Every finding on record at New Eastwood Healthcare and Rehabilitation Center

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on September 3, 2024, at 9:47 a.m., revealed the following: In the walk-in freezer, there was an accumulation of ice at the entry way, on the shelves, and on boxes of potato hashbrowns and nutrition shakes. The ice build up prevented the door from latching and forming a seal when closed. In the walk-in refrigerator, there was a pan of raw ground meat stored above a pan of raw whole beef. At the coffee preparation area, there was an accumulation of dust on the underside of a window air conditioning unit that was above coffee filters and plastic lids. On a storage shelf under a food preparation area, there were two containers of peanut butter stored next to spray bottles of chemical sanitizing solution. In the milk cooler, there was no thermometer observed in the cooler. There was an accumulation of spilled milk on the bottom of the cooler. There was an odor of spoiled milk in the cooler. There were two fans with an accumulation of dust on the grate covers that were stored near clean dish racks in the dish washing area. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary. Previously cited 10/5/23 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to provide care and services in a manner respectful of each resident's dignity for one of 18 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included obstructive uropathy, urinary retention, and enlarged prostate. On August 6, 2024, a physician ordered that Resident 79 utilize an indwelling urinary catheter for urination. Review of the care plan revealed that staff was to maintain a dignity bag or privacy cover over the collection bag when in social settings and when visible to others. Observations on September 3, 2024, at 11:45 a.m., revealed that Resident 79 was seated at an exercise machine in the physical therapy room, and at 1:10 p.m., was seated in a wheelchair in a common lounge area. The indwelling urinary catheter bag was not covered and contained urine. Multiple residents and staff were in the area when observed. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for four of 18 sampled residents. (Residents 35, 47, 49, 244) Findings include: Clinical record review revealed that Resident 35 had diagnoses that included generalized edema and acute kidney failure. A physician's order dated August 8, 2024, directed staff to weigh the resident every Thursday. A review of the Medication Administration Record (MAR) for August 2024, revealed that there was no evidence that staff weighed Resident 35 as ordered on August 22 and 29, 2024. Clinical record review revealed that Resident 47 had diagnoses that included end-stage renal disease requiring dialysis and congestive heart failure. A physician's order dated August 31, 2024, directed staff to weigh the resident daily. A review of the MAR for September 2024, revealed that there was no evidence that staff weighed Resident 47 as ordered on September 1 and 3, 2024. Clinical record review revealed that Resident 49 had diagnoses that included severe protein-calorie malnutrition and congestive heart failure. A physician's order dated August 16, 2024, directed staff to weigh the resident every Friday. A review of the MAR for August 2024, revealed that there was no evidence that staff weighed Resident 49 as ordered on August 23, 2024. Clinical record review revealed that Resident 244 had diagnoses that included congestive heart failure and chronic kidney disease. A physician's order dated August 29, 2024, directed staff to weigh the resident daily. A review of the MAR for August 2024, revealed that there was no evidence that staff weighed Resident 244 as ordered on August 30 and 31, 2024. In an interview on September 5, 2024, at 8:35 a.m. and 1:12 p.m., the Regional Clinical Nurse confirmed that there was no documented evidence that the residents were weighed as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide physician ordered therapeutic diets for two of 18 sampled residents. (Residents 12, 14) Findings include: Clinical record review revealed that Resident 12 had diagnoses that included Alzheimer's disease, dysphagia, and protein calorie malnutrition. A physician's order dated December 20, 2020, directed staff to provide a mechanical soft diet with the addition of enhanced foods. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered, which included enhanced foods. On September 4, 2024, at 12:27 p.m., the resident was observed eating the lunch meal in the dining room. The tray ticket indicated that the resident was to receive fortified mashed potatoes, an enhanced food. There was no fortified food item or enhanced mashed potatoes observed on the resident's tray. Clinical record review revealed that Resident 14 had diagnoses that included muscle weakness, muscle wasting, and dysphagia. A physician's order dated October 9, 2023, directed staff to provide a mechanical soft diet with enhanced foods. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included enhanced foods three times per day. On September 3, 2024, at 12:46 p.m., the resident was observed eating lunch in the dining room. The tray ticket indicated that the resident was to receive fortified pudding, an enhanced food, with her meal. There was no pudding observed on the resident's tray. On September 4, 2024, at 12:27 p.m., the resident was observed eating the lunch meal in the dining room. The tray ticket again indicated that the resident was to receive fortified pudding with the meal; there was no pudding observed with the resident's meal. In an interview on September 5, 2024, at 8:35 a.m., the Regional Clinical Nurse confirmed that residents with physician's orders for enhanced foods should receive fortified food items with meals. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility provided documentation and staff interview, it was determined that the facility failed to ensure that a notice of non coverage for skilled care services and the appeal process was provided to the resident or representative for one of four residents reviewed. (Resident 1) Findings include: Review of Information for Notice of Non-coverage for Medicare (Form CMS-10123-NOMNC) revealed that the facility must inform the resident or resident representative when skilled services will end, and also provide information regarding the ability to appeal the decision. Clinical record reivew revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome, deconditioning and osteomyelitis. The resident had an order by the physician for skilled therapy services. It was determined by therapy, that the last day for covered therapy services was to be on January 12, 2024. There was no documentation that the resident or representative was notified that skilled services would end on that day, nor that the decision could be appealed. In an interview on January 26, 2024, at 10:40 a.m., the Administrator confirmed that the notice was not provided. 28 Pa. Code 201.18(e)(1) Management.

