Every finding on record at Phoebe Berks

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 seven sampled residents. (Resident 3)Findings include:Clinical record review revealed that Resident 3 had diagnoses that included osteoarthritis and osteoporosis. Review of Resident 3's MDS dated [DATE], section J, indicated that the resident had not been assessed for pain. In an interview on March 18, 2026, at 11:27 a.m., the Director of Nursing confirmed Resident 3's MDS was inaccurate and that the resident should have been assessed for pain.

Based on clinical record review, group interview, staff interview, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for seven of 18 sampled residents. (Residents 42, 45, 54, 56, 73, 77, 82) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included radiculopathy (compressed nerve in the spine that cause pain), muscle weakness, and difficulty walking. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 54 had diagnoses that included congestive heart failure, diabetes, muscle weakness, and late onset Alzheimer's disease. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting and dressing. Clinical record review revealed that Resident 56 had diagnoses that included post polio syndrome (condition that causes gradual muscle weakness) and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for transfers and activities of daily living such as toileting, dressing, and personal hygiene. Clinical record review revealed that Resident 73 had diagnoses that included Parkinson's disease and neuromuscular dysfunction of bladder (urinary bladder problems due to a disease). The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. During a group interview on April 30, 2025, at 10:00 a.m., Residents 45, 54, 56, and 73 reported that it took long periods of time (30 minutes or more) for staff to answer their call bells and get assistance. Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 10:38 a.m., Resident 42 stated that staff took a long time to answer call bells which has affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 77 had diagnoses that included a history of traumatic injuries, peripheral vascular disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:00 a.m., Resident 77 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. Clinical record review revealed that Resident 82 had diagnoses that included partial paralysis to the right side following a stroke, chronic kidney disease, muscle weakness, and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required extensive assistance from staff for transfers and activities of daily living such as toileting. In an interview on April 30, 2025, at 11:55 a.m., Resident 82 stated that staff took a long time to answer call bells which has affected her ability to receive care and services in a timely manner. In an interview on April 30, 2025, at 1:00 p.m., the Administrator revealed that staff were expected to respond to a call light within 15 minutes or less. Review of the facility form entitled, Device Activity Report, for Residents 42, 45, 54, 56, 73, 77, and 82, revealed that from April 1 through April 30, 2025, there were 158 occurrences when the call bell response time exceeded 15 minutes which included: April 2, 2025, at 7:39 p.m., Resident 42 waited 68 minutes; April 7, 2025, at 12:37 a.m., Resident 45 waited 58 minutes; April 9, 2025, at 7:36 a.m., Resident 54 waited 91 minutes; April 20, 2025, at 8:16 a.m., Resident 56 waited 20 minutes; April 22, 2025, at 3:46 a.m., Resident 73 waited 65 minutes; April 14, 2025, at 1:53 a.m., Resident 77 waited 168 minutes; and April 9, 2025, at 8:02 a.m., Resident 82 waited 41 minutes. During an interview on May 1, 2025, at 10:45 a.m., the Administrator confirmed the aforementioned residents waited more than the expected response time of 15 minutes. 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 ensure that the baseline care plan summary was provided to the resident or representative for two of 18 sampled residents. (Residents 17, 64) Findings include: Review of the facility policy entitled, Baseline Care Plan, dated January 20, 2025, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include healthcare information necessary to properly care for a resident and must include initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan will include trauma-informed care goals and interventions under the psychosocial well-being care plan if identified immediately upon admission, and the resident and/or representative were to be provided a written summary of the baseline care plan. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE]. The baseline care plan was developed on April 10, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. Clinical record review revealed that Resident 64 was admitted to the facility on [DATE]. The baseline care plan was developed on January 22, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. During an interview on April 30, 2025, at 2:30 p.m., the Administrator confirmed that there was no evidence the baseline care plan summary was provided to the residents and/or their representatives. 28 Pa. Code 201.18 (b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 21 sampled residents. (Residents 47, 60) Findings include: Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], and had diagnoses that included diabetes mellitus and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident had impaired vision and required corrective lenses. The Care Area Assessment (CAA) indicated that vision was to be addressed in the care plan. There was no evidence that interventions to address Resident 47's vision were included in the current care plan. Clinical record review revealed that Resident 60 was admitted to the facility on [DATE], and had diagnoses that included a risk for impaired vision and optic nerve damage (glaucoma), an abnormal gait when walking, and a history of falling. The MDS CAA summary dated February 8, 2024, noted that the resident's vision was to be addressed in the care plan. There was no evidence that interventions to address Resident 60's vision were included in the current care plan. In an interview on April 25, 2024, at 11:05 a.m., the Nursing Home Administrator confirmed that the identified care areas were not addressed in residents 47's and 60's current care plans. