Every finding on record at Pennsburg Manor

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented in relation to administration of medications in a timely manner for three of nine sampled residents. (Residents 1, 2 and 3) Findings include;Review of the facility policy entitled, Medication Administration, reviewed February 2026, revealed that medications were to be given in accordance with physician orders. Medications were to be administered within 60 minutes of the scheduled time except before or after meals orders. In addition, staff was to observe the client for medication actions/reactions and record in nursing notes as appropriate. Any noted adverse consequences were to be reported to the attending physician.Clinical record review revealed that Resident 1 had diagnoses that included multiple sclerosis, constipation, allergies and depressive episodes. Review of current physician orders revealed that staff was to administer a medication for multiple sclerosis, (glatiramer acetate injection), a medication for depression, (sertraline), a medication for allergies, (loratadine), two medications for constipation, (Dulcolax and Glycolax powder), and a supplement, (calcium 600 mineral tablet) every day. A review of the electronic Medication Administration (MAR), revealed that the medications were to be administered at 9:00 a.m Further review of the MAR for June 2026, revealed that on June 26, 2026, the glatiramer acetate injection, sertraline, loratadine, Dulcolax, Glycolax powder and the calcium supplement had not been administered until 12:59 p.m. Clinical record review revealed that Resident 2 had diagnoses that included chronic obstructive pulmonary disease, (COPD) and hypertension. Review of current physician orders revealed that staff was to administer a medication for COPD, (albuterol sulfate), and a medication for hypertension, (metoprolol tartrate), every day. A review of the MAR revealed that the medications were to be administered at 9:00 a.m. Further review of the MAR for June 2026, revealed that on June 26, 2026, the albuterol sulfate and the metoprolol tartrate had not been administered until 1:09 p.m Clinical record review revealed that Resident 3 had diagnoses that included a malignant neoplasm of the right lung, COPD, anemia, neuropathy, hypotension, chronic pain, allergies, gastroesophageal reflux disease (GERD), hypokalemia and heart disease. Review of current physician orders revealed that staff was to administer medications for heart disease, (Advair Diskus inhalation, clopidogrel bisulfate, Eliqus, hydrocortisone, torsemide, and ranolazine) every day. Further review of current physician orders also included that staff was to administer medications for anemia, (ferrous sulfate), pain medications, (gabapentin and Voltaren gel), allergies, (loratadine), deficiency, (magnesium oxide), GERD (omeprazole), COPD (ipratroplum-albuterol), and Hypokalemia, (potassium chloride), every day. In addition, current physician orders also included for staff to apply ace wraps to the bilateral lower extremities every morning and to remove them every evening. Review of the MAR revealed that these medications and the ace wraps were scheduled to be administered by staff at 9:00 a.m. Review of the June 2026, MAR revealed that on June 26, 2026, all of the physician ordered morning medications including the application of the ace wraps had not been administered and applied by staff until 11:29 a.m In addition, there was no documented evidence that nursing staff had notified the physician that the medications had not been administered timely on June 26, 2026, for Residents 2 and 3. In an interview on July 8, 2026, at 11:01 a.m., the registered nurse (RN) 1 stated that the scheduled medications were to be given within a 60 minute time frame of the scheduled time. RN 1 further stated that on June 26, 2026, the scheduled morning medications for Residents 1, 2, and 3, had not been administered as per facility policy and as ordered by the physician. In addition, there was no documented evidence that nursing staff had notified the physician of the medications not being administered in a timely manner for Residents 2 and 3. 28 Pa. Code 211.12(d)((1)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement care plan interventions for one of nine sampled residents. (Resident 3) Findings include:Clinical record review revealed that Resident 3 had diagnoses that included malignant neoplasm of the right lung, arterial fibrillation and chronic pain. Resident 3 had current physician orders for staff to administer an anti-coagulant, (Eliquis), a pain medication, (Gabapentin), and to apply a pain relief gel, (Voltaren), every day. The medications and the gel was scheduled to be administered and applied at 9:00 a.m. A review of the care plan revealed that the resident was at risk for complications related to the use of anti-coagulant therapy. There was an intervention to administer the anti-coagulant as ordered by the physician. A review of the care plan revealed that the resident had exhibited and was at risk for altered comfort related to acute and chronic pain. There was an intervention for staff to medicate the resident as ordered by the physician. Review of the electronic Medication Administration Record for June 2026, revealed that on June 26, 2026, the staff did not administer the anti-coagulant, the pain medication and the pain relieving gel until 11:29 a.m In an interview on July 8, 2026, at 11:01 a.m., RN 1 stated that the medications and the gel had not been administered and applied as ordered and scheduled by the physician in a timely manner. The facility failed to implement care planned interventions in a timely manner. