Every finding on record at Quality Life Services - Henry Clay

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to document notifications of medical providers of increased and decreased capillary blood glucose levels and/or failed to document recheck of out-of-range blood sugar levels for three of seven residents (R25, R25, and R72).Findings:Review of the facility policy, Physician Notification dated 1/22/26, indicated, Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. The policy further stated to document findings related to the change in condition and physician notification and response.Review of the facility policy, Hypoglycemia Protocol dated 1/22/26, indicated that for hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level) the facility staff should Recheck the blood sugar and Notify the MD (doctor of medicine).Review of the clinical record indicated Resident R11 admitted to the facility on [DATE].Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 5/11/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).Review of Resident R11's care plan initiated 10/14/19, revised on 4/30/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify provider and indicated to provide insulin as ordered by the physician. Review of a current physician order dated 1/15/25, indicated to inject Novolin insulin (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R25's blood sugar level was less than 60 (milligrams per deciliter) to call the MD (Doctor of Medicine) and document in the progress notes.Review of Resident R11's blood sugar record revealed the following decreased blood sugar levels without documentation that the provider was notified:5/06/26, at 7:34 a.m. - 61 mg/dL (milligrams per deciliter), no documentation of recheck.5/15/26, at 8:18 a.m. - 57 mg/dL, no documentation of recheckReview of the clinical record indicated Resident R25 admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of diabetes and high blood pressure.Review of Resident R25's care plan initiated 9/24/24, revised on 3/17/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify provider and indicated to administer diabetes medications as ordered. Review of a physician order dated 9/14/25-4/21/26, indicated to inject Novolog insulin (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R25's blood sugar level was less than 60 (mg/dL) to call the MD.Review of a physician's order dated 4/29/25, indicated to administer glucagon emergency injection kit as needed for hypoglycemic protocol for Accu-check less than or equal to 70 (mg/dL) and resident UNRESPONSIVE or UNABLE to swallow. Administer Glucagon IM (intra-muscularly) and recheck in 15 minutes. Review of a physician's order dated 6/20/25, indicated to administer glucose gel 40% as needed for hypoglycemia. If unresponsive and Accu-check (blood sugar check) is less than 70 (mg/dL) administer glucose gel, contact physician, and enter PN (progress note).Review of Resident R25's blood sugar record, medication administration record (MAR), and progress notes for 5/20/26, revealed the following:-7:14 a.m. - Blood sugar check 61 mg/dL, no documentation of recheck.-11:32 a.m. - Blood sugar check 472 mg/dL. -4:00 p.m. - MAR: Glucose gel 40% given.-4:00 p.m. - Note: Resident was leaning over in w/c (wheelchair), diaphoretic, warm and clammy touch, BS 29 (mg/dL) resident in and out of responsiveness, glucose gel administered as resident was able to swallow without difficulty. This progress note had no further documentation of notification to the provider.-4:15 p.m. - Blood sugar check 46 mg/dL-4:30 p.m. - Blood sugar check 37 mg/dL-4:30 p.m. - Note: Glucose gel is ineffective.-4:36 p.m. - Administration of glucagon injection.-4:36 p.m. - Note: Resident's BS (blood sugar) showing minimal improvement, resident remains in and out of unresponsiveness, warm, clammy, and diaphoretic, Glucagon injection administered per order. This progress note had no further documentation of notification to the provider.-4:47 p.m. - Blood sugar check 79 mg/dL-4:47 p.m. - Note: Glucagon injection is effective.Review of the clinical record indicated Resident R72 admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of diabetes and osteomyelitis (inflammation of the bone or bone marrow, usually due to infection).Review of Resident R72's care plan initiated 10/6/25, revised on 3/17/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify the provider. Review of a physician order dated 3/16/26, reordered 4/18/26 (discontinued 4/29/26), indicated to inject insulin lispro (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R72's blood sugar level was less than 60 or greater than 400 mg/dL to call the MD.Review of a current physician order dated 4/29/26, and reordered 5/5/26, indicated to inject insulin lispro per sliding scale, and indicated if Resident R72's blood sugar level was less than 70 or greater than 450 mg/dL to call the MD.Review of Resident R72's blood sugar record and progress notes revealed the following elevated blood sugar levels without documentation that the provider was notified or documentation of a blood