Every finding on record at Quality Life Services - Grove City

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents reviewed (Resident 1). Findings include: Facility policy Skin Integrity and Wound Management dated 6/20/25, revealed the implementation of an individual resident's skin integrity and wound management occurs within the care delivery process. Staff continually observes and monitors residents for changes and implements revisions to the plan of care as needed. Complete comprehensive assessment of the resident's needs prior to admission. Identify resident's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission and weekly by a licensed nurse. Document in PCC[ computer program]. Perform wound assessment and complete proper forms upon initial identification of altered skin integrity weekly, and with any deterioration of wound. Resident R1's clinical record revealed an admission date of 3/11/26, with diagnoses that included spinal stenosis of the cervical region (a narrowing of the spaces within the cervical region of the spine), lack of coordination, muscle wasting and atrophy (the shrinking and loss of muscle mass), and abnormalities of gait and mobility. Resident R1's clinical record revealed assessments dated 3/11/26, for pressure ulcers to the right buttock as 5 cm. (centimeter) x 3.5 cm, slough and left buttock as 3.5 cm. x 1.5 cm. slough. On 3/27/26, a further assessment revealed Resident R1's pressure ulcer to the right buttock as 5 cm. x 3.5 cm x 0.1 cm 50% granulation (new tissue at the base of a healing wound) 50% epithelization [tissue that can form over the granulation tissue as a wound heals] and left buttock as 4 cm. x 2.5 cm x 0.1 cm. 50% granulation 50% epithelization). Resident R1's clinical record lacked weekly assessments from period of 3/12/26, through 5/13/26. During an interview on 5/15/26, at 10:20 a.m. the Nursing Home Administrator (NHA) confirmed that Resident R1's clinical record lacked evidence of weekly wound assessments of pressure ulcers to Resident R1's right and left buttocks. The NHA further confirmed that the facility failed to comprehensively assess pressure ulcers/injuries weekly to ensure proper healing and management of each wound. 28 Pa. Code 211.5 (f)(ii)(iii)(ix) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based upon review of facility policies, observations, and staff interviews, it was determined that the facility failed to monitor sanitization chemicals for one of one three-compartment sinks; failed to ensure that food was stored in accordance with standards for food safety for four of four kitchen refrigerators, one of one solarium refrigerators, and one of one kitchen freezers; and failed to label food brought into the facility with the resident's name and use by date in one of five refrigerators.Findings include: Review of facility policy entitled Cleaning Dishes - Manual Dishwashing, dated 6/18/25, revealed the facility will check the sanitation sink often using a test strip to assure the level of sanitization solution is appropriate and that the facility will test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. Review of facility policy entitled Food Storage, dated 6/18/25, revealed Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit (F) and freezer temperatures to keep food frozen solid (0 degrees F or below). The policy further revealed that each refrigerator / freezer will be supplied with a thermometer and monitored for appropriate temperatures at least two times each day. Facility policy also revealed that all foods should be covered, labeled, and dated before being and that refrigerated or frozen and items will be used within five days or discarded, unless frozen for future use. Observation on 9/23/25, of the main kitchen revealed one upright refrigerator unit that lacked a thermometer and evidence of the facility monitoring the temperature, and one milk cooler, one upright refrigerator, one walk-in refrigerator, and one walk-in freezer lacking evidence of routine temperature monitoring. Review of facility provided temperature logs from February 2025, through August 2025, for milk cooler lacked evidence of temperature checks for two of 56 twice daily checks for February, 17 of 62 twice daily checks for March, 45 of 60 twice daily checks for April, 38 of 62 twice daily checks for May, 54 of 60 twice daily checks for June, 60 of 62 twice daily checks for July, and 61 of 62 twice daily checks for August. Review of facility provided temperature logs from February 2025, through August 2025, for one upright refrigerator in the main kitchen lacked evidence of temperature checks for two of 56 twice daily checks for February, temperature log sheets for March, April, May, June, and July, and 56 of 62 twice daily checks for August. Review of facility provided temperature logs from February 2025, through August 2025, for one walk-in-cooler in the main kitchen lacked evidence of temperature checks for two of 56 twice daily checks for February, 17 of 62 twice daily checks for March, 44 of 60 twice daily checks for April, 37 of 62 twice daily checks for May, temperature log sheets for June, and July, and 57 of 62 twice daily checks for August. Review of facility provided temperature logs from February 2025, through August 2025, for one walk-in-freezer in the main kitchen lacked evidence of temperature checks for six of 56 twice daily checks for February, 20 of 62 twice daily checks for March, 45 of 60 twice daily checks for April, 35 of 62 twice daily checks for May, 33 of 60 twice daily checks for June, temperature log sheet for July, and 61 of 62 twice daily checks for August. During interview on 9/23/25, at approximately 10:55 a.m. Dietary Supervisor stated the one upright refrigerator was new and just put into service approximately a week or so ago and the staff did not ensure a thermometer was put into place and a temperature log was not implemented as required. Dietary Supervisor further confirmed that the one milk cooler, one upright refrigerator, one walk-in refrigerator, and one walk-in freezer lacked evidence of routine temperature monitoring as required. Observation of main kitchen on 9/23/25, revealed staff were utilizing the three-compartment sink to rinse, clean, and sanitize all dishware / kitchen utensils due to the mechanical dishwasher being out of service. Observation revealed there was no evidence of chemical test strips being readily available at the three-compartment sink to verify appropriate chemical sanitization levels, measured in parts-per-million (ppm). Observation also revealed the facility lacked evidence of any prior monitoring / documentation of routine chemical testing for the three-compartment sink. Review of facility provided dish machine temperature and sanitizer logs from June 2025, though September 2025, lacked evidence of wash cycle temperature checks for 40 of 90 three times daily checks for June, 35 of 93 three times daily checks for July, 47 of 93 three times daily checks for August, and 30 of 69 three times daily checks for September. Review of facility provided dish machine temperature and sanitization logs from June 2025 through September 2025, lacked evidence of final rinse cycle temperature checks for 40 of 90 three times daily checks for June, 35 of 93 three times daily checks for July, 46 of 93 three times daily checks for August, and 28 of 69 three times daily checks for September. Review of facility provided dish machine temperature and sanitization logs from June 2025 through September 2025, lacked evidence of sanitization chemical checks for 0 of 90 three times daily checks for June, 0 of 93 three times daily checks for July, 0 of 93 three times daily checks for August, and 0 of 69 three times daily checks for September. During an interview on 9/23/25, at 10:54 a.m. Dietary Aide Employee E5 stated he/she was washing all the dishes in the three-compartment sink because the dishwasher was down and normally they only wash the pots and pans in the three-compartment sink. During an interview on 9/23/25, at 