Based on facility policy review, observation, and staff interview, it was determined the facility failed to store food in a sanitary manner on two of two nursing units. (Sandlewood and Birchwood) Review of the facility policy entitled, Foods Brought by Family/Visitors, dated [DATE], revealed perishable food items were to be labeled with the resident's name, the item, and the use-by date. Expired food items were to be discarded. Observation of the pantry on the Sandlewood unit on [DATE], at 12:01 p.m., revealed the inside of the microwave was dirty with multiple areas of dried food splatter. There were four areas where the interior of the microwave had bubbled and were covered with rust spots on each. In the refrigerator, there was a container of chicken noodle soup, a package of cheese slices, two opened bottles of ranch dressing, and an opened bag of snap peas. These items were not dated or labelled with a name on them. In the freezer, there were three boxes of chicken pot pies and a frozen meal that did not have a name on them. In an interview on [DATE], at 12:10 p.m., Registered Nurse (RN) 1 stated the microwave and refrigerator were only used for the residents. Observation of the pantry on the Birchwood unit on [DATE], at 12:34 p.m., revealed two cups of yogurt with a use-by date of [DATE], and [DATE]. In an interview on [DATE], at 8:45 a.m.,the Regional Clinical Consultant confirmed the food items in the pantries should have been labeled with the residents' names, dated, and expired items removed. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on October 3, 2023, at 9:41 a.m., revealed various items on the ground next to the dumpster, including two used briefs and several pieces of crushed plastic items. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review, observation and resident interview it was determined that the facility failed to ensure a dignified environment for one of 18 sampled residents. (Resident 22) Findings include: Clinical record review revealed the Resident 22 had diagnoses that included multiple sclerosis, insomnia, and chronic pain. Review of the Minimum Data Set assessment, dated September 30, 2022, revealed that the resident had no cognitive impairment and required extensive assistance from staff with activities of daily living. In an interview on November 8, 2022, at 10:41 a.m., Resident 22 stated that she wished she had a way to keep track of when she took medications and when they are due because she doesn't know the time. At that time the clock on the wall across from the resident's bed displayed the incorrect time. Observations on November 8, 2022, from 10:41 a.m. through 12:14 p.m., and on November 9, 2022, from 9:40 a.m. through 12:20 p.m. revealed the clock continued to display the incorrect time. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, clinical record review, and interview, it was determined that the facility failed to ensure that staff administered medications in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Clinical record review revealed that Resident 11 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated September 30, 2021, revealed the resident had no cognitive impairment and required extensive assistance with activities of daily living. On December 12, 2021, the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the medication should not be adminsitered with a systolic blood pressure (pressure of blood pushing against arteries) below 110 millimeters of mercury (mmHg). Observation on December 21, 2021, during the the 8:00 a.m. medication administration, revealed LPN 1 measured Resident 11's blood pressure and recorded the result of 100/57 mmHg. LPN 1 administered the [MEDICATION(S)] to Resident 11, despite that the resident's systolic blood pressure was below 110 mmHg. Clinical record review revealed that Resident 76 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated November 30, 2021, revealed the resident had no cognitive impairment and required extensive assistance with most activities of daily living. On November 24, 2021, the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 76's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On December 17, 2021, the physician revised the medication order to be administered every eight hours, as needed, for breakthrough pain reported at levels 7-10. Review of Resident 76's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on December 22, 2021, at 1:20 p.m., the Director of Nursing stated that the medications should have been administered per the parameters in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 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 monitor and implement a tube feeding modification for one of 19 sampled residents. (Resident 18). Findings include: Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 2, 2021, the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 27, 2021, the registered dietitian, RD 1, documented that Resident 18's weight was 175.4 pounds on July 18, 2021, with no significant weight change within one, three, and six months, that resident received mighty shakes with meals and generally consumed