sugar recheck:4/11/26, at 7:46 p.m. - 425 mg/dL4/24/26, at 8:54 p.m. - 406 mg/dL4/28/26, at 8:30 p.m. - 554 mg/dL5/28/26, at 8:01 p.m. - 476 mg/dL6/04/26, at 8:31 p.m. - 491 mg/dL6/06/26, at 1:10 p.m. - 466 mg/dLDuring an interview on 6/18/26, at 10:24 a.m. the Director of Nursing confirmed that the clinical record failed to reveal documentation of a notification to the provider and or documentation of blood sugar rechecks completed for the above residents. During an interview on 6/18/26, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to document notifications of medical providers of increased and decreased capillary blood glucose levels and/or failed to document recheck of out-of-range blood sugar levels for three of seven residents.28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility documentation, observations, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of five suction units (Harmony Hills Hall Room-29 D).Findings include: Review of a facility document Facility Assessment last reviewed 4/24/26, indicated the facility has a list of medical equipment identified for routine inspection, maintenance checks weekly and recommended maintenance through the manufacturer. Included in the list for routine inspection, maintenance for medical equipment are suction machines (suction used to keep an airway open by removing mucus or other material that a person cannot clear from their airway). During an observation completed on 6/18/26, at 9:00 a.m. the Harmony Hills Hall room [ROOM NUMBER]-D at the bedside of a resident with a tracheostomy (surgical opening in the neck that helps a person breathe), was a suction unit that did not have an inspection/testing log. During an interview completed on 6/18/26, at 9:00 a.m. Registered Nurse (RN) Employee E1 confirmed the Harmony Hills Hall room [ROOM NUMBER]-D suction unit did not have documentation of inspection/testing of the unit and confirmed the facility failed to make certain that equipment was in safe operating condition. During an interview completed on 6/18/26, at 9:10 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the Harmony Hills Hall room [ROOM NUMBER]-D suction unit did not have documentation of inspection/testing of the unit and confirmed the facility failed to make certain that equipment was in safe operating condition. During an interview completed on 6/18/26, at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E23 confirmed the Harmony Hills Hall room [ROOM NUMBER]-D suction unit did not have documentation of inspection/testing of the unit and confirmed the facility failed to make certain that equipment was in safe operating condition. During an interview on 6/18/26, at 10:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain equipment was in safe operation condition. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan for resident and care needs for one of eight residents (Resident R3). Findings include:Review of the facility policy Care Plan and Interdisciplinary Care Conference dated 1/29/25, indicated an individualized, interdisciplinary care plan is initiated within 24 hours for each resident as part of the delivery process. The care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals.Review of the clinical records indicated Resident R3 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/14/25, included diagnoses of history of transient ischemic attack (TIA) and cerebral infarction without residual deficit (a TIA is a temporary blockage of blood flow in the brain and cerebral infarction is a stroke that does cause permanent damage to brain tissue. This diagnosis means that the patient experienced has experienced both and at that time did not have lasting neurological deficits), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), morbid obesity(having too much body fat, which increases the risk of health problems), chronic pain syndrome (persistent pain lasting longer than 3 months, significantly impacting daily life), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (common consequence of a cerebral infarction (stroke) affecting one side of the body), diabetes (blood sugar too high or too low).Review of Resident R3's facility diagnosis list included history of transient ischemic attack and cerebral infarction without residual deficits, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic pain syndrome, diabetes.Review of the clinical record revealed that Resident R3's comprehensive care plan initiated on 6/20/25, failed to include plans of care with goals and interventions for diabetes. Review of the diagnoses list revealed the diagnosis of diabetes was added on 6/20/25 after resident had been transferred to the hospital for evaluation of symptoms (diaphoresis (sweating), thirsty, blurred vision, headache, elevated blood sugar levels) related to new diagnosis of diabetes.During an interview on 7/31/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop and implement a comprehensive care plan for resident and care needs for one of eight residents.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(5) Nursing Services.