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on clinical record review, review of facility documentation, resident interview, and staff interview, it was determined that the facility failed to thoroughly investigate a fall for one of four sampled residents identified at risk for falls. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included congestive heart failure and osteoporosis. Review of the current care plan revealed that Resident 1 was at risk to fall due to muscle weakness and needed staff assistance for activities of daily living, including dressing and incontinence care. Review of the Minimum Data Set assessment completed on November 9, 2023, indicated that Resident 1 did not have impaired cognition. On January 11, 2024, a nurse (RN 1) noted that she was walking by the resident's room and saw Resident 1 sitting on the floor with her left lower leg extended behind her. RN 1 noted a nurse aide (NA 1) who was in the room stated that, She didn't fall. She just lowered to the ground. She wanted me to hold her up and I said that she needs to stand. I can't stand here and hold her up. Review of facility documentation revealed that Resident 1 stated, I told that girl I needed help to stand and she didn't help me. I can't stand on my own. I'm too weak and needed help. A statement from NA 1 on January 11, 2024, indicated that she came to change the resident at 7:00 a.m. and that she put the recliner chair up to help Resident 1 stand with her walker in front of her. NA 1 was trying to clean the resident and change her incontinence pad. She got the resident's brief and the resident slipped on the floor. She asked me to hold her but she was already on the floor. An interdisciplinary team fall review note dated January 12, 2024, stated that the resident was assisted to stand using a walker and lifting of a recliner chair. The NA attempted to provide incontinence care to Resident 1 at that time. Resident 1's left leg slipped out from under her and staff attempted to assist Resident 1 to the ground. Further review of facility documentation revealed that a statement was obtained from NA 2 on January 11, 2024. NA 2 stated that she heard RN 1 ask Resident 1 if she fell and then entered Resident 1's room. Resident 1 was on the floor and her left leg was in a weird position. NA 1 was in Resident 1's room. When NA 1 left the room, Resident 1 told NA 2 that NA 1 let her fall. Resident 1 told NA 2 that NA 1 was trying to change her while she was standing and that she told NA 1 that she could not stand any longer. NA 1 wasn't supporting her and did not have a hand on her. Another statement from NA 1 was obtained on January 12, 2024. She stated that Resident 1 was sitting in her recliner chair and she brought it higher to make it easier for her to stand with her walker in front of her. At the same time, RN 1 came in the room and NA 1 asked RN 1 if she could assist her in changing Resident 1's incontinence pad. She stated RN 1 turned and walked away so she turned away quickly to grab a washcloth and as she was grabbing the washcloth, she saw Resident 1's right leg giving out and before she knew it, she was on the ground. She stated she was holding Resident 1 the entire time and that she never refused to hold her up. In an interview on January 25, 2024, at 1:00 p.m., Resident 1 stated that during the incident NA 1 did not assist her or touch her prior to her fall and that she had told NA she was weak and could not stand. Further review of facility documentation revealed that interventions implemented after the fall were a call don't fall sign by Resident 1's recliner and in her bathroom to remind her to call for help during the night when she needs to transfer or ambulate. There was no documented evidence that the facility thoroughly investigated the reported inconsistencies in order to determine the circumstances of Resident 1's fall and implement appropriate interventions. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, and observation, it was determined the facility failed to ensure that use of a physical restraint was medically justified and failed to conduct an on-going assessment of a restraint for one of 21 sampled residents. (Resident 62) Findings include: Review of the facility policy entitled, Restraint Policy, dated July 25, 2022, revealed that the interdisciplinary team would review and re-evaluate the use of all restraints ordered by physicians. The review would focus on the success or failure of the implementation of the plan, documentation, and recommendations for change if a problem was not resolved. The residents would be followed every 30 days or sooner until the restraint was eliminated or the least restrictive device was found to resolve the area of concern. Further review of the policy revealed that a physician's order must be obtained for use of a restraint and the order would indicate the type of restraint, the specific medical reason for its use, and frequency. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance with dressing and toileting. On May 24, 2022, the physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and remove promptly in the morning. The physician's order did not indicate the specific medical reason for the use of the jumpsuit. Review of the care plan revealed Resident 62 was at risk for behavioral symptoms. Interventions included for staff to apply a jumpsuit in the evening and remove it in the morning when the resident awoke. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed out of bed wearing a one piece jumpsuit that zipped down the back on the nursing unit. The jumpsuit limited his access to his own body and staff assistance was required to put on and take off the jumpsuit. Review of monthly restraint evaluation forms from December 2022 through April 2023, revealed that there was no documented evidence that the interdisciplinary team reviewed or re-evaluated the use of Resident 62's restraint to determine if it was the least restrictive device. 28 Pa. Code 211.8(e)(f) Use of restraints. 28 Pa. Code 201.