the shakes and noted a nutritional goal to maintain a stable weight. The clinical record reflected the prior weights as 162 pounds on January 29, 2021, 170 pounds on April 8, 2021, and 171.6 pounds on June 3, 2021. RD 1 made a recommendation to decrease the [MEDICATION(S)] 1.5 to a rate of 60 milliliters per hour for 12 hours a day. RD 1 charted spoke with resident who reports she has noticed weight gain. Nurse Practitioner notified and will decrease tube feed. On October 20, 2021, RD 1 documented that Resident 18 continued to receive [MEDICATION(S)] 1.5 at 80 milliliters per hour for 12 hours a day and mighty shakes with meals. RD 1 noted resident 18's weight status as 178.6 pounds on October 15, 2021, with no significant weight change for one, three, and six months. The clinical record reflected the resident's weights as follows: 170 pounds on April 8, 2021, 175.4 pounds on July 8, 2021, 177.5 pounds on September 17, 2021. RD 1 recommended to decrease the formula to 60 milliliters per hour for 12 hours a day and that RD 1 had spoke to resident who reports she has noticed weight gain. Medical Doctor notified and will decrease tube feed. On November 2, 2021, the Nurse Practitioner note indicated under the Assessment and Plan Section that the plan for [CONDITION(S)] was to continue to wean down the tube feeding. and the plan noted for Adult Failure to thrive indicated that Resident 18's weight has increased 15 pounds since January 29, 2021 and try to wean off tube feeding as able to. On December 21, 2021, RD 1 documented that the tube feeding continued at 80 milliliters per hour for 12 hours a day and that the mighty shakes with meals continued. RD 1 noted resident 18's weight as 179.1 pounds with no significant weight change for one, three and six months. The clinical record reflected weights of 181 pounds on November 19, 2021, 177.5 pounds on September 17, 2021, and 171.6 pounds on June 3, 2021. RD 1 made the recommendation to decrease the tube feeding rate to 60 milliliters per hour for 12 hours a day. RD 1 noted spoke with resident who is agreeable to try to increase intake with decreasing tube feeding. Medical Doctor notified and will order decreased tube feeding. On December 21, 2021, the physician wrote an order to change the tube feed order to [MEDICATION(S)] 1.5 at 60 milliliters per hour for 12 hours a day. In an interview on December 22, 2021, at 9:30 a.m., RD 1 confirmed the tube feeding recommendations were communicated verbally to the physician on July 27, 2021, and despite multiple notes and interactions that indicated intent to change the tube feeding rate between RD 1 and the physician between July 27, 2021, through December 21, 2021, there was no documented evidence that the tube feeding order was changed as recommended until December 21, 2021. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment in the shower room on one of three nursing units. (Sandalwood unit) Findings include: Observation of the shower room on the Sandalwood nursing unit on December 20, 2021, at 10:18 a.m., revealed a pink colored stain on the seat of the walk-in tub. There was a dark colored substance around the drain insertion point of the tub drain, the drain stop plug had a pink color tinge. There was puddled water on the tub seat that was not cleaned following use. There were pink colored substances and corrosion around the faucet base, handles, and drain of the sink. There were various particles of dirt debris on the floor. There was a pink substance behind the shower seat and around [MEDICATION(S)] chloride piping (PVC) tube insertion sites on the seat. There were various particles of dirt debris on a bariatric shower chair. A second bariatric chair had pink and dark colored substances on the back rail of the PVC tube insertion sites. There was a comb on the counter with hair intertwined in the teeth. There was a white cap on the shower floor. The shower faucet handle was labeled cold on the left and hot on the right. The water remained cold when the faucet was turned to the right, towards the hot label. The water did not feel warm to the touch until the faucet was turned to the left, away from the hot label and past the cold label. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent further decrease in range of motion for one of five sampled residents with limited range of motion. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 21, 2019, indicated that the resident required extensive assistance from staff for most activities of daily living and had functional limitations in range of motion of both arms and both legs. The ongoing care plan, initiated (MONTH) 17, 2019, included the goal of remaining free of complications, such as contractures, related to immobility due to a stroke. Review of an occupational therapy discharge summary, signed by the therapist on (MONTH) 23, 2019, revealed that the resident was to be provided with a restorative nursing program for range of motion of both arms due to a risk for contractures. There was no clinical documentation to support that a restorative program had been provided for the resident's upper extremities. In an interview on (MONTH) 27, 2019, at 12:02 p.m., the Director of Nursing confirmed that the resident was not enrolled in the restorative nursing program for range of motion. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 7/13/18