Based on review of facility policy, facility submitted documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one out of 12 residents reviewed (Resident R1). Findings include: The facility Accidents and Incidents policy dated 1/25/24, indicated that it is the policy of the facility to promote a safe environment for all residents. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarct (stroke - interruption of blood flow within your brain that causes death of brain cells), hemiplegia (paralysis or weakness of one side of the body) affecting right dominant side, and aphasia (comprehension and communication -reading, speaking, or writing - disorder resulting from damage or injury to the specific area in the brain). Review of Resident R1's Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated 2/8/24, indicated that the diagnoses were current upon review. Review of a physician order dated 2/27/24, indicated for Resident R1 to have built up red foam utensil and divided plate for all meals. Further review indicated the order was updated following the incident to include using a sip-a-cup for hot beverages. Review of the Kardex dated 3/10/24, indicated eating/swallowing to maintain current level of function and prevent avoidable decline. Review of the care plan dated 12/8/23, indicated to engage in simple, structured activities that avoid overly demanding tasks, anticipate needs and meet them, ensure to provide a safe environment: make sure call light is always in reach, and that he is not isolated, and encourage to participate to the fullest extent possible. Review of a facility submitted documents dated 3/10/24, indicated Resident R1 was given a cup of coffee in a styrofoam cup during the Coffee Club activity. The cup was placed in the resident's left hand (non-dominant) and spilled the coffee on himself resulting in two areas of redness on his abdomen measuring 10.0 centimeters (cm) by 5.0 cm, and 5.0 cm by 5.0 cm. The resident had on a cloth clothing protector and a t-shirt. Resident R1's skin remained intact. During an interview on 4/1/24, at 11:08 a.m. Activity Director, Employee E1 stated she was not working the date of the incident. She stated the Coffee Club coffee was provided by the kitchen on 3/10/24, and usually everyone gets styrofoam cups, and Resident R1 does not usually come to the activity. The activity takes place in the East Dining Room for all residents that wish to attend. During a telephone interview on 4/1/24, at 11:30 a.m. Activities Aide Employee E2 stated she worked the day of the incident and Resident R1 was not brought to Coffee Club activity. He was brought to the Resident Lounge by the Nurse Aid (NA) Employee E3. She served coffee to the residents involved in the activity, a nurse aide came in and asked if Resident R1 could get a coffee, and a coffee was provided to NA Employee E3 to give to Resident R1. During an telephone interview on 4/1/24, at 12:15 p.m. NA Employee E3 stated Resident R1 was brought to the resident lounge to watch television. When he saw the coffee being delivered to the activity he started pointing and screaming. Resident R1 is unable to speak. Resident R1 was holding the coffee in his left hand and sipping at it. Other resident's in the lounge stated they wanted coffee also, so NA Employee E3 returned to the East Dining Room to obtain more coffee, when she heard Resident R1 yell out. She states she put down the other resident's coffee and went out of the dining room into the lounge, and saw Resident R1 had spilled his coffee on himself. NA Employee E3 stated Resident R1 has previously held styrofoam cups of hot chocolate with no issues. She moved the soaked clothing away from Resident R1's skin and notified nursing. During an interview on 4/1/24, at 1:11 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain Resident R1 received adequate supervision and assistance to prevent accidents as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide ordered fall mats to prevent possible injuries for one of four residents (Resident R60). Findings include: Review of the facility policy Accidents and Incidents dated 1/26/23, indicated the facility will promote a safe environment for all residents. The policy further indicated the licensed nurse responsible for the resident will update residents plan of care as necessary related to the incident / accident. Review of Resident R60's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R60's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 8/10/23, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), osteoporosis (condition when the bones become brittle and fragile), and a seizure disorder. Review of nursing review assessment and progress note, completed 8/5/23, at 4:14 a.m. indicated Resident R60 was at high risk for falls. Review of a facility provided Fall Huddle Tip Sheet dated 8/11/23, indicated Resident R60 had sustained a fall, and an immediate intervention of fall mats was put into place. Review of a physician's order dated 8/11/23, indicated, Mats and bed pillows to both sides of bed for her safety. Review of a facility provided incident report dated 8/14/23, at 11:10 p.m. indicated Resident R60 had sustained a fall with no injury, and further indicated new intervention was to apply floor mats. During an interview on 8/31/23, at 12:33 p.m. the Director of Nursing confirmed that fall mats were not in place at the time of the second fall, as