Every finding on record at Mt Hope Nazarene Retirement Community

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 14 residents reviewed (Residents 8 and 40). Findings include: Review of facility policy, titled Comprehensive Care Plan, last revised June 10, 2024, read, in part, The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental, emotional, and psychosocial wellbeing. Care Plans will be revised as information about the resident and the resident's condition changes. The Interdisciplinary Team is responsible for the review and updating of the care plans. Review of Resident 8's clinical record revealed diagnoses that included jaw pain, anxiety disorder (a persistent feeling of worry, nervousness, or unease), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 8's care plan revealed an activities care plan that had not been updated since October 21, 2022. Further review of Resident 8's activities care plan revealed an intervention for I prefer to dine in the lounge or dining hall, initiated on October 21, 2022. Observation of Resident 8 on September 3, 2024, at 11:57 AM, revealed she was sitting in her room, eating lunch in her recliner. Observation of Resident 8 on September 4, 2024, at 12:04 PM, revealed she was sitting in her room, eating lunch in her recliner. Interview with Employee 1 (Nurse Aide) on September 5, 2024, at 9:52 AM, revealed Resident 8 has been eating in her room since she came here. Interview with Resident 8 on September 5, 2024, at 9:55 AM, revealed she has been eating in her room since she admitted to the skilled nursing facility from her cottage in 2022, because of her issues with her jaw and she can't wear her dentures. Interview with the Director of Nursing (DON) on September 5, 2024, at 11:54 AM, revealed he would expect Resident 8's care plan to be updated to reflect that she prefers to dine in her room. Review of Resident 40's clinical record revealed diagnoses of post-traumatic stress disorder (PTSD-a mental and behavioral disorder that can develop after a person experiences or witnesses a traumatic event) and generalized anxiety disorder (a mental health condition that causes people to feel excessive, irrational, and uncontrollable worry about everyday things for months or years). Review of Resident 40's electronic medical record revealed the diagnosis of post-traumatic stress disorder was added to her medical diagnoses on October 24, 2023. Review of Resident 40's care plan on September 3, 2024, revealed a care plan with a focus area of, I have a mood problem related to depression, anxiety, vitamin D deficiency and PTSD, with a date initiated of October 12, 2023. No triggers for Resident 40's PTSD were found on the care plan. Interview with the Nursing Home Administrator on September 4, 2024, at 1:20 PM, revealed that Resident 40's PTSD triggers were identified at the time of Resident 40's admission and should have been added to the care plan. 28 Pa. Code 211.10(d)(a) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed for limited range of motion (Resident 9). Findings include: Review of facility policy, titled Restorative Nursing Program (RNP), last revised June 2024, read, in part, Restorative care is promoted to enable residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. A licensed nurse shall be appointed as the Restorative Nurse to oversee, coordinate and monitor the RNP. A Certified Nursing Aid will be appointed as the Restorative Aide to implement programs put in place by the restorative nurse. The Restorative Aide will complete task documentation as indicated by program requirements. Review of Resident 9's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side (a condition where a stroke has caused paralysis or weakness on one side of the body), and pain in left ankle. Review of Resident 9's care plan revealed a focus area I have limited physical mobility related to weakness, hemiplegic affecting left side, initiated on February 21, 2024, with interventions for three restorative nursing programs, initiated on February 21, 2024. Further review of Resident 9's care plan revealed a focus area that read, in part, I have an activities of daily living self-care performance deficit related to dementia, history of falling, muscle weakness, initiated on January 10, 2024, with interventions for two nursing restorative programs, initiated on February 21, 2024 Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Active Range of Motion Program #1 Standing at hall rail with gait belt remind to straighten posture every day shift 7-3. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 4, 10, 12, 21, 23, and 24, 2024; April 1, 7, 12, 20, 21, 24, and 28, 2024; May 2, 4, 16, 22 and 27, 2024; June 15 and 16, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 7 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Active Range of Motion Program Using 2# free weight, do right shoulder press, chest press, bicep curls, forearm pro/supination, wrist flex/extension. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 4, 10, 12, 23, and 31, 2024; April 7, 12, 20, and 28, 2024; May 2, 4, 16, and 27, 2024; June 2 and 16, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Dressing/Grooming Program #1 Give washcloth in right hand to wash face, chest and left hand. Cue to lift right arm for sleeve of clothing. Cue to lift right leg for pant leg, sock and shoe. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on March 16, 2024, and April 12, 2024. The task documentation was left completely blank on May 26, 2024, and August 12, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Transfer Program #1 provide minimum assist to contact guard assistance for stand pivot transfer to bed, toilet, wheelchair. Transfer to [Resident 9's] right side when able. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 12 and 23, 2024; April 7, 12, and 28, 2024; May 3, 4, 16 and 27, 2024; July 3, 2024; and August 11, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 8, 2024. Review of Resident 9's nurse aid task documentation starting in February 2024, revealed a task for Nursing Rehab/Restorative Walking Program #1 Left lower extremity bracing and gait belt with wheelchair following and cueing for sequencing with quad cane. 50-70' with contact guard assistance/minimum assist. Further review of the nurse aide task documentation revealed Resident 9 was marked not applicable under the minutes and tolerance documentation on February 25, 2024; March 10, 12, 23, 24, 30 and 31, 2024; April 6, 7, 10, 12, 14, 20, 21, 27 and 28, 2024; May 2-4, 15, 16, 22, and 27, 2024; June 1,2, 5, 9, 13, 16, 22, 29 and 30, 2024; July 7, 19, and 31, 2024; and August 4, 6, 11, and 24, 2024. The task documentation was left completely blank on March 8, 2024; May 1 and 26, 2024; June 6 and 28, 2024; July 1 and 10, 2024; and August 5 and 8, 2024. Interview with the Director of Nursing on September 5, 2024, at 10:34 AM, revealed he was unable to locate documentation to indicate Resident 9's restorative programs were implemented or that he had refused them on the aforementioned dates. No further information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of one of 13 residents reviewed (Resident 45). Findings include: Review of facility policy, titled Continuous Positive Airway Pressure [CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing] disinfecting, effective June 24, 2019, revised October 1, 2023, read, in part, orders to clean and sanitize CPAP machines will be placed into the resident's treatment administration record. Review of Resident 45's clinical record documented they were admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe), asthma (a condition in which a person's airway becomes inflamed, narrow, and swells, and produce extra mucus, which makes it difficult to breathe), anxiety (a feeling of worry, nervousness, or unease), and depression (feelings of severe despondency and dejection). Additionally, on November 2, 2023, the diagnosis of obstructive sleep apnea (intermittent airflow blockage during sleep) was added. Observation on October 31, 2023, at 9:25 AM, in Resident 45's room revealed, on the top of the dresser to the right of the recliner, was a CPAP machine, and the mask was uncovered and resting on the floor. During an interview with Resident 45 on October 31, 2023, at 9:29 AM, it was revealed that she utilizes a CPAP machine and is able to manage use of and care of the machine herself. It was revealed that she brought 2 gallons of water from home and also fills the humidifier herself. Continued discussion revealed that the tubing hasn't been changed, the mask hasn't been cleaned, and that she didn't have a bag to store the mask in between use. Observation with Employee 1 (Licensed Practical Nurse) on October 31, 2023, at 1:23 PM, in Resident 45's room revealed the CPAP mask was on the floor in front of her dresser, to the right of her recliner. During an interview with Employee 1 on October 31, 2023, at 1:24 PM, it was revealed that the CPAP mask should be in a plastic bag. It was further reveled that Employee 1 would obtain a bag and