Every finding on record at Pocopson Home

Based upon review of facility policy and procedure and observation, it was determined the facility failed to ensure adequate infection control measures occurred during medication pass observation on one of two nursing units observed (1 West). Findings include: Review of facility policy and procedure titled Medication Administration, revised June 2022, revealed nurses will wash his or her hands and apply gloves previous to administering any eye medication. Observation of medication administration on the 1 [NAME] nursing unit on March 20, 2024, at 8:56 a.m. revealed Licensed Employee E3 removing medications from pill packs and placing the individual pills in the employee's hand before placing the medication in the medication cup. Licensed Employee E3 was not wearing gloves at that time. Further observation of medication administration on the 1 [NAME] nursing unit on March 20, 2024, at 8:56 a.m. revealed Licensed Employee E3 did not wear gloves when administering eye medications. Interview with the Director of Nursing on March 22, 2024, at 11:00 a.m. confirmed Licensed Employee E3 should have been wearing gloves while administering eye medication and should have placed the pills directly into the medication cup from the pill pack. 28 Pa code 201.14(a) Responsible Licensee 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to restlessness, scoot chair use, restraints, or bed rails for Resident R1 which resulted in harm to Resident R1 by being tied to a scoot chair and sustaining reddened area on abdomen. Findings include: Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident R1, dated December 19, 2023, revealed the resident was severely cognitively impaired, unable to make his/her needs known, required extensive assistance for care activities, incontinent of bowel/bladder, and exhibited inattentive behaviors during the assessment period. Review of Resident R1's clinical record revealed a progress note date December 26, 2023, at 11:01 pm, noting resident awakened approximately 9:00 pm. Resident continues to try to get up and walk around, Resident has to be redirected several times, but behaviors continue. Review of Resident R1's clinical record revealed progress note dated December 27, 2023, at 1:45 pm, noting received resident sitting in front of common area, very restless and anxious. Received PRN [as needed] 0.5 mg Lorazepam tab at 11:01 pm, prior shift ineffective. Interventions toileting, giving snacks/treats and drinks ineffective. Further review of Resident R1's clinical record revealed a progress note dated December 28, 2023, at 11:41 pm, indicating during the beginning of shift resident was noted to be extremely restless and fidgety. Visibly tired and shows signs and symptoms of pain and discomfort. Noted to not be comfortable. Redirection, toileting, snack, and fluids provided with unsuccessful outcomes. Additional review of Resident R1's clinical record revealed a late entry behavior note for 11pm-7 am shift of December 27, 2023, into December 28, 2023, dated December 28, 2023, at 11:41, indicating resident was awake and extremely restless throughout the shift. Redirection and interventions were all ineffective. Review of Resident R1's clinical record revealed progress noted dated December 29, 2023, at 9:53 pm, noted resident awaken around 9:00 pm, and got out of bed and began walking around room. Roommate rang call light to alert staff and resident removed from the bedroom and placed in wheelchair. Resident toileted and placed back into wheelchair. Continued to be restless and grabbing at anyone and anything. Given PRN [as needed] Morphine which had little success. Continued review of Resident R1's clinical record revealed a progress note dated December 30, 2023, at 2:27 pm, indicating the resident woken up for lunch and was observed by this nurse trying to get out of bed, leaning over bed as if to fall. This nurse assisted resident to wheelchair. Fed lunch by this nurse, consumed 100%, During lunch resident restless/anxious unable to sit still or be redirected. Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, indicating Resident R1 was at moderate risk for falls. One of the interventions, dated October 10, 2023, indicated staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted. Further review of Resident R1's records revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. One of the interventions dated December 27, 2021, noted staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). One revised intervention dated June 28,2023 was observed noting staff should redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons. Review facility documentation including a witness statement from Nurse Assistant (Employee E3) dated December 29, 2023, revealed non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up. Review of facility documentation including a witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to the scoot chair with a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted. Review of facility records revealed an occupational therapy treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment per [Hospice provider]. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety. Review of witness statement from a Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit. Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident R1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care. Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails. Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no pre-restraining assessment was performed, and no restraint documentation, including a care plan, was available for Resident R1 since it was the administrations opinion that Resident R1 was not restrained, rather, staff were taking it upon themselves to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. It was confirmed that Resident R1 was approved for window side bedrail and scoot chair yet review of resident records failed to reveal a care plan for either. It was confirmed that Resident R1 showed signs of terminal restlessness yet review of resident records failed to reveal a care plan with interventions for this condition. 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policies, resident clinical records, and facility investigative reports, as well as staff interviews, it was determined that the facility failed to ensure residents were free from physical restraints not required to treat the medical symptoms for one of one residents reviewed, resulting in harm to Resident R1 who was physically restrained using a pair of pajama pants tied tightly around resident's waist, causing a reddened area on the resident's skin. Findings include: Review of the facility policy titled, Restraint/Device/Siderail, dated [DATE], revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted. Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, [NAME]-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed. Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated [DATE], revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period. Review of Resident R1's care plan, dated [DATE], indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music. Review of information received by Department of Health regarding Resident R1, received on February 7, 2024, revealed a witness to Resident R1 tied down to a rolling reclining chair. The incident occurred on [DATE]. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on [DATE]. The Director of Nursing initially failed to interview staff involved in Resident R1's care. Review of resident records, facility grievance reports, and electronic reporting system failed to reveal any documentation of incident. Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicated the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint. Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls. Review of witness statement from Nurse Assistant (Employee E3) dated [DATE], revealed that non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up. Review of witness statement from a Registered Nurse, (Employee E4), dated [DATE], revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to the scoot chair with a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted. Review of witness statement from a Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit. Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident R1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care. Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident. Review of Resident R1's records revealed a fall risk care plan dated [DATE], documenting Resident R1 was at moderate risk for falls. One of the interventions dated [DATE], noted staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted. Further review of Resident R1's clinical record revealed a care plan dated [DATE], documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated [DATE], indicated staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). Another intervention which was revised [DATE] was for staff to redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons. Review of facility records revealed an occupational therapy treatment encounter note dated [DATE], documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment per [hospice provider]. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety. Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails. Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine the need for restraining the resident by tying him/her to a scoot chair. Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.8(a) Use of restraint

Based on policy, facility documentation, and clinical record review, it was determined that the facility failed to thoroughly investigate an allegation of physical restraint in a timely manner for one of one resident reviewed (Resident R1). Findings include: Review of the facility policy titled, Restraint/Device/Siderail, dated [DATE], revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted. Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, [NAME]-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed. Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated [DATE], revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period. Review of Resident R1's care plan, dated [DATE], indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music. Review of information received by the Department of Health received on February 7, 2024, revealed a witness to Resident R1 tied to a rolling reclining chair. The incident occurred on [DATE]. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on [DATE]. The Director of Nursing initially failed to interview staff involved in Resident R1's care. Review of resident records, facility grievance reports, and facility reported incident system failed to reveal any documentation of incident. Review of documentation provided by Director of Nursing including a witness statement by Nurse Assistant (Employee E3) dated [DATE], revealed, non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up. Review of witness statement from a Registered Nurse, (Employee E4), dated [DATE], revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to a scoot chair using a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted. Review of witness statement from Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit. Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident E1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care. Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicate the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint. Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls. Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident. Review of Resident R1's records revealed a fall risk care plan dated [DATE], documenting Resident R1 was at moderate risk for falls. One of the interventions dated [DATE], noted staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted. Further review of Resident R1's clinical record revealed a care plan dated [DATE], documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated [DATE], indicated staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). Another intervention which was revised [DATE] was for staff to redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons. Review of facility records revealed an Occupational Therapy (OT) treatment encounter note dated [DATE], documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment according to Hospice provider notes. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety. Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails. Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine need for restraint usage with Resident R1. Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, facility documentation, and staff interviews it was determined that the facility failed to report allegations of abuse including physical restraint of Resident R1 for one of one residents reviewed. Findings include: Review of the facility policy titled, Restraint/Device/Siderail, dated [DATE], revealed it is the policy of Pocopson Homes that all residents are free from physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical condition. Restraints will be applied only after a physician's order has been obtained and the family has been notified. Consent must also be signed by the responsible party of the resident. The care plan should be updated, and the appropriate record will be initiated to track the use and release of the restraint. The physician order will include the type of restraint, reason for restraint, how often the restraint is removed. Physical or occupational therapy will be consulted. Further review of the policy revealed that physical restraints include but are not limited to leg/arm restraints, hand mitts, soft ties, vests, [NAME]-walkers, seatbelts which the resident cannot easily open or remove, specialty chairs which resident cannot easily rise from, low beds, bed against the wall, and side rails which prevent the resident from easily getting out of bed. Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated [DATE], revealed the resident was severely cognitively impaired, was not able to make his/her needs known, required extensive assistance for care activities, incontinent of bowel and bladder, and exhibited inattentive behaviors during the assessment period. Review of Resident R1's care plan, dated [DATE], indicated the resident wandered relative to impaired safety awareness. Interventions indicated were to provide structured activities, toileting, walking inside and outside, reorientation strategies including signs and pictures, wander guard bracelet, conversation, and music. Review of information received by the Department of Health received on February 7, 2024, revealed a witness to Resident R1 tied to a rolling reclining chair. The incident occurred on [DATE]. Review of facility's records failed to reveal an investigation was initiated and Resident R1 was unable to be interviewed due to his/her death on [DATE]. The Director of Nursing initially failed to interview staff involved in Resident R1's care. Review of resident records, facility grievance reports, and facility reported incident system failed to reveal any documentation of incident. Review of documentation provided by Director of Nursing including a witness statement by Nurse Assistant (Employee E3) dated [DATE], revealed, non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up. Review of witness statement from a Registered Nurse, (Employee E4), dated [DATE], revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to a scoot chair using a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted. Review of witness statement from Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit. Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident E1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care. Interview with Nursing Home Administrator on February 12, 2024, at 2:00 p.m., revealed the Administrator was not aware of the incident. The Administrator indicated the incident was not reported to the Department of Health, an investigation was not conducted, nor does the facility use any type of restraint. Interview with Director of Nursing on February 12, 2024, at 2:10 p.m., revealed witness statements were provided by staff, but no investigation was initiated of the incident since the resident was known for being restless and attempting to get out of bed and/or chair on his/her own, thus increasing fall risk. Further interview with Director of Nursing revealed the belief that being tied to the scoot chair was not considered a restraint, rather as a method of keeping the resident safe from falls. Interview conducted with nurse aide, Employee E3 on February 14, 2024, revealed Employee E3 indicated Resident R1 was not therapy approved for scoot chair use, Resident R1 was able to get up on his/her own. When licensed Employee E5 took Resident R1 to the bathroom for continence care Employee E5 noticed the resident was tied to the scoot chair with pajama pants. Employee E5 requested Employee E3 observe his/her findings as a witness. Resident R1was unable to move, due to the material being tightly tied. Further interview with Employee E3, Licensed staff member, Employee E4, requested written statements at the time of the incident. Employee E3 stated to his/her knowledge no further investigation was conducted, and he/she was not questioned further regarding the incident. Review of Resident R1's records revealed a fall risk care plan dated [DATE], documenting Resident R1 was at moderate risk for falls. One of the interventions dated [DATE], noted staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted. Further review of Resident R1's clinical record revealed a care plan dated [DATE], documenting Resident R1 as a wanderer relative to impaired safety awareness. Intervention, dated [DATE], indicated staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). Another intervention which was revised [DATE] was for staff to redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons. Review of facility records revealed an Occupational Therapy (OT) treatment encounter note dated [DATE], documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment according to Hospice provider notes. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety. Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails. Review of Resident R1's records failed to reveal evidence that a pre-restraining assessment and review was completed to determine need for restraint usage with Resident R1. Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no report was made by the facility, no investigation was initiated prior to Department of Health's visit, no pre-restraining assessment was performed, and no restraint documentation was available for Resident R1 since it was the resident was not restrained, rather, staff initiated the restraint to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of the facility's policy, observation, clinical records review, and interview with resident and staff, it was determined that the facility failed to notify the physician of a significant weight change for one of the 13 residents reviewed (Resident 79). Findings include: Review of the facility's policy titled Notification of Change In Resident Condition, with an effectivity date of April 2018, revealed that it is the facility's policy to inform the physician, resident, resident's family/legal representative anytime there is a change in resident condition or change the current plan of care. The nursing staff will notify the physician and family/legal representative of any resident if there is a change in weight or nutritional status. Review of Resident 79's diagnosis list revealed Hypertension (Elevated blood pressure), Peripheral Vascular Disease (PVD-A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and localized edema (swelling). Review of Resident 79's weights and vitals revealed a weight of 196 pounds on February 7, 2023, and 206. 6 pounds on February 14, 2023, a 10.6 pounds (5.41%) significant weight gain in one week period. Review of the Nutrition/Dietary notes dated February 21, 2023, at 11:51 a.m., revealed weekly weights obtained on February 7, 2023, was 196, and February 14, 2023, was 2023. 11 pounds gain occurred in one week, pitting (+1) edema to bilateral lower extremity noted on February 6, 2023. Diet continues as same with no change in intakes, continue to monitor weights weekly for further changes. Review of clinical records failed to reveal that the significant weight change identified on February 14, 2023, was reported to the physician. Observation and interview with Resident 79 were conducted on April 25, 2023, at 1:30 p.m. Resident was sitting on a wheelchair, resident was wearing a stocking on both legs. The resident reported that his/her legs had been swollen. Interview with the Director of Nursing (DON) was conducted on April 27, 2023, at 11:00 a.m. The DON reported that nursing notifies the physician of a significant weight change. The DON confirmed that the nurse did not notify the physician of Resident 79's significant weight change identified on February 14, 2023. The DON also confirmed that the dietitian identified and documented Resident 79's significant weight change but did not communicate it with nursing, thus physician was not notified. The facility failed to notify the physician of Resident 79's significant weight change. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. code 211.10(a)(d) Resident care policies

Based on clinical record and facility policy review, and staff interview it was determined the facility failed to provide care and service to maintain or improve incontinence for one of one resident reviewed. (Resident 14) Review of facility policy and procedure titled Bowel and Bladder Assessment and Training/Toileting Program, review June 2019, revealed each incontinent resident will have their toileting program monitored over a 72 hour period utilizing the 72 hour Bowel and Bladder Monitoring Tool upon admission to the facility, quarterly, and any change in continence, and when a foley catheter has been removed. When the 72 hour evaluation has been completed to determine patter, the nursing staff will evaluate the resident ' s continence status by completing a bowel and bladder assessment form. Nursing will evaluate the results of the bowel and bladder assessment as well as the 72 hour diary to determine the type of incontinence and if the resident will benefit from a training/toileting program. Review of resident 14's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated March 21, 2023, revealed the resident is occasionally incontinent of urine. Review of Resident 14's Bowel and Bladder Program Screener dated March 17, 2023 revealed the resident is a good candidate for a training program. Review of Resident 14's care plan revealed the resident is care plan for urinary incontinence but there are no details as to the resident training program to improve or maintain incontinence. Review of Resident 14's clinical record revealed no evidence of a 72 hour voiding diary or that a training program had been developed despite being assessed as incontinent and a good candidate for retraining. Interview with the Director of Nursing on April 27, 2023 at approximately 11:30 a.m. confirmed there was no 72 hour voiding diary or a training/toileting program developed for Resident 14. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. code 211.10(a)(d) Resident care policies