ordered. During an interview on 8/31/23, at 1:45 p.m the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide ordered fall mats to prevent possible injuries for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on group interview and staff interviews, it was determined that the facility failed to provide access to mail delivered on Saturdays for three of 8 residents (Residents R200, R201, and R202). Findings include: During the group interview on 8/30/23, at 9:45 a.m. three of eight residents verbalized a concern that the facility holds all mail delivered Saturdays until Monday. During an interview on 8/31/23, at 12:35 p.m. Licensed Practical Nurse Employee E1 stated that mail is delivered by Activities department staff, Monday through Friday. During an interview on 8/31/23, at 12:40 p.m. Activities Department Employee E2 stated that during the week, Activities staff receive the mail from Administrative Employee E3. She further stated We don ' t usually deliver the mail on the weekend because she (Administrative Employee E3) is out of office. During an interview on 8/31/23, at 1:11 p.m. Administrative Employee E3 confirmed that all mail to the facility comes to her office Monday through Friday, and she separates facility mail from resident mail, and Activities staff distribute the resident mail. She further confirmed that mail received on Saturdays is placed in a box on her door, and distributed on Monday. During an interview on 8/31/23, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide access to mail delivered on Saturdays for three of 8 residents. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of 20 residents reviewed (Resident R8, R26, and R29). Findings include: A review of the facility policy Advanced Directives last reviewed 1/27/22, indicated the upon admission the facility will inquire about the existence of any written advanced directive, if the resident or resident's representative indicate he/she had not established one, the facility staff will offer assistance in establishing one. A review of the medical record indicated Resident R8 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record failed to reveal an advanced directive or documentation that Resident R8 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record failed to reveal an advanced directive or documentation that Resident R26 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R29 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record failed to reveal an advanced directive or documentation that Resident R29 was given the opportunity to formulate an Advanced Directive. During an interview on 9/14/22, at 12:30 p.m. the Admission Employee E1 confirmed that the clinical record did not include documentation that residents were afforded an opportunity to formulate an Advance Directive (POA or Living Will) for Resident R8, and R26, and R29. During an interview on 9/14/22, at 3:20 p.m. the Nursing Home Administrator confirmed that the clinical record did not include documentation that Residents R8, R26, and R29 were not afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based review of facility policies, observations and staff interviews, it was determined that the facility failed to make certain that hand washing facilities were accessible to staff on two of two nursing units. (East Wing Nursing Unit and West Wing Nursing Unit). Findings include: A review of the facility Hand Hygiene Policy dated 01/01/2020, indicated that the facility practices hand washing that will prevent the transmission of infections. During an observation on 12/14/2020, at 10:40 am it was observed that the West Wing Nursing Unit's soiled utility room sink was blocked by a scrub bucket and a soiled linen cart and that the East Wing Nursing Unit soiled utility room sink was blocked by a housekeeper's cart which prevented access to the sink for staff to preform hand washing. During an interview on 12/14/2020, at 10:45 am the Director of Nursing confirmed that the facility failed to make certain that staff had access to hand washing facilities in the soiled utility rooms located on the West and East Wing Nursing Units which prevented staff access to to hand washing facilities. 28 Pa Code: 211.12 (d)(1)(2)(5) Nursing services

Based on review of the facility resident handbook, observation, and resident and staff interviews, it was determined that the facility failed to accommodate the needs and preferences for one of 12 residents (Resident R17). Findings include: A review of the Resident Handbook, indicated that resident would have their physical needs met and have their dignity maintained. During an interview on 6/6/18, at 8:53 a.m. Resident R17 reported that her wheelchair does not fit under the sink in her restroom, and that she is unable to wash her hands. During an observation on 6/6/18, at 1:30 p.m. Resident R17 attempted to use her sink, and was unable to do so, due to the handrail brace not allowing her wheelchair within reachable distance to the sink. During an interview on 6/6/18, at 1:30 p.m. Maintenance Director Employee E1 confirmed that the facility failed to provide handwashing capabilities for Resident R17. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to periodically re-assess residents for smoking safety for two of four residents (Resident R57 and R61). Findings include: The facility policy entitled Smoking dated 1/22/18, indicated that a resident Smoking Assessment will be completed upon admission, quarterly and as needed if there is a decline in resident Activities of Daily Living skills. Review of the Minimum Data Sheet (MDS - periodic assessment of care needs) dated 5/16/18, indicated that Resident R57 had [DIAGNOSES REDACTED]. Review of the clinical record for Resident R57 indicated that the Smoking Assessment to determine safety risks had not been completed since 5/1/17. Review of the MDS dated [DATE], indicated that Resident R61 had [DIAGNOSES REDACTED]. Review of the clinical record for Resident R61 indicated that the Smoking Assessment to determine safety risks had not been completed since 7/8/16. During an interview on 6/6/18, at 10:48 a.m., Assistant Director of Nursing Employee E2 confirmed that Resident R57 and Resident R61 had no current Smoking Assessments to identify smoking risks and hazards. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/7/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 7/7/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/7/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical records and facility documents and staff interview, it was determined that the facility failed to include problem interventions on the clinical record for one of 17 residents (Resident R39). Findings include: The facility policy entitled Resident Protection from Abuse, Neglect or Exploitation dated 1/22/18, indicated that the facility will implement procedures in the areas including prevention investigation and protection to protect residents from any abuse, neglect or exploitation and to provide adequate supervision to identify inappropriate behaviors and to ensure care/services are provided safely and as needed. The facility policy entitled Care Plan and Interdisciplinary Care Conferences dated 1/22/18, indicated that the care plan is based on all available resident specific information and it is reviewed and updated when there are newly identified risk factors. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/2/18, indicated that Resident R39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an incident investigation report dated 2/23/18, involving a witnessed incident of physical abuse by a family member of Resident R39. During an interview on 6/05/18, at 2:18 p.m., ADON Employee E2 confirmed that the witnessed physical abuse incident by a family member and stated in order to protect Resident R39 that the family member must have supervised visitation. The ADON Employee E2 confirmed that the implemented intervention involving supervised visitation was not included on Resident R39's clinical record. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/7/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 7/7/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/7/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy, observation and staff interview, it was determined that the facility failed to maintain dignity and respect for three of 24 residents (Resident R2, R3 and R4). Findings include: The facility Resident Handbook that is given to every resident upon admission, indicated under resident rights that(NAME)Clay Villa is committed to providing services in an atmosphere of dignity and respect. During an observation of the dinner service in the West Dining Room on 7/5/17, between 5:25 p.m. and 5:55 p.m. the following was observed: There were 20 residents sitting at six tables. All of the residents were given something to drink except Residents R2, R3 and R4 who were seated at the last table. The first food cart arrived at 5:25 p.m. and meals were served to the first 17 residents. Four more residents arrived later and were also served their meals. The three residents sitting at the last table sat and watched while everyone else ate their meals. The second food cart arrived at 5:40 p.m. and Resident R2 was served a drink. The two other residents did not get served a drink. At 5:43 p.m. Residents R2, R3 and R4 were served their meals after watching all the other residents eat for 18 minutes. During an interview on 7/5/17, at 5:55 p.m. Employee E2 confirmed that the facility did not serve meals in a dignified or respectful manner for Resident R2, R3 and R4. 28 Pa. Code: 201.29(j) Resident rights.

Based on manufacturer guidelines, observation and staff interview, it was determined that the facility failed to properly store medications in one of two medication rooms (East wing medication room). Findings include: The manufacture guidelines for storing medication that need refrigerated should be stored at a temperature of 36 degrees - 46 degrees or should be discarded due to possible degradation which may effect potency. During an observation on 7/5/17, at 1:40 p.m. of the East wing medication room refrigerator the following was revealed to be stored at 20 degrees: 1 Humalog Insulin, 1 bottle of Neurontin Suspension, 2 Omeprazole power, 2 Tuberculin Serum, 1 vial of Pneumovax, 1 Novolog Insulin, 1 Lantus Insulin, 2 Risperdal, 3 Trulicity, 1 Oral Syringe, 1 Insulin Emergency Kit which had a Pharmacy label which stated DO NOT FREEZE, Toujeo Solostar Pen, 2 Lorazepam Intensol 30 ml, 6 Lorazepam Intensol 1 ml and 70 Marinol Capsules. During an interview on 7/5/17, at 2:15 p.m., Director of Nursing confirmed that the medications were not stored at the proper temperature and had not been discarded as required. 28 Pa. Code 211.9(a) Pharmacy services. Previously cited 7/10/15.