let Resident 45 know how to properly store the mask in the bag. Review of Resident 45's September 2023 and October 2023 physician orders and treatment administration records failed to document orders for use of a CPAP machine or cleaning of the CPAP machine. Review of hospital emergency after visit summary dated September 26, 2023, read, in part, to continue use of ResMed with Modem CPAP 10 cm (unit of measure) water, mask, supplies, heated humidifier, compliance data, and small dream [NAME] nasal mask. Review of progress note dated September 27, 2023, (a Wednesday) at 1:40 PM read, in part, Resident post ER for dizziness and headache. No complaint of headache at this time. Resident said she feels dizzy occasionally throughout the shift. And that the oxygen that she wears at night helps a lot. Resident is to receive her CPAP machine Friday per resident. Review of Cardiology consult dated September 22, 2023, documented to continue durable medical equipment -ResMed with Modem CPAP 10cm water, mask, supplies heated humidifier, compliance data, and small dream [NAME] nasal mask, LON99. During an interview with the Nursing Home administrator and Employee 2 (Registered Nurse) Infection Preventionist on November 1, 2023, at 9:40 AM, it was revealed that Resident 45 was admitted to the facility from another skilled Nursing Care facility, and the discharge summary didn't include use of a CPAP machine. It was further revealed that Resident 45's family brought her personal belongings from her home, and the facility didn't realize that Resident 45 had a CPAP machine. It was also revealed that the staff missed the CPAP on the hospital summary and the cardiology consult. Further, it was revealed an order for use of the CPAP should've been obtained and the Resident provided with supplies and educated on the care and storage of the machine and mask. 28 Pa code 211.12(d)(1)(2)-Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of 13 residents reviewed (Resident 23). Findings Include: Review of Resident 23's clinical record revealed diagnoses that included chronic diastolic heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly) and essential hypertension (high blood pressure). Review of Resident 23's Admission MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated July 8, 2023, revealed that Section O0100, Special Treatments, Procedures, and Programs (K. Hospice Care, 1. While not a resident of this facility and within the last 14 days) was marked No. Review of a Promedica Revocation of Hospice Benefit document dated October 10, 2023, revealed that Resident 23 started hospice care on April 3, 2023, and revoked hospice on October 10, 2023. Written communication received from Employee 3 (Registered Nurse Assessment Coordinator) on November 1, 2023, revealed that Section O was marked in error and has since been amended to reflect Resident 23 was receiving hospice services prior to coming into the facility. Interview with the Nursing Home Administrator and Director of Nursing on November 2, 2023, at 12:05 PM, revealed that they would have expected Section O. K. Hospice care to have been captured on the MDS completed on July 8, 2023. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observations and staff interview, it was determined that the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances, orally or in writing; the right to file grievances anonymously; the contact information of the grievance official, with whom a grievance can be filed, including his or her name, business address (mailing and email), and business phone number, for two of two resident areas reviewed (First and Second floors) and review of the facility's admission packet. Findings Include: Observations on the first and second floors, on November 14, 2022, at 9:48 AM, and November 15, 2022, at 10:52 AM, revealed no information posted regarding the facility's designated greivance official or the required information, to include the name and contact information. Review of the facility's admission packet revealed no documentation of the designation of a grievance official or the required information, to include the name and contact information. An interview with the Nursing Home Administrator, on November 16, 2022, at 10:43 AM, revealed she and the Director of Social Services handle grievances for the facility. No information regarding an established grievance official or his or her contact information was provided at the time of the survey. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, and adult protective services, in a form and manner accessible and understandable to residents / resident representatives for two of two resident areas observed (First and Second Floors). Findings Include: Observations on the facility's first and second floors, on November 15, 2022, at 11:32 AM, revealed postings on behalf of residents did not include the required State agencies and advocacy groups elements, including mailing and email addresses. An interview with the Nursing Home Administrator, on November 16, 2022, at 10:38 AM, revealed the facility has created documents for posting with the required information that will presently be available for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on document review and staff interview, it was determined that the facility failed to ensure each resident is informed periodically during the resident's stay of services available in the facility and charges for those services, including any charges for services not covered under Medicare/Medicaid, for two of three residents reviewed at the end of their Medicare A stay (Residents 13 and 32). Findings Include: Review of Resident 13's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form (SNF-ABN) revealed the Resident was discharged from Medicare A skilled services on August 20, 2022. According to the SNF-ABN, Resident 13 would be responsible for the facility's rate of charges not covered under Medicare or Medicaid. Further review of the SNF-ABN reveled Resident 13, nor the Resident's Responsible Party were informed of the charges no longer covered. Review of Resident 32's SNF-ABN revealed the Resident was discharged from Medicare A skilled services on May 17, 2022. According the the SNF-ABN, Resident 32 would be responsible for the facility's rate of charges not covered under Medicare or Medicaid. Further review of the SNF-ABN revealed Resident 32, nor the Resident's Responsible Party were informed of the charges no longer covered. An interview with Employee 2 on November 14, 2022, at 11:37 AM, revealed she historically has not documented or discussed the facility's daily rate of non-covered services, post Medicare A coverage, with the Residents and/or their responsible parties. The interview also revealed the charges would be discussed going forward. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on policy review, observation, record review, and interviews, it was determined that the facility failed to conduct regular inspections of bed rails/enabler bars to identify areas of possible entrapment for three of three residents reviewed (Residents 18, 20, and 46). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record documented diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body). Interview with Resident 18 on November 13, 2022, at approximately 12:02 PM, it was revealed that she utilized the enabler bars on both sides of the bed to assist her to stand and transfer in and out of bed, and for bed mobility. Further review of Resident 18's clinical record revealed an order for bilateral enabler bars, with an order date of November 14, 2022. Review of progress notes revealed a health status note dated November 14, 2022, at 2:26 PM, documenting order received for bilateral enabler bars, and a message was left for the Resident Representative to return the Director of Nursing's call. Review of health status note dated November 15, 2022 at 8:05 AM, documented that verbal consent was received from Resident Representative approving Resident 18 to utilize enabler bars. Review of Resident 18's initial enabler bar screenings was dated December 30, 2016, and enablers were indicated for use. Review of Resident 18's care plan and kardex documented use of enabler bars to assist with bed mobility. Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of available information provided by the facility and contained in Resident 20's clinical record revealed no documented measurements of entrapment zones as a result of the use of bed enablers. Review of Resident 46's clinical record revealed diagnoses that included muscle weakness and hypertension (elevated blood pressure). An observation of Resident 46, on November 13, 2022, at 9:35 AM, revealed bilateral enabler bars attached to the bed. Continued review of Resident 46's clinical record revealed a document titled Enabler Bar Screener dated September 27, 2022. The form documents the enabler bars are indicated for use at that time. Further review of Resident 46's clinical record revealed the facility obtained an order for the use of the bilateral enabler bars on November 15, 2022. Interview with the Nursing Home administrator (NHA) on November 15, 2022, at approximately 9:00 AM, it was revealed that the facility does not utilize side rails, they utilize only enabler bars. The facility utilizes only certain style enabler bars, small enough to not cause concerns with entrapment. It was also revealed that the facility does not conduct routine or initial safety measurements. NHA was not aware that measurements of the enabler bars, in relation to the 5 zones of entrapment, was required for enabler bars. It was also revealed that approximately 36 residents utilize enabler bars. It was also noted that, if a resident transfers to another room, the bed moves with them. However, enabler bars are removed from bed frames when they are not utilized or appropriate, and are attached to bed frames as needed. 28 Pa. Code 205.71 Bed and furnishings