10:57 a.m. Dietary Aide Employee E3 stated he/she has been here since March 2025 and was never told to check or document the chemical level in the three-compartment sink. During an interview on 9/23/25, at 11:00 a.m. Dietary Aide Employee E4 stated he/she has been here full-time since July 2025 and he/she knows that they are supposed to check and document the chemical level in the three-compartment sink, but has never seen anything to document this in. During an interview on 9/23/25, at 11:03 a.m. Dietary Supervisor confirmed he/she had to go and find testing strips for staff to use as they were not readily available, and he/she also confirmed the facility lacked any evidence of the chemical levels for the three-compartment sink being checked and documented as required. Observation of third floor solarium mini refrigerator / freezer on 9/24/25, at 9:41 a.m. revealed the unit lacked a thermometer and any evidence of temperatures or contents being monitored. The freezer contained an 8-ounce cool whip container with vegetable soup with no name and no date. The refrigerator contained two Activia yogurts with no name and an expiration date of 7/13/25, an empty box of chocolates and a 20-ounce bottle of orange cream cola with no name and no date. During an interview on 9/24/25, at 9:47 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the third-floor solarium mini refrigerator / freezer lacked a thermometer and evidence of temperature monitoring as well as items that were expired and contained no name and no date. LPN Employee E2 stated that this refrigerator is not to be used for resident items, and he/she was unaware that it contained anything at all. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of six residents reviewed for unnecessary medications (Resident R10).Findings include:Facility policy entitled Behavior Standard dated 6/18/25, revealed that the facility will identify, address and eliminate or reduce underlying cause of distressed behaviors and will develop interventions that are specific to the resident's interest, abilities, strengths, and needs. Resident R10's clinical record revealed an admission date of 8/22/25, with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), chronic obstructive pulmonary disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone)Resident R10's clinical record revealed a physician's order dated 8/22/25, with a discontinuation date of 9/22/25, for Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) every 12 hours PRN for anxiety. Further review revealed another physician's order dated 9/22/25, with a discontinuation date of 12/21/25, for Lorazepam 0.5 mg every 12 hours PRN for anxiety. Resident R10's August 2025 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used ten times (8/22/25, 8/24/25, 8/25/25, twice on 8/26/25, twice on 8/28/25, twice on 8/29/25, and 8/30/25). Review of the August MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam three of the ten times it was used. Resident R10's September 2025 MAR revealed that the PRN Lorazepam was used 23 times (twice on 9/1/25, twice on 9/4/25, 9/5/25, twice on 9/7/25, 9/8/25, 9/9/25, 9/10/25, twice on 9/11/25, 9/12/25, 9/13/25, 9/14/25, 9/16/25, 9/18/25, 9/19/25, 9/20/25, 9/21/25, 9/23/25, 9/24/25, and 9/25/25). Review of the September MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam 17 of the 23 times it was used. During an interview on 9/26/25, at 8:40 a.m. the Nursing Home Administrator confirmed that the facility lacked evidence of non-pharmacological interventions being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered for Resident R10. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, and clinical records, and staff interview, it was determined that the facility failed to provide the Resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of four residents reviewed for hospitalization (Residents R5 and R11). Findings include: Facility policy entitled Notice of Bed Hold Policy at Time of Transfer Due to Hospitalization or Therapeutic Leave dated 6/18/25, revealed policy is provided to residents at the time of transfer of a resident for hospitalizations or therapeutic leave. Facility policy entitled Transfer of Resident To Another Care Community dated 6/18/25, revealed to promote continuity of care during transfer the facility will copy / prepare documents needed for transfer, including, but not limited to face sheet, advanced directive, current physician orders, current medication administration record, diagnosis list, history and physical, a list of all outstanding appointments, recent lab work, and other information as indicated. Resident R5's clinical record revealed an admission date of 2/21/25, with diagnoses that included rectal cancer, benign prostatic hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R5's clinical record revealed a progress note dated 05/14/2025, indicating Resident R5 was being transferred to the hospital from the wound clinic, where he/she was admitted . The clinical record lacked evidence indicating that Resident R5 and/or their representative were provided with a copy of the facility Bed Hold policy upon transfer or within twenty-four hours of transfer. Resident R5's clinical record revealed another progress note dated 6/3/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. During an interview on 09/26/2025, at 8:40 a.m. the Nursing Home Administrator (NHA) confirmed that Resident R5's clinical record lacked evidence that the resident and/or their representative were provided a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer for the 5/14/25, hospitalization and that Resident R5's clinical record lacked evidence that necessary clinical information was communicated to the receiving health care provider for the 6/3/25, hospitalization. Resident R11's clinical record revealed an admission date of 7/19/21, with diagnoses that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and high blood pressure. Resident R11's clinical record revealed a progress note dated 7/24/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R11's clinical record also lacked evidence indicating that Resident R11 and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Further review revealed a progress note dated 8/11/25, indicating a transfer to the hospital. The clinical record lacked evidence that Resident R11 and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer During an interview on 9/26/25, at 1:00 p.m. the NHA confirmed that Resident R11's clinical record lacked evidence that necessary clinical information was communicated to the receiving health care provider and the clinical record lacked evidence that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately date and discard outdated medications for one of two medication rooms reviewed (third floor medication storage room). Findings include: Review of a facility policy entitled Storage of Medications dated 6/18/25, indicated that when the original seal of the manufacturer's vial is initially broken, the vial will be dated. The nurse will place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial will be 30 days unless the manufacturer recommends another date. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. Observation of drug storage on 9/24/25, at approximately 3:26 p.m. of the third floor medication storage room refrigerator revealed one open vial of Tubersol with no date indicating when the vial was opened. During an interview at the time of observation, Registered Nurse Employee E1 confirmed that the open Tubersol vial lacked an opened date, and staff were unable to determine the discard date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of facility policy and infection control guidelines, clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding Transmission Based Precautions (TBP) during observation of a resident with COVID-19 for one of three residents reviewed for TBP (Resident R64).Findings include: Facility policy entitled Droplet Precautions with a policy review date of 6/18/25, indicated, droplet precautions should be used in addition to standard precautions for residents with infections that can be transmitted by droplets. Droplet transmission involves contact with the conjunctiva or mucus membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganisms generated from a person who has a clinical disease or is a carrier of the microorganism. Droplets may be generated by the resident's coughing, sneezing, talking, or during the performance of procedures.Review of Pennsylvania Department of Health PAHAN dated 5/11/23, with a subject of Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings Post visual alerts (e.g.,signs, posters) at the entrance and in strategic places with instructions about current Infection Control Procedures (IPC).Resident R64's clinical record revealed an admission date of 5/13/25, with diagnoses that included Heart failure (Chronic condition in which the heart does not pump blood as well as it should), lack of coordination, muscle wasting, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Resident R64's clinical record revealed a progress note dated 9/17/25, that Resident R64 had a fever of 102.4 degrees; COVID test positive; doctor and Infection Preventionist notified; Resident moved to another room to isolate; droplet isolation initiated and maintained. Observations on 9/23/25, at about 1:00 p.m., 9/24/25, at about 9:30 a.m., and 9/25/25, at 10:15 a.m., revealed Resident R64's room without any signage alerting persons entering the room of COVID positive resident and droplet precautions for infection control outside of the room visible.During an interview on 9/25/25, at about 11:15 a.m. the Infection Preventionist and Assistant Director of Nursing confirmed that Resident R64's room lacked signage of Droplet Precautions and COVID positive resident for a resident currently in isolation precautions for positive COVID-19. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of two resident neighborhoods (2nd Floor). Findings include: Review of a facility policy dated 2/22/24, entitled Wheelchair Cleaning Policy, indicated the facility will provide clean, functional, and safe resident and facility owned wheelchairs through at least monthly cleaning or as needed. Observation of the 2nd Floor on 10/09/24, between 11:13 a.m. and 11:20 a.m. revealed concerns with four resident wheelchairs. Resident R8's wheelchair was observed to have dust and dried debris on the frame of his/her wheelchair. Resident R14's wheelchair was observed to have dried liquid and debris down the side of his/her wheelchair and on the frame of his/her wheelchair. Resident R55's wheelchair was observed to have dust and dried debris on the frame of his/her wheelchair. Resident R74 was observed to have a dried spaghetti noodle as well as other dried debris and dust on the edge of his/her wheelchair near and under the wheelchair cushion and on the frame of his/her wheelchair. During an interview on 10/09/24, at approximately 11:33 a.m. Registered Nurse (RN) Employee E1 confirmed that Residents R8, R14, R55, and R74's wheelchairs were unclean and with dried debris and dust. RN Employee E1 further stated that the nursing staff are responsible for cleaning the wheelchairs. 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical record, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were accurate and reflected the status and care provided to one of 21 residents reviewed (Resident R8). Findings include: Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included stroke, diabetes, and dementia (loss of cognitive functioning affecting a persona memory and behaviors). Resident R8's clinical record revealed a task dated 12/16/20, indicating Resident R8 was to wear a left upper extremity resting hand splint for up to four hours twice a day and to check skin integrity before and after splint wearing. Further review of Resident R8's clinical record revealed it lacked a physician's order for the left upper extremity resting hand splint. Observation of Resident R8 on 10/09/24, at approximately 11:50 a.m. revealed he/she was wearing a left resting hand splint. During an interview on 10/10/24, at 2:44 p.m. the Nursing Home Administrator confirmed that Resident R8 was utilizing a left resting hand splint and there was no physician's order for the use of the left resting hand splint. 28 Pa. Code 211.5(f)(i) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of facility policy and clinical record, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R35). Findings include: Review of a facility policy dated 2/22/24, entitled Oxygen Concentrator indicated to check inlet filter pad to be sure it is clean and in place and not to run the concentrator without a filter or with a dusty filter as this can cause damage to the concentrator and alter the oxygen concentration. Policy also indicated to remove, rinse, and pat dry the air intake filter weekly or more often if needed to keep clean and free of dust. Resident R35's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), dementia (loss of cognitive functioning affecting a persona memory and behaviors), and high blood pressure. Resident R35's physician's order dated 12/28/22, revealed that oxygen was ordered at two liters per minute every shift via nasal cannula (tubing that enters into the nostrils to administer oxygen). Further review of physician orders revealed an order dated 1/05/24, to clean oxygen filters every Friday on night shift. Observations on 10/08/24, at approximately 1:44 p.m. and 10/09/24, at approximately 11:25 a.m. revealed that Resident R35's oxygen concentrator had a filter on each side of the concentrator that contained a gray dusty substance. During an interview on 10/9/24, at approximately 11:32 a.m. Registered Nurse Employee E1 confirmed that the oxygen concentrator filters contained a gray dusty substance and should not as they are to be cleaned on a weekly basis. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and the facility's written menus, observation, and resident and staff interviews, it was determined that the facility failed to follow their planned menu for four of six meals (lunch meal 10/08/24, dinner meal 10/08/24, dinner meal 10/09/24, and lunch meal 10/10/24). Findings include: Review of a facility policy dated 2/22/24, entitled Menu Substitutions indicated that substitutions will be provided when an uncontrollable situation has temporarily made the item unavailable and all changes will be recorded on the menu extension sheets and menu substitution sheet. Policy further stated that if a substitution is required more than one time, the Registered Dietitian must sign off to make a permanent change along with a permanent adjustment to the spreadsheet. Review of the facility's written and printed menu for the lunch meal on 10/08/24, revealed that the residents were to receive herb marinated chicken thigh, rice pilaf, green beans, wheat bread, cherry crisp, and coffee/tea. Observation of the lunch meal on the resident's unit on 10/08/24, at 12:24 p.m. revealed that the facility prepared and served chicken breast, white rice, corn, white bread, and chocolate chip cookie. Interview with Resident R1 at the time of observation revealed the following: This happens frequently, not as bad as today, but something is usually always different. Review of the facility's written and printed menu for dinner meal on 10/08/24, revealed that the residents were to receive macaroni and cheese, stewed tomatoes, parslied cauliflower, pineapple chunks, and coffee/tea. Interview with Resident R1 on 10/9/24, at 11:45 a.m. revealed the residents did not get the parslied cauliflower for the dinner meal on 10/08/24, like the menu indicated. Review of the facility's written and printed menu for dinner meal on 10/09/24, revealed that the residents were to receive Italian wedding soup, saltines, ham and provolone sandwich, pasta salad, seasonal fruit choice, and coffee/tea. Interview with Resident R1 on 10/10/24, at 12:17 p.m. revealed the residents received macaroni