Every finding on record at Orwigsburg Nursing and Rehabilitation Center

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to protect the residents' right to privacy and confidentiality through the use of photography for one of six sampled residents. (Resident 1)Findings include:Review of the facility policy entitled, Compliance Risks - Privacy, Security, and Breach Notifications, last reviewed January 2025, revealed that the facility complies with the laws governing privacy and security to ensure resident privacy and confidentiality. Clinical record review revealed that Resident 1 had diagnoses that included multiple sclerosis. Review of the Minimum Data Set assessment, dated August 2, 2025, revealed the resident had no cognitive impairment. Further review of the clinical record revealed that Resident 1 had declined authorization and consent for the production and use of any images taken on behalf of Orwigsburg Center or its agent on January 4, 2023.Review of facility documentation dated November 1, 2025 revealed that Nurse Aide 1 (NA 1) stated that Nurse Aide 2 (NA 2) showed her a photograph of the resulting waste products of Resident 1's personal care. NA 1 further stated that NA 2 had shown her similar photographs in the past. In a witness statement dated, November 3, 2025, NA 2 admitted to taking a photograph of the items.In an interview on November 12, 2025, at 8:47 a.m., the Nursing Home Administrator stated that the photographs were against policy.28 Pa. Code 201.14 (b) Responsibility of licensee.28 Pa. Code 201.18 (b)(2) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.12 (d)(1) Nursing services.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physicians' orders for four of 25 sampled residents. (Residents 8, 62, 86 and 115)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included chronic kidney failure, congestive heart failure, and diabetes. A physician's order dated March 24, 2025, directed staff to administer a medication (isosorbide mononitrate) daily in the morning for heart disease. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 115 millimeters of mercury (mm/Hg). Review of Resident 8's medication administration records (MARs) revealed that staff administered the medication six times in May 2025, five times in June 2025, and four times in July when the resident's SBP was less than 115 mmHg.Clinical record review revealed that Resident 62 had a diagnosis of hypertension (high blood pressure). On March 5, 2025, the physician ordered staff to administer a blood pressure medication (losartan potassium) one time a day. Staff were not to administer the medication if the resident's systolic blood pressure was less than 110 mmHg. Review of Resident 62's MAR revealed that staff administered the medication three times in July 2025, when the SBP was less than 110 mmHg. Clinical record review revealed that Resident 86 had a diagnosis of hypertension (high blood pressure). On April 15, 2025, the physician ordered staff to administer a blood pressure medication (metoprolol tartrate) two times a day. Staff were not to administer the medication if the resident's SBP was less than 110 mmHg. Review of Resident 86's MAR revealed that staff administered the medication six times in July 2025, when the SBP was less than 110 mmHg.In an interview on August 7, 2025, at 9:00 a.m., the Administrator confirmed that medications were administered outside of the established parameters for Residents 8, 62, and 86. Clinical record review revealed that Resident 115 had diagnoses that included partial paralysis on the right side following a cerebral infarction (stroke) and chronic respiratory failure with hypoxia (a condition in which the body's tissues do not receive enough oxygen). A physician's order dated June 22, 2022, directed staff on every shift to administer oxygen via a padded nasal cannula at a pressure of two liters per minute (LPM). On August 7, 2025, at 10:34 a.m., Resident 115 was observed sitting in a wheelchair in the second-floor hallway, where staff had placed her with an empty oxygen tank and no nasal cannula. In an interview on August 7, 2025, at 10:45 a.m., the facility Regional Nurse stated that oxygen was not administered to resident 115 per physician's orders. 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 complete an accurate Minimum Data Set (MDS) assessment for one of 25 sampled residents. (Resident 3)Findings include:Clinical record review revealed that Resident 3 had diagnoses that included anxiety, depression, and atrial fibrillation (irregular heartbeat). Review of Resident 3's MDS assessment dated [DATE], indicated that Resident 3 had a tracheostomy (surgical hole in the front of the neck for breathing). Review of Resident 3's clinical record revealed no physician's orders or care plan indicating the resident had a tracheostomy. In an interview on August 7, 2025, at 9:02 a.m., the Administrator confirmed Resident 3's MDS was inaccurate and that Resident did not have a tracheostomy.

Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure each resident's environment was free of accident hazards by ensuring illegal substances were not accessible to two of six sampled residents. (Residents 1 and 2) In addition, the facility failed to ensure the safety of residents in all areas of the facility in one of two nursing units (Unit A) and first floor common areas. This failure resulted in an Immediate Jeopardy situation.Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure each resident's environment was free of accident hazards by ensuring illegal substances were not accessible to two of six sampled residents. (Residents 1 and 2) In addition, the facility failed to ensure the safety of residents in all areas of the facility in one of two nursing units (Unit A) and first floor common areas. This failure resulted in an Immediate Jeopardy situation. Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included alcoholic cirrhosis of the liver (liver disease linked to heavy alcohol use), major depressive disorder, and diabetes (disease that affects blood sugar). According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs), dated March 19, 2025, the resident had no cognitive (ability to think, reason, and remember) impairment. According to the care plan, Resident 1 ambulated (walked) independently. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic pain, alcohol abuse, and other psychoactive substance abuse (misuse of drugs that affect the brain). According to the MDS assessment, dated March 15, 2025, the resident had mild cognitive impairment. According to the care plan, Resident 2 ambulated independently. On April 9, 2025, a nurse noted that an unknown substance was found in Resident 2's bed. Review of facility documentation revealed the police were contacted, and the unknown substance was identified as a methamphetamine. The facility documentation further indicated that Resident 2 was interviewed on April 9, 2025, by the facility and police and identified Resident 1 as the source who sold him the methamphetamine. Resident 1 was then interviewed by the facility and police and was found to have a bag of the substance in his possession. Residents 1 and 2 were drug tested on [DATE], with positive results for methamphetamine. Resident 1 was then taken into police custody on April 9, 2025. In an interview on April 11, 2025, at 11:25 a.m., Resident 2 confirmed that he purchased the illicit substance from Resident 1, used it, and maintained it's possession in his room under his bed sheets. In an interview on April 11, 2025, at 12:00 p.m., the Administrator stated that staff had checked the unit where Resident 1 and 2 resided (Unit B) and the second floor common areas for additional illegal substances, but that the search did not included any resident areas or common areas on the first floor of the building, including Nursing Unit A. On April 11, 2025, 2024, at 1:40 p.m., the Administrator was notified that the failure to ensure a resident's environment was free of accident hazards by ensuring illegal substances were not accessible to residents and that the facility's failure to ensure the safety of residents in all areas of the facility constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on April 11, 2025, at 5:05 p.m. The facility's action plan contained the following: 1. The facility immediately removed the substance found in Resident 2's room on April 8, 2025. 2. The police were contacted on April 9, 2025, and drug screens were completed on Residents 1 and 2 on April 9, 2025. 3. Resident 1 was taken into police custody On April 9, 2025, where he remains. 4. The facility searched all resident rooms and common areas to ensure there were no additional illegal substances. Searches were completed on April 11, 2025, at 2:30 p.m 5. The facility monitored residents for signs and symptoms of illegal drug use or a change in condition on April 9, 2025, which is ongoing. 6. The facility educated all staff on the procedure for discovery of unidentified substances, and the new procedure to check in packages and bags with the receptionist or nursing. All staff that were available on April 11, 2025, were immediately educated. Other staff will be educated prior to the start of their next shift. 92% of facility staff were educated on April 11, 2025. The remaining 8% of staff will be educated by April 12, 2025. 7. Signs were hung on April 9, 2025, in the lobby for residents to see the receptionist upon return from a leave of absence. 8. Resident 2 and his responsible party have consented to randomized drug testing and to having a limited supply of money in his possession. The survey team validated that the Immediate Jeopardy was removed on April 11, 2025, at 5:05 p.m., through review of the facility training, and review of facility procedures following the facility's implementation of the plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a)(b) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and interviews, it was determined that the facility failed to follow policy related transmissions-based precautions and use of personal protective equipment for one of 24 sampled residents. (Resident 47) Findings include: Review of the facility policy entitled, Isolation- Categories of Transmission-Based Precautions, last reviewed on January 16, 2024, revealed that transmission-based precautions (TBP) were additional measures to protect staff, visitors, and other residents from becoming infected when a resident was diagnosed with specific pathogens. A sign was hung on the room entrance door so that staff and visitors were aware of the need for precautions. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with a diagnoses that included dementia, pneumonia, and methicillin-resistant staphylococcus aureus (a drug resistant infection) in the sputum. On May 13, 2024, a physician ordered that staff use TBP when providing care. On July 24, 2024, at 9:35 a.m., a sign was observed outside Resident 47's room that directed staff and visitors to follow TBP, including use of a gown and gloves, when in the room. On July 24, 2024, from 9:38 a.m. to 9:50 a.m., Nurse Aide (NA) 1 was observed without a gown in Resident 47's room and providing care, including incontinence care and assistance with bathing without a gown. On July 24, 2024, at 1:08 p.m., a visitor was observed in the room without a gown. In an interview on July 25, 2024, at 10:37 a.m., the Infection Preventionist confirmed that Resident 47 was on TBP and that all staff and visitors in the resident's room should have followed the policy and worn appropriate protective equipment including gowns. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, observation, and resident interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for one of 24 sampled residents. (Resident 27) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included diabetes mellitus and congestive heart failure. A Minimum Data Set assessment dated [DATE], indicated that the resident was alert and able to make his needs known. Resident 27's ongoing care plan revealed he had the potential to be at nutritional risk and an intervention was to honor his food preferences. On July 23, 2024, at 10:55 a.m., Resident 27 stated that he frequently received items he disliked on his meal trays. On July 23, 2024, at 12:40 p.m., Resident 27's lunch tray was observed and he received rice as a side dish. Review of Resident 27's meal ticket at that time revealed that rice was listed as a food the resident disliked. In an interview at that time the resident stated that he did not want the rice and would not eat it.

