Every finding on record at Rehabilitation Center at Brethren Village LLC

Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to ensure appropriate supervision was provided to prevent a fall of one of the eight residents reviewed (Resident 3) Findings include: A review of Resident 3's diagnosis list revealed Parkinson's Disease, repeated falls, and a left humerus fracture. A review of Resident 3's Initial Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated June 19, 2023, revealed resident required extensive with two people assistance with transferring. A review of Resident 3's ADL (Activity of Daily Living) care plan initiated on June 13, 2023, revealed resident required two-person staff assistance, a handheld stand pivot with transferring. A review of nursing progress notes dated June 20, 2023, at 7:45 p.m., revealed Resident 3 was lowered to the floor by the aide during the transfer from the wheelchair to the recliner chair after night care. The resident landed on her/his bottom and did not hit the head with no injury noted. The resident reported she/he lost her/his balance. Staff educated to follow Kardex. A review of the facility documentation, Employee E3 revealed that while transferring the resident to the recliner, the resident lost her/his balance, resident was lowered to the floor. The same statement revealed that the report indicated that the resident now required one person's assistance (transferring). x A review of the facility documentation, Employee E4 revealed that a mistake in the documentation was made with transfer status which was supposedly for another resident. An interview with the Director of Nursing on July 6, 2023, at noon, confirmed that the resident was not provided with two-person assistance with transferring which resulted in lowering the resident on the floor. The facility failed to ensure Resident 3 was provided with an appropriate number of staff assistance during transfer. 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to comprehensively assess and administer medication to a wound; and timely administer wound treatment to a sacral wound for one of seven residents reviewed. (Resident 11). Findings include: Review of Resident 11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 11's Minimum Data Set (MDS- assessment tool used to facilitate the management of care) dated August 3, 2021, revealed that the resident required extensive of two- person assistance with bed mobility. The MDS also revealed that the resident was frequently incontinent of bowel and bladder. Review of Resident 11's Braden Risk Assessment (assessment tool used to determine risk factors for pressure sore development) dated July 22, 2021, revealed a score of 16 which indicates the resident as At-Risk for developing a pressure ulcer. Review of Resident 11's clinical record revealed a provider progress note dated July 23, 2021, at 3:23 p.m., indicating Resident 11 was admitted (July 22, 2021) to the facility for a rehab [rehabilitation] stay after hospitalization . Review of Resident 11's admission assessment dated [DATE], at 5:00 p.m., revealed that the resident was admitted with an excoriation (linear erosion of skin tissue resulting from mechanical means) on the sacrum (large triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) with a measurement of 0.5 x 0.5 cm (centimeter). Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 11's Skin and Wound Evaluation dated July 23, 2021, at 9:32 a.m., revealed the sacral wound is categorized unstageable (full thickness tissue loss in which the base of the ulcer is covered with slough) with 100% slough (separation of dead tissue, yellow, tan, gray, green or brown) and had a measurement of 1.2 x 0.8 cm (centimeter). Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated July 23, 2021, at 10:21 p.m., revealed that the Santyl medication for the sacrum did not arrive from the pharmacy. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated July 23, 2021, at 7:07 p.m., revealed an open area noted to bilateral buttocks and sacrum. A clinical records review failed to reveal an assessment for the identified open area to the bilateral buttock. Further review of the clinical records failed to reveal the physician was notified of the open area therefore wound treatment was not initiated for the bilateral buttock open area at the time of discovery. Review of the progress notes dated July 24, 2021, for day and evening shift revealed the air mattress was not in place at this time. Review of the progress notes dated July 24, 2021, at 10:56 p.m., revealed the sacral wound bed had a 100% yellow/white slough, open area dime-sized. The same note also revealed a mild excoriation above site, a smaller open area to the side of the larger one, the surrounding area was reddened. [MEDICATION(S)] was unavailable, but Vaseline was applied. Further review of Resident 11's clinical records failed to reveal an assessment completed for the wound (area next to left buttock wound) and a treatment order was not initiated. Review of the progress notes on July 24, 2021, at 12:18 a.m., revealed that there were two open areas on Resident 11's back. The sacrum is approximately 1/2 '' X 1/16'' dressed in Santyl and padded bandage, and a pea-size opening on her left buttock, no [MEDICATION(S)] available. Review of the progress notes dated July 25, 2021, at 10:49 p.m., revealed the sacral wound is nickel size with yellow/white slough, left buttock wound is pea-sized, and wound bed now has a moderate amount of yellow slough, slough not noticed in this wound last night. The note also revealed a new right buttock wound with a pink wound bed and with a measurement of a pin-head sized. The physician was notified. Progress notes dated July 26, 2021, at 12:36 a.m., revealed Resident 11 had three open areas on the back area: sacral area; left buttocks (pea size); and right buttocks area (size of a pinhead, perhaps from loose stool). A review of the weekly Skin and Wound Evaluation dated July 27, 2021, at 11:42 a.m., revealed an unstageable wound to sacrum 100 % slough, serous drainage, with a measurement of 1.7 x 1.0 cm. The report also revealed that the