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 21 sampled residents. (Residents 52, 62) Findings include: Clinical record review revealed that Resident 52 had diagnoses that included fracture left hip and anxiety. Section B of the MDS assessment dated [DATE], indicated that the resident was not in a vegetative state and that the resident's hearing, speech, and vision should be assessed. The MDS indicated Resident 52's hearing, speech, and vision were coded as not assessed. In an interview on May 11, 2023, at 11:19 a.m., the Administrator stated that Resident 52's hearing, speech, and vision should have been assessed. Clinical record review revealed that Resident 62 had diagnoses that included moderate intellectual disability and depression. On May 24, 2022, a physician ordered for staff to apply a jumpsuit to Resident 62 in the evening and to remove promptly in the morning. On May 10, 2023, from 8:00 a.m. through 10:15 a.m., Resident 62 was observed wearing a jumpsuit that zipped down the back that restricted the resident's movement. Section P of the MDS assessment dated [DATE], indicated that the resident did not use a restraint device. In an interview on May 11, 2023, at 11:25 a.m., the Administrator confirmed that Section P of the MDS indicated that Resident 62 did not use a restraint device.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 21 sampled residents. (Resident 75, 88) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had cognitive impairment. The Care Area Assessment (CAA) summary, identified that cognitive loss/dementia was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address Resident 75's cognitive loss/dementia. Clinical record review revealed that Resident 88 had diagnoses that included depression and anxiety. Review of the MDS assessment dated [DATE], identified that the resident received psychotropic medications. According to the CAA summary, the facility identified that the resident's psychotropic medication use was a problem and should have been included on the resident's 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 psychotropic medications. In an interview conducted on May 11, 2023, at 11:59 a.m., the Administrator confirmed that there was no care plan developed with interventions to address the above problem areas for Residents 75 and 88. 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 provide services to increase range of motion and/or prevent further decrease in range of motion for one of 21 sampled residents. (Resident 75) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and difficulty in walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff for activities of daily living, such as transferring, moving in bed, and dressing. A physical therapy discharge summary dated April 27, 2023, noted that staff were to implement a restorative nursing program for ambulation of 25 to 100 feet. There was a lack of documentation to support that the physical therapist's recommendation for a restorative walking program was implemented for Resident 75. During an interview on May 11, 2023, the Therapist confirmed that there was no documentation that the restorative walking program for Resident 75 was implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity in two of three dining rooms. ([NAME] Corner South Hallway, Heritage Court) In addition the facility failed to provide up to date activity schedules to one of 18 sampled residents. (Resident 81) Findings include: Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. On May 21, 2022, the physician ordered for staff to feed Resident 45 all meals. On May 24, 2022, from 12:25 p.m. through 12:50 p.m. LPN 1 was observed standing while feeding the resident her lunch. Clinical record review revealed that Resident 32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. On March 31, 2022, the physician ordered for staff to feed Resident 32 all meals. On May 24, 2022, from 12:50 p.m. through 1:00 p.m., and on May 25, 2022, from 12:20 p.m. through 12:50 p.m. LPN 1 was observed standing while feeding the resident her lunch. Clinical record review revealed that Resident 41 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident required extensive assistance from staff with eating. On May 25, 2022, from 11:55 a.m. through 12:10 p.m. RN 1 was observed standing while feeding the resident his lunch. Clinical record review revealed that Resident 47 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the MDS assessment dated [DATE], the resident required extensive assistance from staff with eating. On May 25, 2022, from 12:35 p.m. through 12:45 p.m. RN 1 was observed standing while feeding the resident his lunch. Clinical record review revealed that Resident 19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the MDS assessment dated [DATE], the resident required supervision from staff while eating. On May 11, 2022, the physician ordered that the resident was to have finger foods when possible. On May 25, 2022, at 12:20 p.m. Resident 19 was served turkey and mashed potatoes with gravy and cooked carrots for lunch. Resident 19 was observed eating her lunch with her fingers and picking food off her clothing through 1:00 p.m. At no time during the observation did staff provide assistance to Resident 19 with her meal. Clinical record review revealed that Resident 46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that the resident had cognitive impairments and required supervision with eating. On May 26, 2022, from 11:55 a.m. until 12:23 p.m., Resident 46 was observed seated in the dining room watching a resident at her table eat her lunch while calling out to staff I'm hungry., Where's my lunch?, and When is my food coming?. Clinical record review revealed that Resident 81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident had no cognitive impairments, and that involvement in activities was important to her. In an interview on May 24, 2022 at 11:50 a.m., Resident 81 stated that she does not usually go to activities because she does not know what they are and she wishes she had more people to talk to. Observations on May 24 and 25, 2022 revealed an activity schedule posted in the hallway outside Resident 81's room. The posted schedule was for the previous week, May 15, 2022 through May 21, 2022. 28 Pa. Code 201.29(j) Resident Rights

