Every finding on record at Phoebe Richland HCC

Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was maintained for one of 26 sampled residents. (Resident 126)Findings include: Clinical record review revealed that Resident 126 had diagnoses that included parkinsonism, urinary retention, and hypotension. On February 12, 2026, the physician ordered for the resident to have an indwelling catheter for urination. Observations on February 17, 2026, from 12:04 p.m. through 12:35 p.m., and February 18, 2026, from 11:59 a.m. through 12:30 p.m., revealed Resident 126 sitting in a wheelchair in the dining room. The Foley catheter bag was not covered and contained urine. Multiple residents and staff were present in the area during those time periods. In an interview on February 19, 2026, at 10:45 a.m., the Director of Nursing confirmed that Resident 126 should have been provided with a cover for the catheter bag when in the dining room. 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 Minimum Data Set (MDS) assessments were completed to accurately reflect the residents' current status for two of 26 sampled residents. (Residents 4, 28) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included atherosclerotic heart disease, heart failure, and cerebral infarction (stroke). The MDS assessment dated [DATE], incorrectly indicated in Section H (Bladder and Bowel) that Resident 4 had an indwelling catheter. There was no documented evidence that Resident 4 had an indwelling catheter during the MDS review period. Clinical record review revealed that Resident 28 had diagnoses that included an artificial opening of the urinary tract and dementia. A physician's note dated January 7, 2026, indicated that Resident 28 had nephrostomy tubes in place. Review of the care plan revealed the resident had bilateral nephrostomy tubes in place. The MDS assessment dated [DATE], indicated in Section H (Bladder and Bowel) that Resident 28 had an indwelling catheter and incorrectly indicated the resident was always incontinent of urine. In an interview on February 19, 2026, at 10:45 a.m., the Director of Nursing confirmed that Resident 4's and 28's MDS assessments were inaccurate and that Resident 28's urinary continence should not have been rated due to the use of nephrostomy tubes.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 26 sampled residents. (Residents 42, 108)Findings include: Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], and had diagnoses that included displaced right femur fracture, anxiety, and dementia. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated January 27, 2026, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records for January and February 2026, revealed the resident received an antianxiety medication (lorazepam), classified as a psychotropic drug, daily during the review period. Interventions to address Resident 42's psychotropic drug use were not included in the care plan. Clinical record review revealed that Resident 108 was admitted to the facility on [DATE], and had diagnoses that included atrial fibrillation, neuromuscular dysfunction of the bladder, and urinary retention. The MDS assessment and CAA summary dated January 28, 2026, noted that the resident had an indwelling catheter and it was to be addressed in the care plan. Interventions to address Resident 108's indwelling catheter were not included in the care plan. In an interview on February 19, 2026, at 1:30 p.m., the Director of Nursing confirmed that the identified care areas were not addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further limitations in range of motion for one of six sampled residents who required use of a splint and/or had limitations in range of motion. (Resident 7)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included a stroke with paralysis on the right side. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, required assistance with dressing, and had impairment in range of motion on both sides of the upper and lower extremities. On April 29, 2025, a physician ordered for staff to apply a resting hand splint to the right hand after morning care. Review of an occupational therapy Discharge summary dated [DATE], revealed that there was a recommendation for staff to apply a resting hand splint to the right hand after morning care for contracture management. The summary indicated that the resident was tolerant of the splint with separator for at least eight hours a day. The therapist indicated that the existing orders in place remained appropriate for staff to apply the splint after morning care and remove the splint after dinner. Observations on February 17, 2026, at 11:40 a.m., 12:10 p.m., 12:44 p.m., and 1:30 p.m., revealed that the resident was dressed and seated in a chair. There was no resting hand splint on her right hand during the observations. In an interview on February 18, 2026, at 11:00 a.m., the Administrator stated that the right resting hand splint should have been in place as ordered by the physician and as recommended by the occupational therapist. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and review of facility documentation, it was determined that the facility failed to provide adequate supervision to prevent falls for a resident with behavioral symptoms for one of six sampled residents who experienced falls. (Resident 33)Findings include: Clinical record review revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses that included dementia with agitation, insomnia, traumatic subdural hemorrhage (bleeding between the brains surface and outer covering), and anxiety disorder. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, exhibited wandering behavior and had a history of falling. A review of the care plan revealed the resident was at risk for falls and injury due to an unawareness of safety needs, dementia, and impaired mobility. Review of facility documentation dated January 10, 2026, revealed that the resident was found on the floor on his back in his room holding onto the lever of his roommate's recliner at 3:30 a.m. The facility documentation indicated that the resident was trying to get into bed and fell and that he had restlessness. Review of facility documentation dated January 13, 2026, revealed that the resident was found on the floor in his room at 3:00 a.m. The documentation indicated that the resident was trying to get into bed and fell and that he was likely to have terminal restlessness. On January 15, 2026, the social worker noted that the resident had been exhibiting wandering behavior and had cognitive impairment related to his dementia. On January 16, 2026, social services documented that the resident was moved to a locked dementia unit due to behavior concerns. On February 5, 2026, at 11:03 p.m., a nurse documented a behavioral note that indicated the resident had an increase in restlessness and anxious behaviors throughout the shift. He was noted to continually seek a wall rail to pull himself up from his chair and that he became impulsive upon redirection and reassurance. He was noted with agitation and was administered an anti-anxiety medication at 10:00 p.m. He continued with insomnia, restlessness, and an angry mood at that time. A nurse documented that the anti-anxiety medication had been ineffective. Further review of a nursing behavior note dated February 6, 2026, at 5:17 a.m., revealed that the resident had refused to lie down or get ready for bed until about 2:00 a.m. He was noted as paranoid, angry, and verbally demanding. He was noted as increasingly agitated when spoken to and was pacing in his wheelchair. He went to bed at approximately 2:40 a.m. Review of additional facility documentation dated February 6, 2026, revealed that the resident was found in his room standing near his bed at 3:17 a.m., stating that he needed to use the bathroom. At that time, the resident turned quickly and fell onto his right side, striking his head on the dresser. The facility failed to provide adequate supervision to prevent falls for a resident who had agitated and restless behaviors and had three falls around the same time during the night within 30 days of admission to the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and resident interview, it was determined that the facility failed to ensure that a functioning call bell was accessible for one of 25 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included heart failure, muscle weakness, and chronic respiratory failure. Review of the resident's care plan revealed that he required assistance from staff for activities of daily living and was at risk for falls. The interventions were for staff to ensure that a functioning call bell system was in reach and the resident should be encouraged to use it. On January 28, 2025, from 12:16 p.m. through 12:22 p.m., the resident was observed in his room sitting out of bed. The resident stated that he was soiled and needed to be changed. He also stated that his call bell did not work. The resident pressed the call bell button; the light outside of his room that alerted staff to a need for assistance, did not activate. On January 29, 2025, at 1:48 p.m., the resident was observed in his room out of bed. He stated that he would like ice cream. The resident attempted to reach his call bell. The call bell button was hanging below the resident's bed and out of reach. The resident was again observed at 2:23 p.m., the call bell was in the same position and not accessible to the resident. In an interview on January 31, 2025, at 9:53 a.m., the Administrator stated that the resident's call bell light was not functioning properly and needed to be repaired. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that adaptive equipment was provided to two of three sampled residents who required adaptive equipment with meals. (Residents 6, 24) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included dysphagia and hemiparesis (muscle weakness to one side of the body) to the right dominant side. Review of the care plan revealed that the resident was at risk for nutritional problems. The intervention was for staff to provide adaptive equipment, which included drinks in a handled mug with a lid. A physician's order dated December 7, 2024, revealed that the resident was to receive adaptive equipment which included handled mugs with lids. On January 29, 2025, during the lunch meal observation from 12:25 p.m. through 1:45 p.m., Resident 6 was observed in the dining room eating her lunch meal. The resident was served beverages in handled mugs; the lids were not in place. Clinical record review revealed that Resident 24 had diagnoses that included dementia, Parkinson's disease, and muscle weakness. Review of the care plan revealed that the resident was at risk for nutritional problems. The intervention was for staff to provide adaptive equipment with meals, which included handled mugs with lids. A physician's order dated October 23, 2024, directed staff to provide a handled mug with a lid. On January 29, 2025, during the lunch meal observation from 12:25 p.m. through 1:45 p.m., Resident 24 was observed in the dining room eating her lunch meal. The resident was served beverages in a handled mug; the lids were not in place. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, review of facility documentation, observation and interview, it was determined the facility failed to serve and store food in a safe and sanitary manner during meal service in one of six dining rooms. (Country Inn Dining Room). Findings include: Review of the facility policy entitled, Heating Foods and Beverages in the Microwave, revealed that once a food or beverage had been reheated, staff were to remove it from the microwave and take the temperature in multiple sites; food and beverages should have reached a temperature of 165 degrees Fahrenheit (F). The item should be left to cool for two minutes and the temperature should be retaken in multiple sites. The food or beverage would be acceptable to serve if it was within the acceptable serving temperature of 135 degrees F through 165 degrees F. Review of a facility meal temperature log revealed that if a food item's temperature was below 135 degrees F but previous temperature taken within two hours was above 135 degrees F, the food should be reheated to 165 degrees F. Observation of the lunch meal service on January 28, 2025, from 12:25 p.m. through 1:30 p.m., revealed the following: Dietary employees 1 (E1) and 2 (E2) were serving food from the steam table. E1 was observed leaving the service line, turned on the faucet in the sink, and rinsed a knife under. E1 then returned to the tray line and proceeded to serve food without changing her gloves. E1 was observed picking paper meal tickets off the ground, she then returned to serving food without changing her gloves. E2 was observed leaving the service line and touched the refrigerator handle and microwave handle. E2 then proceeded to serve food, that included touching ready to eat bread, without changing her gloves. E2 removed chicken broth from the refrigerator and reheated it in the microwave. E2 then served the chicken broth on a resident meal tray without taking a temperature. During observations of the lunch meal service on January 29, 2025, from 12:21 p.m. through 1:50 p.m., revealed the following: E2 and dietary employee 3 (E3) were observed serving food from the steam table. Both E2 and E3 were observed leaving the tray line area, and opening cabinets to obtain items, and adjusting their glasses and masks. E2 and E3 returned to tray line to continue serving food after touching the handles, glasses and masks without changing their gloves. E3 was observed dishing pureed soup into bowls that were placed on a surface beside the heated steam table wells, they were not on a hot holding element. Later in the meal service, E3 poured the contents of those soup bowls back into the large pan of pureed soup that was on the steam table. The temperature of the soup in the bowls was not obtained to determine if they had fallen below 135 degrees F to ascertain if they required to be reheated to 165 degree F. E3 proceeded to mix the pureed soups together and proceeded to dish the soup back into individualized bowls which were served on resident trays. There was no temperature obtained. E2 was preparing sandwiches for resident trays. E2 proceeded to touch her eyeglasses three times without changing her gloves or performing hand hygiene and continued to assemble sandwiches for resident meal trays. Observations of the Country Inn kitchen on January 30, 2025, at 11:55 a.m., revealed the following: There was dirt and debris under the steam table. There was dirt and debris under the dish machine, where clean dish racks were stored. There was a brown substance on the inner walls and top of the microwave. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that staff implemented physician's orders for one of 22 sampled residents. (Resident 30) Findings include: Clinical record review revealed that Resident 30 had diagnoses that included orthostatic blood pressure (low blood pressure when changing positions) and hypertensive chronic kidney disease. On November 21, 2022, a physician order directed staff to administer a medication (midodrine) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) of 130 or more. A review of the November 2022, December 2022, and January 2023, Medication Administration Records, revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter three times in November, three times in December, and seven times in January. During an interview on February 9, 2023, at 9:20 a.m., the Director of Nursing confirmed that the staff failed to follow the physician's order due to the fact that Resident 30 received the midodrine when their systolic blood pressure was above 130. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for three of 23 sampled residents. (Residents 15, 31, 76) Findings include: Clinical record review revealed that Resident 15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance from staff for activities of daily living, including bed mobility, and toileting. Review of the current care plan, revealed the resident was at risk for falls with an intervention to keep the call bell within reach and encourage it's use. On March 8, 2022, at 9:54 a.m. and March 9, 2022, from 9:50 a.m. through 10:30 a.m., the resident was observed in bed with her call bell draped over a box on the wall behind her bed, out of reach. Clinical record review revealed that Resident 31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident required extensive assistance from staff for activities of daily living, including bed mobility, and personal hygeine. Review of the current care plan revealed that the resident had a self care performance deficit and was at risk for falls with interventions to keep the call bell within reach and encourage it's use. On March 8, 2022, from 10:34 a.m. through 1:00 p.m., and on March 9, 2022, from 9:56 a.m. through 10:20 a.m., the resident was observed in her recliner with her call bell hanging off of her bed onto the floor, out of reach. Clinical record review revealed that Resident 76 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living, including bed mobility, and toileting. Review of the current care plan revealed that the residnet was at risk for falls with an intervention to keep the call bell within reach and encourage it's use. On March 8, 2022, from 11:07 a.m. through 1:01 p.m., and on March 9, 2022, from 9:57 a.m. through 12:20 p.m., the resident was observed in bed with her call bell hanging onto the floor next to the bed, out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to address an identified problem area for two of 23 sampled residents. (Residents 54, 62) Findings include: Clinical record review revealed that Resident 54 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a cognitive loss. The Care Area Assessment (CAA) for this MDS triggered cognitive loss/dementia as an area to be care planned. Review of the current care plan did not include any interventions to address Resident 54's cognitive status and dementia. Clinical record review revealed that Resident 62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], revealed that the resident had urinary incontinence. The CAA for this MDS triggered urinary incontinence as an area to be care planned. Review of the current care plan did not include any interventions to address Resident 62's urinary incontinence. In an interview on March 10, 2022, at 10:55 a.m., the Director of Nursing stated that there had been no care plan developed to address the CAA area. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to adequately supervise a resident who was at risk for wandering in order to prevent an elopement for one of two sampled residents who were at risk for elopement. (Resident 153) Findings include: Clinical record review revealed that Resident 153 was admitted to the facility on [DATE], at 5:22 p.m She had diagnoses that included dementia, altered mental status, [CONDITION(S)], bilateral hearing loss and an artificial knee. Review of the admission nursing assessment revealed that the resident was admitted from the hospital, needed assistance with activities of daily living, had neurological impairment, was disoriented, had a history of falls and used a walker and a wheelchair. Review of the Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, she exhibited wandering behavior and she was not steady with walking and turning around. On March 1, 2022, a nurse noted that the resident had been seen walking in the hallway and was escorted back to her room by an aide and a licensed nurse. At 9:47 p.m., the facility received a call from a concerned neighbor that there was an elderly resident on her door step. The neighbor stated that she was not at home at the time but that she had a camera on her porch and she could see the resident on the door step. On March 2, 2022, a physician noted that the resident had dementia and had been admitted to the facility