Based on clinical record review and staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for one of 24 sampled residents. (Resident 57) Findings include: Clinical record review revealed that Resident 57 had diagnoses that included schizophrenia and anxiety. On June 10 and 24, 2024, and July 8 and 22, 2024, the physician ordered an anti-anxiety medication, alprazolam, be given every eight hours as needed for 14 days. Review of the medication administration records for June and July 2024, revealed that staff had administered the as needed alprazolam 30 times. There was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. In an interview on July 26, 2024, at 10:05 a.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore as much bladder function as possible for two of 24 sampled residents. (Residents 57, 60) Findings include: Review of the facility policy entitled, Urinary Continence and Incontinence - Assessment and Management, last reviewed January 16, 2024, revealed that facility staff was to complete a urinary incontinence assessment periodically and when there was a change in voiding. Staff would define each resident's level of continence and identify the type of incontinence. Clinical record review revealed that Resident 57 was admitted to the facility on [DATE], with diagnoses that included anxiety and hemiplegia. A Bowel and Bladder Program Screener was completed on April 3, 2024, and May 1, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated June, 24 2024, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Further review of the Bowel and Bladder Program Screeners revealed that Resident 57's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. Clinical record review revealed that Resident 60 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus. A Bowel and Bladder Program Screener was completed on December 27, 2023, March 27, 2024, and June 28, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the MDS assessment, dated June 29, 2024, the resident needed assistance from staff for toileting, was frequently incontinent of urine, and was not on a toileting program. Further review of the Bowel and Bladder Program Screeners revealed that Resident 60's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. In an interview on July 26, 2024, at 10:00 a.m., the Director of Nursing confirmed that there was no documented evidence that the residents' urinary incontinence had been assessed in accordance with facility policy or that toileting programs were implemented for Residents 57 and 60. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for four of 20 sampled residents. (Residents 17, 31, 68 and 87) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included diabetes and a history of respiratory disease. According to the Minimum Data Set (MDS) assessment, dated June 10, 2024, she could communicate her needs and required supervision with her activities of daily living (ADLs) such as personal hygiene. The resident was hospitalized from July 8 to 18, 2024, after a decline in condition. After returning from the hospital, she was more dependent on staff for all mobility and care, including her ADLs. On July 23, 2024, at 12:28 p.m., the resident was observed in bed with long and jagged finger and toe nails. At that time, the resident stated, They haven't helped me trim my nails in a while. On July 25, 2024, at 12:49 p.m., the resident was again observed with untrimmed finger and toe nails. Clinical record review revealed that Resident 31 had diagnoses that included diabetes and hypertension. According to the MDS assessment, dated May 30, 2024, he could communicate his needs and required substantial assistance from staff for all ADLs such as personal hygiene. On July 23, 2024, at 1:38 p.m., the resident was observed in his chair with long, yellow, and jagged fingernails. In an interview with the resident at that time, he stated that he preferred his nails short but needed help to cut them. On July 24, 2024, at 11:52 a.m., and on July 25, 2024, at 10:04 a.m., the resident was again observed with untrimmed fingernails. Clinical record review revealed that Resident 68 had diagnoses that included macular degeneration and anxiety. According to the MDS assessment, dated June 12, 2024, he could communicate his needs and required substantial assistance from staff for ADLs such as personal hygiene. On July 23, 2024, at 10:34 a.m., the resident was observed in bed with long, yellow, jagged fingernails with dark debris caked underneath the nails. In an interview with the resident at that time, he referenced his hands and stated, I can't get any help here with them. On July 24, 2024, at 11:25 a.m., and on July 25, 2024, at 9:37 a.m. and 12:41 p.m., the resident was again observed with untrimmed fingernails. On July 25, 2024, at 12:41 p.m., the resident stated, these nails are really sharp and dangerous and I keep trying to get them to help me. Clinical record review revealed that Resident 87 had diagnoses that included history of a stroke with residual weakness to one side of the body and osteoarthritis. According to the MDS assessment, dated April 6, 2024, he could communicate his needs and was dependent on staff for ADLs such as personal hygiene. On July 23, 2024, at 10:40 a.m., the resident was observed in bed with long and jagged fingernails. In an interview with the resident at that time he stated that he did not prefer his nails this long but could not cut them on his own. On July 24, 2024, at 12:08 p.m., and on July 25, 2024, at 10:14 a.m., the resident was again observed with untrimmed fingernails. In a group interview on July 24, 2024, at 10:07 a.m., Residents 7, 23, 24, 34, 45, 98, and 99, stated that routine nail care was not done by staff as a part of ADL assistance. In an interview on June 25, 2024, at 1:54 p.m., the Director of Nursing stated that staff was to perform nail care with the residents' showers. 