Based on clinical record review and observation, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for two of eight sampled residents at risk for falls. (Residents 60, 82) Findings include: Clinical record review revealed that Resident 60 had diagnoses that included dementia with behavioral disturbance, muscle weakness, difficulty in walking, and a history of falling. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive staff assistance with dressing, required limited staff assistance with walking, and had fallen since the previous assessment completed on February 3, 2022. A physician's order dated January 21, 2020, indicated that the resident was to ambulate all destinations on the unit without a device with supervision; assistance of one as needed. The care plan identified that the resident was at risk for falls and that the resident had four falls since December 21, 2021, including three that were unwitnessed. Interventions included to ensure that the resident was wearing proper footwear. Observation of Resident 60 on May 24 and May 26, 2022, at multiple times, revealed that the resident was wearing long, loose sweatpants and gripper socks. The excessive length of the sweatpants obstructed the grip material of the socks and created a tripping hazard. Observation ofthe resident on both dates revealed that she was ambulating throughout the unit with her pants under her feet. Clinical record review revealed that Resident 82 had diagnoses that included dementia, generalized muscle weakness, difficulty in walking, and other abnormalities of gait and mobility. The MDS assessments dated February 4, 2022, and May 5, 2022, indicated that the resident had memory problems and required extensive staff assistance for walking and transferring between surfaces. Review of the care plan revealed that the resident ambulated with a rolling walker and was at risk for falls. An intervention added on March 24, 2022, directed that the resident was to be encouraged and assisted to participate in activities or social settings that minimize the potential for falls and to ensure that she was wearing proper footwear. On March 30, 2022, an additional intervention directed that the resident was to be monitored for fatigue and to encourage periods of rest in the recliner in the common area for close observation due to poor safety awareness. Nursing documentation on April 2, 2022, stated that the resident frequently ambulated without her walker and that she had removed her shoes and socks at the time of an unwitnessed fall on that date. A physical therapy discharge summary dated April 27, 2022, indicated that the resident was to ambulate all destinations on the unit with supervision and required supervision to stand-by assistance for transferring. It was also noted that she needed reminders to use her walker. On May 1, 2022, the resident experienced an unwitnessed fall in her room and nursing noted that she had taken her shoes off and had not been using her walker. A nurse's note dated May 3, 2022, indicated that the resident was observed walking in her room without her walker. On May 19, 2022, at 2:55 p.m., Resident 82 experienced an additional unwitnessed fall in her room and was found with her shoes removed. Review of facility incident reports and nursing documentation revealed that the resident had fallen 10 times January 7, 2022, through May 19, 2022, and that eight of those falls were unwitnessed. 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 ensure that physician's orders were implemented or that a skin condition was addressed for three of 18 sampled residents. (Residents 45, 5, 51) Findings include: Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that Resident 45 was cognitively impaired and required assistance from staff for most activities of daily living. On June 25, 2021, the physician ordered for staff to provide a blue bolster for positioning to her left side while in her wheelchair. On May 24, 2022, from 12: 20 p.m. through 1:30 p.m. Resident 45 was observed in her wheelchair without the blue bolster to her left side. On May 25, 2022, from 10:35 a.m. through 1:00 p.m., and on May 26, 2022, from 11:45 a.m. through 12: 40 p.m. Resident 45 was observed in her wheelchair with the blue bolster on the right side of her chair. In an interview on May 27, 2022, at 10:44 a.m. the occupational therapist (OT 1) stated that Resident 45's blue bolster was ordered for positioning while in her wheelchair and that it should have been placed on the left side of her wheelchair. Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident did not walk and required extensive staff assistance for transferring. The resident had a physician's order dated November 30, 2021, to utilize an abduction cushion to the lower extremities at all times to prevent her legs from crossing and contractures. The resident was observed on May 25, 2022, 12:00 p.m. through 1:17 p.m. seated in her wheelchair in the dining area with no abduction cushion in place. Clinical record review revealed that Resident 51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive staff assistance for activities of daily living, including dressing. The care plan included a goal that the resident would be free of complications related to anticoagulant use and also identified the potential for alteration in skin integrity. Interventions included that skin was to be monitored daily by the nurse aide and any changes or abnormalities were to be reported to the nurse and that geri-sleeves or long sleeves must be on the resident. The resident had a physician's order dated August 8, 2020, for geri-sleeves or long sleeves every shift. Observation of Resident 51 on May 24, 2022, from 11:08 a.m. to 12:40 p.m. and May 25, 2022, at 11:56 a.m., revealed that the resident was seated in the dining room with no arm coverings and both arms exposed. In addition, on both dates, an undated dressing was observed on her left forearm. There was no documentation in the clinical record regarding the dressing or any skin abnormality of the left forearm. When the bandage was removed by LPN 2 on May 26, 2022, at 11:00 a.m., a scabbed area was observed. At that time, LPN 2 confirmed that she was unaware of the scabbed area or dressing and that there was no documentation in the resident's record regarding the area. 