from the hospital with a diagnoses of altered mental status secondary to worsening dementia. The physician noted that the resident had eloped from the facility. Review of the incident report dated March 1, 2022, revealed that the facility received a call from a neighbor at 9:47 p.m., that there was an elderly person on her doorstep. Staff then realized the resident was missing and they went outside and found her on the porch of the neighbor's home. Review of a statement from an LPN revealed that the resident had been exhibiting behaviors after she was admitted to the facility and had stated that she is going home because she has bills to pay tomorrow. In an interview on March 9, 2021, at 1:30 p.m., the Administrator stated that on March 1, 2022, the resident had walked down the hallway into the employee breakroom. The resident had exited out an emergency door and left the facility without staff knowledge. The resident walked up the sidewalk along side of the facility crossed the street and was found on the neighbor's back porch at 9:47 p.m The facility failed to provide adequate supervision in order to prevent an elopement. CFR 483.25(d) Accidents. Previously cited 4/14/21 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review and clinical record review, it was determined that the facility failed to immediately inform the resident representative when a resident's change in condition was identified for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy titled, Notification of Changes, last approved March 5, 2021, revealed that the facility will immediately inform the resident and/or resident representative when there is a significant change in condition and that the notification will be recorded in the resident's medical record. The purpose is to ensure the notification of significant changes in status; including abnormal radiology test results. Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident understood others with clear comprehension. Review of nursing documentation revealed that the resident experienced a fall on June 3, 2021, and that based on the complaint of right groin pain, the physician ordered a pelvic X-ray on June 4, 2021. The X-ray report noted , in the setting of recent fall with pain a mildly displaced fracture is not excluded. A nurse's note dated June 4, 2021, at 9:39 p.m., indicated that Resident 1's pelvic X-ray results had been reviewed with the physician earlier in the p.m. There was no documentation to support that the resident and/or resident's responsible party had been immediately notified of the abnormal radiology test results. Nursing documentation on June 5, 2021, at 9:15 a.m. noted that the responsible party was notified of the X-ray results and expressed concern of the possibility of a hip fracture. The physician was called and ordered the resident's transfer to the hospital. Resident 1 was admitted to the hospital on June 5, 2021, with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, observations, interviews, and review of manufacturer's instructions it was determined that the facility failed to maintain medication storage in three of three medications carts (Gateway, Gateway West and Springhouse D2), and one of three medication storage rooms (Gateway). Findings Include: Review of the facility policy entitled Medication Administration-General Guidelines, dated [DATE], revealed that medications were to be dated when opened and should be discardred when expired. Observation of the Gateway West medication cart on [DATE], at 10:08 a.m., revealed one open [MEDICATION(S)] injection pen (insulin) and one Amelog injection pen (insulin) with no identified open or expiration date. The manufacturer's instructions indicated that medications in use more than 28 days should be discarded. Observation of the Gateway medication cart on [DATE], at 10:30 a.m., revealed one open [MEDICATION(S)] Flex pen (insulin) with no identified open or expiration date. There was one [MEDICATION(S)] Injection Pen (Insulin), and one [MEDICATION(S)] injection pen (insulin) with no identified open or expiration date. One [MEDICATION(S)] injection pen (insulin) had no resident identifier and no open or expiration date. The cart also contained one open [MEDICATION(S)] injection pen (insulin) with no identified open or expiration date. Observation of the Springhouse D2 medication cart on [DATE], at 11:00 a.m., revealed one open [MEDICATION(S)] Injection Pen (Insulin) and one [MEDICATION(S)] Injectable Pen (Insulin) with no open or expiration date. Observations of the Gateway medication storage room refrigerator on [DATE], at 11:20 a.m., revealed two open vials of [MEDICATION(S)] (tuberculin) with no identified open or expiration date. There was one [MEDICATION(S)] (tuberculin) medication storage box labeled with an open date of [DATE], the open vial was dated [DATE], no year identified. During an interview on [DATE], at 11: 15 a.m., the Director of Nursing stated that medications require an open and expiration date that includes the day, month and year. 28. Pa. Code 211.9 (h)(i) Pharmacy services. 28. Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and review of incident investigations, it was determined that the facility failed to ensure that an assessed safety intervention was implemented in a timely manner in order to prevent accidents for one of eight sampled residents who was at risk for falls. (Resident 54) Findings include: Clinical record review revealed that Resident 54 was admitted on [DATE], with diagnoses of dementia, abnormal gait, and repeated falls. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, exhibited behaviors such as pacing, and required limited assistance from staff for walking in the corridor and on the unit. The assessment further indicated that the resident was not steady moving from a seated to a standing position and was not steady with surface to surface transfers. Review of the current care plan revealed that the resident had a potential for falls due to deconditioning and a history of falls. Review of a physical therapy discharge summary dated December 10, 2020, revealed that the resident had been cleared to transfer and ambulate unassisted with a rolling walker. Review of an incident report dated December 11, 2020, at 1:33 a.m., indicated that the resident was found on the floor on her buttocks facing the bed with her legs straight underneath the bed. Staff assisted her into her wheelchair at this time. A review of the investigation into the fall revealed the resident had been in her wheelchair in her room prior to the fall and that the wheelchair locks were not on. The documentation indicated that the resident was not cleared by therapy to use the wheelchair and the wheelchair was to be removed from her room. Review of an incident report dated December 15, 2020, at 5:20 p.m., revealed that the resident was witnessed getting up from her wheelchair by staff and she lost her balance and fell to the floor before staff could reach her. Documentation on the report identified that the wheelchair was the root cause of the fall and had not been removed after the prior fall that occurred on December 11, 2020, in order to help prevent further falls. 28 Pa. Code 211.12(d)(1)(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 to four residents in one of six dining rooms. (Residents 19, 47, 62, 67) Findings include: Clinical record review revealed that Resident 19 had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated (MONTH) 25, 2019, the resident was cognitively impaired and required extensive assistance from staff with eating. Review of occupational therapy notes dated (MONTH) 19 through (MONTH) 22, 2019, revealed that Resident 19 tended to be distracted very easily, needed cues to be redirected, and needed hand over hand assistance to scoop food while eating. On (MONTH) 4, 2019, at 12:50 p.m., the resident was observed in the Heritage dining room seated at a table with three other residents. All residents at the table received their food at 1:00 p.m. At 1:05 p.m. a nurse aide put a spoon in Resident 19's hand and proceeded to assist two other residents at the the table. Resident 19 fed herself one spoonful of food from 1:05 p.m. through 1:30 p.m. At no time did staff cue Resident 19 to eat or provide her with hand over hand assistance to scoop her food. Clinical record review revealed that Resident 47 had [DIAGNOSES REDACTED]. According to the MDS assessment, dated (MONTH) 18, 2019, the resident was cognitively impaired and required supervision from staff with eating. On (MONTH) 3, 2019, from 1:00 p.m. through 1:15 p.m., the resident was observed in the Heritage dining room eating squash from her plate with her fingers. At no time did staff redirect or assist the resident. Clinical record review revealed that Resident 62 had [DIAGNOSES REDACTED]. According to the MDS assessment, dated (MONTH) 31, 2019, the resident was cognitively impaired and required extensive assistance from staff with eating. On (MONTH) 4, 2019, at 12:30 p.m. Resident 62 was observed in the Heritage dining room. From 12:30 p.m. through 1:00 p.m. the resident was observed eating soup, spilling it onto her clothing protector, and eating food off of her clothing protector. At no time did staff redirect or assist the resident. Clinical record review revealed that Resident 67 had [DIAGNOSES REDACTED]. According to the MDS assessment, dated (MONTH) 3, 2019, the resident was cognitively impaired and required limited assistance from staff with eating. On (MONTH) 3, 2019, at 12:30 p.m. the resident was observed in the Heritage dining room. At 12:40 p.m. Resident 67 was given a bowl of soup and started to feed himself. At 12:55 p.m. the resident's clothing protector fell into his soup while he was eating. Resident 67 proceeded to use his fingers to eat soup from the edge of the bowl. At no time did staff assist the resident. 