Every finding on record at Saint John Xxiii Home

Based on review of clinical records and the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status of one of 16 residents reviewed (Resident R2). Findings include: Review of MDS instructions for Section H Bladder and Bowel subsection H0300 Urinary Continence indicated that urinary continence is to be coded as not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (tubing from the bladder to drain urine into the bag), condom catheter, ostomy, or no urine output for the entire seven days. Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included 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), depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed), gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Resident R2's clinical record revealed a physician's order dated 3/4/24, for an Indwelling Catheter. Resident R2's discharge MDS with Assessment Reference Date (ARD) of 5/30/24, admission MDS with ARD of 6/10/24, and quarterly MDS's with the ARD's of 9/10/24, 12/10/24, and 3/12/25, Subsection H0100 Appliances was coded as Indwelling Catheter and Subsection H0300 Urinary Continence was coded as Always Continent, although Resident R2 had an indwelling catheter for the entire seven-day look-back period. During an interview on 3/28/25, at 8:53 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that the 5/30/24, 6/10/24, 9/10/24, 12/10/24 and 3/12/25, MDS's were coded inaccurately and urinary continence should have been coded as not rated for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of three residents reviewed (Resident R17). Findings include: Review of facility policy entitled Oxygen Administration dated 3/24/25, indicated to check and clean oxygen equipment at regular intervals. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. Resident R17's clinical record revealed a physician's order dated 9/17/24, for oxygen at 2 liter per min (lpm) via nasal cannula (a thin tube with two prongs that fit in a resident's nostrils to deliver oxygen) continuously, every shift for low oxygen level. Further review revealed a physician's order dated 5/31/21, that identified while on O2 (oxygen), change tubing, O2 humidifier bottle, clean concentrator and filter as needed. Observations on 3/25/25, at 11:40 a.m. and 3/27/25, at 10:18 a.m. revealed Resident R17 lying on his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 2 lpm via nasal cannula. Further observation of the concentrator filter on the back of the oxygen concentrator revealed a large amount of a gray fluffy substance covering the entire filter. During an interview on 3/27/25, at 10:18 a.m. the Director of Nursing confirmed that Resident R17's oxygen concentrator filter contained a large amount of gray dusty substance and should be cleaned. 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 and clinical records, and staff and resident interviews, it was determined that the facility failed to have complete and accurate documentation regarding indwelling catheter changes for one of two residents reviewed with an indwelling catheter (Resident R2). Findings include: Review of facility policy entitled Catheter Care dated 3/24/25, indicated under General Documentation Guidelines to document date, time, procedure, signature and title. And under General Infection Control Guidelines that all indwelling urinary catheters are to be changed every month unless otherwise ordered by the physician. Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included 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), depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed), gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Resident R2's clinical record revealed that on 11/5/24, their physician ordered an indwelling catheter change to be completed monthly and as needed. Review of Resident R2's Treatment Administration Records (TAR) for January 2025 and February 2025, lacked documentation indicating the catheter change was completed per physician's orders. During an interview on 3/25/25, at 12:00 p.m. Resident R2 stated the facility changes his indwelling catheter on a monthly basis. During an interview on 3/28/25, at 9:46 am. the Director of Nursing confirmed that Resident R2's treatment records did not have complete documentation regarding indwelling catheter changes. 