Based on observation, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure the development and implementation of a comprehensive plan of care for one of 13 residents reviewed (Resident 20). Findings include: Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of Resident 20's comprehensive plan of care revealed that enabler bars were not included in the comprehensive plan of care. On November 16, 2022, at 9:30 AM, a facility document was reviewed regarding the application of bilateral enabler bars to Resident 20's bed. Review of the document revealed that on August 19, 2022, facility therapy department evaluated Resident 20 due to a decline in ability to perform activities of daily living. The document stated that as a result of the assessment, Therapy determined that the resident needed bilateral enabler bars, Therapy asked maintenance to place enabler bars on the resident's bed, Maintenance placed enabler bars on resident bed as requested. Enabler bars were placed on bed the week of August 22nd [2022] through August 26th 2022. Review of Resident 20's documented Care Conference (multidisciplinary team meeting to discuss changes to a resident's plan of care with the resident and/or resident representative), revealed that Resident 20 had a Care Conference held on September 16, 2022 (prior Care Conference conducted July 29, 2022), due to Resident 20 having a significant change in condition. Review of Care Conference documentation, specifically the Nursing and Rehabilitation/Therapy services sections, revealed that the addition of bilateral enabler bars was not addressed by any discipline in attendance. Specifically, Rehab Summary, stated, Resident requires max encouragement to participate in skilled [physical therapy] treatment sessions to increase [bilateral lower extremity] strength, ambulation and safe transfers. Finally, review of Resident 20's clinical record revealed no documented evidence that the risks and benefits of bilateral enabler bars was discussed and informed consent was obtained for their use for Resident 20. On November 15, 2022, the facility submitted documentation to the State Survey agency that demonstrated the addition of bilateral enabler bars to Resident 20's comprehensive plan of care, which were added on November 14, 2022. 28 Pa code 211.11(a)(d) Resident care plan

Based on policy review, observation, record review, and interviews, the facility failed to complete a risk benefit analysis and obtain consent for use of an enabler bar for three of three residents reviewed (Residents 18, 20, and 46). Findings include: Review of facility policy Enabler Bar, effective date December 10, 2021, read, in part, enabler bar assessment will be completed upon admission and if the resident has a change in condition. Verbal/written consent will be obtained from resident or resident representative, and emergency contact will be called to obtain verbal/written consent. Review of Resident 18's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply), epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hemiparesis (paralysis of one side of the body). Interview with Resident 18 on November 13, 2022, at approximately 12:02 PM, it was revealed that she utilized the enabler bars on both sides of the bed to assist her to stand and transfer in and out of bed, and for bed mobility. Further review of Resident 18's clinical record revealed an order for bilateral enabler bars, with an order date of November 14, 2022. Review of progress notes revealed a health status note dated November 14, 2022, at 2:26 PM, documenting order received for bilateral enabler bars, and a message was left for the Resident Representative to return the Director of Nursing's call. Review of Health status note dated November 15, 2022, at 8:05 AM, documented that verbal consent was received from Resident Representative approving Resident 18 to utilize enabler bars. Review of Resident 18's initial enabler bar screenings was dated December 30, 2016, and enablers were indicated for use. Surveyor requested a copy of the consent for use of enabler bars for Resident 18, and was provided a signature page dated December 30, 2016, verifying that the pamphlet Working Together for Safety (education regarding the hazards of side rail usage) was provided to the Resident and/or Resident Representative. Review of Resident 20's clinical record on November 13, 2022, at approximately 11:30 AM, revealed diagnoses including unspecified dementia (irreversible, progressive degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). During observations on November 13, 2022, Resident 20 was observed lying in bed with bilateral enabler bars affixed to the Resident's bed frame. Review of Resident 20's clinical record on November 13, 2022, at approximately 3:00 PM, revealed that Resident 20's most recent enabler bar assessment (assessment tool utilized to determine if a resident is a candidate for the safe use of enabler bars) was completed on October 11, 2017. Review of Resident 20's clinical record revealed no assessment for enabler bar since. Review of Resident 20's physician orders revealed no physician order for the bilateral enabler bars. Review of Resident 20's comprehensive plan of care revealed that enabler bars were not included in the comprehensive plan of care. On November 16, 2022, at 9:30 AM, a facility document was reviewed regarding the application of bilateral enabler bars to Resident 20's bed. Review of the document revealed that on August 19, 2022, facility therapy department evaluated Resident 20 due to a decline in ability to perform activities of daily living. The document stated that as a result of the assessment, Therapy determined that the resident needed bilateral enabler bars, Therapy asked maintenance to place enabler bars on the resident's bed, Maintenance placed enabler bars on resident bed as requested. Enabler bars were placed on bed the week of August 22nd [2022] through August 26th 2022. Review of Resident interdisciplinary progress notes for the time period of August 10, 2022, to August 26, 2022, revealed no facility staff member documented the installation of bed enablers to Resident 20's bed frame. Review of Resident 20's documented Care Conference (multidisciplinary team meeting to discuss changes to a resident's plan of care with the resident and/or resident representative), revealed that Resident 20 had a Care Conference held on September 16, 2022 (prior Care Conference conducted July 29, 2022), due to Resident 20 having a significant change in condition. Review of Care Conference documentation, specifically the Nursing and Rehabilitation/Therapy services sections, revealed that the addition of bilateral enabler bars was not addressed by any discipline in attendance. Specifically, Rehab Summary, stated, Resident requires max encouragement to participate in skilled [physical therapy] treatment sessions to increase [bilateral lower extremity] strength, ambulation and safe transfers. Review of Resident 20's clinical record revealed no documented evidence that the risks and benefits of bilateral enabler bars was discussed and informed consent was obtained for their use for Resident 20. During staff interviews on November 14, 2022, the facility Nursing Home Administrator (NHA) and Director of Nursing (DON) was informed of the observations of bilateral enabler bars on Resident 20's bed, the lack of a physician's order for the bilateral enabler bars, the lack of inclusion of bilateral enabler bars in Resident 20's comprehensive plan of care, and the lack of an assessment dated after October 11, 2017, for the use of enabler bars. On November 15, 2022, the facility submitted documentation to the State Survey agency which included a physician's order, dated November 14, 2022 for Resident 20's bilateral enabler bars; an assessment for the safe use of the enabler bars, dated November 14, 2022; and the addition of bilateral enabler bars to Resident 20's comprehensive plan of care, dated November 14, 2022. Review of Resident 46's clinical record revealed diagnoses that included muscle weakness and hypertension (elevated blood pressure). An observation of Resident 46, on November 13, 2022, at 9:35 AM, revealed bilateral enabler bars attached to the bed. Continued review of Resident 46's clinical record revealed a document titled Enabler Bar Screener dated September 27, 2022. The form documents the enabler bars are indicated for use at that time. Further review of Resident 46's clinical record revealed the facility obtained an order for the use of the bilateral enabler bars on November 15, 2022. An interview with the DON on November 15, 2022, at 9:38 AM, revealed the Resident/Responsible Party are notified of the risks and benefits at the time of admission. Review of Resident 46's clinical record revealed no documentation of a review of the risks/benefits of enabler bar use at the time of the screening and indication for use. Interview with the NHA on November 15, 2022, at approximately 9:00 AM, it was revealed that the facility provides the residents and/or resident representatives information about the risks and benefits of utilizing enabler bars at the time of admision, and a consent is signed at that time. 28 Pa. Code 205.71