wound progress was deteriorating. Additional review of the report failed to reveal a wound assessment for the right and left buttock. A review of Resident 11's current care plan revealed a pressure ulcer care plan initiated on August 3, 2021. The care plan is for an unstageable pressure ulcer to the left buttock and sacrum. Interventions on the care plan include: Assess, record, and monitor wound healing; Measure the length, width, and depth where possible; Report improvements and declines to the physician; Weekly treatment documentation to include measurement of each skin breakdown's width, length, depth, type of tissue and exudate. Clinical records review failed to reveal documentation of the left buttock unstageable wound assessment and treatment. The unstageable sacral wound continued with Santyl treatment daily. A review of the Weekly Skin and Wound Evaluation dated August 4, 2021, at 10:07 a.m., revealed that Resident 11's sacral wound was unstageable with 50 % slough, moderate serous drainage, and a measurement of 1.5 x 1.3 x 0.3 cm. A review of the same report failed to reveal an assessment for the unstageable left buttock wound. Wound observation occurred on August 11, 2021, at 1:10 p.m., in the presence of Employee E3 revealed sacral wound was 50% covered with a white slough, with moderate serous drainage. The left buttock wound was pink with no drainage. The sacral wound was covered with a bordered gauze, the left buttock wound was covered with the edge of the bordered gauze from the sacral wound. Review of the weekly Skin and Wound Evaluation dated August 12, 2021, at 7:34 a.m., revealed Resident 11's sacral wound was determined unstageable, with 50% slough, light serous drainage, and a measurement of 1.3 x 0.8 x 0.3 cm. During an interview on August 12, 2021, at 10:00 a.m., with the Director of Nursing, it was revealed that when a skin opening is identified, the registered nurse must complete a thorough wound assessment which include the wound measurement (with use of a wound measuring tape), wound type, and drainage characteristics. The physician is notified and a wound treatment order is obtained. An interview on August 12, 2021 at 10:00 a.m. with the Director of Nursing (DON) revealed a wound round was conducted on the morning of July 23, 2021. The DON further indicated; she is responsible for the tracking of wounds. Additionally, the DON confirmed that an RN (Registered Nurse) assessed Resident 11's skin on July 22, 2021. According to the Director of Nursing, the physician was notified regarding the resident's sacral wound and a new treatment order (Santyl) was made. The DON does not have an explanation why the Santyl medication did not arrive from the pharmacy on July 23, 2021. An interview conducted with the DON on August 12, 2021, at 1:00 p.m., revealed that the DON was unable to remember the presence of the right and left buttock wound during the weekly wound rounds. Additionally, during the interview with the DON on August 12, 2021, at 1:00 p.m., revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor informed Director of Nursing of the absence of a documented treatment order for the left-wound and the right wound after it was identified on July 23, 2021. During the interview, the DON also confirmed, the Santyl treatment to the sacrum was not administered to the wound timely. The DON confirmed that the identified left buttock wound was not comprehensively assessed and had no treatment order. The facility failed to comprehensively assess and provide an ordered medication to the left buttock wound and timely administer wound treatment to the sacral wound of Resident 11. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services

Based on a review of facility policy, record review, and staff interview it was determined that the facility failed to assess a pressure ulcer for one of one residents reviewed (Resident #[AGE]). Findings include: Review of facility policy, Wound Rounds, revised August 2019, revealed that wound rounds are held weekly. All residents with pressure ulcers will be assessed and followed by the wound team. The RN Wound Specialist/or designee will document weekly in the EMR (Electronic Medical Record) addressing progress of the wound. Review of progress note dated January 10, 2020, revealed Resident #[AGE] was admitted due to rhinovirus/[MEDICAL CONDITION] (inflammation of the lining of the lungs) and had a stage two pressure ulcer (ulcer involving loss of the top layers of skin) area on the buttock. physician's orders [REDACTED]. Review of skin condition/wound progression note of January 12, 2020, revealed stage two pressure ulcers to the coccyx measuring 0.2 centimeters x 0.2 centimeters x 0.2 centimeters, 1.5 centimeters x 0.2 centimeters x 0.1 centimeters, and 0.2 centimeters x 0.2 centimeters x 0.1 centimeters. Further review of the clinical record revealed no additional evaluation of the pressure ulcers from January 12, 2020 to January 23, 2020. Interview with the Director of Nursing on January 23, 2020, at 2:05 p.m. revealed that Resident #[AGE] was to be followed by the wound team weekly on Mondays, but the resident was not seen on January 20, 2020. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observation, facility documentation and staff interview, it was determined the facility failed to ensure food was prepared in a sanitary manner in the kitchen. Findings include: Observations of the kitchen conducted on January 9, 2018 at 12:17 p.m. revealed the hood covering the grill in the kitchen was covered with a coating of grease and dust. Interview with Employee E3 at the time of the finding confirmed that the hood was in an unsanitary condition due to the coating of grease and dust and needed to be clean. Further interview with Employee E3 revealed that the hood was not cleaned in the previous week due to a shortage of staff because of the adverse weather conditions. Review of the Daily Cleaning and Sanitation Duties checklist revealed the hood filers should be cleaned weekly and free of dust daily. These duties were not checked off as completed from January 3 to January 8, 2018. 28 Pa. Code: 211.6(f) Dietary Services