Based on the facility policy, clinical record review, observations and staff interviews revealed that the facility failed to ensure the residents enironment remains free of accident hazards for one out of 32 residents reviewed (Resident 73). Findings include: Review of the facility policy named Nursing Policy Procedure for Restraint/Device/Siderail, dated May 2015, revealed that side-rail assessment forms located in PCC will be completed on admission, annually, and any significant change in condition. Review of Resident 73' s clinical record reveald a nursing note dated December 3, 2022, stating the resident was heard saying ouch by roommate and came out in the hall and made staff aware that Resident 73 is saying her arm hurt. Upon arrival Resident 73's left arm was lodged between the side rail. The nurse aide (employee E3) states the resident got a hold of the bed control and raised the head of the bed which also raises the side rails. Slight swelling noted and states ouch when palpated. Swelling decreased. Followup with pain and the resident states her arm feels better. Observations were conducted on April 24, 2023, and April 25, 2023, revealed that Resident 73's bed rails were on the bed. Further review of the clinical record revealed that a Bed Rail Assessment, was last completed on January 18, 2022. An interview with the Director of Nursing on April 27, 2023, at 11:36 a.m. confirmed that a new bed rail assessment was not done at the time of the injury and the bed rail was not removed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and interviews with staff it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for two of 32 residents reviewed (Resident 73 and 146). Findings include: Review of Resident 73's clinical record revealed that on Jaunary 4, 2023, the resident returned from the hospital for seizure activity (new diagnosis). Review of Resident 73's clinical record revealed the care plan did not include the diagnosis of seizure activity. Interview with the Director of Nursing on April 27, 2023, 10:30 a.m. revealed that a care plan for seizure activity was not created. Review of the facility's policy titled Elopement Risk Assessment, with an effectivity date of June 2019, revealed nursing will complete an elopement risk assessment if the resident has an unsafe wandering, exhibiting exit seeking behavior, or has eloped the building. Review of Resident 146's diagnosis list revealed Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Major Depressive Disorder. Review of Resident 14's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 6, 2023, revealed that the resident had moderate cognitive impairment and was independent with locomotion on the unit. Review of the progress notes dated March 11, 2023, at 12:12 a.m., revealed resident was awake sitting up on the edge of the bed stating, I'm going to go. The same note revealed, the nurse attempted to reorient the resident but was ineffective, resident was helped into the wheelchair where she/he is now exit seeking. The resident had not slept all night during a previous shift on March 10, 2023. Review of Clinical records failed to reveal that an elopement assessment and a care plan were completed after the above incident. Review of the nursing progress notes dated April 17, 2023, at 3:45 p.m., revealed that a call was received from staff development and reported that Resident 146 was there. The same note revealed that the resident self-propelled wheelchair and was looking for her/his daughter. The resident was redirected back to the unit. Observation conducted on April 27, 2023, at 10:30 a.m., with a licensed nurse Employee E4 revealed that the staff development's office was located on the same floor on 2 West, separated by two double doors. Review of Clinical records revealed that an elopement assessment was completed on April 17, 2023, indicating the resident was At Risk but failed to reveal that a care plan for elopement was developed. Interview with the Director of Nursing (DON) on April 27, 2023, at 11:00 a.m., confirmed that a care plan for elopement was not completed for Resident 146 after an exit-seeking behavior identified on March 11, 2023, and wandering behavior on April 17, 2023. The facility failed to ensure a comprehensive care plan was completed for Resident 146 after being identified as an elopement risk. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation, and staff interviews, it was determined that the facility failed to ensure infection control and prevention was implemented on one of eight units (Two West Women). Findings include: Review of the facility's policy titled Managing Pandemic Influenza/[CONDITION(S)] Respiratory Illness undated, revealed Nursing, Infection Control, and Department Heads require symptomatic employees to go home. Review of the facility documentation revealed that licensed Employee E3 tested positive for COVID 19 virus on July 24, 2022. Review of the staffing report revealed Employee E3 worked on 3 Jones from 3:00 p.m. until 5:00 p.m. but was switched assignments to work on 2 West Woman from 5:00 p.m., until 11:00 p.m. Interview with Employee E3 was conducted on August 10, 2022, at 2:55 p.m. Employee E3 reported on the morning of July 24, 2022, she/he woke up feeling achy and tired, Employee E3 reported taking pain medication (Tylenol) which relieved her/his aches; she/he denied having cough and/or fever. Employee E3 reported coming to work on 3 Jones nursing unit but was switched to 2 West Woman unit afterward. At around 8:00 p.m., after passing the evening medication of the residents, Employee E3 tested self for COVID 19 virus with a positive test result. Approximately 8:00-8:30 p.m., Employee E3 informed the nursing supervisor of his/her COVID positive test result and was told the possibility of transferring to work in the COVID unit. According to Employee E3 during interview, the nursing supervisor informed him/her of returning with an answer regarding transferring to another unit to work. Further interview with Employee E3 revealed the nursing supervisor did not not return and Employee was not informed of swiching work assignements. Employee E3 confirmed staying in the unit and potentially exposing residents and staff to the virus through the end of the shift after testing positive for COVID at 8;00 p.m. Employee E3 reported wearing a blue surgical mask at the start of the shift and after getting a positive COVID result, she/he reported doubled the surgical mask instead of wearing an N-95 mask. Multiple attempts to interview the nursing supervisor were made on August 9, and August 10, 2022, but was unsuccessful. The above information was conveyed to the Director of Nursing on August 10, 2022. The facility failed to ensure infection control and prevention was maintained on 2 West Woman when Employee E3 stayed in the unit after receiving a positive COVID test result and wearing inappropriate PPE (Personal Protective Equipment). 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 5/25/22