Based on observations during the initial and daily environmental tours, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards on one of three nursing units. (Birchwood) Findings include: Observations during the initial tour of the Birchwood nursing unit, conducted on (MONTH) 25, 2019, from 9:35 a.m. to 1:30 p.m., revealed one linen cart that was unsecured in the hallway. The cart contained two bottles of shaving cream, two bottles of deodorant, and one bottle of mouthwash. Observations during a subsequent tour of the Birchwood unit on (MONTH) 26, 2019, from 10:15 a.m. to 11:48 a.m., again revealed one linen cart that was unsecured in the hallway. The cart contained one bottle of deodorant, two bottles of shampoo, and one tube of A&D ointment. The tube and bottles were labeled with a manufacturer's warning regarding the caustic content and to keep out of the reach of children. There were 26 total residents who resided on this unit, and nine of these residents were cognitively impaired, mobile and had access to these potentially harmful products. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review, policy review, observation and interview, it was determined that the facility failed to ensure that staff implemented precautions (contact precautions) in order to prevent the spread of infection for one of two sampled residents receiving treatment for [REDACTED]. (Residents 4, 70) Findings include: Review of the facility policy entitled Isolation- Categories of Transmission-Based Precautions and Contact Precautions-Diarrhea associated with [MEDICAL CONDITION] (C. Diff) dated (MONTH) 2019, revealed that staff was to implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident, environmental surfaces, or resident-care items in the resident's environment. Staff was to wear gloves and a disposable gown upon entering a resident's room who was on contact precautions, dispose of these items before leaving the room and hand hygiene (handwashing) should be performed immediately. Clinical record review revealed that Resident 74 was admitted to the facility on (MONTH) 4, 2019, with a [DIAGNOSES REDACTED]. A personal protective equipment cart containing gowns and gloves was placed outside the resident's room for use when providing assistance to the resident from staff. The admission Minimum Data Set (MDS) assessment dated (MONTH) 11, 2019, noted that the resident was incontinent of bowel. On (MONTH) 25, 2019, at 11:27 a.m., Housekeeper 1 was observed entering the resident's room without wearing gloves and a gown and had direct contact with personal items on the resident's tray table and environmental surfaces. Housekeeper 1 then proceeded to leave the resident's room and did not wash her hands. Clinical record review revealed that Resident 70 was admitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. A physician's order dated (MONTH) 6, 2019, directed staff to provide the resident with an enteral feeding of [MEDICATION NAME] via feeding tube every shift. Observation on (MONTH) 26, 2019 from 9:05 a.m. through 10:22 a.m., revealed that the [MEDICATION NAME] was attached to tubing which was suspended freely from the feeding pole in the resident's room, without the protective cap on the tip of the tubing. In a subsequent observation, on (MONTH) 26, 2019 at 10:23 a.m., the tip of the tubing was re-inserted into the resident's port and the tube feeding began infusing. Clinical record review revealed that Resident 4 had [DIAGNOSES REDACTED]. The resident was ordered by the physician to receive continuous liquid nutrition. On (MONTH) 26, 2019, at 12:11 p.m., the resident was observed in room [ROOM NUMBER] with the [MEDICATION NAME] attached to tubing that was disconnected from the resident's port. The tubing tip was uncovered and placed in a hole in the back of the tube feeding pump and subsequently reinserted for continued feeding. In an interview on (MONTH) 27, 2019, at 11:10 a.m., the Director of Nursing confirmed that the staff failed to cover the tube feeding tip when not in use in an effort to prevent the spread of infection. 28 Pa. Code 211.10(d) Resident care policies Previously cited 7/13/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 7/13/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents and/or their responsible parties were notified of the transfers and the reasons for the transfer in writing for three of four sampled residents who were sent to the hospital. (Residents 26, 43, 51) Findings include: Clinical record review revealed that Resident 26 was transferred to the hospital on (MONTH) 28, (YEAR), after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 43 was transferred to the hospital on (MONTH) 7, (YEAR) and again on (MONTH) 1, (YEAR), after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 51 was transferred to the hospital on (MONTH) 8, (YEAR), after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. In an interview on (MONTH) 13, (YEAR), at 1:00 p.m. the Nursing Home Administrator stated that the residents and/or responsible parties had not been notified of the transfers in writing. 