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 implement treatment and services to promote healing and prevent new ulcers from developing for one of three sampled residents with pressure sores. (Resident 67) Findings include: Clinical record review revealed that Resident 67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive staff assistance for most activities of daily living (including turning and positioning), was dependent on staff for transferring in and out of bed, and had one stage 2 pressure ulcer. There was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 22, 2022, the physician ordered that the resident continue the use of the boots at all times, that she use a black abductor between the knees when out of bed, and that she should go back to bed between meals for off-loading for wound management and be propped in a side-lying position. The care plan identified the resident as at risk for skin breakdown/pressure ulcers related to decreased mobility and incontinence and that a stage two buttock wound was present. Interventions included try to keep off of right side as much as possible. Observation of Resident 67 on May 25, 2022, from 12:14 p.m. through 1:21 p.m. revealed that the resident was out of bed and seated in her chair with no abductor cushion and no heel boots in place. During an interview on May 27, 2022, at 10:44 a.m., the lead therapist (OT 1) confirmed that the abductor cushion was used to avoid feet on feet contact and to prevent a pressure area. Observation of Resident 67 on May 26, 2022, revealed that the resident was seated in her broda chair finishing her breakfast in the dining area at 10:21 a.m. Following breakfast, she remained in the same position and was wheeled in the same chair to the activities area at 10:40 a.m. She remained in the same chair and position at 11:59 a.m. when she was wheeled back to the dining area for lunch. The resident was not taken back to bed as ordered by the physician and was not repositioned in her chair during the observation. 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 monitor nutrition per policy for two of 18 sampled residents. (Residents 59, 234) Findings include: Review of the facility policy entitled, Weight Monitoring and Management, dated May 18, 2022, revealed that staff was to confirm any weight change of more than five pounds with a re-weight within 24 hours, and document it into the electronic chart. Clinical record review revealed that Resident 59 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and required supervision with eating. Review of the current care plan revealed Resident 59 had a nutritional problem related to diabetes, and was to be weighed per facility policy. On January 31, 2022, the resident weighed 174.4 pounds (lbs). On February 7, 2022, she weighed 182 lbs, a difference of 7.6 lbs. On February 14, 2022, she weighed 177 lbs, a difference of five lbs from her February 7, 2022 weight. On March 7, 2022, Resident 59 weighed 184.4 lbs. On March 28, 2022, she weighed 178.4 lbs, a difference of six lbs. On April 18, 2022, Resident 59 weighed 179.6 lbs and on April 25, 2022, she weighed 170.8 lbs, a difference of 8.8 lbs. On May 2, 2022, Resident 59 weighed 171.2 lbs. On May 9, 2022 she weighed 166 lbs, a difference of 5.2 lbs. There was no documented evidence that Resident 59 was reweighed per facility policy. Clinical record review revealed that Resident 234 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that Resident 234 had no cognitive impairments and was independent with eating. Review of the current care plan revealed that the resident was at increased nutrition risk related to diabetes. On May 10, 2022, Resident 234 weighed 242.6 lbs. On May 11, 2022, the resident weighed 247.6 lbs, a difference of five pounds. On May 15, 2022, the resident weighed 237.8 lbs, a difference of 9.8 lbs from his May 11, 2022 weight. On May 22, 2022, Resident 234 weighed 227.8 lbs, a 10 lb difference from his May 15, 2022 weight. There was no documented evidence that Resident 234 was reweighed per facility policy. In an interview on May 27, 2022, at 10:12 a.m., the Director of Nursing confirmed the reweights were not completed per facility policy. 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 provide adequate supervision to prevent elopement from the facility for one of 24 sampled residents. (Resident 74) Findings include: Clinical record review revealed that Resident 74 had diagnoses that included Alzheimer's disease and dementia. The Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 74 was cognitively impaired. Review of elopement risk assessments dated August 1, 2020, August 17, 2020, November 28, 2020, and February 18, 2021, revealed that she wandered in the facility and had a history of wandering and elopement interventions were recommended. Review of the care plan revealed that Resident 74 was at risk for wandering/elopement and there was an intervention for an elopement prevention bracelet initiated on August 1, 2020. On March 23, 2021, Resident 74 was found outside of the facility in her wheelchair without staff knowledge and no elopement bracelet in place. There was no documented evidence that the facility provided adequate interventions and supervision to prevent the resident from leaving the facility unsupervised. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that staff notified the resident's responsible party of a decline in the resident's medical status for one of eight sampled residents. (Resident CR 1) Findings include: Review of the facility policy entitled Notification of Changes, dated March 5, 2021, revealed that nursing staff was to assure that each resident/and or resident representative was notified timely of change in status, significant change in treatment, abnormal lab, or diagnostic test results associated with the health of the resident. Clinical record review revealed that Resident CL1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was not alert and required extensive assistance from staff for activities of daily living. Nursing documentation on December 20, 2020, indicated the resident had a change in condition. Resident was fatigued with an elevated temperature of 100.4. Staff notified the physician of the resident's condition and the physician ordered on December 21, 2020, a urinalysis and a urine culture and sensitivity test to test for the presence of infection. There was a lack of evidence to support that staff notified the resident's responsible party about this decline in the resident's condition, and about the new order for the urine tests. In an interview on March 25, 2021 at 1:30 p.m., the Nursing Home Administrator stated that there was no documented evidence that the resident's responsible party had been notified of the changes in the resident's medical treatment and condition. 