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure accuracy of the resident assessment for one of 13 residents reviewed (Resident 29). Findings include: Review of Resident 29's clinical record on November 13, 2022, at approximately 1:00 PM, revealed diagnoses including diabetes mellitus type 2 (disease in decreases the body's ability to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 29's quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), with an assessment reference date of September 21, 2022, revealed in section N0300 Injections, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days, was coded as 0 indicating Resident 29 had received no injections during the 7 days prior to September 21, 2022. Further, due to assessment response in Section 0300 Injections, Sections N0350 Insulin, subsection A, Insulin injections - Record the number of days that insulin injections were received ., and subsection B, Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days . were subsequently disabled, indicating that the Resident did not receive any insulin injections during the prior 7 days leading up to September 21, 2022. Review of Resident 29's physician orders and Medication Administration Record for the month of September, 2022, revealed that during the 7 day assessment period leading up to the September 21, 2022, assessment date, Resident 29 received insulin injections on 7 of 7 days. During a staff interview on November 14, 2022, at approximately 1:00 PM, the facility was informed of the identified discrepancy with Resident 29's quarterly MDS with an assessment reference date of September 21, 2022. During a staff interview on November 15, 2022, at approximately 11:00 AM, Director of Nursing confirmed that Resident 29's aforementioned MDS was incorrect and that the facility had reviewed the MDS and submitted a corrected assessment. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on observation, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to be treated with respect, dignity, and care in a manner that promotes maintenance or enhancement of his or her quality of life for one of 13 residents reviewed (Resident 46). Findings Include: Review of the facility's policy, titled Quality of Life and Dignity for Resident, recently reviewed October 1, 2022, reads, in part, The resident has the right to a dignified existence. Also, A facility must treat each resident with respect and dignity and care .in a manner and environment that promotes maintenance or enhancement of his or her quality of lie. Review of Resident 46's clinical record revealed diagnoses that included retention of urine (a condition in which you are unable to empty all the urine from your bladder) and hypertension (elevated blood pressure). Continued review of Resident 46's clinical record revealed the need for the use of an indwelling foley catheter ( a common type of indwelling catheter. It has soft, plastic or rubber tube that is inserted into the bladder to drain the urine). An observation of Resident 46, on November 13, 2022, at 9:37 AM, revealed the catheter bag to be uncovered with observed urine in the catheter bag. The catheter bag was found to not be covered to ensure privacy and dignity. An inteview with the Director of Nursing, on November 15, 2022, at 11:22 AM, revealed that the catheter bag cover was sent to the laundry for cleaning and not available for use to cover the catheter bag at the time of the observation. 28 Pa. Code 201.29 (j) Resident Rights

Based on observations, facility documentation, policy review, and staff interviews, it was determined that the facility failed to ensure multi-use medications were dated upon opening for one of two medication storage carts reviewed (second floor medication cart one of two). Findings include: Review of facility policy titled, Med[ication] Pass Policy, initial date March 1, 2012, last reviewed date October 24, 2022, revealed section 1. Documentation, stated, White dots that are on eye drops, ear drops, liquids, injectables, are there so that the nurse who first opens/uses the medication has a place to document his/her initials and the date and time. Unit dose boxes should have the nurse's initials and date and time that the box was opened. The Medication Administration Record (MAR) needs to be marked when a new box, bottle, inhaler, etc. is started. Place a mark with a colored marker on the day/time space when the container has been opened- this is for accountability purposes. PRN [as-needed] medications must have documentation on the front and back of the MAR. You must indicate initials, date, time, and reason for use and effectiveness. Review of the facility's clinical records, including the Medication Administration Record system, revealed that, at the time of the survey, the facility utilized an electronic Medication Administration Record and that the policy indicated a process to document using a Medication Administration Record that was hard-copy (physical sheets of paper utilized to document medication administration and/or nurses notes). During medication administration observations on November 14, 2022, at approximately 10:20 AM, Facility Employee 3 was observed preparing medications to be administered to Resident 45. During the observation, Facility Employee 3 retrieved polyvinyl alcohol 1.4% eye drops for administration. Observations of the polyvinyl alcohol 1.4% eye dropper revealed that it was previously opened. Observations revealed no open date was recorded on the pharmacy bag that contained the eye drops, nor on the container of eye drops. Observations of medication cart one of two for the second floor unit on November 15, 2022, at approximately 1:00 PM, revealed two insulin injector pens that were opened and partially used. Both insulin injector pens had stickers placed by pharmacy for the purpose of recording the date opened, the expiration date of the medication, and the nurses' initials upon opening. Neither insulin pens observed had open dates, nor nurses' initials recorded on the sticker. Observations of Resident 45's polyvinyl alcohol 1.4% drops were also made and revealed that there was still no open date listed on the eye drop or the pharmacy bag that contained the eye drops. At the time of the observation, Facility Employee 3 confirmed that there was no open date on the eye drops; at which time Facility Employee 3 utilized the electronic health record to identify when the eye drops were delivered to the facility. Facility Employee 3 then recorded that date on eye drop container. During a staff interview on November 15, 2022, at approximately 1:15 PM, Director of Nursing (DON) observed the two identified insulin pens and confirmed the absence of a date to identify when the pens were initially opened for use. During the interview, DON revealed that the insulin pens should have had a date that they were opened along with the initials of the nurse that opened them included on the sticker identified for such purpose. During a staff interview on November 16, 2022, at approximately 10:30 AM, the DON was made aware of the observations of Resident 45's eye drops that did not have an open date during medication administration and subsequent observations. During the staff interview, DON revealed that the facility was preparing to increase medication cart checks that are performed by the consulting pharmacist. 