28 Pa. Code 201.29(f) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, family member or legal representative at the time of transfer to the hospital for three of four sampled residents who were transferred to the hospital. (Residents 26, 43, 51) Findings include: Clinical record review revealed that Resident 26 was transferred and admitted to the hospital on (MONTH) 28, (YEAR). There was no documented evidence that the resident or responsible party were provided written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during hospitalization ) and the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility. Clinical record review revealed that Resident 43 was transferred and admitted to the hospital on (MONTH) 7, (YEAR), and (MONTH) 1, (YEAR). There was no documented evidence that the resident or responsible party were provided written information about the facility's bed-hold policy and the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility. Clinical record review revealed that Resident 51 was transferred and admitted to the hospital on (MONTH) 8, (YEAR). There was no documented evidence that the resident or responsible party were provided written information about the facility's bed-hold policy and the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility. In an interview on (MONTH) 13, (YEAR), at 1:00 p.m., the Nursing Home Administrator confirmed that the aforementioned residents were not provided written information regarding the facility's bed hold policy upon transfer to the hospital. 28 Pa. Code 201.29(f) Resident rights.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide physician ordered documented skin checks to prevent new skin areas from developing for one of three sampled residents at risk for compromised skin integrity and notify the physician regarding ordered weight parameters for one of 18 sampled residents. (Resident 20, 43) Findings include: Clinical record review revealed that Resident 20 had [DIAGNOSES REDACTED]. On (MONTH) 12, (YEAR), the physician ordered that any new skin areas were to be documented in the clinical record and the physician and the supervisor were to be notified. The Minimum Data Set (MDS) assessment dated (MONTH) 19, (YEAR), identified the resident at risk of developing pressure ulcers, and the resident care plan dated (MONTH) 12, (YEAR), also identified the resident's potential impairment to skin integrity related to fragile skin. A daily Skin Observation Tool from (MONTH) 18, (YEAR) to (MONTH) 11, (YEAR), identified no compromised skin integrity. Observation on (MONTH) 10, (YEAR), from 10:17 am to 11:10 a.m., revealed Resident 20 in bed with reddened scabbed areas on both inner ankles. Subsequently, the resident then repositioned herself on her right side applying direct pressure on the reddened scabbed areas. On (MONTH) 11, (YEAR), at 9:43 a.m., the resident was observed in her wheelchair with both the right and left ankle reddened scabbed exposed and uncovered. Review of the clinical record revaled no evidence the facility had identified or assessed the reddened, scabbed inner ankles. In an interview on (MONTH) 12, (YEAR), at 2:20 p.m., the Director of Nursing confirmed that the facility had no evidence to support that new skin areas had been identified in accordance with the physician's orders [REDACTED].>Clinical record review revealed that Resident 43 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During the following dates, Resident 43 had gained more than three pounds in one day: June 8 through (MONTH) 9, (YEAR), (MONTH) 1 through (MONTH) 2, (YEAR) and (MONTH) 4 through (MONTH) 5, (YEAR). There was no documented evidence that the physician was notified of Resident 43's weight gains. In an interview on (MONTH) 13, (YEAR) at 1:20 pm, the Director of Nursing confirmed that the facility had no evidence to support that the physician had been notified of Resident 43's weight gains in accordance with the physician's orders [REDACTED].>483.25 Quality of care Previously cited 8/10/17 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/10/17

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of four sampled residents identified at risk for falls. (Resident 51) Findings include: Clinical record review revealed that Resident 51 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. The ongoing and current care plan identified that the resident was at risk to fall related to ambulatory dysfunction and a history of falling. On (MONTH) 27, (YEAR), Resident 51 fell in her room. Review of the interdisciplinary team note dated (MONTH) 28, (YEAR), and the current care plan revealed that staff was to place a Call Don't Fall sign on the resident's bedside table as an intervention to remind the resident to use her call bell for assistance to prevent future falls. On (MONTH) 10, (YEAR), at 11:15 a.m. Resident 51 was observed in her room. There was no Call Don't Fall sign on her bedside table or in her room. Subsequent observations from (MONTH) 11, (YEAR), at 9:30 a.m. through (MONTH) 13, (YEAR), at 10:30 a.m. revealed no Call Don't Fall sign in the resident's room. Resident 51 had two more falls on (MONTH) 7 and 9, (YEAR). In an interview on (MONTH) 13, (YEAR) at 10:00 a.m., RN 1 stated that Resident 51 should have a Call Don't Fall sign on her bedside table. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/10/17