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 staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident CR 1) Findings include: Clinical record review revealed that CR1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff with activities of daily living. Review of the care plan revealed that the resident had bladder incontinence due to dementia and impaired mobility, and that staff was instructed to monitor and document signs and symptoms of urinary tract infections (UTIs), urine output, urine frequency, and changes in behavior. On December 20, 2020, nursing documentation indicated the resident had change in condition. The resident was fatigued with an elevated temperature of 100.4. Nursing progress notes indicated staff notified the physician of the resident's medical condition. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to obtain a urine sample timely. Clinical record documentation reflected that staff did not obtain the urine sample and send it for testing until five days later, on December 27, 2020, when a nurses' note at 12:10 PM reflected that staff had finally sent the sample to be tested . Nurses' notes about five hours later that day at 5:35 PM reflected that the test showed that the resident did have a urinary tract infection. In an interview on March 25, 2021, at 1:30 p.m., the Nursing Home Administrator confirmed that staff failed to obtain the urine sample and send it for testing timely, in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] CFR 483.25 Quality of Care Previously cited: 1/11/19, 12/6/19 28 Pa. Code 211.12 (d)(5)Nursing Services

Based on policy review, clinical record review and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse or neglect for one of 21 sampled residents. (Resident 35) Findings include: Review of the facility policy, Abuse Policy - Prevention, Investigation, Reporting dated (MONTH) 20, 2019, revealed that the facility was to investigate all reported instances of abuse including injuries of unknown origin. This included thoroughly investigating the possible causes of fracture of unknown origin. According to the policy, staff was to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately. Clinical record review revealed that Resident 35 had [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated (MONTH) 4, 2019, identified that the resident had memory impairment and was dependent on staff for activities of daily living. Documentation in the clinical record on (MONTH) 20, 2019, revealed the resident's right hip was swollen and painful. Further, the resident was having more difficulty walking than usual. On (MONTH) 21, 2019, the resident was transferred to the hospital due to increased pain and was admitted for a right [MEDICAL CONDITION]. There was no evidence that the facility completed a thorough investigation into the cause of the injury for Resident 35. In an interview on (MONTH) 6, 2019, at 12:30 p.m., the Nursing Home Administrator confirmed there was no documentation to support that the facility thoroughly investigated the cause of the right [MEDICAL CONDITION] for Resident 35 to rule out abuse or neglect. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that there was documented evidence in the clinical record that a resident and responsible party were afforded the opportunity to attend and participate in care plan meetings for one of 21 sampled residents. (Resident 87) Findings include: Clinical record review revealed that Resident 87 had an admission Minimum Data Set assessment completed on (MONTH) 15, 2019. There was no documented evidence that an interdisciplinary care plan meeting was held after the assessment that allowed the responsible party and the resident to participate in the care plan process including the development of care plan goals. In an interview on (MONTH) 5, 2019, at 1:25 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that the resident and responsible party were invited and afforded the opportunity to participate in the care plan meeting. 28 Pa. Code 211.11(e) Resident care plan.

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 21 sampled residents. (Resident 58) Findings include: Clinical record review revealed that Resident 58 had [DIAGNOSES REDACTED]. From (MONTH) 12, 2019, a physician order directed staff to administer medications ([MEDICATION NAME] and [MEDICATION NAME]) daily to treat the resident's hypertension. Staff was to hold the medications if the resident had a systolic blood pressure of 110 or less. A review of the (MONTH) and (MONTH) 2019 Medication Administration Record, [REDACTED]. On (MONTH) 22 and 25, 2019, staff administered [MEDICATION NAME] when Resident 58's systolic blood pressure was below 110. On (MONTH) 5, 2019, staff administered [MEDICATION NAME] when the resident's systolic blood pressure was below 110. In an interview on (MONTH) 6, 2019, at 12:35 p.m., the Nursing Home Administrator, confirmed that staff did not administer Resident 58's medications in accordance with the physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/11/19