salad instead of the pasta salad for the dinner meal on 10/08/24, like the menu indicated. Review of the facility's written and printed menu for lunch meal on 10/10/24, revealed that the residents were to receive baked crunchy ranch chicken thigh, baked sweet potato half, winter blend vegetable (broccoli and cauliflower), choice of roll, gingersnap cookie, and coffee/tea. Observation of the lunch meal on the resident's unit on 10/10/24, at 12:17 p.m. revealed that the facility prepared and served baked chicken leg, sweet potato, broccoli, white bread, and cherry crisp cobbler. Interview with Resident R1 at the time of observation revealed the following: I can't remember the last time we received a dinner roll like it says, it is always a slice of bread. I don't know maybe the dinner rolls are too expensive and I crossed off the dessert for today, because it said it was going to be a gingersnap cookie and I don't care for those. During an interview on 10/09/24, at approximately 2:15 p.m. six of seven residents interviewed during a Resident Council meeting revealed that menus are not followed. Residents further indicated it was always a surprise what was under the lid when a meal was served. During an interview on 10/10/24, at approximately 10:30 a.m. the Dietary Manager stated they served chicken breast on Tuesday instead of the chicken thighs because the chicken thighs have too much fat on them and the residents don't care for them. He / she also stated they didn't serve the cherry crisp cobbler on Tuesday as scheduled because staff didn't realize it needed thawed out before they could cook it. During an interview on 10/10/24, at approximately 12:10 p.m. Nurse Aide (NA) Employees E2, E3, and E4 stated they are not aware of menu changes ahead of time and know what is served to the residents when they remove the lids from the trays. During an interview on 10/10/24, at approximately 1:30 p.m. the Nursing Home Administrator stated the Dietary Manager informs the Assistant Director of Nursing, or the first nurse he/she sees of any menu changes. During an interview on 10/11/24, at approximately 10:25 a.m. the Dietary Manager confirmed the menu was not followed as posted for the lunch meal 10/08/24, dinner meal 10/08/24, dinner meal 10/09/24, and lunch meal 10/10/24. The Dietary Manager stated some changes he/she was aware of and others the staff changed without prior approval. The Dietary Manager also confirmed that the facility does not use chicken thighs because of the fat, and the menus have not been updated to reflect that change. 28 Pa. Code 211.6 (a) Dietary Services

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure the presence of necessary documentation to support the specific reasons for discharge versus returning to the facility after an emergency transfer to an acute care facility for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an initial admitted [DATE], with diagnoses that included edema (swelling), dysphagia (difficulty swallowing) and short bowel syndrome (malabsorption disorder caused by lack of functional small intestine). Review of a progress note, dated 12/09/23, and as a late entry, revealed that Resident R1 was displaying behaviors including verbal, throwing things, putting other residents at risk, interfering with resident care and participation in activities. Another nursing note at 1:00 p.m., revealed that Crisis was called and Resident R1 was transferred to an acute care facility on a 302 petition and evaluation. Review of Resident R1's clinical record revealed that there was no physician documentation concerning the basis for the transfer/discharge; the specific resident's needs the facility could not meet; the facility efforts to meet the needs of the resident; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. During an interview on 1/24/24, at 2:25 p.m. the Nursing Home Administrator confirmed the clinical record did not contain the required physician documentation as to the rationale that Resident R1's clinical symptoms could not be treated at the facility. 28 Pa. Code 201.29(a)(c) Resident rights

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide the resident and resident representative of a Notice before Transfer/Discharge in writing for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy entitled 30 Day Discharge Notice AR-29 revealed to ensure proper notice is given and to secure a safe discharge location per state regulations. Review of Resident R1's clinical record revealed an initial admitted [DATE], with diagnoses that included edema (swelling), dysphagia (difficulty swallowing) and short bowel syndrome (malabsorption disorder caused by lack of functional small intestine). Review of Resident R1's clinical record revealed a progress note dated 12/09/23, at 1:00 p.m., which identified that Resident R1 was transferred to the hospital. The clinical record lacked documentation that Resident R1 and their representative was provided with a copy of a Notice of Transfer/Discharge as required. During an interview on 1/24/24, at 2:25 p.m. the Nursing Home Administrator confirmed that there was no evidence that Resident R1 and his/her representative was provided with a copy of the Notice of Transfer/Discharge. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) drainage bag for two of five residents reviewed for catheters (Residents R88 and R47). Findings include: Review of a facility policy entitled, Indwelling Urinary Catheter dated 2/23/23, indicated .drainage bag should be placed in a position lower than the bladder , policy also indicated The catheter bag should have a privacy cover applied at all times Review of Resident R88's clinical record revealed an admitted [DATE], with diagnosis that included, Obstructive and Reflux Uropathy (a condition that will not let the urine drain naturally), Diabetes (condition of inadequate insulin levels and blood sugar control), and Hypertension (high blood pressure). Review of Resident R88's foley catheter care plan revealed an intervention for position catheter bag and tubing below the level of my bladder, without kinks and secure with leg strap - facing away from the entrance to my room. Observation on 11/14/23, at 12:44 p.m. revealed Resident R88 sitting in his/her wheelchair in his/her room and his/her urinary catheter drainage bag visible from the hallway without a privacy cover. Observation on 11/15/23, at 11:55 a.m. revealed Resident R88 sitting in his/her wheelchair in his/her room and his/her urinary catheter drainage bag was hanging from the arm rest on his/her wheelchair visible from the hallway without a privacy cover. Further observations on 11/16/23, at 9:00 a.m. revealed Resident R88 sitting in his/her wheelchair in the dining area, which is a common area within the facility, with his/her urinary catheter drainage bag hanging from the back of his/her wheelchair visible without a privacy cover. During an interview on 10/15/23, at 11:55 a.m. Licensed Practical Nurse Employee E1, confirmed that the urinary catheter drainage bag should be placed below the resident's bladder and covered to ensure resident privacy and dignity. Review of Resident R47's clinical record revealed an admitted [DATE], with diagnoses that included paraplegia (loss of use of the lower body), lack of coordination, and abnormal posture. Observation on 11/15/23, at 2:10 p.m. revealed Resident R47 in the front lobby, which is a common area within the facility, with their urinary catheter drainage bag containing urine hanging on his/her wheelchair without a privacy cover. During an interview on 11/15/23, at 2:15 p.m. the Director of Nursing confirmed that R47's urinary catheter drainage bag lacked a privacy cover and that there should have been a privacy cover in place. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed (third floor pantry). Findings include: Review of a facility policy entitled Food brought in from outside sources dated [DATE], indicated that items brought into the facility must be labeled with the resident's name and the date prepared. The policy also indicated condiment type foods may be kept for 2 months or until factory marked date whichever is first. Review of a facility policy entitled Food Storage dated [DATE], indicated that food is stored by methods designed to prevent contamination or cross contamination. Observations on [DATE], at approximately 10:30 a.m. a refrigerator in the pantry for resident use on the third floor revealed three bottles of Pepsi with no resident name, an open container of 2.0 Cal med pass (a supplement given to resident during medication administration) with no open date, an open half empty bottle of parmesan cheese with no resident name and an expiration date of [DATE], a chef salad with no resident name and a best by date of [DATE], an open bottle of salad dressing with no resident name and an unreadable expiration date, and an open container of cream cheese with no open date. Further observation of the freezer revealed an ice pack that was used for treatments on resident's bodies, next to ice cream and a breakfast sandwich. During an interview at the time of observation with Licensed Practical Nurse Employee E1 he/she confirmed that items in the refrigerator should be labeled and dated. He/she also confirmed that items should be discarded if expired or unable to read expiration dates and that the ice packs that were used on resident's bodies should not be stored in the resident food freezer. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, and facility documents, and staff interview it was determined that the facility failed to ensure each resident received the required mobility assistance using assistive devices to prevent accidents that resulted in actual harm of the right lower leg for one of eight residents reviewed (Closed Record Resident CR2). This deficiency is being cited as past non-compliance. Findings include: Review of Resident CR2's clinical record revealed an admitted [DATE], with diagnoses that included broken left lower leg, lack of coordination, abnormal gait and mobility, falls, and muscle wasting. Review of hospital discharge records dated 7/24/23, included a Closed fracture of left fibula (lower leg) assessment and plan indicated, Patient is partial weight bearing due to distal fibula/ankle fracture. Patient with assistance of caregiver can pivot between bed to chair, wheelchair, and commode with Sit-to-Stand or patient would be confined without the use of a Sit-to-Stand. Review of physician's orders revealed the following orders for Resident CR2: 7/26/23- weight bearing full; 7/26/23- short air cast boot; 7/27/23- transfer with a stand-up lift; and 7/27/23- weight bearing as tolerated with use of walking boot for transfers. Review of Resident CR2's clinical record revealed a nurse aide tasks record dated 7/26/23, that identified Resident CR2 was to be transferred with extensive assistance of two staff. The nurse aide task record did not include the current 7/27/23, physician orders for the use of a stand-up lift for transfers. Review of departmental progress notes dated 8/03/23, revealed that Resident CR2 was working with therapy and was yelling out and grimacing, and his/her right foot was bruised, swollen, and rotated outward. X-rays from 8/03/23, revealed new buckle/angulated fractures of both bones in the right lower leg. The facility began an investigation on 8/03/23, and determined that the therapy order dated 7/27/23, to transfer Resident CR2 using the stand-up lift was not transcribed to the nurse aide tasks and that staff were transferring him/her with extensive assistance of two people. The facility initiated a whole-house audit of residents with transfer orders and identified and reconciled an additional 18 resident transfer orders. Facility obtained statements from staff who provided care to Resident CR2. Review of facility documents revealed that the facility conducted licensed nursing staff education on 8/04/23, related to proper transcription of resident mobility orders into the nurse aide 'tasks' portion of the electronic health records. Interviews on 8/16/23, at 12:40 p.m. and 1:05 p.m. with the Therapy Supervisor, Director of Nursing, and Nursing Home Administrator confirmed that they were reviewing all new transfer orders in morning meeting and ensuring that the orders are consistent in the electronic health record and nurse aide tasks. The facility identified an opportunity for error during the entry of new therapy transfer orders, and that corporate scheduled additional training for therapy staff to enter transfer orders in the nurse aide tasks when they are entered into the electronic health record. Facility has also educated therapy staff on entering new transfer status orders into the nurse aide tasks in the electronic health record. This deficiency is being cited as past non-compliance. The facility has demonstrated compliance with the transcription of resident mobility orders since 8/04/23. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for two of 18 residents reviewed (Residents R4 and R32) Findings include: Review of facility policy dated 2/23/22, entitled Care Plan and Interdisciplinary Care Conference indicated The care plan is reviewed and updated at least quarterly, and is based on ongoing assessment and evaluation of resident needs. It may be specifically reviewed and updated as the resident's condition changes . Review of Resident R4's clinical record revealed an admitted [DATE], with diagnoses that included bladder cancer, anxiety, and dysphagia (difficulty swallowing foods or liquids). Resident R4's clinical record revealed a physician's order dated 5/11/22, for admission to hospice services on 5/11/22. The clinical record lacked evidence that a care plan had been developed to address Resident R4's terminal condition or hospice services. Review of Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia, and osteoporosis (a condition in which bones become weak and brittle). Resident R32's clinical record revealed a physician's order dated 7/21/22, for admission to hospice services. The clinical record lacked evidence that a care plan had been developed to address Resident R32's terminal condition or hospice services. During an interview on 12/7/22, at 1:03 p.m. Registered Nurse Assessment Coordinator confirmed that a care plan had not been developed to address Resident R4 and R32's hospice services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide written evidence to residents or the responsible parties of a notice of bed-hold policy when transported to the hospital for two of 18 residents reviewed (Residents R21 and R66). Findings include: Review of Resident R21's clinical record revealed an admitted [DATE], with diagnoses that included dementia, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone) and diabetes. Review of progress notes revealed that Resident R21 was transferred to the hospital for evaluation and treatment on 11/6/22 and returned to the facility on [DATE]. There was no documented evidence to indicate that notification regarding the bed-hold policy was provided to Resident R21 or their responsible party before the transfer to the hospital. Review of Resident R66's clinical record revealed an admitted [DATE], with diagnoses that included cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels) affecting right dominant side, cognitive and communication deficit, and muscle wasting/ atrophy. Review of progress notes revealed that Resident R66 was transferred to the hospital for evaluation and treatment on 11/1/22 and returned to the facility on [DATE]. There was no documented evidence to indicate that notification regarding the bed-hold policy was provided to Resident R66 or their responsible party before the transfer to the hospital. During an interview on 12/09/22, at 12:00 p.m. the Nursing Home Administrator confirmed that there was no evidence or documentation that written notification of the bed hold policy was sent with Resident R21 or Resident R66 or their representatives when transferred to the hospital. Pa. Code 