Based on observation, facility policy and staff interviews, it was determined that the facility failed to make certain that proper infection control practices were followed while performing a dressing change for one of 15 residents (Resident R1). Findings include: The facility policy titled Contact Precautions last reviewed 1/6/17, under section III Gowns, states that a gown should be donned prior to entering the room or resident cubicle and the Addendum to Precautions indicated that a sign shall be placed on the resident's door or wall next to his name alerting staff and visitors to report to the nurse before entering the room. A review of Resident R1's admission record dated 5/15/12, included a [DIAGNOSES REDACTED]. A nurse's weekly skin note included that the resident went to the wound clinic on 6/26/17, and reported that Resident R1 had Methacillin Resistant Staphylococcus Aureus (MRSA) (a multi-drug resistant microorganism) to the wound on his lower leg. A physician order [REDACTED]. Cleanse medial and lateral wounds of right lower leg with wound cleanser, sprinkle with crushed [MEDICATION NAME] 500mg tablet, cover with non-adherent [MEDICATION NAME] (a non-adherent dressing used for wounds), then apply ABD pads (dressing used for large wounds or wounds that require high absorbency) and rolled gauze, change daily. During an observation of a dressing change for Resident R1 on 7/6/16, at 11:45 a.m. the sign to report to the nurse before entering the room was in place the resident's door. Licensed Practical Nurse (LPN) Employee E1 failed to don a protective gown upon entering the private room of Resident R1. Resident R1 was in a private room due to isolation precautions for MRSA. While in Resident's R1 room, Employee E1 then continued and performed the dressing change without wearing a protective gown. During an interview with LPN Employee E1 on 7/6/17, at 11:55 a.m. confirmed that she failed to wear a protective gown before entering Resident's R1 room and failed to wear a gown during the dressing change. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(c) Staff development. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy and facility documents and staff interview, it was determined that the facility failed to make certain that tracking and trending of accidents, incidents, and injuries of unknown origin were complete and accurate for 11 of 11 months (July 2015 - May 2016.) Findings include: A review of the facility policy Resident Protection From Abuse dated 2/4/16, indicated that resident incident reports will be utilized to determine suspicious events and patterns of bruises, skin ears, etc. A review of the facility policy Accidents and Incidents dated 2/4/16, indicated that all accidents and incidents involving residents will be reported and investigated for corrective action and quality improvement. A review of facility incident tracking and trending logs indicated that falls were the only events that were tracked and trended by the facility for the period of July 2015 - May 2016. During an interview on 6/16/16, at 8:40 a.m., the Director of Nursing confirmed that the facility failed to track and trend all resident incidents, accidents and injuries of unknown origin for the period of July 2105 - May 2016. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument Manual and clinical records, and staff interviews, it was determined that the facility failed to complete an accurate assessment for four of 13 residents (Resident R5, R8, R10 and R11). Findings include: A review of the RAI Manual Section O, Influenza and Pneumococcal vaccines, indicated that if the Influenza and Pneumococcal vaccines were previously given, offered and/or declined, the assessment would identify this. The influenza vaccination value from the current influence season is carried forward until the new influenza season begins. A review of the facility Immunization Report dated 6/16/16, indicated that Resident R5 received influenza vaccinations on 10/16/14, and 11/24/15. A review of Section Z of the MDS indicated that a signature of the person completing a specified section of the assessment indicated that the information accurately reflects resident assessment information. The Minimum Data Set (MDS-periodic assessment of care needs) dated 8/25/15, Section O 0250B Influenza vaccine was blank indicating that the facility failed to carry forward the influenza vaccination value from the current influenza season until the new influenza season begins and 0250C was coded with a 9 (none of the above) indicating that the status of this vaccine was either not administered or unknown for Resident R5 by the facility. During an interview on 6/15/16, at 2:10 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed the incomplete Section O on the MDS for Residents R5 and that the facility failed to complete an accurate assessment for this resident. A review of the MDS Section H0300, dated 5/5/16, indicated that Resident R8 is coded as 0 for urinary incontinence, indicating that Resident R8 is always continent of urine. A review of a plan of care for Resident R8, with a revision date of 11/30/15, and a target date of 7/24/16, indicated that Resident R8 has a plan of care for bladder incontinence. During an interview on 6/15/16, at 10:00 a.m., RNAC Employee E1 confirmed that Resident R8 is occasionally incontinent of urine and that the MDS dated [DATE], is not coded accurately to reflect Resident R8's continence status. A review of an outside facility Discharge Instructions dated 3/4/16, indicated that Resident R10 had previously received the influenza vaccination outside of the facility. The MDS, dated [DATE], and 