Based on a review of the facility's policy, clinical and facility documents, and staff interview, it was determined that the facility failed to ensure the resident was free from a significant medication error for one of seven residents reviewed (Resident 115). Findings include: Review of the facility's policy titled Medication Administration with an effectivity date of Mach 2017, revealed, all medications will be administered safely and accurately. Before administering any medication, the licensed nurse will check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 115 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 115's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 115's nursing progress notes dated April 24, 2022, (6:21 p.m.), revealed resident received 50 mg of [MEDICATION(S)] instead of 12.5 mg, then later the resident became barely responsive in the dining room for a short period of time. The same note revealed resident was placed back into bed then start to arouse and become more responsive. Further review of Resident 115's clinical record revealed, the Resident's BP at 6:00 p.m. was 98/51, pulse rate (PR) was 44. At 6:15 p.m., BP (Blood Pressure) was 90/47, PR was 56, the resident was more alert in bed, and the physician was notified and ordered to transfer the resident to the hospital. Review of Resident 115's hospital records including After Visit Summary dated April 24, 2022, revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., Respirations-14 per min. and oxygen saturation of 98%. The resident was observed and was discharged back to the facility with recommendations to follow up with the primary care physician. Review of Resident 115's nursing progress notes dated April 25, 2022, (5:16 a.m.), revealed Resident 115 returned to the facility at 4:45 a.m., resident was awake, alert but confused. Vitals signs; BP-142/74, PR-51, R-18. The same note revealed tests were performed in the hospital with no adverse results. Interview with licensed Employee E3 on May 24, 2022, at 12:00 p.m., revealed resident's medications come in a blister pack. Medication information appears on the computer once scanned. Employee E3 reported that the nurse verifies the medication three times to ensure the medication was administered correctly. Review of the facility documentation revealed that the medication error occurred when Employee E4 administered a peer's dosage of [MEDICATION(S)] as Employee was distracted by other residents approaching the medication cart with questions and requests. Employee E4 was educated regarding medication administration which includes the use of a scanner before administering medications to each resident. The facility failed to ensure Resident 115 was free from a significant medication error. 28 Pa. Code 211.5(f) Clinical records Previously cited 5/20/21 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 5/20/21

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the use of an anti-anxiety medication for one of 33 residents reviewed (Resident 131). Findings include: Review of facility policy Psychoactive Drug Monitoring, effective January 2017, revealed that residents who are receiving prescribed antipsychotic medications shall receive behavioral interventions in effort to discontinue use of these medications. Review of Resident 131's physician's orders dated April 14, 2021, revealed an order for Lorazepam (antianxiety medication) 0.5 milligrams every six hours as needed for restlessness/anxiety. Review of Resident 131's April 2021 Medication Administration Record (MAR) revealed that Lorazepam was administered ten times from April 14 - April 30, 2021. Further review of the clinical record revealed no documented evidence that alternative behaviorial interventions were attempted prior to the medication administration. Review of Resident 131's May 2021 MAR revealed that Lorazepam was administered eleven times from May 1-19, 2021. Further review of the clinical record revealed no documented evidence that alternative behaviorial interventions were attempted prior to the medication administration. Interview with the Director of Nursing on May 20, 2021, at 2:26 p.m. confirmed behavior interventions were not consistency implemented prior to the medication administration. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of medication manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to ensure that medications were properly labeled and stored in one of seven medication carts (4 Jones Medication Cart B) and one of six medication rooms observed (1 Jones Medication Room). Findings include: An observation of the 4 Jones Medication Cart B on May 18, 2021, at 9:37 a.m., in the presence of Licensed Nurse Employee E4 revealed the following: one bottle of Brominidine Ophthalmic solution (medication used to treat increased eye pressure), opened and undated; two bottles of [MEDICATION(S)] Ophthalmic solution (medication used to treat increased eye pressure), both bottles were opened and undated; one bottle of [MEDICATION(S)] (medication used to treat eye itchiness, and redness), opened, and undated; and one bottle of [MEDICATION(S)] (medication used to treat high pressure in the eye) opened, and undated A review of the (Alphagan) Brominidine Ophthalmic solution manufacturer's storage guidelines revealed that the eye drops must be discarded four weeks after opening. A review of the [MEDICATION(S)] Ophthalmic Solution manufacturer's storage guidelines revealed that once the bottle has been opened, the drug can be kept at a temperature of 36 degrees Fahrenheit (F) to 77 degrees F for up to six weeks then discard. A review of the [MEDICATION(S)] manufacturer's storage guide revealed to discard each bottle four weeks after it has been opened. A review of the manufacturer's guidelines revealed [MEDICATION(S)] eye drops must be used within six weeks after opening the bottle. During an interview on May 18, 2021, at 9:40 a.m. Licensed Nurse Employee E4 stated that she/he was not the regular nurse on the unit and confirmed that the eye drops identified as above should have been dated once opened. Observation of 1 Jones Medication room was conducted on May 18, 2021, at 9:48 a.m. The observation of the medication refrigerator in the presence of Employee E5 revealed 38 [MEDICATION(S)] suppositories (medication used to treat constipation) kept in a red biohazard specimen bag, and 32 Acetaminophen suppositories (medication used to treat mild pain and fever) kept in a red biohazard specimen bag. Both bags were unlabeled. During an interview on May 18, 2021, at 9:50 a.m. Employee E5 verified that the medications in the red biohazard specimen bag must have been a stock medication and that medications should have been stored in their original box/container. The above was conveyed to the Director of Nursing on May 19, 2021, at 12:00 p.m. The facility failed to ensure that medications were properly labeled and stored on 4 Jones Medications Carts, and 1 Jones Medication room. 28 Pa. Code 211.9(g)(h) Pharmacy services 28 Pa. Code 211.12(c) Nursing services 28 Pa. 