Based on clinical record review, facility policy review, observation and staff interview, it was determined that the facility failed to implement proper protective equipment during the disposal of infectious material for one of three sampled residents with infection. (Resident 5) Findings include: Review of the facility policy for Contact Precautions entitled Personal Protective Equipment- Using Gowns, dated (MONTH) 9, (YEAR), revealed that staff was to wear a gown during the disposal of infectious material to prevent splashing or spilling and the spread of infection. Clinical record review revealed that Resident 5 had laboratory testing on (MONTH) 7, (YEAR), that identified a multi-drug resistant infection in his urine and the physician ordered contact precautions. On (MONTH) 10, (YEAR), at 9:30 a.m., NA1 was observed in the resident's room without wearing a gown and had handled and disposed of bodily fluids in the bathroom receptacle. NA1 then exited the resident's room and had direct contact with other residents on the unit. In an interview on (MONTH) 12, (YEAR), at 12:15 p.m. the Infection Control Coordinator stated that staff was to use a disposable gown during the disposal of infectious material to prevent splashing or spilling and the spread of infection. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/10/17

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for one of four residents sampled. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] ,with [DIAGNOSES REDACTED]. On September 29, 2017, a physician ordered staff to administer enteral feedings (nutrition by a way of a tube inserted into the stomach) five times daily. Review of the Treatment Administration Record (TAR) for September 2017 revealed that staff failed to administer the enteral feedings on September 29, 2017, at 7:00 p.m. and 11 p.m. In an interview on October 7, 2017, at 10:00 a.m., the Nursing Home Administrator stated that staff failed to administer the enteral feedings as ordered. 483.25 Quality of care. Previously cited 8/10/17, 7/1/16 28 Pa. code 211.12(d)(1(5) Nursing services. Previously cited 8/10/17, 7/1/16

Based on clinical record review and incident report review, it was determined that the facility failed to ensure that an assessed safety measure was in place to prevent a resident identified at risk for falls from suffering an injury related to a fall, for one of six sampled residents. (Resident R72) In addition, the facility failed to ensure that the resident's environment was free of accident hazards on two of three nursing units. (West wing nursing unit and East wing nursing unit) Findings include: Clinical record review revealed that Resident R72 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS) dated [DATE] indicated that the resident had cognitive impairment and was dependant on staff for activities of daily living. The resident had five falls from from December 19, 2012 through March 25, 2013, all from bed. The care plan dated December 19, 2012, identified the resident at risk for falls with an intervention to ensure that fall mats were in place on both sides of the bed when the resident was in bed. A physician's orders [REDACTED]. Review of a facility incident report revealed that on March 25, 2013 at 9:00 p.m., Resident R72 was found lying on the floor on the left side of the bed. The resident had sustained a laceration to the front of her head requiring transfer to the hospital and nine sutures. Review of the incident investigation report revealed the contributing factor was "one fall mat not in place." Review of an employee witness statement dated March 25, 2013, indicated "floor mat from the side of the table was missing." The resident's head and left leg were lying on the metal base of the bed side table and she was bleeding from the left side of her head. The facility failed to ensure that the left fall mat was in place and the resident was found on the floor, on the left side of the bed without the fall mat, sustaining a laceration to her head from the metal frame of the bedside table. Observation on August 6, 2013 at 11:40 a.m. revealed the corner of the heating register in resident room 223 in the bathroom was bent at a 90 degree angle and protruded out two inches, impeding the walking area. Observation on August 7, 2013, from 1:02 p.m., to 1:08 p.m., revealed an unlocked and unattended medication cart on the second floor. On the same day from 2:40 p.m., to 2:50 p.m., another medication cart was observed unlocked and unattended on the second floor, with a half pill in a cup on top of the cart. Observation on August 8, 2013, from 1:13 p.m., until 1:30 p.m., revealed an unlocked and unattended treatment cart on the second floor West wing nursing unit. 28 Pa. Code 211.12(d)(5) Nursing Services. previously sited 9/21/12