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBPs) and the use of personal protective equipment (PPE) to prevent the spread of infection for two of 21 sampled residents. (Residents 2 and 11)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed November 14, 2025, revealed that, in addition to standard precautions, Enhanced Barrier Precautions (EBPs) would be used (when Contact precautions do not otherwise apply) for novel or targeted Multi-Drug-Resistant-Organisms (MDROs). Staff was to wear a gown and gloves during high contact resident care activities such as dressing, transferring from the bed to chair and back, and changing linens to prevent infections even when exposure to body fluids and blood was not anticipated. EBPs were used to help reduce the transmission of MDROs by requiring the use of gowns and gloves during specific high contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of acquiring an MDRO. Residents at risk include but are not limited to those with feeding tubes, indwelling urinary catheters, central vascular lines, tracheostomy tubes, and wounds. Standard precautions such as hand hygiene always applied and precautions included the use of protective gowns and gloves during high-risk activities. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included cellulitis (a spreading skin infection, most commonly of the lower leg caused by bacteria entering through a break in the skin) of the right and left lower limbs , rhabdomyolysis (the breakdown of skeletal muscle tissue leading to the release of myoglobin and other harmful substances into the bloodstream), sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), and diabetes mellitus. The care plan revealed that Resident 2 required Enhanced Barrier Precautions and interventions included that staff wear gloves and gowns during close contact interactions, including bed transfers. Observation on March 24, 2026, at 12:40 p.m., revealed that a nurse aide (NA 1) collected a soiled gown and bed linens from Resident 2 without the use of a gown or gloves, carried them unbagged to the soiled closet, then obtained a mechanical lift for the resident. Staff did not wash or sanitize her hands before obtaining the lift for the resident. NA 1 entered Resident 2's room to transfer Resident 2 with a registered nurse (RN 1) and the mechanical device from the bed. Neither RN 1 nor and NA 1 wore a gown and NA 1 did not wear gloves to perform the transfer with Resident 2. At the time of the observation, RN 1 confirmed that the Resident 2 had an open wound on his right leg. There was an EBP sign posted on his door. Clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses that included hypothyroidism (an overactive thyroid gland), dementia, and pain. Review of the clinical record revealed that Resident 11 had a pressure ulcer on the left heel and was identified on the care plan as at risk for MDRO colonization/infection due to the left heel wound. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 11 had one unhealed pressure ulcer. On March 25, 2026, at 8:33 a.m., a sign was observed on Resident 11's door indicating EBPs were required for care. At that time, RN 2, entered the resident's room and proceeded to assist the resident with dressing. RN 2 did not wear a gown to perform care. On March 26, 2026, at 1:30 p.m., the Director of Nursing confirmed that the above identified staff did not follow the facility infection control policy. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to restore continence to the extent possible for one of four sampled residents with urinary incontinence. (Resident 87) Findings include: Review of the facility policy entitled, Continence Management, last revised July 15, 2025, revealed that residents were to be assessed for continence management. Residents who were incontinent of bladder were to receive appropriate treatment for prevention of incontinence associated dermatitis and to restore bladder continence to the extent possible. A nursing assessment was to be conducted to determine the type of incontinence, voiding patterns, physical and cognitive functional abilities, and any pertinent diagnoses. The facility was to develop individualized interventions and a plan of care based on information from assessments and voiding records. Clinical record review revealed that Resident 87 had diagnoses that included difficulty walking and history of a malignant neoplasm of the uterus. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and was frequently incontinent of urine. A review of the care plan revealed that the resident required assistance from staff for toileting due to limited mobility. There were no interventions to attempt to restore bladder continence. Review of nursing documentation revealed that for the last 30 days, the resident was noted to be incontinent of urine greater then 50 times throughout the month. There was no documented evidence that staff had completed a nursing assessment to determine the type of incontinence, voiding patterns, and any pertinent diagnoses that may affect bladder continence. In addition, there was no documented evidence that the facility developed a care plan with interventions to provide treatment and services to attempt to restore bladder continence. In an interview on March 26, 2026, at 9:35 a.m., the Director of Nursing confirmed that the resident had not been assessed for continence management and a care plan was not developed with interventions to attempt to restore as much bladder function as possible per facility policy. CFR 483.25(e)(2) IncontinencePreviously cited 5/6/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to maintain sanitary conditions in the dietary department. Findings include: An environmental tour of the food service department on May 4, 2025, at 9:06 a.m., revealed the following: There were five stained ceiling tiles above a table that contained a large coffee maker. There were areas on the back splash of the stove and around the burners that were stained with a blackish/brown substance. The bottom of the convection oven was dirty with burnt crumbs. The doors on the inside of the convection oven were covered with grease and burnt substances. 28 Pa.Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide treatment and services to restore bladder function as much as possible for one of four sampled residents with urinary incontinence. (Resident 97) Findings include: Review of the policy entitled, Continence Management, last reviewed January 2025, revealed that residents were to be assessed for the need for a continence management program as part of the nursing assessment process. A urinary incontinence assessment was to be completed upon admission. The purpose was to provide appropriate treatment and services for residents with urinary incontinence to minimize urinary tract infections and restore continence to the extent possible. The facility was to develop individualized interventions and a plan of care based on information from assessments and voiding records/documentation. Clinical record review revealed that Resident 97 was admitted [DATE], and had diagnoses of encephalopathy, disturbance of the brain, and weakness. The Minimum Data Set assessment dated [DATE], indicated that the resident was only slightly cognitively impaired, was frequently incontinent of bowel and bladder, and was not on a toileting program. The assessment also indicated that the problem of urinary incontinence was to be addressed in the care plan. On March 6, 2025, a nurse documented that the resident was incontinent of urine and used adult briefs. There was no documented evidence that a urinary incontinence assessment was completed upon admission in order to assess and provide treatment and services to the resident for urinary incontinence in order to restore bladder continence to the extent possible. In addition, there was no care plan developed with specific interventions to address/restore urinary incontinence. In an interview on May 6, 2025, at 11:00 a.m., the Administrator stated that the staff had not completed a urinary incontinence assessment nor developed and implemented specific care planned interventions to address and attempt to restore bladder function as per facility policy. 28 Pa.Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and interview, it was determined that the facility failed to provide care and services in a manner respectful of each resident's dignity to promote the quality of life for one of 26 sampled residents. (Resident 257) Findings include: Review of the facility policy entitled, Patient Security Bracelet, last reviewed July 1, 2024, revealed that residents were evaluated for the need of a wandering security bracelet to serve as a safety measure to prevent elopement (unauthorized departure from the facility) and wandering in unsafe areas of the center. Clinical record review revealed that Resident 257 was admitted to the facility on [DATE], with diagnoses that included pyogenic arthritis of the right knee joint (inflammation in one or more of the joints caused by an infection) and spinal stenosis (narrowing of the space in the spine). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was not cognitively impaired, required supervision with ambulation and transfers, and did not exhibit wandering behavior. Review of Resident 257's Elopement Evaluation dated April 20, 2025, revealed that the resident was not ask risk for elopement. Further review revealed another Elopement Evaluation dated April 30, 2025, stating that the resident had expressed a desire to go home and that the resident wandered. However, there was no evidence in the clinical record to support that Resident 257 had wandered or attempted to elope from the facility. Observation on May 4, 2025, at 12:19 p.m., revealed Resident 257 sitting up in bed with a wandering security bracelet on the left ankle. In an interview at that time, Resident 257 stated, This band is an insult to my intelligence; where am I going to go? I am here for antibiotics and physical therapy. I just want to go outside when it's nice and they won't allow it. There was no evidence in the clinical record to support that the wandering security bracelet was discussed with the resident or that the resident was agreeable to its use. In an interview on May 6, 2025, at 9:35 a.m., the Administrator stated that the resident should not have had the wandering security bracelet. 