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 adaptive equipment to assist with eating meals for one of 24 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dysphagia and aphasia. On March 19, 2024, the physician ordered that staff provide the resident a two handled cup at all meals. Review of an occupational therapy note dated July 17, 2024, revealed that it was recommended for the resident to continue to use a two handled mug or regular mug/cup with a lid and straw to aid independence. On July 23, 2024, from 12:40 p.m. through 12:55 p.m., and on July 25, 2024, from 12:40 p.m. through 12:55 p.m., Resident 1 was observed in the dining room without a two handled cup or regular mug/cup with a lid and straw for her beverages. In an interview on July 26, 2024, at 10:20 a.m., Registered Nurse 1 confirmed that the resident should have received her drink in a two handled cup at all meals. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement treatment and services to prevent a further decrease in range of motion for one of six sampled residents with limited range of motion. (Resident 46) Findings include: Clinical record review revealed that Resident 46 had diagnoses that included quadriplegia (the inability to be able to move any muscles from the neck down), muscle spasm, and traumatic brain injury. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, dependent on staff for activities of daily living, and had a limitation in range of motion on both sides of the upper extremities. On March 8, 2022, the occupational therapist (OT) recommended a restorative nursing program (RNP) for range of motion for both shoulders and the right elbow. A physician's order dated March 9, 2022, directed staff to provide the RNP and provide a prolonged stretch for both shoulders and also to extend the right elbow five times and hold it for 30 seconds. There was no evidence that staff had implemented the RNP. In an interview conducted on August 3, 2023, at 10:12 a.m., Quality Regulatory Consultant 1 confirmed there was no evidence that the RNP was provided and that it was not on the task list for nursing care duties. In an interview conducted on August 3, 2023, at 11:00 a.m., The Director of Therapy stated that Resident 46 required the RNP as recommended for both shoulders and right elbow for muscle contractures. In an interview conducted on August 3, 2023, at 12:09 p.m., Nurse Aide 1 (NA1) stated that nurse aides viewed the required daily care duties and RNPs on the task list. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 23 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included paraplegia (loss of feeling or movement in part of the body), anxiety, depression, and chronic pain. A physician's order dated June 21, 2023, directed staff to administer Percocet (a pain medication) every four hours as needed for severe pain of eight to 10 on the pain scale. Review of the June, July, and August 2023, medication administration records revealed that staff administered the medication when the resident's pain was rated below eight on the pain scale eight times in June, 19 times in July, and one time in August. In an interview on August 4, 2023, at 9:45 a.m., Quality Regulatory Consultant 1 confirmed that staff had administered the Percocet when the resident's pain was below the established parameters. CFR 483.25 Quality of Care Previously cited 10/6/22 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 develop a comprehensive care plan for one of 20 sampled residents. (Resident 20) Findings include: Clinical record review revealed that Resident 20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident received [CONDITION(S)] medications. According to the Care Area Assessment of the MDS assessment the facility identified the resident's [CONDITION(S)] medications use was a problem and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop a care plan with interventions to address the need for [CONDITION(S)] medications. In an interview conducted on October 6, 2022, at 11:07 a.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address the need for [CONDITION(S)] medications for Resident 20. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 20 sampled residents. (Resident 73 ) Findings include: Clinical record review revealed that Resident 73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On September 10, 2022, a physician ordered that staff administer a medication ([MEDICATION(S)]) once daily in the morning to treat the resident's hypertension. Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats, and the pressure is at its highest) of less than 100 millimeters of mercury (mm/Hg). A review of the September 2022, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview conducted on October 6, 2022, at 11:25 a.m., the Director of Nursing confirmed that Resident 73 received the [MEDICATION(S)] outside prescribed parameters on three occasions in September 2022. CFR: 483.25 Quality of Care Previously cited 10/29/2021. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide necessary services for residents unable to independently maintain good grooming and personal hygiene for two of 20 sampled residents. (Residents 44, 51) Findings include: Clinical record review revealed that Resident 44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment indicated that the resident required extensive assistance from staff for personal hygiene. During an interview on October 5, 2022, at 1:50 p.m., Resident 44's hands were observed held tightly in a fist position and the resident demonstrated the inability to fully extend the fingers. The resident's fingers (especially the right fifth digit) were observed curled into the palm when relaxed. All of the resident's fingernails were long with the nail of the right fifth digit pushing into the palm. Resident 44 confirmed dependence on staff for nail care and reported the desire to have short fingernails. The resident was unaware that staff provided the service. Clinical record review revealed that Resident 51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated the resident was totally dependent on staff for bathing. On August 16, 2022, that physician ordered that staff provide the resident a shower twice a week. The resident was observed in bed on October 4, 2022, at 10:49 a.m. and October 5, 2022, at 1:45 p.m., with hair that appeared oily and unclean. At the time of the observations, Resident 51 stated that showers were desired and it had been a long time since one was offered. There was a lack of documentation to support that Resident 51 had been offered a shower (or tub bath) for at least 30 days previous to October 4, 2022. 28 Pa. Code 201.19(j) Resident rights. 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 notify a resident's representative of a significant change in condition for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 16, 2022, the facility identified Stage II pressure ulcers on the resident's right and left buttocks. On March 28, 2022, an additional Stage II pressure ulcer was identified on the resident's lower back (sacrum). On April 11, 2022, a nurse noted that the resident's sacral pressure ulcer had merged with the right buttock pressure ulcer, had increased in size and depth, and worsened to a Stage III pressure ulcer. There was no documented evidence that the resident's representative was notified of the significant change in the resdient's pressure ulcer until April 20, 2022, when the wound had further worsened and increased in size. In an interview conducted on May 13, 2022, at 1:39 p.m., the Director of Nursing confirmed that there was no evidence that the responsible party was notified of the significant decline in Resident 1's pressure ulcers. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 19 sampled residents. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was ordered pain medication ([MEDICATION(S)]), 5 milligrams (mg) every four hours as needed for moderate pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that non-pharmacological interventions were attempted prior to administration of the as needed narcotic pain medication. Clinical record review revealed that Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan instructed staff to encourage Resident 2 to participate in group activities such as aromatherapy, arts and crafts, manicures, pet therapy, and music entertainment as an intervention for pain management. Review of the (MAR) revealed that the resident received the as needed narcotic pain medication 74 times in August 2021, 51 times in September 2021, and 58 times in October 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. In an interview on October 29, 2021, at 9:20 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions were offered to Resident 1 and Resident 2 prior to or in conjunction with the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, staff interview, and observation, it was determined that the facility failed to assess and document the status of pressure ulcers for two of 19 sampled residents. (Residents 53, 67). The facility also failed to ensure treatments were done in accordance to facility policy and /or were in place for two of 19 sampled residents who had or were at risk for pressure ulcers. (Residents 21, 67) Findings include: Review of the facility policy entitled, Pressure Ulcers/Skin Breakdown, dated August 17, 2021, revealed that staff was to document/ report a full assessment of a resident's pressure ulcer including location, stage, length, width, and depth. In an interview on October 29, 2021, at 9:35 a.m., the Director of Nursing stated that pressure ulcers were to be evaluated and documented weekly. Review of the facility policy entitled Wound Care, dated August 17, 2021, revealed that during the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review revealed that Resident 53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound assessment completed on admission revealed that Resident 53 had pressure ulcers to his left foot, sacrum, right outer ankle, right calf, and left heel. On October 4, 2021, Resident 53's left foot and heel wounds were assessed by the wound physician. There was no documented evidence that Resident 53's wounds on his sacrum, right outer ankle, and right calf were assessed since admission on September 27, 2021, through October 25, 2021. There was also no documented evidence that the resident's left foot and heel wounds were assessed from October 4, 2021, through October 20, 2021. In an interview on October 