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 written notices of emergency transfers to the hospital were provided to the Office of the State Long Term Care Ombudsman for 11 of 33 residents reviewed (Residents 11, 16, 59, 66, 94, 106, 122, 155, 159, 161 and 166) Findings include: Review of Resident 11's progress note dated April 22, 2021, at 6:12 p.m. revealed that the resident was transferred to the hospital due to vomiting, weakness and lethargy. Review of Resident 16's progress note dated March 6, 2021, revealed that the resident was sent to the hospital for evaluation to rule out seizures. Review of Resident 59's clinical record revealed a progress note indicating that the resident was sent to the hospital on March 16, 2021 for a [CONDITION(S)]. Review of Resident 66's clinical record revealed a progress note indicating that the resident was sent to the hospital on March 28, 2021 for a fracture. Review of Resident 94's clinical record revealed a progress note indicating that the resident was sent to the hospital on March 29, 2021 for a gastrointestinal (GI) bleed. Review of Resident 106's progress note dated January 22, 2021 revealed that the resident was sent to the hospital for left knee pain. Review of Resident 122's clinical record revealed a progress note indicating that the resident was sent to the hospital on April 18, 2021 for a GI bleed. Review of Resident 155's clinical record revealed a progress note indicating that the resident was sent to the hospital on January 29, 2021 for a fracture. Review of Resident 159's clinical record revealed a progress note indicating that the resident was sent to the hospital on April 20, 2021 for a urinary tract infection and [CONDITION(S)] (infection). Review of Resident 161's clinical record revealed a progress not indicating that the resident was sent to the hospital on March 26, 2021 for an evaluation at the emergency room and was admitted for [CONDITION(S)]. Review of Resident 166's progress note dated March 1, 2021, revealed the resident requested to go to the hospital for evaluation and was sent out of the facility. Resident was admitted with urinary tract infection, failure to thrive, and [CONDITION(S)]. Interview with the Nursing Home Administrator on May 20, 2021, at 10:35 a.m. confirmed that the facility did not send notifications to the Office of the State Long Term Care Ombudsman's office when residents were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management

Based on clinical record review, it was determined that the facility failed to send all appropriate clinical documentation for residents transferred to acute care facilities for three of three residents reviewed (Resident #31, Resident #145, and Resident #165). Findings Include: Review of Resident #31's progress note dated (MONTH) 29,2019 indicated that Resident #31 was hospitalized following a fall and diagnosed with [REDACTED]. Further review of Resident #31's clinical record revealed no evidence that all appropriate documentation was sent to the acute care facility. Review of Resident #145's progress notes indicated Resident #145 was hospitalized (MONTH) 22, 2019 for scheduled surgery to remove lower extremity. Further review of Resident #145's clinical record revealed no evidence that all appropriate documentation was sent to the acute care facility. Review of Resident #165's progress notes indicated Resident #165 was sent to the hospital on (MONTH) 21, 2019 for signs/symptoms of Hypertension (elevated blood pressure). Continued review of Resident #165's progress notes revealed a note dated (MONTH) 2, 2019 indicated that the physician ordered Resident #165 be sent to the emergency room for evaluation and was admitted with a [DIAGNOSES REDACTED]. Further review of Resident #165's clinical record revealed no evidence that all appropriate documentation was sent to the acute care facility. Interview occurred on (MONTH) 18, 2019 at approximately 12:18 p.m. with the Nursing Home Administrator when information regarding appropriate clinical documentation not sent to acute care facilities with residents was presented. 28 PA Code 201.18(b)(1)(2) Management Previously cited on 06/07/18

Based on clinical record review, policy review, and interviews with the staff, it was determined that the facility failed to ensure the safety of the residents by providing proper supervision from hazards for two out of 40 residents (Resident #69 and Resident #237). Findings include: Review of Resident #69's Quarterly Minimum Data Set (resident assessment tool) dated on (MONTH) 2, 2019, section C (Cognitive Patterns) revealed a three out of fifteen (severe impairment) on her Brief Interview for Mental Status (BIMS). Further review of Resident #69's clinical record revealed a nursing note dated (MONTH) 27, 2019, stating that a possible ingestion of DermaVera Soap occurred. Review of the incident report dated this same date stated that Resident was found sitting in the front lobby chair with 60oz cup full of DermaVera Skin and Hair cleaner from her bedside table. Resident #69 offered the cup to the supervisor on the unit and stated that it taste horrible. An interview conducted with the Nursing Home Administrator on (MONTH) 18, 2019, at approximately 9:20 a.m. revealed that the soap should have been returned to the caddy and locked at the nurse's station. Review of the facility policy dated (MONTH) (YEAR) and labeled Resident Smoking, revealed that the interdisciplinary team will review the smoking assessment on a quarterly basis or with any change in a resident's condition that may affect the ability to smoke safely. Review of Resident #237's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident #237's clinical record revealed a nursing note dated (MONTH) 26, 2019, stating that unsafe smoking was observed by the activity staff. Staff removed a cigarette butt from her mouth and now is deemed unsafe in handling cigarettes and smoking privileges have been taken away. Further review of Resident #237's clinical record revealed the last smoking assessment prior to (MONTH) 26, 2019 was completed on (MONTH) 25, (YEAR) (22 months ago). An interview with Employee E3 conducted on (MONTH) 18, 2019 at approximately 10:25 a.m. revealed that there were seven to eight residents that she was supervising at the time that this incident occurred. Employee E3 states that Resident #237 was smoking a cigarette and later the resident was chewing on something and could not find the finished cigarette. When Resident #237 was asked what she was chewing on, the cigarette butt was found in the resident's mouth. Employee E3 removed the cigarette butt and threw it away. Resident #237 was given a second cigarette and the cigarette butt was not found after the cigarette was completed. Employee E3 did not know if the resident ate the cigarette butt and reported this event to the charge nurse and supervisor. An interview was conducted with the Nursing Home Administrator on (MONTH) 18, 2019 at approximately 11:15 a.m. and stated that smoking assessments should have been completed more often for Resident #237. The facility failed to ensure the safety of the residents by providing proper supervision from hazards for Resident #69 and Resident # 237. F689 483.25(d) Accidents Previously cited 6/7/2018 28 PA Code 211.10(d) Resident Care Policies 28 PA Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 6/7/2017

Based on observation, review of facility policy and staff and group interview, it was determined that the facility failed to provide sufficient dining services staff to ensure that resident meals were served timely on one of seven nursing units (4th floor Jones). Findings include: During the group interview on (MONTH) 5, (YEAR), at approximately 2:00 p.m. it was revealed by two residents that the breakfast meals were served at 8:30 in the morning, which they believed was late. Review of the facility policy revealed that the breakfast meal was scheduled to be served on 4th(NAME)at 7:58 a.m. with a plus or minus of 10 minutes. Observation of the breakfast meals on (MONTH) 6, (YEAR) on 4the floor(NAME)revealed that the trays arrived on the unit at 8:21 a.m. a 13 minutes delay according to the facility policy. Interview with Licensed Employee E10 on (MONTH) 6, (YEAR), at approximately 8:25 a.m. revealed that the floor was normally served at this time or later. During an interview with Nursing Home Administrator (NHA) on (MONTH) 7, (YEAR), at 1:10 p.m. NHA revealed that residents should be served meals in accordance to their policy. 28 Pa Code 211.6(c) Dietary services. 28 Pa. Code 201.18(b)(6) Management