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 the responsible party was notified of a change in condition for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart disease and major depressive disorder. On December 20, 2024, a physician ordered for staff to administer an increased dosage of an anti-depressant medication (Zoloft) from 50 milligrams (mg) to 75 mg. There was no documentation to support that the resident's responsible party was notified that the medication dosage was increased. In an interview on December 20, 2024, at 3:30 p.m., the Director of Nursing confirmed that there was no documented evidence that the responsible party had been notified the dosage of the medication had been increased. 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 physician's orders were implemented for one of 28 sampled residents. (Resident 64) Findings include: Clinical record review revealed that Resident 64 had diagnoses that included hypertension (high blood pressure). A physician's order dated March 30, 2024, directed staff to administer a medication (midodrine) one time a day. Staff were not to administer the medication 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 more than 90 millimeters of mercury (mmHg). Review of Resident 64's medication administration record revealed staff administered the medication four times in April 2024, when the resident's SBP was greater than 90 mmHg. In an interview on April 19, 2024, at 9:10 a.m., the Nursing Home Administrator confirmed the medication was administered outside established parameters for Resident 64. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to implement a physician's order for one of four sampled residents. (Resident CR2) Findings include: Clinical record review revealed that Resident CR2 was admitted to the facility with diagnoses that included bipolar disorder, depression, and deconditioning. A physician's order dated September 26, 2023, directed staff to administer a medication to treat depression (cariprazine) once daily. Review of the Medication Administration Record (MAR) for October 2023, revealed that the medication was not administered as ordered by the physician on October 7 and 8, 2023. 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, functional and comfortable environment for residents on one of two nursing units. (second floor nursing unit) Findings include: During an environmental tour of the second floor nursing unit on March 7, 2023, at 10:28 a.m., observation revealed the following: The walls were marred and scratched in the bathrooms of resident rooms 201, 203, 214, 215, 218, and 227. In addition, in the bathrooms of resident rooms [ROOM NUMBER], the flooring was buckled. The garbage can in resident bathroom [ROOM NUMBER] was overflowing and there was garbage scattered on the floor. Observation in the central bathroom on the North side of the unit revealed that the toilet seat was very loose and coming apart from the toilet. There was no toilet paper holder in the bathroom of resident room [ROOM NUMBER]. In resident room [ROOM NUMBER], there were floor tiles missing underneath the bottom of the bed by the window. The bottom edging of the door frame of resident room [ROOM NUMBER] was jagged and sticking out from the wall. The walls in resident room [ROOM NUMBER] were marred and scratched. Both medication carts for the North and South wings were soiled with spillage on the sides and along the bottom rims of the carts. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, staff interview and clinical record review it was determined that the facility failed to ensure that the administration of pain medication was consistent with physician's orders and assessed pain levels and failed to offer non-pharmacological interventions prior to the administration of an as needed pain medication for three of 21 sampled residents who were on a pain management program. (Residents 73, 82, 254) Findings include: Review of the facility policy, Pain Management, dated June 1, 2021, revealed that residents were to be assessed for the presence of pain by making an inquiry of the resident or by observing for signs of pain. Further, residents were to be offered non-pharmacological interventions prior to the administration of the as needed medications. During an interview on June 4, 2021, at 9:30 a.m., the Director of Nursing stated that a pain level of one to three would be considered mild pain, four to seven would be considered moderate pain, and eight to ten would be considered severe pain when administering a medication with specific pain severity instructions. Clinical record review revealed that Resident 73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented, was understood, and understands others