211.5(f) Clinical records Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 18 residents reviewed (Residents R9 and R66). Findings include: Review of the facility policy entitled, Documentation and Communication of consultant pharmacist recommendations dated 2/23/22, stated Procedures: The consultant pharmacist reviews the medication regimen of each resident at least monthly. Review of Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, dementia (a disease of the brain that affects mood, decision making, and behavior), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and kidney disease. Resident R9's physician's orders included Lantus 100 unit/milliliter (Insulin Glargine) inject 10 units subcutaneously in the morning for diabetes mellitus, Tramadol HCL 50 milligrams (mg) give 1/2 tablet three times a day for polyarthritis, and Torsemide 20 mg give two tablets in the morning for cardiac heart failure. There was no documented evidence that pharmacy completed a monthly drug regimen review for Resident R9 from March 2022 to December 2022. During an interview on 12/08/22, at 12:05 p.m. the Director of Nursing (DON) confirmed there were no pharmacy reviews for Resident R9 for March 2022 to December 2022. Review of Resident R66's clinical record revealed an admitted [DATE], with diagnoses that included cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels) affecting right dominant side, cognitive and communication deficit, and muscle wasting/ atrophy. Resident R66's physician's orders included Donepezil HCL tablet 5 mg give one tablet by mouth in the morning for dementia, Eliquis tablet 5 mg give one tablet by mouth two times per day for a CVA (cardiovascular accident-stroke), quetiapine fumarate tablet 100 mg give 1 tablet by mouth at bedtime for dementia, and Sertraline HCL tablet 100 mg give 1.5 tablets by mouth in the morning for depression. There was no documented evidence that pharmacy completed a monthly drug regimen review for Resident R66 for October and November 2022. During an interview on 12/08/22, at 12:25 p.m. the DON confirmed that there were no pharmacy reviews for Resident R66 for October and November 2022. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for one of five residents reviewed for unnecessary medications (Resident R184). Findings include: Review of Resident R184's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and anxiety. A physician's order dated 11/18/22, identified to administer Alprazolam (anti-anxiety agent) 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety, and lacked the required stop date within 14-days or a clinical rationale for continued use beyond 14-days. Review of Resident R184's Medication Administration Records (MAR) revealed he/she received the Alprazolam past the 14-days on 12/2/22, 12/3/22, 12/4/22, 12/5/22, and 12/6/22. Review of Resident R184's MAR for November 2022 revealed that the PRN Alprazolam was used 22 times between 11/18/22, and 11/30/22. Review of the November 2022 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Alprazolam 22 of the 22 times the Alprazolam was utilized in November 2022. Review of Resident R184's MAR for December 2022 revealed that the PRN Alprazolam was used 10 times between 12/1/22, and 12/6/2022. Review of the December 2022 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Alprazolam 10 of the 10 times the Alprazolam was utilized in December 2022. During an interview on 12/7/22, at 2:34 p.m. the Director of Nursing confirmed that Resident R184's Alprazolam order lacked the required stop date within 14-days or a clinical rationale for continued use beyond 14-days and that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Alprazolam 32 of the 32 times it was administered between 11/18/22, and 12/6/2022. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies and documentation and clinical records and staff interviews, it was determined that the facility failed to immediately initiate a thorough investigation regarding an allegation of abuse for one of 18 residents reviewed (Resident R9). Findings include: Review of facility policy, Resident protection from abuse, neglect or exploitation dated 2/23/22, revealed under Reporting/Response - The following procedure will be implemented by the homes when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknown source, or misappropriation of resident property resident abuse (including injuries of unknown source), alleged or suspected. This includes allegations involving other residents, visitors, employees, or any other person. Any situation of abuse or suspected abuse will be reported as follows. The Administrator or Director of Nursing (DON) must be notified immediately. Review of Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, dementia (a disease of the brain that affects decision making, mood and behavior), diabetes mellitus (a condition that affects the way the body processes blood sugar), and kidney disease. Review of Resident R9's care plan dated 2/03/21, revealed a focus on potential or actual bowel incontinence related to immobility, Transient Ischemic Attack (TIA) with interventions to check on me at least every two hours and assist with toileting as needed and provide me with a bedpan or bedside commode as needed. Review of Resident R9's progress notes dated 9/19/22, 3:45 p.m. revealed CNA came to DON stated Resident R9 had a complaint. CNA told DON that Resident R9 stated he/she was not checked on all night, he/she had bowel movement (BM) all over. Allegation of neglect, Resident R9 assessed, no injury, investigation initiated. No further documentation of a prior investigation was noted from the midnight and dayshift facility staff. Review of information submitted by the facility dated 9/20/22, revealed Factual Description reported by the DON, At 1430 a Certified Nursing Assistant (CNA) came to me and reported that when he/she went to get Resident R9 out of bed this morning he/she was crying. Was incontinent of a large amount of loose stool some of which was dried on skin. Resident R9 stated, No one came in all night to check on me, how could they forget about me? Also stated, they probably came in and turned around and walked out when they smelled me. No further documentation was noted in the facility report or a Risk Management Report to indicate an investigation was immediately initiated during or after the midnight shift of the incident by any facility staff until 1:30 p.m. 9/19/22, when the DON was notified by a CNA. During an interview on 12/07/22, at 2:30 p.m. the DON confirmed that no thorough investigation was immediately initiated until he/she was notified at 1:30 p.m. 9/19/22 of Resident R9's allegation of no incontinence care during the night shift (11 p.m. - 7 a.m.) 9/19/22. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility staff inservice posting, clinical records, and staff interviews it was determined that the facility failed to administer prescribed medications to eight of 14 residents (Residents R3, R5, R7, R9, R10, R11, R12 and R13), placing these residents in Immediate Jeopardy due to the danger of significant adverse consequences, and failed to administer prescribed medications to six of 14 residents (Residents R1, R2, R4, R6, R8 and R14). Findings include: An undated staff inservice posting, "Medication not available," indicated that when a medication is not available for a resident, the nursing staff should make a note on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This posting also indicated that not giving a medication can be considered a medication error. During an interview on May 11, 2011, at 11:00 a.m., the Director of Nursing confirmed that the posting was part of an inservice held on January 13, 2011, and on January 14, 2011. The admission face sheet indicated that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) every 12 hours, [MEDICATION NAME] (medication used to treat dementia) 5 mg. twice daily, [MEDICATION NAME] (medication used to treat anxiety and depression) 1 mg. twice daily, [MEDICATION