Based on observations of the meal service, it was determined that the facility did not ensure a home-like environment for the residents on three out of seven nursing units. (One West, Two West and 5 Jones). Findings include: Observations of the delivery of meals on the one west dining room on (MONTH) 4, (YEAR) at approximately 1:15 p.m. and 5:30 p.m., (MONTH) 5, (YEAR) at 1:20 p.m. and (MONTH) 6, (YEAR) at 1:25 p.m., revealed that meals were being delivered on trays to the residents. The food items not removed from the trays. All food items remained on the trays for the duration of the meals. Observation of the meals served on (MONTH) 4, (YEAR) at approximately 12:30 pm and again on (MONTH) 5, (YEAR) at approximately 12:40 p.m. on 2 West for lunch meals were being delivered on trays to the residents. The food items not removed from the trays. All food items remained on the trays for the duration of the meals. Observation of the meal served on (MONTH) 7, (YEAR) at approximately 12:45 p.m. on 5(NAME)revealed that meals were being delivered on trays to the residents. The food items not removed from the trays and all items remained on the trays for the duration of the meal. An interview was conducted on (MONTH) 7, (YEAR), with the Director of Nursing and the Nursing Home Administrator at 1:30 p.m. revealed that eating on trays for meals was not home-like. 28 Pa. Code 201.18(a)(b)(3)(e)(1) Management 28 Pa. Code 201.29(a)(j) Resident rights

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prepare food under sanitary conditions in the kitchen and in on one of 9 the dining rooms. (One West) Findings include: Review of facility policy, Dress Code, policy effective date (MONTH) 20, (YEAR), revealed that dietary staff hair must be covered entirely by a hair net. Observation on (MONTH) 4, (YEAR), at 12:00 p.m. during the initial tour in the kitchen revealed dietary staff, Employee E4 not wearing a beard guard while serving food. Observation on (MONTH) 7, (YEAR), at 10:10 a.m. during a follow up tour in the kitchen revealed dietary staff, Employee E4, Employee E5, and Employee E6 not wearing a beard guard while preparing food and beverages. Interview with Dietary Department Director, Employee E7 on (MONTH) 7, (YEAR) at 10:15 a.m. indicated that beard guards should be worn for facial hair. Observations of the lunch meal on (MONTH) 5, (YEAR), at approximately 1:11 p.m. on One West revealed Employee E9 using her teeth to open a salad dressing packet. Interview with the Nursing Home Administrator on (MONTH) 7, (YEAR) at approximately 1:15 p.m. revealed that it was not an acceptable practice. 28 Pa Code 201.18(b)(1)(e)(1) Management Previously cited 5/9/2017 28 Pa Code 211.6(f) Dietary Services

Based on review of facility policies and procedures and staff interview, it was determined that the facility failed to ensure the understanding of required Notice of Medicare Provider Non-Coverage and for the appeal process for one of three clinical records reviewed. (Resident # 234) Findings include: The form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- , (a notice that informs the receipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months revealed that Resident # 234 did not have the form NOMNC CMS- signed by the beneficiary or their representative until 43 days after the last covered day of Part A service, confirming that the form was given and they understood the appeals process. Interview with Licensed nursing staff, Employee E 8 on (MONTH) 7, (YEAR) at approximately 11:45 a.m. confirmed that the facility did not find evidence that Resident # 234 or their representative recieved or signed the NOMNC CMS- notice in a timely manner. 28 Pa Code 201.18(b)(2) Management Previously cited 28 Pa Code 201.18(e)(1) Management Previously cited 5/9/2017

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to follow interventions which were in place to prevent resident to resident altercations for two of 30 residents reviewed (Residents L4 and P7) resulting in actual harm to Resident P7 who sustained a pelvic fracture. Findings include: Review of Resident L4's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident L4's Quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs) completed on May 18, 2017, revealed the resident's BIMS (Brief Interview for Mental Status - a screening tool to determine cognitive ability) score was 09, which indicated the resident was moderately cognitively impaired. Further review of the resident's MDS revealed under Section E, Behaviors, that in the lookback period, the resident exhibited physical behaviors towards others for one to two days and verbal behaviors directed towards others for one to two days. Review of Resident P7's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident P7's annual MDS completed on April 11, 2017, revealed the resident's BIMS score was 03, which indicated the resident was severely cognitively impaired. Further review of the resident's MDS revealed under Section E, Behaviors, that in the lookback period, the resident exhibited physical behaviors towards others for one to two days and verbal behaviors directed towards others for three or more days. Review of Resident P7's Fall Risk assessment dated [DATE], revealed the resident scored a 15, indicating the resident was at high risk for falls. Observation during the initial tour of 4 Jones on July 19, 2017, at approximately 12:00 p.m. Residents L4 and P7's rooms were located next to each other in front of the nurses' station. Review of facility documentation revealed that on May 17, 2017, at 6:15 p.m. Residents L4 and P7 were observed in an altercation in the 4 Jones hallway by the nurses' station. Resident P7 was observed to be grabbing Resident L4's right arm, and being verbally aggressive. The facility documentation revealed that an intervention put in place to prevent the incident from occurring was to, maintain safe distance between peers. Review of facility documentation revealed that on May 21, 2017, at 5:40 p.m. Residents L4 and P7 were observed in an altercation in the 4 Jones hallway by the nurses' station. Per the documentation: Screaming heard by staff near nurses desk, observed altercation. (Resident P7) had a hold of (Resident L4's) fingers on right hand. The facility documentation revealed that an intervention put in place to prevent the incident from occurring was, again, to, maintain safe distance between peers. Review of facility documentation revealed that on May 29, 2017, at 1:00 p.m. Residents L4 and P7 were observed in an altercation in the 4 Jones hallway by the nurses' station. Per the documentation: Resident (P7) was walking toward peer (Resident L4) who was in manual w/c (wheelchair) and before nursing staff could intervene, (Resident L4) pushed resident from the front and pushed (Resident P7) to the floor. (Resident P7) fell on her buttocks and then laid supine (on her back). Review of Resident P7's progress notes revealed a nurses' note on May 29, 2017, at 6:56 p.m. stating, Received resident lying in bed, agitated, calling out. Resident complains of pain to the right hip area, and becomes rigid with repositioning. The physician was contacted and X-rays were ordered. Review of Resident P7's radiology report dated May 29, 2017, revealed the resident had a nondisplaced fracture of the right ischium and inferior ramus of the right pelvic bone (pelvic fracture.) Residents P7 and L4's pattern of altercations and the failure of the staff to keep them apart resulting in an altercation that led to Resident P7's pelvic fracture were discussed with the Director of Nursing on July 21, 2017, at approximately 11:00 a.m. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 09/09/15, 09/14/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/29/15, 09/09/15, 09/14/16, 12/12/16, 05/09/17, 06/29/17 28 Pa. Code 201.18(b)(1) Management Previously cited 07/29/15, 09/09/15, 09/14/16, 12/12/16, 05/09/17, 06/29/17 28 Pa. Code 201.18(b)(3) Management Previously cited 07/29/15, 12/12/16 28 Pa. Code 201.18(e)(1) Management Previously cited 07/29/15, 09/09/15, 09/14/16, 12/12/16, 05/09/17 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited 07/29/15, 09/09/15, 06/30/16, 09/14/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 07/19/15, 09/09/15, 09/14/16