clearly. Narcotic pain medication (hydrocodone-acetaminophen) was ordered by the physician on April 29, 2021, to be given every six hours as needed for moderate pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered the narcotic pain medication (hydrocodone-acetaminophen) on May 26, 2021, to be given every four hours as needed for moderate pain. Review of the MAR for May 2021, revealed that the resident received the as needed narcotic one time with a recorded pain level of zero and two times with a recorded pain level of three which was less than the standard measurement for moderate pain. Clinical record review revealed that Resident 82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident had memory impairment. Narcotic pain medication (oxycodone) was ordered by the physician on April 29, 2021, to be given every six hours as needed for severe pain. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the resident received the as needed narcotic two times in May 2021, with no documented non-pharmacological interventions offered prior to the administration of the as needed medication. Clinical record review revealed that Resident 254 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident was oriented, was understood, and understands others clearly. Narcotic pain medication (oxycodone) was ordered by the physician on May 29, 2021, to be given every four hours as needed for moderate pain. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for June 2021, revealed that the resident received the narcotic one time with no documented non-pharmacological interventions prior to the administration of the as needed medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations it was determined that the facility failed to ensure a sanitary homelike environment for residents and staff on two of two nursing units (First and Second Floor nursing units) and on the ground floor. Findings include: On September 4, 2020, at 9: 00 a.m., 10:43 a.m., and 11:30 a.m.,the hallway floors throughout the first floor nursing unit had dirt and debris. Room 121, had buckled damaged wallpaper above and behind the bed. At the end of the hallway outside of Room 121, the window sill had peeling wallpaper. On September 4, 2020 at 10:35 a.m., and 11:35 a.m., the hallway floors throughout the second floor nursing unit had dirt and debris. At the end of the hallway near Room 221, the window sill had a damaged wall with peeling wallpaper. The drape in front of the window was soiled. In Room 220, the wall below the window was damaged and the floor molding was detached from the wall. At the end of the hallway near Room 208, the window sill had peeling wallpaper. Observations on September 4, 2020 at 10:15 a.m., revealed an ice machine near the kitchen with an accumulation of black dust on the floor. On September 4, 2020, at 11:40 a.m, the ventilation duct in the laundry had a black substance on the grille of the vent and a black substance on the wall surrounding the vent. 28 Pa. Code 207.2 (a) Administrator's responsibility.

Based on observation and staff interview, it was determined that the facility failed to store, prepare, and distribute food in a manner to prevent the potential for food borne illness in the main kitchen and on two of four nursing units (first floor, and second floor, north hall). Findings include: Observation in the facility's main kitchen on (MONTH) 13, (YEAR), at 11:30 AM revealed a cart in the preparation area with hot chocolate and pretzels stored on it with dust, and food debris on the shelves of the cart; the bottom shelves of three tables in the preparation area contained dried spills and dried food debris. The floors under the preparation tables along the side and back wall of the food preparation area where the mixer was located contained a large amount of dried food debris and dried spills under the tables and along the wall edge. Four meal tray delivery carts in the kitchen contained dried spills on the outside of the carts and on the tray holders inside the carts. One of the meal tray delivery carts was then observed on the first floor carrying lunch trays on (MONTH) 13, (YEAR), at 12:21 PM with the same dried spills on the outside of the cart as observed in the kitchen earlier that day. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 15, (YEAR), at 2:30 PM. On (MONTH) 13, (YEAR), at 11:45 AM, Employee 1, food service worker, was observed plating the resident lunch meal from the portable steam table on the second floor, north hall. Employee 1 was observed cutting toasted cheese sandwiches and scooping tater tots with gloved hands and plating the food. Employee 1 was observed touching a brown plastic bin to obtain prepared plated salads and sandwiches covered with plastic wrap and returned to cutting sandwiches and scooping tater tots with the same gloves used to touch the plastic bin and serve the prepared food. Concurrent interview with Employee 1, acknowledged the above findings. The above findings were reviewed with the Nursing Home Administrator on (MONTH) 14, 2108, at 2:30 PM. 483.60 (i)(1)-(3) Food Procure, Store/Prepare/Serve-Sanitary Previously cited 11/9/17 28 Pa. Code 211.6 (c)(d)(f) Dietary services