NAME] (medication used to lower cholesterol) 40 mg. every day at bedtime, [MEDICATION NAME] (medication used to treat high blood pressure) 40 mg. every eight hours, Tylenol PM, (medication used to treat pain or sleeplessness) 500/25 mg. two tablets every day at bedtime and [MEDICATION NAME] swish and swallow (medication used to treat infections of the mouth) 5 milliliters (ml.) four times daily. The April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The admission face sheet indicated that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice a day, and [MEDICATION NAME] /[MEDICATION NAME] (medication used to treat diabetes) 5/500 by mouth two times a day. The April 2011 MAR for Resident R5 indicated that the Potassium was not administered as ordered on April 18, 2011, at 5:00 p.m., the [MEDICATION NAME] was not administered on April 18, 2011, at 4:00 p.m., and the [MEDICATION NAME]/[MEDICATION NAME] 5/500 was not administered on April 21, 2011, at 5:00 p.m. The admission face sheet indicated that Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, [MEDICATION NAME] (medication used to improve breathing) 1 puff at bedtime and [MEDICATION NAME] LA (medication used to treat congestion) 600 mg. twice daily. The April 2011 MAR for Resident R7 indicated that the [MEDICATION NAME] was not administered on April 15, 2011, the [MEDICATION NAME] LA and the [MEDICATION NAME] were not administered on April 9, 2011, at 8:00 p.m. The admission face sheet indicated that Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. two tablets twice a day, [MEDICATION NAME] (medication used to treat depression) 5 mg. daily, Doc Q-Lace (stool softener) 100 mg. twice a day, and [MEDICATION NAME] XR (medication used to treat depression) 75 mg. in the a.m. The April 2011 MAR for Resident R9 indicated that the [MEDICATION NAME], and Doc Q-Lace was not administered as ordered on April 10, 2011, at 8:00 a.m., and the [MEDICATION NAME] XR was not administered on April 10, 2011, April 17, 2011, April 18, 2011, and April 19, 2011, at 8:00 a.m. The admission face sheet indicated that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated February 13, 2011, indicated that Resident R10 was to receive [MEDICATION NAME] (medication used to treat high blood pressure) 25 mg. twice daily. The April 2011 MAR for Resident R10 indicated that the [MEDICATION NAME] was not administered on April 19, 2011 or April 20, 2011, at 8:00 a.m. and 5:00 p.m., and was not administered on April 21, 2011, at 8:00 a.m. The admission face sheet indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily at bedtime, [MEDICATION NAME] (medication used to treat high blood pressure) 12.5 mg. every morning, [MEDICATION NAME] HCl (medication used to treat itching) 25 mg. two tablets at bedtime, and Iron Complex 150 mg. twice a day with meals. The April 2011 MAR for Resident R11 indicated that the [MEDICATION NAME] and [MEDICATION NAME] were not administered on April 19, 2011 at 8:00 p.m., the [MEDICATION NAME] was not administered on April 24, 2011, at 8:00 a.m., and the Iron Complex was not administered on April 19, 2011 and April 20, 2011, at 5:00 p.m., and on April 23, 2011 and April 24, 2011, at 8:00 a.m. The admission face sheet indicated Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. at bedtime, [MEDICATION NAME] (medication used to treat depression) 50 mg. daily, [MEDICATION NAME] 20 mg. at bedtime, [MEDICATION NAME] (medication for high blood pressure) 5 mg. daily, and [MEDICATION NAME] (fiber laxative) 0.52 grams by mouth daily. The April 2011 MAR for Resident R12 indicated that the [MEDICATION NAME] and [MEDICATION NAME] were not administered on April 15, 2011 and April 29, 2011, at 8:00 a.m., the [MEDICATION NAME] and [MEDICATION NAME] were not administered on April 1, 2011, at 8:00 p.m., and the [MEDICATION NAME] was not administered on April 28, 2011 and April 29, 2011, at 8:00 a.m. The admission face sheet indicated that Resident R13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. every day at bedtime, with an original order date of March 4, 2011, and [MEDICATION NAME] (medication used to treat high blood pressure) 300/12.5 mg. daily. The April 2011 MAR for Resident R13 indicated that the [MEDICATION NAME] was not administered on April 5, 2011, at 8:00 p.m., and the [MEDICATION NAME] was not administered on April 17, 2011, or April 18, 2011. The admission face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. two times a day. The April 2011 MAR for Resident R1 indicated that the [MEDICATION NAME] were not administered on April 22, 2011, at 8:00 a.m., and the [MEDICATION NAME] was not administered on April 14, 2011, at 8:00 p.m., April 15, 2011, at 8:00 a.m. or 8:00 p.m., and April 19, 2011, at 8:00 a.m.. The admission face sheet indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. every morning and 10 mg. daily at bedtime. The April 2011 MAR for Resident R2 indicated that the [MEDICATION NAME] was not administered as ordered on April 15, 2011, at 8:00 a.m. and 8:00 p.m. The admission face sheet indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated March 17, 2011 and April 1, 2011, respectively, indicated that Resident R4 was to receive [MEDICATION NAME] 10 mg. twice daily and [MEDICATION NAME] ophthalmic ointment (antibiotic medication for the eyes) apply to both eyes at bedtime. The April 2011 MAR for Resident R4 indicated that the [MEDICATION NAME] was not administered on April 24, 2011, at 8:00 a.m. or 8:00 p.m., and April 26, 2011, at 8:00 p.m., and the [MEDICATION NAME] was not administered on April 4, 2011, April 5, 2011, and April 26, 2011, at 8:00 p.m. The admission face sheet indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated April 19, 2011, indicated that Resident R6 was to receive [MEDICATION NAME] one daily. The April 2011 MAR for Resident R6 indicated that the [MEDICATION NAME] was not administered on April 20, 2011. The admission face sheet indicated that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated April 19, 2011 and April 25, 2011, respectively, indicated that Resident R8 was to receive [MEDICATION NAME] (medication used to reduce stomach acid) 40 mg. twice daily and [MEDICATION NAME] (topical medication to treat [MEDICAL CONDITION]) 10 drops to anterior, posterior, medial and lateral aspects of right knee three times a day. The April 2011 MAR for Resident R8 indicated that the [MEDICATION NAME] was not administered from April 18, 2011 through April 23, 2011, and the [MEDICATION NAME] was not applied April 25, 2011, at 2:00 p.m., and 8:00 p.m., and April 26, 2011 through April 29, 2011, at 8:00 a.m., 2:00 p.m., and 8:00 p.m. . The admission face sheet indicated that Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders, dated May 1, 2011, with an initial order date of August 9, 2010, indicated Resident R14 was to receive [MEDICATION NAME] 0.5 mg. daily at bedtime. The April 2011 MAR for Resident R14 indicated that the [MEDICATION NAME] was not administered on April 1, 2011. During interviews on May 5, 2011, at 8:30 a.m., Registered Nurse (RN) Employee E1 and RN Employee E2 confirmed that nursing staff failed to administer the above noted medications because they were not made available in a timely manner by the facility pharmacy. During an interview on May 5, 2011, at 2:45 p.m., the Director of Nursing (DON) confirmed that nursing staff failed to administer medications because they were not made available in a timely manner by the facility pharmacy. The DON confirmed that administration was aware of ongoing problems with the delay in receiving requested medications from the pharmacy in a timely manner since January 13, 2011. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 2/25/11. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 2/25/11, 1/29/10. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 201.29(j) Resident rights. Previously cited 2/25/11, 1/29/10. 28 Pa. Code: 211.9(k) Pharmacy services. Previously cited 2/25/11. 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 2/25/11.