Based on clinical record review, observations, review of facility policies and procedures and staff interviews, it was determined that the facility failed to provide the necessary care and services to prevent the development of a pressure ulcer; and further failed to promote healing to prevent further decline of the pressure ulcer for one of 30 residents reviewed, resulting in actual harm to resident (Resident T4). Findings include: Review of facility policy, entitled Wound Measuring and Documentation Guidelines, dated January 2010, indicated that weekly measurements were necessary to track the progress of the wound and would include: depth; tunneling/ undermining; care plan updates and staging of all pressure related wounds, according to the National Pressure Ulcer Advisory Panel (NPUAP). Review of facility policy, entitled Skin and Wound Care, dated January 2010, indicated that facility policy was to ensure that residents admitted to facility without a pressure ulcer do not develop a pressure ulcer and the resident with a pressure ulcer receives appropriate treatment to promote healing and prevent change in skin integrity. Review of Resident T4's clinical record revealed that resident was admitted to facility on August 29, 2013; and readmitted on [DATE] status [REDACTED]. Review of resident's 14 day readmission scheduled assessment, dated April 14, 2014, indicated that resident was severely, cognitively impaired and required exstensive assistance from two staff for bed mobility and transfering; was at risk for pressure ulcer development and was being provided with a pressure reducing device for bed. Review of nurse note, dated May 8, 2014 at 2:30 p.m., documented that during weekly skin assessment, the nurse noted resident with a 1 centimeter by 0.5 centimeter hard discolored area to right heel and left heel discolored, but no hardened areas. There was no facility documented evidence that staff measured the discolored, left heel when first identified on May 8, 2014. Review of initial wound team care note, dated May 14, 2014 at 1:00 p.m., documented that resident's left heel was soft and discolored area measured 2.8 centimeters by 2.5 centimeters; right heel was described with a hard, darkened area that measured 0.6 centimeter by 1.0 centimeter in size and resident complained of discomfort when palpitating feet. Review of resident's current physician orders for June 2014, indicated that resident was not ordered for a pressure relieving mattress until May 8, 2014. An order was obtained on May 13, 2014 to offload heels. Review of resident's May 2014 plan of care for being at risk for impaired skin integrity/potential for skin breakdown related to decreased mobility secondary to [MEDICAL CONDITION] hip, failed to provide evidence that the plan of care was updated to include a pressure reducing mattress until June 3, 2014. Interview with licensed Employee E5, on June 17, 2014 at 12:55 p.m., confirmed that Resident T4 was being managed and monitored by the wound team for intact, deep tissue injuries and had a treatment order for the application of skin prep (skin protectant wipe that forms a film/barrier over intact skin) to bilateral heels. Observation of Resident T4, on June 17, 2014 at 1:00 p.m., accompanied by licensed nurse Employee E5, revealed resident in a day room reclining in a geriatric chair and with no pressure relieving device in place to offload the heels. Employee E5 confirmed that general nursing staff were to offload pressure from the resident's bilateral heels with a positioning, foam wedge but for past couple weeks the wedge was not staying in place. Employee E5 indicated that resident could be restless and push the wedge from underneath and off the recliner. Employee E5 searched for the foam wedge on the floor but the wedge was not located in day room. At surveyor request, Resident T4 was transported on June 17, 2014 at 1:10 p.m., by licensed nurse Employee E5, to resident's room for further observation of resident's bilateral heels. This observation revealed that resident's left heel was no longer intact and a moderate amount of brownish exudate (drainage) had soiled the foot rest surface area. Review of wound team tracking note, dated June 18, 2014, documented that the resident's left heel wound measured 1.8 centimeter by 1.5 centimeter but wound team failed to measure the depth of the open area on the left heel. and failed to stage the wound as per facility policy and procedure. A second observation of Resident T4, on June 18, 2014 at 1:00 p.m., revealed resident sitting in recliner with bilateral heels not offload and the wound dressing to the left heel was not secure. This was confirmed by licensed nurse Employee E5 on June 18, 2014 at 1:10 p.m. Interview with licensed nurse Employee E3, on June 19, 2014 at 9:50 a.m., revealed that the facility's assistant director of nursing provides oversite to the wound team which consists of four licensed practical nurses. Employee E3 confirmed that the wound team should have measured the depth of resident's left heel wound on June 18, 2014. Subsequent wound documentation, dated June 19, 2014 at 2:52 p.m., indicated that resident's open area to the left heel measured a depth of 0.2 centimeter. Physician order, dated June 18, 2014, revealed that resident was to have the left heel cleansed with non-saline solution, santyl nickel thick applied and covered with nonsaline moistened gauze and border gauze. Final observation of Resident T4, on June 19, 2014 at 10:25 a.m., revealed resident resting in recliner by elevators and the left heel was exposed to air, not protected with a treatment dressing and not offloaded. Interview with Employee E5, on June 19, 2014 at 10:30 a.m., confirmed that the left heel had no wound dressing in place and the wedge needed to be repositioned. Employee E5 further revealed that resident received a shower earlier this morning but a dressing was not able to be applied after completion of the shower, because this employee was involved in a team meeting. Employee E5 was also unable to confirm if the recliner leg rest area had been sanitized by staff prior to transferring resident into the recliner, further exposing resident's left heel to a heel surface area which had been soiled by exudate (drainage) on June 17, 2014, and placing the resident at risk for wound contamination and potential for infection The facility failed to implement initial interventions to prevent skin breakdown from developing in one resident who was determined to be at risk. Facility also failed to maintain the physician order [REDACTED]. 28 Pa. Code: 201.18(b)(1)(e)(1) Management Previously cited 7/25/2013 28 Pa. Code: 211.5(f) Clinical records Previously cited 7/25/2013 28 Pa. Code: 211.5(g) Clinical records 28 Pa. Code: 211.10(c) Resident care policies Previously cited 7/25/2013 28 Pa. Code: 211.10(d) Resident care policies 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 7/25/2013