Based on resident and staff interview and clinical record review, it was determined that the facility failed to ensure that the residents received quarterly statements of their personal funds for the one resident reviewed (Resident 103). Findings include: Clinical record review for Resident 103 revealed a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates cognitively intact) score of 13 indicating that she was capable of making her own decisions. During an interview with Resident 103 on (MONTH) 13, (YEAR), at 11:36 AM revealed that she never knows how much money she has in her personal funds account. She stated that when she asks the facility they just tell her that her son takes care of it. When asked if she has ever received a statement she stated, Never, but I would appreciate one. An interview with the Nursing Home Administrator, Director of Nursing, and Employee 2 (business office manager) on (MONTH) 15, (YEAR), at 1:25 PM revealed that Resident 103's son gets the quarterly statements of her personal funds. The facility sends the quarterly statements to the responsible party without asking the resident what their preference is. 28 Pa. Code 201.18(h) Management

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them regarding care preferences for two of two residents reviewed (Residents 62 and 103). Findings include: Clinical record review for Resident 62 revealed the resident had a physician's orders [REDACTED]. Further review of Resident 62's clinical record revealed she was weighed on (MONTH) 17, (YEAR). A significant change Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated (MONTH) 25, (YEAR), indicated Resident 62 had a BIMS (Brief Interview for Mental Status) score of 14 indicating she was cognitively intact. In an interview with Resident 62 on (MONTH) 15, (YEAR), the resident was questioned regarding being weighed on (MONTH) 17, (YEAR), after she had an order for [REDACTED]. The resident was then asked if she requested to not have lab work completed and she stated she never said she did not want lab work completed and if she needed lab work she wanted it to be done. Resident 62 indicated she did not know why her weights or needed lab work would be stopped. Further review of Resident's 62's clinical record did not reveal any evidence that the facility staff discussed the resident wishes regarding weights and lab work prior to implementing an order to discontinue both on (MONTH) 3, (YEAR). The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 15, (YEAR), at 2:15 PM. Clinical record review for Resident 103 revealed a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates cognitively intact) score of 13 indicating that she was capable of making her own decisions. Review of Resident 103's physician orders [REDACTED]. Review of Resident 103's record of weights indicated that on (MONTH) 18, (YEAR), there was a notation last weight obtained, weights discontinued. An interview with Resident 103 on (MONTH) 15, (YEAR), at 4:00 PM revealed she was not aware that the facility had stopped her lab work and had stopped weighing her. She responded, Did they stop my blood tests because the insurance won't pay? How are they going to know what is wrong with me? I want to know how much I weigh. I have been losing weight and I would like to keep doing that. An interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 15, (YEAR), at 4:15 PM revealed that they had discussed the above with Resident 103's son but not the resident. 28 Pa. Code 201.29(j) Resident rights

Based on observation and staff interview, it was determined that the facility failed to ensure that sanitary conditions were met. Findings include: Observation of the dietary department on November 7, 2017, at 8:45 a.m. revealed that the refrigerator had a sign that directed staff to document an opened and used by date on all items. Review of manufacturer's instructions on thickened beverages revealed that thickened water was to be discard ten days after opened. There were three opened thickened water containers in the refrigerator that had no opened and used by date. Manufacturer's instructions for thickened juice products indicated that the thickened juice was to be discarded seven days after being opened. There were two thickened juice containers in the refrigerator that had no opened and used by date. Additionally, there were 12 trays of dessert products that were not covered in the refrigerator. Observation of the dish washing procedure at 9:00 a.m. revealed that Dietary Employee 1 (DE1) was stacking and the rinsing soiled dishes and glassware. (DE1) would proceed to remove the sanitized dishware from the other end of the dishmachine without washing his hands. This was observed for five consecutive rounds of dishwashing. Observation of the food plating process from the steamtable at 12:20 p.m. on November 7, 2017, revealed that Dietary Employee 2 was plating lunch for the residents in the main dining room. Dietary Employee 2 (DE2) would repeatedly pick up the hamburgers and placed them into buns with her gloved hands, even though there was a utensil readily available. The employee also picked up fried onions with her gloved hand and again there was a utensil readily available. Throughout the