Based on clinical record review, review of facility policies, investigative reports and staff interview, it was revealed that, for two of six sampled residents at risk for falls, the facility failed to ensure that the residents were adequately supervised to prevent accident and injury. (Residents R33, R44) In addition, the facility failed to adequately supervise a cognitively impaired resident to prevent the resident from exiting the building without staff's knowledge (elopement) for one of three sampled residents who were at risk for elopement. (Resident R59) Findings include: Clinical record review revealed that Resident R33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, dated July 23, 2010, indicated that Resident R33 had problems with long and short term memory, was moderately impaired for daily decision-making, had periods of altered perception or awareness of surroundings, and variable mental function during the day. The initial assessment also indicated that the resident required extensive assistance of two staff to get out of bed or chair, and to walk in his room. The assessment identified the presence of behavioral symptoms, and indicated that the resident was receiving an antipsychotic drug. Physicians' orders at the time of admission included, "FYI: may not ambulate ad lib." A fall risk assessment, completed on July 16, 2010, failed to address risk factors of antipsychotic use, decline in cognitive skills, unsteady gait, need for assistive device, incontinence, cardiovascular disease, or whether there was a need for fall interventions. Nurses' notes, dated July 16, 2010, at 6:45 p.m., indicated that the resident was restless and confused, and that mobility alarms had been placed on the resident's chair and bed. Documentation on July 20, 2010, indicated that staff had responded to the resident's alarm, at 11:10 p.m. on July 19th, and found the resident on his knees, in the middle of the room. At 8:00 a.m. on July 20, 2010, staff identified bruising to the resident's torso, measuring 15.6 by 6.6 centimeters. On July 22, 2010, at 7:40 a.m., nurses' notes indicated, "Between 2330 and 0100, resident was found ambulating in the hallways...disoriented...napped until 0330, then again found wandering numerous times." The note went on to indicate that the resident was seen coming out of another resident's room, and was "returned to his own room. Found he had flipped his recliner over...no injuries noted." There was no indication whether the resident's mobility alarm sounded, or why staff were unable to respond to the alarm in a timely manner. On July 22, 2010, and August 10, 2010, documentation in nurses' notes continued to indicate that the resident was found ambulating in the corridor during the night. On July 23, 2010, at 11:00 a.m., nurses' notes indicated that, while participating in skilled therapy, the resident became unresponsive and experienced a drop in blood pressure, that was relieved by placing the resident in a reclined position, with feet elevated. On August 2, 2010, a verbal order was written by the certified occupational therapy assistant (COTA), that the "resident may ambulate in room independently, out of room ambulation with supervision." There was no documentation of a rationale for that order; however, when interviewed, on January 5, 2011, at 12:50 p.m., the COTA stated that the order was based on the resident's progress in skilled therapy, and concerns that the mobility alarms were upsetting the resident, and resulting in agitated behavior, such as moving furniture around in the room, and tying bed linens to the furniture, to form a "tent." The COTA also stated that the resident had been turning the alarm off, although that was not indicated in the clinical record. According to documentation in a facility report, the resident was found lying on the floor of his room, at 1:30 p.m. on August 18, 2010, and complained of pain in his right leg. Hospital evaluation identified a fracture of the femoral neck. The resident was admitted for treatment, and returned to the facility on [DATE]. Nurses' notes, dated August 25, 2010, indicated that a mobility alarm was placed on the resident's bed, at the request of the resident's daughter. A fall risk assessment, completed on August 25, 2010, failed to identify risk factors of incontinence or antipsychotic use, but did identify that bed and chair alarms were in use. Documentation in nurses' notes, dated September 26, 2010, at 7:30 p.m., indicated that the resident had been seated in the unit lounge, when staff responded to the mobility alarm, and found the resident sitting on the floor in front of his wheelchair. The resident had removed one of his shoes, and thrown it in a trash receptacle. He had a small lump on the back of his head. When asked what had happened, he did not reply. A verbal order was received from the physician on September 26, 2010, for bed and chair alarms; however, subsequent documentation in nurses' notes indicated that staff were not responding to the alarms in a timely manner, as follows. On October 5, 2010, at 4:30 a.m., the resident was found standing in the corridor, near the door to his room. The mobility alarm was not activated. The resident stated, "I was trying to help that woman," and the note indicated that, "Later found out that he was in (another resident's room)." The resident reportedly asked staff to show him how to turn the alarm off. There was no evidence that the facility addressed the possibility that the resident was deactivating the alarm. On October 25, at 7:00 a.m., nurses' notes indicated that the resident was "found ambulating in hall undressed at midshift." Documentation did not indicate whether the mobility alarm was activated at that time. On November 7, 2010, at 5:00 a.m., documentation indicated that the resident got out of bed and walked to the unit lounge (a distance of over 50 feet), without using his walker, before staff responded to the mobility alarm. On November 15, 2010, at 3:15 a.m., documentation indicated that staff responded to the resident's mobility alarm, and found the resident straightening his bed linens. When asked whether he needed to use the bathroom, the resident replied, "I already did." On November 22, 2010, at 5:30 a.m., nurses' notes indicated that, at 1:15 a.m., staff responded to the resident's bed alarm, and found the resident seated on the bed. The resident reportedly indicated that he was looking at "kids" and that there were "people everywhere." The resident declined an offer to use the bathroom, and staff left the resident unattended in the room. At 1:30 a.m., the alarm sounded again, and the resident was found on the floor of his room, with a laceration to the forehead and complaints of shoulder pain. Hospital evaluation identified a fracture of the clavicle. According