Based on review of facility policies, facility documents, and staff interviews, it was determined that the facility failed to maintain pharmaceutical services to obtain and administer prescribed life-saving medications on a timely basis for eight of 14 residents (Residents R3, R5, R7, R9, R10, R11, R12 and R13), placing these residents in Immediate Jeopardy due to the danger of significant adverse consequences, and failed to maintain pharmaceutical services to six of 14 residents (Residents R1, R2, R4, R6, R8 and R14). Findings include: The facility Pharmacy Service Agreement for the period January 1, 2011, until January 1, 2012, indicated "the pharmacy will provide order processing and delivery services on an emergency basis, at any time." The facility pharmacy policy dated October 1, 2010, indicated "Medications and related products are received from the pharmacy on a timely basis." If medications were needed before regular delivery, prompt delivery could be requested, which would be within four hours. There was no indication of an alternate plan to obtain the needed medications or notify the physician of the situation if the facility pharmacy could not supply the requested medications. During an interview on 5/05/11 at 11:00 a.m., the Nursing Home Administrator indicated that occasionally the facility's pharmacy did not have an ordered medication in stock and/or they were conversing with the resident's payor sources which was time consuming. Each situation was resolved independently. This indicated that there was no back-up plan to provide medications as ordered by the physicians. The admission face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) two times a day. The April 2011 MAR for Resident R1 indicated that Nephrocap was not administered on April 22, 2011, at 8:00 a.m., and the Ranexa was not administered on April 14, 2011, at 8:00 p.m., April 15, 2011, at 8:00 a.m. or 8:00 p.m., and April 19, 2011, at 8:00 a.m. The admission face sheet indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. every morning and 10 mg. daily at bedtime. The April 2011 MAR for Resident R2 indicated that the Namenda was not administered as ordered on April 15, 2011, at 8:00 a.m. and 8:00 p.m. The admission face sheet indicated that Resident R3 was admitted to the facility on [DATE], with Diagnoses: [REDACTED]. A physician's orders [REDACTED]. every 12 hours, Namenda 5 mg. twice daily, Ativan (medication used to treat anxiety and depression) 1 mg. twice daily, Zocor (medication used to lower cholesterol) 40 mg. every day at bedtime, Isosorbide (medication used to treat high blood pressure) 40 mg. every eight hours, Tylenol PM (medication used to treat pain and sleeplessness) 500/25 mg. two tablets every day at bedtime and Nystatin swish and swallow (medication used to treat infections of the mouth) 5 milliliters (ml.) four times daily. The April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The admission face sheet indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. twice daily and Ilotycin ophthalmic ointment (antibiotic medication for the eyes) to both eyes at bedtime. The April 2011 MAR for Resident R4 indicated that the Namenda was not administered on April 24, 2011, at 8:00 a.m. or 8:00 p.m., or April 26, 2011, at 8:00 p.m., and the Ilotycin was not administered on April 4, 2011, April 5, 2011, and April 26, 2011 at 8:00 p.m. The admission face sheet indicated that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice a day, and Glyburide /Metformin (medication used to treat diabetes) 5/500 two times a day. The April 2011 MAR for Resident R5 indicated that the Potassium was not administered as ordered on April 18, 2011, at 5:00 p.m., the Lasix was not administered on April 18, 2011, at 4:00 p.m., and the Glyburide/Metformin 5/500 was not administered on April 21, 2011, at 5:00 p.m. The admission face sheet indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The April 2011 MAR for Resident R6 indicated that the Nephrocap was not administered on April 20, 2011. The admission face sheet indicated that Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily, Advair (medication used to improve breathing) 1 puff at bedtime and Guaifenesin LA (medication used to treat congestion) 600 mg. twice daily. The April 2011 MAR for Resident R7 indicated that the Zestril was not administered on April 15, 2011, and the Guaifenesin LA and Advair were not administered on April 9, 2011, at 8:00 p.m. The admission face sheet indicated that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. twice daily and Pennsaid (topical medication used to treat osteoarthritis) 10 drops to anterior, posterior, medial and lateral aspects of right knee three times a day. The April 2011 MAR for Resident R8 indicated that the Prilosec was not administered from April 18, 2011 through April 23, 2011, and the Pennsaid was not applied April 25, 2011, at 2:00 p.m., and 8:00 p.m., and April 26, 2011 through April 29, 2011, at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The admission face sheet indicated that Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. two tablets twice a day, Abilify (medication used to treat depression) 5 mg. daily, Doc Q-Lace (stool softener) 100 mg. twice a day, and Effexor XR (medication used to treat depression) 75 mg. in the a.m. The April 2011 MAR for Resident R9 indicated that the Keppra, Abilify, and Doc Q-Lace were not administered as ordered on April 10, 2011, at 8:00 a.m., and the Effexor XR was not administered on April 10, 2011, April 17, 2011, April 18, 2011, and April 19, 2011, at 8:00 a.m. The admission face sheet indicated that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. twice daily. The April 2011 MAR for Resident R10 indicated that the Aldactone was not administered on April 19, 2011 and April 20, 2011, at 8:00 a.m. and 5:00 p.m., and was not administered on April 21, 2011, at 8:00 a.m. The admission face sheet indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily at bedtime, and Hydrochlorothiazide (medication used to treat high blood pressure) 12.5 mg. every morning, Hydroxyzine HCl (medication used to treat itching) 25 mg. two tablets at bedtime, and Iron Complex 150 mg. twice a day with meals. The April 2011 MAR for Resident R11 indicated that the Norpramin and Hydroxyzine were not administered on April 19, 2011, at 8:00 p.m., the Hydrochlorothiazide was not administered on April 24, 2011, at 8:00 a.m., and the Iron Complex was not administered on April 19, 2011 and April 20, 2011, at 5:00 p.m., and on April 23, 2011 and April 24, 2011, at 8:00 a.m. The admission face sheet indicated Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. by mouth at bedtime, Zoloft (medication used to treat depression) 50 mg. daily, Zocor 20 mg. at bedtime, Norvasc (medication used to treat high blood pressure) 5 mg. daily, and Metamucil (fiber laxative) 0.52 grams by mouth daily. The April 2011, MAR for Resident R12 indicated that the Zoloft and Norvasc were not administered on April 15, 2011 and April 29, 2011, at 8:00 a.m., the Haldol and Zocor were not administered on April 1, 2011, at 8:00 p.m., and Metamucil was not administered on April 28, 2011 and April 29, 2011, at 8:00 a.m. The admission face sheet indicated that Resident R13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. every day at bedtime and Avalide (medication used to treat high blood pressure) 300/12.5 mg. daily. The April 2011 MAR for Resident R13 indicated that the Aricept was not administered on April 5, 2011, at 8:00 p.m., and the Avalide was not administered on April 17, 2011, or April 18, 2011. The admission face sheet indicated that Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. daily at bedtime. The April, 2011 MAR for Resident R14 indicated that the Ativan was not administered on April 1, 2011. During interviews on May 5, 2011, at 8:30 a.m., Registered Nurse (RN) Employee E1 and RN Employee E2 confirmed that nursing staff failed to administer the above noted medications because they were not made available in a timely manner by the facility pharmacy. During an interview on May 5, 2011, at 2:45 p.m., the Director of Nursing (DON) confirmed that nursing staff failed to administer medications because they were not made available in a timely manner by the facility pharmacy. The DON confirmed that administration was aware of ongoing problems with the delay in receiving requested medications from the pharmacy in a timely manner since January 13, 2011. Refer to F157, F333 and F490. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 2/25/11. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 2/25/11, 1/29/10. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.9(k) Pharmacy services. 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) Nursing services. Previously cited 2/25/11.