observation, DE2 would touch other containers such as various condiments, and the refrigerator doors. DE2 did not change gloves or wash her hands throughout this continual observation. On November 8, 2017, at 11:00 a.m. DE2 was observed repeatedly picking up waffles and pieces of cooked chicken with her gloved hand and placed them on plates for residents in the main dining room. There were appropriate utensils readily available. Again, DE2 would touch condiments, tray line tickets and other surfaces while intermittently making sandwiches without changing her gloves or washing her hands. At 11:55 a.m., this same employee was observed providing ice and beverages into glasses for residents. Without changing gloves, the employee would use her gloved hand to put the ice from a pitcher into the resident's glass and then pour the beverage. The employee was observed doing this repeatedly for three residents. CFR 483.60(i)(l)-(3) Food Procure,Store/Prepare/Serve-Sanitary Previously cited 10/21/16 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that staff implemented interventions and provided education to residents, staff and visitors to prevent the potential spread of infection for one of 24 sampled residents. The facility also failed to ensure that linens were handled appropriately to prevent cross contamination. (Residents R14, R15) Findings include: Review of the facility policy Shingles (Herpes [MEDICATION NAME]) revised November 28, 2016, revealed that staff contact with the resident should be limited to those individuals that are immune to the virus. A sign was to be placed outside of the resident room Stop and see the nurse before entering the room. Staff, residents and visitors were to be made aware regarding resident contact and hand hygiene. Clincal record review revealed that Resident R14 was diagnosed with [REDACTED]. A note by the nurse practitioner revealed that the resident was contagious until the lesions would blister and dry. Staff, visitors and residents (Resident R15, roommate) that are were in contact with the resident and his living area were to be educated on infection control practices, primarily hand hygiene. In an interview with Resident R15 on November 7, 2017, at 12:00 p.m., the resident was unaware why the Stop sign was placed at the entrance to his room, he was also unaware of the need for hand hygiene when in contact with any surface that he shares with the roommate Resident (R14). In an interview on November 8, 2017, at 2:00 p.m., the facility confirmed that there was a lack of documented evidence that Resident R15, staff that care for the residents and visitors were instructed on hand hygiene practices. Review of the facility's policy entitled Linen Handling revised November 28, 2016, revealed that clean linen and soiled linen was to be covered and soiled linen was to be separate from clean linen at all times to prevent cross contamination. Observation on November 7, 2017, at 9:45 a.m. revealed that Rehab Employee 1 transported soiled linen to the laundry area and entered and then left the soiled laundry in the clean area of the laundry department. The employee did not use the separate soiled linen entryway. On November 9, 2017, at 1:10 p.m. staff transported covered soiled laundry from the dining room into the laundry area. On November 8, 2017, from 11:00 a.m. through 2:00 p.m. a basket with clean linen was in the hallway outside of the Rehab Department uncovered. On November 9, 2017, 8:20 a.m. a basket with clean linen was in the hallway outside the Rehab Department uncovered. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/21/16 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and observation, it was determined that the facility failed to maintain sanitary conditions and proper food storage in the dietary department. Findings include: Review of the facility's policy entitled Food and Nutrition Services Policies and Procedures, dated August 22, 2016, revealed that all foods were to be labeled with the name of the product, the date received and a use by date once opened. Observation during the environmental tour of the dietary department on October 18, 2016, at 9:30 a.m. revealed debris (cups and lids) on the floor of the beverage preparation area. In this same area there was a fan mounted on the wall that was covered with dust. The grouting of the floor was heavily soiled. A second wall fan mounted in the dishmachine room that was covered with dust. There were stained ceiling tiles over the ovens and cooking preparation areas and there was debris on the floor behind the ovens. Observation in a dessert cooler revealed a large tray of dessertss that was not labeled or dated. Observation in a second dessert cooler revealed a large tray with puree fruits and desserts that was not labeled or dated. Observation in the walk in freezer revealed three bags of frozen french fries that were not labled or dated. Observation in the walk in refrigerator revealed a large container of soup that was not labeled or dated. There was also two blocks of sliced cheese, a bag of diced chicken and a package of hot dogs that had been opened, re-sealed and had not been labeled or dated. Observation on the same date at 10:00 a.m., revealed that there was dirt and debris on the floor surrounding the ice machine that was located directly outside of the dietary department.