to the facility policy entitled "Fall Management Program," last reviewed April 2010 the facility used a fall investigation protocol to investigate falls. Review of the fall investigation protocols for Resident R33 revealed that the facility failed to address the effectiveness of mobility alarms in enabling adequate supervision of the resident. In addition, indicators for closer staff supervision were not addressed, either in the investigative protocols or in the resident's plan of care. Recommendations of the fall risk assessment team were usually limited to continuing with skilled occupational and physical therapy, despite indications that the resident was unable to retain basic safety instructions. After the fall of November 22, 2010, the fall review indicated that a low bed and bedside mat would be provided. Staff supervision was not addressed. On December 16, at 2:30 p.m., nurses' notes indicated that the resident was moved to a room on the the south unit, where the resident would be able to participate in day programming designed for residents with cognitive impairment. Documentation in nurses' notes, dated December 23, 2010, at 5:45 a.m., indicated that, at 11:40 p.m., on the previous evening, a nurse was walking by Resident R33's room, and observed the resident kneeling at the bedside. The resident had sustained a number of skin tears, and complained of pain in his wrist. He stated that he had been to the bathroom, and tripped over the fall mat on his way back to bed. The resident had activated his call bell, but the mobility alarm was not sounding. Hospital evaluation revealed that the resident had sustained a wrist fracture. Review of the investigative protocol revealed that the facility had not addressed effective use of the mobility alarm, appropriateness of the bedside mat, or need for increased supervision. Nurses' notes indicated that, on December 25, 2010, at 11:00 a.m., Resident R33 was seated in the the south unit lounge, listening to a volunteer play Christmas music on the piano, when the unit charge nurse heard the mobility alarm, and "heard a thump." The resident was found on the floor, with bruising and skin tears to his face, knee and hand. He stated that he had gotten out of the chair "to get the music book." According to interview with the unit charge nurse, on January 4, 2011, at 1:55 p.m., she had been supervising residents in the lounge, during the activity, but left the area to assist another resident with toileting. Resident R33 had been "sitting quietly," but got up and fell , shortly after being left unattended. Clinical record review revealed that Resident R44 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Interventions listed on the resident's plan of care, to reduce the risk of falls, included use of mobility alarms to bed and chair. Documentation in nurses' notes, dated November 10, 2010, at 7:30 p.m., indicated that Resident R44 was found lying on the floor, in the corridor. The resident's wheelchair alarm did not sound, to alert staff that the resident was attempting to get out of the chair without assistance. Review of the facility fall investigative protocol revealed that staff speculated that another resident may have turned off the resident's mobility alarm; however, there was no evidence that the facility addressed that issue, or implemented any measures to prevent a reoccurrence of the incident, or ensure that the resident was adequately supervised by staff. Clinical record review revealed that Resident R59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], identified that the resident exhibited wandering behavior. A nurse's note on December 27, 2010 at 8:30 a.m., documented that Resident R59 was alert with confusion and attempting to go out the facility's front door. The resident was noted to be difficult to redirect and one to one staff supervision was provided. At that time, staff applied a wanderguard to the resident. A wanderguard is a electronic device that is worn by a resident to alert facility staff by an audible alarm when a resident wearing the device attempts to exit facility doors or utilize the elevator. The alarms at the facility doors and elevator were observed to continue to alarm until staff disarm them. The elevator was observed not to move from floor to floor when the wanderguard system was activated until staff turned off the alarm. On December 17, 2010, Resident R59's care plan was updated to identify the unsafe wandering behavior of the resident and noted a number of staff interventions including the use of the wanderguard to prevent the resident from exiting the building. There was no documentation on the care plan to address how staff was going to supervise the resident when the resident exhibited exit seeking behavior. On December 29, 2010, at 7:20 p.m., a nurse noted that the resident was restless, confused and exhibiting exit seeking behavior. On January 1, 2011, at 4:15 p.m., a nurse noted that the resident was found in the facility parking lot at 2:45 p.m. Staff had not witnessed the resident leaving the facility. When the resident was brought back into the facility the resident's wanderguard was in place and functioning. Review of the incident investigation revealed that staff was notified by a visitor (who was looking out a window of the facility) that Resident R59 was in the parking lot trying to get into a car and also trying unsuccessfully to get back into the building through a dining room door. Staff interviews revealed that the resident was wandering the corridors of the nursing unit that day and that no staff had witnessed the resident leaving the facility. The resident was last observed sometime between 1:00 p.m., and 1:30 p.m. Further review of the facility documentation revealed that the resident resided on the second floor of the building and had to utilize the elevator and exit through two alarmed front doors to access the parking lot. There was no evidence that staff had responded to an alarmed door or elevator when the resident had exited the building. The facility failed to adequately supervise Resident R59 to prevent the resident from exiting the building without staff's knowledge. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited January 16, 2009