, at 10:48 a.m. confirmed that Resident 45 did not have leg rests on her chair because she did not have any. An annual MDS assessment for Resident 76, dated (MONTH) 6, 2019, revealed that the resident was cognitively impaired and required assistance for care. The resident's care plan, dated (MONTH) 25, (YEAR), indicated that he had a self-care deficit due to limited physical mobility. Observations of Resident 76 on (MONTH) 17, 2019, at 11:20 a.m. revealed that he was being pushed in his wheelchair by Nurse Aide 4. There were no leg rests on the wheelchair and Resident 76's feet were sliding on the floor. Interview with Nurse Aide 4 at that time confirmed that leg rests were to be used when transporting residents in a wheelchair and she did not have a reason for not using them. Interviews with the Director of Nursing and the Director of Therapy Services on (MONTH) 19, 2019, at 2:00 p.m. confirmed that Residents 45 and 76 should have had leg rests on their wheelchairs while being transported in them by staff. The facility's policy regarding call bells, dated (MONTH) 2, 2019, indicated that the residents' call bells were to be placed within their reach. A [DIAGNOSES REDACTED]. The resident's care plan, most recently reviewed on (MONTH) 13, 2019, revealed that the resident was at risk for falls, had a fall on (MONTH) 13, 2019, and was to have his call bell in reach at all times. Observations of Resident 62 on (MONTH) 17, 2019, at 9:40 a.m. revealed that he was sitting in his recliner chair and his tap bell was behind his chair on his overbed table, which was not within his reach. Interview with Nurse Aide 8 on (MONTH) 17, 2019, at 9:47 a.m. confirmed that Resident 62 fell recently, was capable of using his call bell, and that it should have been placed within his reach. Interview with the Director of Nursing on (MONTH) 17, 2019, at 1:37 p.m. confirmed that Resident 62's call bell should have been in reach. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/17/18. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/17/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 5/17/18. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/18, 5/18/17.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for one of 27 residents reviewed (Resident R9). Findings include: The facility's policy regarding weighing residents and reporting significant weight changes, dated 4/17/14, indicated that if a weight loss of five or more pounds was noted between weights, staff were to verify the weight loss in the presence of the charge nurse and then report the loss to the physician, dietitian, and the resident's responsible party. A quarterly resident assessment, dated 1/29/14, for Resident R9 revealed that the resident was confused at times, could make herself understood, required assistance with all of her care and had experienced an unintended significant weight loss. Her weight was 104 pounds (a decrease of seven pounds in 30 days). A nutritional assessment completed by the dietitian on 1/29/14 revealed that the resident was at risk for malnutrition, her weight would be monitored closely, and her nutritional supplement would be increased if the weight loss continued. Following this weight loss, there was no documented evidence that the physician was notified or that new weight management strategies were implemented. An annual resident assessment, dated 4/16/14, identified that the resident experienced another unintended significant weight loss. Her weight was recorded as 96 pounds (a decrease of 15 pounds in 90 days). A nutritional assessment completed by the dietitian on 4/25/14 revealed that the resident was now considered to be malnourished. Following this second significant weight loss, there was no documented evidence that the physician was notified or that new weight management strategies were implemented. Interview with the Dietitian on 5/8/14 at 10:40 a.m. revealed that she became aware of the resident's weight loss while doing the quarterly assessment in January 2014. She stated that she placed the resident on her "Nutritional Alert List" but could offer no documented evidence that the physician was made aware of the weight loss. Interview with Nurse Aide 14 on 5/8/14 at 11:30 a.m. revealed that she did not inform anyone of the resident's weight loss over the past several months. Nurse Aide 14 also stated that the resident's nutritional supplements had not changed since her admission. Interview with Licensed Practical Nurse 8 on 5/8/14 at 11:30 a.m. confirmed that she was not aware that the resident had been losing weight or she would have notified the dietician and the physician. Interview with the Director of Nursing on 5/8/14 at 11:50 a.m. confirmed that the resident had experienced significant weight loss and that no new weight management strategies had been implemented to prevent further loss. 28 Pa. Code 211.12 (d)(3) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 7/23/13.