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that less restrictive alternative measures were attempted for one of one sampled residents that was physically restrained. (Resident R53) Findings include: Review of the facility's policy entitled Restraints: Use of, dated May 19, 2016, revealed that the purpose was to provide a restraint-free environment and/or the least restrictive environment when medical symptoms warrant the use of restraints. Clinical record review revealed that Resident R53 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments dated April 4, 2016, and July 12, 2016, revealed that the resident was cognitively impaired, required assistance from staff for most activities of daily living and utilized a trunk restraint on a daily basis. On November 24, 2015, a physician ordered for staff to apply an alarming seatbelt when the resident was in the wheelchair and to release the restraint every two hours and as needed. There was no documented evidence that the facility had attempted a less restrictive alternative measure or device to reduce the use of the restraint until it was discontinued on August 12, 2016. In an interview on October 21, 2016, at 9:48 a.m., the Director of Nursing confirmed that there was no documented evidence to support that a less restrictive device or measure was attempted between November 4, 2015 until August 12, 2016 when the use of the restraint had been discontinued. 28 Pa. Code 211.8(f) Use of restraints. 28 Pa. Code 211.10(d) Resident care policies.

Based on clinical record review and incident report review, it was determined that the facility failed to ensure that safety interventions were in place and functional for one of five sampled residents with falls that resulted in a fracture. (Resident R7) The facility also failed to ensure that medications were not left unattended during observation of the medication pass on one of two nursing floors. (First floor) Findings include: Clinical record review revealed that Resident R7 had [DIAGNOSES REDACTED]. The care plan initiated on January 11, 2012, identified the resident at risk for falls. On February 4, 2012, at 6:51 p.m., a nurse documented that staff had witnessed the resident getting into bed without assistance. At that time, a chair alarm (a safety device that alarms to alert staff of the resident's attempts to self transfer from the wheelchair) and dycem (a covering that prevents sliding) were applied to the wheelchair and the wheelchair cushion on February 7 and 8, 2012. Review of the physician's orders [REDACTED]. The Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and required two staff for transfer between surfaces. On April 28, 2012, at 3:16 p.m., a nurse documented that the resident fell to the floor from her wheelchair in her room. Review of the corresponding incident report revealed that on April 28, 2012, at 3:05 p.m., Resident R7's roommate reported that the resident was "trying to get into bed." Review of the facility's investigation, including staff statements, revealed that the resident had been transferred to her wheelchair at 10:45 a.m., on April 28, 2012, and a nurse aide applied the alarm. The resident was then escorted off the nursing unit and was in therapy from 11:20 a.m., until 12:00 p.m., then she went to lunch in the main dining room. The resident returned to therapy at 12:45 p.m., until 1:45 p.m., and then went directly to an activity program until 3:00 p.m., when she returned to the nursing unit. The therapy room, dining room and activity room were all located on the same floor. The therapist statement noted "does not remember alarm being on chair at all because resident stood up many times in therapy with the therapist and therapist does not remember ever turning off a alarm." A statement from the activity aide noted that the chair alarm had not sounded during the activity nor was the staff able to see the chair alarm on the wheelchair. Five minutes after returning to tne nursing unit (3:05 p.m.), the resident fell and sustained a fractured hip. Review of all of the facility's investigation revealed that the "chair alarm was off" and the Dycem was not in place at the time of the fall. There was a lack of evidence to support that staff had assessed the resident upon her return to the nursing unit to ensure that safety devices were in place and functional. During observation of the medication pass on October 16, 2012, at 9:18 a.m., LPN 3 poured eight medications for Resident R53. The nurse carried four of the eight medications into the resident's room leaving the other four (all liquid medications) on top of the medication cart in the hallway. LPN3 was unable to view the medication cart while she was in the resident's room. There was a resident in the vicinity as well as other staff in the hallway that had access to the liquid medications unattended on top of the medication cart. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 9/16/11. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 9/16/11 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/16/11, 11/21/11