28 Pa code 211.9(h) Pharmacy services 28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on observation, product manufacturer label, and facility policy review, it was determined that the facility failed to ensure a medication rate of less than 5 percent. Findings include: Based on observation of 34 medication opportunities, three medication errors were identified, which equated to an error rate of 8.82 percent. Review of facility policy titled, Med[ication] Pass Policy, last reviewed October 24, 2022, revealed that section 3. Medication Administration stated, Inhalers - wait one minute between puffs . During medication administration observations on November 14, 2022, at approximately 10:20 AM, Facility Employee 3 was observed preparing medications to be administered to Resident 45. During the observation, Facility Employee 3 retrieved polyvinyl alcohol 1.4% eye drops for administration. Observations of the polyvinyl alcohol 1.4% eye dropper revealed that it was previously opened. Observations revealed no open date was recorded on the pharmacy bag that contained the eye drops, nor on the container of eye drops. Facility Employee 3 was observed administering the eye drops to Resident 45 at approximately 10:23 AM. During medication administration observations on November 15, 2022, at approximately 9:30 AM, Facility Employee 4 was observed preparing medication to be administered to Resident 8. During preparation, Facility Employee 4 was observed preparing Breo 100 mcg/25 mcg (combination inhalation medication used to treat respiratory disease). Facility Employee 4 also prepared Combivent 20 mcg/100 mcg (combination inhalation medication used to treat respiratory disease). Finally, Facility Employee 4 was observed preparing one packet Metamucil in water for administration to Resident 8. Review of the manufacturer's box for the Breo medication was a sticker with the instructions to allow one full minute after administration of the Breo before administering further inhalation medication. Observation revealed that Facility Employee 4 administered Resident 8's Breo inhalation medication first and then Combivent inhalation medication, with approximately 10 second between each medication and did not allow for a full minute between administrations. Further observation of the medication administration reveled that Resident 8 did not finish the full amount of Metamucil. Facility Employee 4 left the remaining amount of Metamucil on Resident 8's bedside table and left the room and did not observe the complete consumption of the Metamucil. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 16 residents reviewed (Resident 30). Findings include: Review of Resident 30's physician's orders [REDACTED]. Review of Resident 30's clinical record failed to reveal a PT/INR obtained on December 6, 2019. Interview with the Director of Nursing on February 20, 2020 at approximately 12:30 p.m. confirmed that the facility failed to obtain Resident 30's PT/INR as ordered by the physician. 28 Pa. Code 211.5(f) Clinical record. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observations, staff interview and facility documentation, it was determined that the facility failed to assure that resident's dignity was maintained to one out of three residents reviewed. (Resident R3) Findings include: Review of Resident R3's clinical record indicated that her current [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set :a periodic assessment of resident needs) revealed that the resident was scored an 8 on the BIMS (Brief Interview for Mental Status a test for cognitive ability) indicating moderately impaired thinking/reasoning ability. Interview conducted on December 5, 2017 at approximately 9:45 a.m. with the Nursing Home Administrator and Director of Nursing revealed that as part of the quality assurance project the facility was monitoring the development of excoriation on resident. The resident's incontinence briefs were marked on the inside of the closure tab to check that residents were being changed regularly. This quality assurance project did not target specific residents or specific staff members who provided care. The NHA and the DON confirmed during the interview that a resident was marked with a pen marker to determined if through care was being provided. Both the NHA and the DON stated that they became aware of the resident being marked with a pen at the time that the Area Office of Aging visited the facility to investigate this allegation approximately a month previously. The DON determined by staff interview that one nurse had used a marker near Resident R3's under arm to assure that she was being washed regularly. Interview with Employee E7, the Director of Social Services on December 5, 2017 at approximately 1:00 p.m. revealed that she had heard about the instance of a resident being marked to check care and agreed that that was a resident concern. The DON related that she had counseled the employee involved but was not able to provide any incident investigation documentation, counseling documentation or staff education to assure that the employee involved understood that however well meaning, marking the resident to determine if care was provided compromised this resident's dignity. F241 483.10(a)(1) Dignity Previously cited 12/27/16 28 Pa. Code 201.29 (j) Resident rights

Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to inform the physician of a change in a the skin condition of one of 13 residents reviewed (Resident CL1). Findings include: Review of the facility policy for Change in Condition Documentation revised date: September 15, 2015; revealed that a change in a resident condition is to be communicated in an expedient/immediate manner. A change in condition may also include but not limited to: resident fall, injury, abnormal lab results, change in physical, mental or psychosocial status, deterioration in health and or mental status in either life threatening conditions or clinical complications, discovery of medication error, new consultation reports, new orders, and death of a resident. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the physician's orders for admission revealed that the right arm was to remain in a sling at all times and the right arm was non weight bearing. Review of Resident CL1's therapy notes for July 10, 2016 revealed that the resident complained her right elbow bothered her during the therapy session. The sling was carefully removed by the nurse and therapist to view the elbow and found a reddened area. Upon further investigation a nursing note dated on July 13, 2016 state that therapy found a darkened reddened area on the right elbow and possible a deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) which was reported to the physician. There was no further documentation stating that the physician was notified prior to this date of July 13, 2016, a delay of three days of the dark reddened area identified on the right elbow. The facility failed to inform the physician of a change in the skin condition of Resident CL1 in a timely manner. 28 pa. Code 211.10(a) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that cognitively intact residents established their own advance directives and POLST (Pennsylvania Orders for Life Sustaining Treatment) form determination for one of 13 residents reviewed. (Resident A9). Findings include: Review of Resident A9's [DIAGNOSES REDACTED].) and diabetes mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident A9's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated July 12, 2016, Section C, Cognitive Patterns, Brief Interview for Mental Status (an assessment of the resident ' s current cognitive functioning with 0 being severely impaired and 15 indicating no cognitive impairment), indicated a score of 15 (no cognitive impairment). Review of Resident A9's clinical record revealed care plan note dated July 15, 2016 completed by the certified nurse practitioner indicating that Resident A9 has the ability to make decision for self. Review of Resident A9's clinical l record indicated that the resident had Power of Attorney (POA) paperwork indicating that if the resident becomes incapacitated in making decisions, the resident's daughter would be the health care designee or POA enabling the resident to make healthcare decisions for the resident. Review of Resident A9's clinical record revealed that on July 6, 2016 the resident's POA signed the POLST form indicating that the resident would be a DNR (do not resuscitate) in the event of heart failure. Interview with the Director of Nursing and Nursing Home Administrator on December 27, 2016 at approximately 1:00 p.m. confirmed that Resident A9's POA signed the POLST form and indicated a DNR status for the resident on July 6, 2016 even though Resident A9 was not incapacitated and was capable of making decisions regarding healthcare. The facility failed to ensure that Resident A9 who was assessed as cognitively intact was able to establish her own advance directives and POLST (Pennsylvania Orders for Life Sustaining Treatment) form determination. 28 Pa. Code 201.18(b)(1) Management Previously cited 1/6/16 28 Pa. Code 201.29 (L)(1)(2) Resident Rights