5/18/16, Section O 0250B Influenza vaccine was blank and 0250C was coded with a 5 (not offered) indicating that the vaccine was not offered to Resident R10 by the facility. During an interview on 6/16/16, at 9:30 a.m., RNAC Employee E1 confirmed the incomplete Section O on the MDS for Residents R10 and that the facility failed to complete an accurate assessment for this resident. A review of the facility Resident Immunization Informed Consent dated 2/11/16, revealed that Resident R11 refused the influenza vaccine. The MDS, dated [DATE], and 5/10/16, Section O 0250B Influenza vaccine was blank and 0250C was coded with a 5 (not offered) indicating that the vaccine was not offered to Resident R11 by the facility. During an interview on 6/16/16, at 9:50 a.m., Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed the incomplete Section O on the MDS for Residents R11 and that the facility failed to complete an accurate assessment for this resident. 28 Pa. Code: 211.5(f) Clinical records. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to display the name of the facility and total amount of hours worked for nursing staff for two of three days (6/14/16, and 6/15/16), and failed to retain the daily facility staffing information for 11 of 11 months as required (August 2015 through June 2016). Findings include: A review of the daily nursing hours form dated 6/14/16, through 6/15/16, revealed the data displayed on a dry erase board did not include the name of the facility and the total number of actual hours worked for nursing staff. During an interview on 6/15/16, at 11:35 a.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to consistently include the facility name and the total of actual hours for nursing staff on the Nursing Hours form and did not retain daily facility staffing information for the period of August 2015 - June 2016. Nursing hours displayed were erased daily and not retained as required. 28 Pa. Code: 201.18(a)(b)(3) Management.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain that clinical records were complete and accurate for two of two discharged residents (Resident CR14 and CR15.) Findings include: A review of the facility policy Resident Medical Records dated 2/4/16, indicated that appropriate medical/clinical records shall be maintained for each resident and reflect the day to day activities, services and treatments provided to the resident. A review of the facility policy Resident Discharge dated 2/4/16, indicated that discharge instructions and a disposition of medications are completed upon discharge. A review of the admission record indicated that Resident CR14 was admitted to the facility on [DATE], and discharged to home on 5/13/16. The review of Resident CR14's clinical record did not indicate that detailed discharge instructions and a list of discharge medications with quantities were documented in the clinical record upon discharge. A review of the admission record indicated that Resident CR15 was admitted to the facility on [DATE], and discharged to home on 6/8/16. The review of Resident CR15's clinical record did not indicate that detailed discharge instructions and a list of discharge medications with quantities were documented in the clinical record upon discharge. During an interview on 6/16/16, at 9:30 a.m., the Director of Nursing confirmed that the facility failed to make certain that the clinical records of Resident CR14 and CR15 were complete and accurate. 28 Pa. Code: 211.5(f) Clinical records.

Based on facility policy, observation, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage of food to prevent the potential for microbial growth in foods and conditions which increased the risk of food borne illness with thickened drink on two of three nursing carts (carts number two and three). Findings include: Facility policy entitled Culinary policy and Procedures dated December 2014, indicates that All foods should be covered labeled and dated, and leftover food is used within 3 days or discarded. During an observation of medication administration on 7/7/15 at 4:14 p.m., medication cart number two had two opened undated thickened liquid drinks being dispensed to residents during the medication administration. During an interview on 7/7/15 at 4:15 p.m., with Employee E2, a Licensed Practical Nurse (LPN), confirmed that the drinks were opened and not dated. During an observation on 7/7/15 at 4:34 p.m., medication cart number 3 had an opened, undated, thickened liquid drink being dispensed to residents during medication administration. During an interview on 7/7/15 at 4:34 p.m. with Employee E3, an LPN, confirmed that the drink was opened and not dated. During an interview on 7/7/15 at 5:08 p.m. with Employee E1, Assistant Director of Nursing, confirmed that the packages should have been dated when opened. 28 Pa. Code: 211.6(c)(d) Dietary services.

Based on resident and staff interviews, it was determined that the facility failed to provide the opportunity to vote in the November 2014, and May 2015 elections for two of five residents (Residents R50 and R51). Findings include: During a Resident Group Meeting on 7/8/15, at 10:30 a.m., Residents R50 and R51, identified by the facility as alert and interviewable, indicated that facility staff did not approach them about voting in the May 2015 election. Residents R50 and R51 indicated that they were very interested in voting. During an interview on 7/8/15, at 11:50 a.m., the Activities Director Employee E5 confirmed that residents were not approached to vote in the May 2015 election and that no residents of the 74 bed facility voted in the November 2014 election. 28 Pa. Code: 201.29(i) Resident Rights.