28 Pa. Code 201.29(j) 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 residents and responsible parties were afforded the opportunity to attend and participate in care plan meetings for three of 25 sampled residents. (Residents 50, 61, 105) Findings include: Clinical record review revealed that Resident 50 had a quarterly Minimum Data Set (MDS) assessment completed on (MONTH) 30, 2019. There was no documented evidence that an interdisciplinary care plan meeting was held after the assessment that allowed the responsible party to participate in the care plan process including the development of care plan goals. Clinical record review revealed that Resident 61 had an admission MDS assessment completed on (MONTH) 30, 2019. There was no documented evidence that an interdisciplinary care plan meeting was held after the assessment that allowed the responsible party to participate in the care plan process including the development of care plan goals. Clinical record review revealed that Resident 105 had an admission MDS assessment completed on (MONTH) 20, 2019. There was no documented evidence that an interdisciplinary care plan meeting was held after the assessment that allowed the responsible party to participate in the care plan process including the development of care plan goals. In an interview on (MONTH) 6, 2019, at 10:10 a.m., the Nursing Home Administrator confirmed that there was no documented evidence that the residents or responsible parties were invited and afforded the opportunity to participate in the care plan meetings. 28 Pa. Code 211.11(e) Resident care plan.

Based on observation, it was determined that the facility failed to ensure corridor handrails were accessible to residents on one of five nursing units. (Springhouse unit) Findings include: On (MONTH) 21, (YEAR) from 11:29 a.m., through 11:53 a.m., handrails in front of the Springhouse C dining room were obstructed from resident use on both sides of the corridor. Staff had positioned eight residents in wheelchairs in front of the handrails on one side of the corridor and a dining equipment cart and activities cart in front of the handrails on the other side the corridor.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to review the risks and benefits of the use of side rails with residents or their representatives and obtain informed consent for utilization of side rails for three of 28 sampled residents. (Residents 3, 26, 29) Findings include: Clinical record review revealed that Resident 3 had a history of [REDACTED]. A side rail assessment dated (MONTH) 20, (YEAR) identified that the resident utilized the side rails to assist in bed mobility. There was no evidence to support a discussion of the risk versus benefits or that consent had been obtained from the resident or representative for the use ot the side rails. Clinical record review revealed that on (MONTH) 5, (YEAR), the facility determined that Resident 26 utilized two bilateral quarter side rails to assist in bed mobility. On (MONTH) 21, (YEAR), at 11:17 a.m., Resident 26 was in bed with two bilateral side rails in the up position at the head of the bed. There was no evidence to support a discussion of the risk versus benefits or that consent had been obtained from the resident or representative for the use ot the side rails. Clinical record review revealed that during a quarterly assessment completed on (MONTH) 10, (YEAR), the facility determined that Resident 29 utilized two bilateral quarter side rails to assist in bed mobility. On (MONTH) 21, (YEAR), at 10:09 a.m., Resident 29 was in bed with two bilateral side rails in the up position at the head of the bed. There was no evidence to support a discussion of the risk versus benefits or that consent had been obtained from the resident or representative for the use ot the side rails. In an interview on (MONTH) 27, (YEAR), at 11:27 a.m., the Administrator stated that the facility had no evidence to support that residents or their responsible parties were provided information on the risks and benefits of utilizing side rails and consented for the side rails to be utilized.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that an as needed antianxiety medication was necessary and not excessive in dose for one of twenty-four sampled residents. (Resident 41) Findings include: Clinical record review revealed that Resident 41 had [DIAGNOSES REDACTED]. A Minimum Data Set Assessment completed (MONTH) 26, (YEAR), identified that resident was cognitively impaired. Resident 41 had a physician's order dated (MONTH) 2, (YEAR) and, again, ordered on (MONTH) 15, (YEAR), for staff to administer an antianxiety medication ([MEDICATION NAME] gel) topically 0.5 mL (0.25mg) once daily as needed in the morning if the routine oral morning dose was refused. Record review revealed that there was no physician's order for a morning dose of the medication. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Additionally, Resident 41 had a physician's order for [MEDICATION NAME] gel, every 21 hours, as needed for agitation related to restlessness, for a 14 day period starting on (MONTH) 25, (YEAR). Review of the MAR indicated [REDACTED]. [MEDICATION NAME] gel was administered again on (MONTH) 27, (YEAR), at 1:07 a.m. and 8:34 p.m. (19 hours and 27 minutes apart). On these two days the resident received an excessive dose of the [MEDICATION NAME] gel that was not in accordance with the physician's order. Review of the MAR indicated [REDACTED]. In an interview on (MONTH) 24, (YEAR), 9:25 a.m., the Director Of Nursing (DON) stated that staff failed to document behaviors in the clinical record that required the administration of the antianxiety medication. The DON further stated that there was no morning dose of antianxiety medication ordered by the physician. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and review of facility incident reports, it was determined that the facility failed to ensure that staff sufficiently supervised two of 13 sampled residents to prevent falls and injuries. (Residents R100, R108) Findings include: Clinical record review revealed that Resident R100 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident R100 was cognitively impaired, required staff assistance with transfers and walking and had a history of [REDACTED]. Preventative interventions included that staff "provide supervision and cue as indicated, anticipate resident's needs and keep frequently used items in reach." Review of the facility incident reports and corresponding investigation revealed that from January 27, 2013, to March 21, 2013, the resident had seven falls. Five of these falls were the result of the resident attempting to stand and walk unassisted from the wheelchair. Interventions to prevent reoccurrence included that staff was to provide supervision, frequent observational checks and keep the resident in the common area to be viewed at all times. Four of the five falls were not witnessed by staff. The resident continued to have falls from the wheelchair on March 23, April 6 and 12, 2013, following attempts to stand without staff assistance. Although established safety interventions called for the resident to be within staff view when in his wheelchair, there was no staff supervision provided at the time of the March 23, 2013, fall according to the incident/investigative report. On May 21, 2013, at 9:58 p.m., and May 22, 2013, at 6:38 p.m., and May 24, 2013, at 9:26 p.m., a nurse documented that the resident was continually attempting to get out of his wheelchair and/or trying to walk without his walker and staff assistance. The resident also had two falls from his bed during this four day time frame. On May 25, 2013, at 6:25 p.m., the resident was found on the floor after staff was informed by a visitor. Review of the nurse documentation and incident/investigative report revealed that at the time of the fall there was no staff supervising the resident. As a result of the fall, the resident was hospitalized with a fractured hip. Since the resident's readmission to the facility on [DATE], following surgical repair of the fractured hip, the resident had an additional five falls, three of the falls were from a chair. Review of the physical therapy discharge summary revealed that on June 14, 2013, the resident was walking 15 feet with assistance compared to the February 27, 2013, physical therapy discharge summary when he was able to walk 60 feet with supervised assistance. The resident also required increased medication for pain management following the hip fracture. Clinical record review revealed that Resident R108 had [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE], indicated that the resident was at risk for falls due to poor balance, confusion and impulsive behavior. The MDS assessment dated [DATE], indicated that the resident had memory impairment, and frequently experienced wandering behaviors, along with physical outbursts and other behaviors such as pacing and rummaging. The assessment also indicated that the resident had a history of [REDACTED]. The initial care plan dated February 2013 and the current plan of care identified the resident at risk for falls due to poor safety awareness and that the resident wandered on the unit on a daily basis. Review of facility incident reports and corresponding investigation revealed that from March 1, 2013 to July 21, 2013, the resident had eight falls. All eight of the falls occurred either on the 3:00 p.m. to 11:00 p.m., or the 11:00 p.m. to 7:00 a.m., shift. Five of the falls were not witnessed by staff. Interventions to prevent reoccurrence included that staff was to provide close monitoring and supervision and to keep the resident in view when he was ambulating or in the common areas on the unit. Although the incident reports indicated that there was increased supervision and monitoring on the unit at the time of the falls there is a lack of documented evidence to support that additional staff was available and was able to adequately supervise the resident in order to prevent accidents and falls. CFR 483.25(h) Accidents. Previously cited 8/10/12 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/10/12