Based on clinical record review and staff interview, it was determined that the facility failed to timely and accurately develop plans of care to reflect the residents' current health status for two of 13 residents reviewed (Resident A6 and Resident CL2). Findings include: Review of Resident A6's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident A6's clinical notes dated August 2, 2016 revealed that a Wanderguard (device worn by residents which electronically locks doors when residents approach) was placed on the resident upon admission on August 2, 2016. Review of Resident A6's active plan of care failed to reveal a care plan for elopement risk or placement of the Wanderguard device until October 7, 2016, two months after admission and two months after placement of the device on the resident. Interview with the Director of Nursing on December 27, 2016 at approximately 1:00 p.m. confirmed that Resident A6 should have had an active plan of care for the Wanderguard device placement on August 2, 2016. Review of Resident CL2's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident CL2's social service admission note dated October 3, 2016 stated that the resident was designated for short term rehabilitation and anticipated to return home with family. Review of Resident CL2's care plan failed to reveal a plan for discharge and did not set goals or interventions for the resident to return home. An interview was conducted with Employee E4 on December 27, 2016 at approximately 10:40 a.m. revealed that a care plan was not developed for the anticipated discharge home. The facility failed to individualize plans of care for residents with wanderguard use and for residents anticipated to discharge back to the community. 28 Pa. Code 211.5(f) Clinical Records Previously cited 1/6/16 28 Pa. Code 211.12(c) Nursing Services Previously cited 1/6/16 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 1/6/16 28 Pa. Code 211.12 (d)(1)(5) Nursing Services Previously cited 1/6/16

Based on clinical record review and staff interview, it was determined that the facility failed to maintain and promote residents dignity by placing a elopement device on a resident who had no prior elopement history for one of 13 residents reviewed (Resident A6). Findings include: Review of facility policy entitled Elopement and Wandering Policy, reviewed November, 2016, revealed that on admission or readmission to the facility, residents will be assessed for elopement and wandering risk, in order to identify potential risk for elopement or wandering. This assessment will also be completed quarterly, annually and with any significant change. The scale risk is as follows: 0-5 indicates low risk; 6-8 indicates a risk to wander; 9 or higher indicates high risk to wander. If a resident is assessed with [REDACTED]. Review of Resident A6's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident A6's clinical notes dated August 2, 2016 revealed that a Wanderguard (device worn by residents which electronically locks doors when residents approach) was placed on the resident upon admission on August 2, 2016. Review of Resident A6's Admission Wandering/Elopement Risk Assessment completed on August 2, 2016 revealed a score of N/A (not applicable). Further review of the Wandering/Elopement Risk assessment dated [DATE] also revealed the following comment no elopement history. Review of Resident A6's Quarterly Wandering/Elopement Risk Assessment completed on November 8, 2016 revealed a score of 4 which indicated that the resident was a low risk for wandering and/or elopement. Further review of the Wandering/Elopement Risk assessment dated [DATE] also revealed the following comment no s/s (signs and symptoms) of elopement or wandering. Review of Resident A6's Wandering/Elopement Risk Assessment completed on December 16, 2016 revealed a score of N/A. Further review of the Wandering/Elopement Risk assessment dated [DATE] revealed the following comment not elopement risk. Interview with the Director of Nursing on December 27, 2016 at approximately 1:30 p.m. confirmed that Resident A6 was not at risk for wandering and/or elopement. The facility failed to maintain Resident A6 dignity by placing a elopement device on the resident who had been assessed with [REDACTED]. 28 Pa. Code 201.18(b)(1) Management Previously cited 1/6/16 28 Pa. Code 201.29(a) Resident Rights Previously cited

Based on clinical record review, staff interview and review of facility policies and procedures, it was determined that the facility failed to monitor resident status for one of eight sampled residents with a significant weight loss (Resident C48). Findings include: Review of Resident C48's hospital transfer sheet dated January 5, 2012, revealed that the resident was readmitted to the nursing home following a repair of a left [MEDICAL CONDITION] secondary to a fall on December 28, 2011. The physician orders for January 2012, also listed [DIAGNOSES REDACTED]. Review of the hospital nutrition notes dated January 2, 2012, revealed that the resident may require nutritional support post-operatively secondary to poor meal consumption. Review of the significant change in status assessment in the Minimum Data Set ( a periodic assessment form completed for residents) dated January 12, 2012, related that the resident was readmitted on [DATE], with a weight of 173 pounds and was at risk for developing a pressure ulcer. The readmission nutrition note dated January 17, 2012 (12 days post readmission), listed an admission weight of 173 pounds and a carbohydrate controlled, no added salt diet and that the resident consumed 70 % of meals. The nutrition note dated on January 24, 2012, indicated that the resident's weight had declined to 152 pounds, a loss of 21 pounds since readmission on January 5, 2012 (19 days post readmission). The note further stated that Prosource (nutrition protein supplement) was recommended due to an open area. There was no documentation that the Registered Dietitian's recommendation was forwarded to the physician for review until February 28, 2012, when an order was obtained from the physician. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility policy titled, Weight Loss Protocol (policy), revised April 12, 2012, and revealed that an unplanned weight loss was defined as a weight loss of more than 5% in one month or more than 10% in a six month period. The policy also stated that interventions would be initiated which included weekly weights and the provision of nutritional supplements. Review of the facility procedure titled, Weight Loss Protocol, revised April 12, 2012 indicated that if a resident consumed less than 50% of a meal, 8 ounces of a nutritional supplement would be offered to the resident. However, review of Resident C48's meal intake records for dates January 7, 2012, through January 30, 2012, confirmed that out of a possible 70 meal opportunities, 48 times the resident consumed less than 50% of a meal. There was no documentation indicating that a supplement was offered to the resident as stipulated in the Weight Loss Protocol. Review of Resident C48's weight record, revealed that no weekly weights were obtained as stipulated in the facility policy for February and March 2012. There were no nutrition notes indicating weight loss until January 24, 2012, which listed Resident C48's weights as 152 pounds (21 pounds weight loss from the weight of 173 pounds from readmission on January 5, 2012). The dietary notes dated January 31, 2012, recommended adding a nutrition supplement, Resource 2.0, 120 cc (cubic centimeters) three times daily with medications to provide 720 calories. This recommendation was faxed to the physician on January 31, 2012, but was not signed until April 4, 2012, and was never implemented. Another dietary note dated March 6, 2012, related to increase the Resource to 240 cc three times daily. This recommendation was faxed to the physician on March 6, 2012, and signed on March 9, 2012, and the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Registered Dietitian on April 13, 2012 at 10:00 a.m. confirmed that there was no mechanism to record percent of supplements consumed by the resident. Interview with the Director of Nursing (DON) on April 13, 2012, at approximately 12:00 p.m., revealed that there was no system to record the actual percentage of the supplement (Resource 2.0, 240 cc three times daily) consumed by the resident. The DON stated the amount consumed of the supplement was not documented. The resident's weight on March 6, 2012, was now 137 pounds (36 pound loss since readmission January 5, 2012). The dietary supplements were not provided timely when the resident showed significant weight loss since readmission. Interview with the Director of Nursing on April 13, 2012, at 10:00 a.m., confirmed that weights were not obtained weekly as stipulated in the facility policy for February 2012, and March 2012, and that a nutritional supplement was not initiated for the resident until March 9, 2012. The facility failed to accurately assess and monitor the resident's nutritional status to assist in weight gain and nutritional support secondary to the resident's loss of 36 pounds in three months (weight decreased from 173 pounds to 137 pounds) resulting in a weakened condition and actual harm. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/23/2012. 28 Pa. Code 211.5(c) Clinical records. 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/10/2010, 2/23/2012. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 1/19/2012. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/10/2010, 1/19/2012, 2/23/2012. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/19/2012, 2/23/2012.