29, 2021, at 9:40 a.m., the Director of Nursing confirmed there was no documented evidence that Resident 53's wounds were assessed per facility policy and weekly. Clinical record review revealed that Resident 67 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated October 2, 2021, revealed the resident had cognitive impairments, and required total dependence with dressing and hygiene, and extensive assistance with bed mobility. Review of the current care plan revealed that the resident had the potential for skin breakdown and an intervention for bilateral heel boots. On September 14, 2021, the physician ordered for staff to elevate the resident's heels off the bed with pillows. On September 20, 2021, a nurse documented a stage four pressure ulcer to Resident 67's right heel and a deep tissue injury (DTI) to the left heel in the weekly skin evaluation. On October 25, 2021, a nurse again documented a stage four pressure ulcer to Resident 67's right heel and a DTI to the left heel in the weekly skin evaluation. There was no documented evidence that Resident 67's left heel DTI was assessed and monitored after September 20, 2021 and prior to October 25, 2021. On October 27, 2021 at 1:09 p.m., Resident 67 was observed laying in bed with only a right heel boot in place. On October 28, 2021 at 10:43 a.m., Resident 67 was observed in her wheelchair with a only a right heel boot in place. On September 20, 2021, the physician ordered that Resident 67's right heel be cleansed with normal saline and Mesalt (a salt impregnated dressing) and a dry dressing applied, and that Resident 67's left heel be cleansed with normal saline and skin prep applied. On October 27, 2021, at 1:11 p.m., Licensed Practical Nurse (LPN) 1 was observed providing the prescribed treatments to Resident 67's right and left heels. LPN 1 failed to remove her gloves and cleanse hands after removing the old dressing and before applying the new dressing per facility policy during the observation. In an interview on October 29, 2021 at 9:29 a.m., the Director of Nursing confirmed there was no documented evidence that Resident 67's left heel DTI was assessed per facility policy. Clinical record review revealed that Resident 21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order dated December 19, 2019, instructed staff to put bilateral heel boots on both feet to prevent pressure. Review of the MDS dated [DATE], revealed that Resident 21 had severe cognitive impairment, required total dependence from staff for all activities of daily living, and was at risk for developing pressure ulcers/injuries. Review of the current care plan revealed that resident had the potential for impaired skin integrity due to decreased mobility. There was an intervention for staff to provide heel boots as ordered. On October 27, 2021, and October 28, 2021, Resident 21 was observed in his wheelchair without the heel boots on to prevent pressure. There was no documentation to support that staff attempted to apply or that Resident 21 refused to wear the heel boots during those observation periods. 28 Pa Code 211.10(a)(d) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services to restore or maintain continence to the extent possible for one of 19 sampled residents. (Resident 51) Findings include: Review of the facility policy entitled, Behavioral Programs and Toileting Plans for Urinary Incontinence, dated August 17, 2021, revealed that staff was to monitor, record, and evaluate information about the resident's bladder habits, and continence, or incontinence, including type of incontinence and assess the resident for appropriateness of behavioral programs that promote urinary continence. Clinical record review revealed that Resident 51 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A bowel and bladder screening tool dated July 3, 2021 and October 3, 2021, revealed that Resident 51's type of incontinence was never identified. The assessments also indicated that the resident was a candidate for scheduled toileting (timed voiding). There was no documented evidence to support that a scheduled toileting plan was ever initiated for Resident 51. In an interview on October 29, 2021, at 11:00 a.m., the Director of Nursing confirmed that there was no documented evidence that a scheduled toileting plan was initiated for Resident 51. CFR. 483.25(e) Incontinence. Previously cited 10/16/20 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 physician's orders were implemented for one of 19 sampled residents. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment, dated August 22, 2021, revealed that the resident had no cognitive impairments, and required extensive assistance from staff with activities of daily living, including dressing, bed mobility and personal hygiene. Review of Resident 22's current care plan revealed she was at risk for pain. In an interview on October 26, 2021, at 11:12 a.m., Resident 22 stated she had chronic pain, especially after sitting for too long. On July 1, 2021, the physician ordered for the resident to have a steroid injection for right shoulder pain. There was no documented evidence that the steroid injection was addressed with the resident or that the resident received the injection. In an interview on October 29, 2021, at 9:25 a.m., the Director of Nursing was unable to provide documentation that the steroid injection was addressed with the resident or that it was completed as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.