Based on a review of facility policies, clinical record review, observations and interviews with staff, it was determined that the facility failed to monitor and provide timely and accurate wound assessment resulting in actual harm to one of eight sampled residents (Resident C48). Findings include: Review of the facility Wound Care Protocol procedure, revised date March 6, 2012, revealed that when a pressure ulcer is identified, staff would first measure the wound and complete a Wound Flow Sheet (a documentation form that describes the type of pressure ulcer, size, appearance, pain). The staff would notify the physician, the wound team (i.e. the Director of Nursing) and the Dietitian and provide a pressure relieving device such as an air mattress. Review of the facility Skin Breakdown Protocol, dated March 6, 2012, indicated that weekly wound monitoring sheets would be completed. Review of Resident C48's admission notes dated November 4, 2011, revealed that the resident was admitted with [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait) and a left hip replacement. A nursing note dated December 28, 2011, revealed that the resident sustained [REDACTED]. Review of nursing notes dated January 5, 2012, revealed that Resident C48 was readmitted to the facility on [DATE]. Review of the hospital nutrition assessment record, dated January 2, 2012, identified that the resident was at high risk for skin breakdown due to poor nutritional intake, bedfast condition and a Braden Scale (scale for predicting pressure sore risk) assessment score of 12 (total score of 12 or less represents high risk for predicting pressure ulcer risk). An interview with the Director of Nursing on April 13, 2012, at 2:00 p.m., confirmed that the facility failed to obtain a Braden Scale assessment score for Resident C48 secondary to his readmission to the facility on [DATE]. The facility completed a Braden Scale assessment for the resident, dated April 15, 2012, which identified that the resident was high risk for skin breakdown with a score of 11. Review of the facility's readmission nursing assessment, dated January 5, 2012, identified the resident with a left buttocks abrasion, measuring 1.0 centimeter (cm) x 1.0 cm. Review of the nursing notes, dated January 10, 2012, at 6:25 a.m., revealed that the resident complained of sore buttocks. The nursing notes, dated January 11, 2012, at 6:10 a.m., revealed that the resident complained of pain and discomfort and showed signs of pain during incontinence checks and changes. The nursing notes, dated January 26, 2012, at 1:30 p.m. indicated that the resident had an open area on the sacrum (large triangular bone at the base of the spine). No other description of the sacral would was listed. Review of the initial wound team note, dated February 27, 2012, at 2:00 p.m., indicated that the resident had a Stage II pressure ulcer (an ulcer involving loss of the top layers of skin) which measured 4.0 centimeters by 4.5 centimeters and a depth of 0.2 centimeters with yellow slough (a mass of dead tissue) on the right gluteal fold (groove between buttock). A wound team note, dated March 5, 2012, revealed an open area on the coccyx (tailbone; previously listed on the right gluteal fold) measured 3.6 centimeters by 2.8 centimeters with 0.1 centimeter depth and area surrounding the wound had [DIAGNOSES REDACTED] (redness) and had serous drainage (blood tinged drainage). There were no weekly notes describing the wound condition, as per facility policy, for dates March 5, 2012 through March 20, 2012 until a nurse's dressing change note, dated March 21, 2012 (16 days later) and then again no weekly wound condition note for the dates March 22, 2012 through April 6, 2012 (15 days later) when a wound note dated April 6, 2012, listed a Stage III pressure ulcer (ulcer involving full thickness skin loss, exposing tissue) on the coccyx with yellow slough. The facility documentation failed to address measurements, appearance of the wound or pain condition as per the facility policy. A wound note, dated April 12, 2012 (3:00 p.m. - 11:00 p.m.), described a wound on the left buttock gluteal cleft (anal fold) previously listed on the tailbone, and another wound on the right buttock. Documentation did not include the measurements or the staging of the wounds. Observation of the wound on April 13, 2012, at 10:45 a.m., revealed that the wound was on the left gluteal cleft (anal fold) and was measured by Employee E4 as 2.5 centimeters by 2.0 centimeters. An additional open area on the right buttock was noted and Employee E4 confirmed that the area was indeed open and measured 1.0 centimeter round. The surveyor requested that the [DIAGNOSES REDACTED]tic (reddened) area around the wound be measured by the facility which was noted by nursing Employee E4 to be 8.5 centimeters round. Further observation on April 13, 2012, at 10:45 a.m., revealed that Resident C48's overlay alternating pressure mattress was underinflated. The heavier parts of the resident's body, such as the sacrum and heels, were in direct contact with the regular mattress resulting in pressure to those areas. When pointed out to the licensed nurse, Employee E4, she stated that she would report this for repair. Interview with the Director of Nursing on April 13, 2012, at 12:00 p.m., confirmed that Resident C48 had a new Stage II pressure ulcer to the right buttock that was identified April 12, 2012. The Director of Nursing further confirmed that the resident's attending physician had not been notified of this new open area and no new treatment orders had been obtained as of April 13, 2012. Review of the medical record failed to reveal that the care plan, dated November 22, 2011, regarding the potential for skin breakdown was implemented or updated when the pressure ulcer was identified as a Stage II pressure ulcer, on February 27, 2012, even though the resident was readmitted to the facility, on January 5, 2012, with an open abrasion on the left buttock. Interview with the Director of Nursing, on April 13, 2012, at 2:00 p.m., confirmed that the weekly wound assessments were not done as per facility policy. The facility failed to follow their policies for monitoring and assessing the development of bilateral pressure ulcers for a resident with a history of fractures, causing decline to the area and actual harm to the resident. Refer to F325. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 2/23/2012. 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/10/2010, 2/23/2012. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 12/10/2010, 1/19/2012, 2/23/2012. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/10/2010, 1/19/2012, 2/23/2012. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/19/2012, 2/23/2012.

Based on clinical record review, review of facility policies, facility documentation and interview with staff, it was determined that the facility failed to inform the physician of mental status changes following a medication error and to follow medical orders resulting in actual harm for one of one resident who sustained injuries resulting from a fall (Resident R1). Findings include: Review of Resident R1's quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment, dated February 3, 2012, revealed that the resident had [DIAGNOSES REDACTED]. Review of the facility event report submitted to the State Survey Agency, dated February 21, 2012, revealed that Resident R1 was given another resident's medications which included: [MEDICATION NAME] 1 milligram (antianxiety); [MEDICATION NAME] 100 milligrams (mood stabilizer); [MEDICATION NAME] 100 milligrams (anti-[MEDICAL CONDITION]) and [MEDICATION NAME] 250 milligrams (mood stabilizer/anti-[MEDICAL CONDITION]). Review of the facility policy titled, Medication Errors Policy, dated October 27, 2009, indicated that the attending physician should be notified of all life-threatening errors and omissions immediately by the RN (registered nurse). The Director of Nursing (DON) should also be notified. Interview with the Certified Registered Nurse Practitioner (CRNP), Employee E10, on February 23, 2012, at 1:30 p.m., revealed that Employee E10 was notified of the medication error on February 20, 2012, around 10:00 p.m., and gave verbal telephone orders for Employee E4 to hold all of Resident R1's medications, check the vital signs (blood pressure, pulse, respiration monitoring) and neurological status (alertness of the resident and physical motor function response) every 4 hours for 24 hours, monitor for increased sedation and mental status changes and call with any concerns. Interview with the DON on February 23, 2012, at 10:00 a.m., confirmed that the licensed nurse, Employee E4, telephoned her at home on February 20, 2012, at approximately 10:30 p.m., to inform her of the medication error to the Resident R1. The DON further stated that Employee E4 was advised to make sure the night nurse, Employee E3, was informed of the medication error and to follow the CRNP, Employee E10' s orders for monitoring the resident for any adverse reactions or for a change in condition. Review of the neurological assessment flowsheet for February 20 - 21, 2012 documented vital signs and neurological checks were done at 11:00 p.m., 2:00 a.m., 5:30 a.m., and 6:30 a.m. Review of a late nurses' note for 2:00 a.m., February 21, 2012, dated February 21, 2012, at 7:00 a.m., indicated that the resident was in a deep sleep and did not wake up when the vital signs were taken and when incontinence care was provided. Facility documentation of incident, related resident in deep sleep and did not wake up at 4:00 a.m. There was no documentation in the nursing notes that the physician or CRNP, Employee E10, were called regarding the mental status change that the resident had or that the physician was called concerning the medication error. Interview with the DON on February 23, 2012, at 1:00 p.m., stated that the resident's usual behavior throughout the night shift hours, prior to the medication error, was to be up and down all night and the resident's behavior was unusual as he was in a deep sleep on February 21, 2012. The DON stated, "This should have been a red flag of concern for the nursing staff." Interview with the CRNP, Employee E10, on February 23, 2012, at 1:30 p.m., confirmed that the licensed nurse should have notified the resident's attending physician of the resident's increased sedation status. Review of the nurses' notes, dated February 21, 2012, at 7:00 a.m. revealed that Resident R1's bed alarm (a soft mat that sounds when a resident is no longer lying/sitting on the device to alert staff that the resident is getting up) went off and the staff found the resident on the floor with the left eyebrow bleeding. Review of facility documentation related to the fall, dated February 21, 2012, at 9:01 a.m., revealed that the resident fell at 5:15 a.m., "Resident was found lying on the left elbow, left eyebrow bleeding." The licensed nurse, Employee E3, notified the resident's Attending Physician by telephone of this fall at 5:45 a.m. on February 21, 2012. Review of a faxed, written statement from the Attending Physician dated February 23, 2012, confirmed that the facility did not inform the Attending Physician of the medication error prior to or after the resident's fall on February 21, 2012. The faxed physician note related that the physician was informed on February 23, 2012, of the medication error. Interview with the DON on February 23, 2012, at 3:00 p.m., confirmed that Resident R1's attending physician was formally notified of this medication error on February 23, 2012, secondary to inquiry from the surveyor. Interview with the Nursing Home Administrator and the DON, on February 23, 2012, at 3:15 p.m., confirmed that licensed nursing staff failed to effectively implement the CRNP's orders for Resident R1 by failing to monitor for increased sedation and mental status changes and call with any concerns. Licensed nursing staff failed to inform the physician of a medication error and failed to monitor the resident's status as ordered by the CRNP. The facility further failed to notify the physician of the resident's metal status changes, and to provide adequate monitoring to prevent a fall after a significant medication error, which resulted in actual harm to the resident who sustained injuries requiring hospitalization . CFR 483.25 Quality of Care. Previously cited 01/19/2012. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/10/2010. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/10/2010. 28 Pa Code 211.12 (c)(d)(3) Nursing services. Previously cited 01/19/2012. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 01/19/2012, 12/10/2010.

Based on clinical record review, facility documentation and staff interviews, it was determined that the facility failed to monitor and supervise one of one resident at risk for falls to ensure that appropriate interventions were in place to prevent the resident from sustaining a fall (Resident B22). Findings include: Review of Resident B22's quarterly assessment dated [DATE], indicated that the resident required extensive assistance for walking and locomotion with one person physical assist (the staff provide weight bearing support). Review of the physician orders [REDACTED]. Review of Resident B22's care plan regarding the potential for falls related to an unsteady gait, impaired vision and poor safety awareness, dated February 24, 2009, indicated that the resident utilized a walker for ambulation. Interview with the Director of Nursing on April 12, 2012, at 10:00 a.m., confirmed that Resident B22 likes to sit outside on the bench in the warm weather, but sometimes the resident does not dress appropriately for the outside. Consequently, the facility applied a Wanderguard (electronic bracelet alert system to alert caregivers when an individual exits through a monitored door) alarming device, ordered on January 31, 2012, for the resident's rolling walker, with the intent to alert staff when the resident was exiting the building. Review of nursing notes, dated March 20, 2012, at 1:30 p.m., indicated that while the staff were looking outside the window, Resident B22 was observed outside the facility, lying on the ground on his right side beside the bench. Review of the facility documentation dated March 20, 2011, generated during the fall investigation, indicated that because the resident had difficulty with vision and light colors, the resident likely misjudged the bench and sustained a fall. The resident's care plan for recurrent falls and decreased vision, dated March 20, 2012, indicated that secondary to the fall of March 20, 2012, the bench would be repainted a dark color. Review of nursing notes, dated March 21, 2012, at 5:45 p.m., revealed that the resident had a second fall outside the facility, less than 24 hours from the previous fall of March 20, 2012, while outside at the bench. The nursing notes, dated March 21, 2012, indicated that the resident sustained [REDACTED]. Review of the Treatment Administration Record for March 2012 revealed that Resident B22 required treatment for [REDACTED]. Interviews with the Director of Nursing (DON) and licensed nurse Employee E5 both confirmed on April 12, 2012, at 11:30 a.m., that the alarm on the rolling walker was not effective in monitoring the resident's whereabouts. Interview with the DON on April 12, 2012, at 2:00 p.m., confirmed that the care plan was updated on March 20, 2012, secondary to the resident's first fall. The facility failed to implement the intervention, to paint the bench, prior to Resident B22 gaining access to the outside on March 21, 2012, and subsequently sustaining a second fall. The facility failed to adequately supervise Resident B22 who was at risk for falls when the resident was found unsupervised outside the facility on March 20, 2012 and March 21, 2012. The resident sustained [REDACTED]. 483.25(h) Free of accidents hazards/supervision/devices. Previously cited 12/10/2010, 1/19/2012. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 2/23/2012. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 1/19/2012. 28 Pa. Code 211.10(c) Resident care policies Previously cited 12/10/2010, 1/19/2012, 2/23/2012. 28 Pa. Code 211.11(a)(d)(e) Resident care plan. Previously cited 1/19/2012. 28 Pa. Code 211.12(a) Nursing services. Previously cited 1/19/2012. 28 Pa. Code 211.12(c)(d)(3) Nursing services. Previously cited 1/19/2012, 2/23/2012. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/10/2010, 1/19/2012, 2/23/2012.