28 Pa. Code 211.5(f)(ii)(iii)(viii)(ix) Medical records 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 maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Temperature Log, last reviewed 7/26/2023, revealed The dish machine temperature log should be completed to ensure proper temperatures are met before sending ware through dish machine. Documentation must include date, temperature of wash and final rinse and initials of the recorder at each mealtime. The temperature log also identified that the final rinse temperatures should be at least 165 degrees Fahrenheit (F) and up to 180 degrees F to ensure proper sanitization. Upon observation of the dish machine on 4/22/2024, at 1:05 p.m. it was confirmed that the dish machine was a hot water temperature machine. During an interview with Employee E1 on 4/22/2024, at the time of the observations, it was confirmed that they only record the wash temperatures on the dish machine temperature log. Review of the dish machine temperature logs revealed that since February 1, 2024, until April 22, 2024, only the wash temperatures have been recorded at each mealtime and there were no final rinse temperatures were recorded to ensure proper sanitization. During an interview, on 4/23/2024, at 9:15 a.m. it was confirmed by the Dietary Manager, that only the wash temperatures have been recorded for the time period of February 1, 2024 until April 22, 2024, and no final rinse temperatures have been recorded. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy, 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 for one of five residents reviewed (Resident R1). Findings include: Review of a facility policy entitled, Psychotropic Medications dated 7/2022, indicated that PRN orders for psychotropic medications other than antipsychotic medications are limited to 14-day orders. The attending physician or prescriber may extend the order beyond 14 days if he/she believes the order is appropriate. The prescriber must document the rationale and duration when extending the order. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included muscle wasting, atrial fibrillation (irregular heartbeat), repeated falls, type II diabetes, and anxiety. A physician's order dated 4/27/23, identified to administer Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 6 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. The physician's order was updated on 5/1/23 to administer Ativan (anti-anxiety) 0.5 milligrams (mg) by mouth every 6 hours as needed for anxiety day to include non-pharmacological interventions and continued to lack the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. During an interview on 5/03/23, at 12:20 p.m. the Director of Nursing confirmed that Resident R1's Ativan orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, 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 an as needed (PRN) [CONDITION(S)] (mind altering) medication for two of six residents reviewed for unnecessary medications (Residents R1 and R35). Findings include: Review of a facility policy entitled [CONDITION(S)] Medications dated 7/21/21, indicated The facility will consider and use non-pharmacological interventions in an attempt to reduce or eliminate the need for these medications and Staff will attempt non-pharmacological interventions and monitor for effectiveness before administration of PRN medications. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a group of social and thinking symptoms that interferes with daily function), anxiety, and high blood pressure. The clinical record revealed that on 2/7/22, Resident R1's physician ordered [MEDICATION(S)] (medication ordered to treat anxiety) 0.25 milligrams (mg) every twelve hours PRN for anxiety. Review of the February 2022 Medication Administration Record (MAR) for Resident R1 revealed that the PRN [MEDICATION(S)] was used nine times between 2/7/22, and 2/28/22. Review of the February 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the nine of nine times the [MEDICATION(S)] was utilized in February 2022. Review of the March 2022 MAR for Resident R1 revealed that that PRN [MEDICATION(S)] was used twenty times between 3/1/22, and 3/31/22. Review of the March 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the twenty times the [MEDICATION(S)] was utilized in March 2022. Review of the April 2022 MAR for Resident R1 revealed that the PRN [MEDICATION(S)] was used twenty-four times between 4/1/22, and 4/30/22. Review of the April 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 [MEDICATION(S)] for the twenty-four times the [MEDICATION(S)] was utilized in April 2022. Review of the May 2022 MAR for Resident R1 revealed that the PRN [MEDICATION(S)] was used twenty-one times between 5/1/22, and 5/31/22. Review of the May 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the twenty-one times the [MEDICATION(S)] was utilized in May 2022. Review of the June 2022 MAR for Resident R1 revealed that the PRN [MEDICATION(S)] was used one time between 6/1/22, and 6/2/222. Review of the June 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the one time the [MEDICATION(S)] was utilized in June 2022. Review of Resident R35's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, depression, and [CONDITION(S)] (disturbance in mental abilities that result in confusion and reduced awareness of the environment). The clinical record revealed that on 11/4/21, Resident R35's physician ordered [MEDICATION(S)] (medication to treat anxiety) 0.5 mg every twelve hours PRN for anxiety agitation for sixty days. The clinical record revealed that Resident R35's physician again ordered [MEDICATION(S)] 0.5 mg every four hours PRN for agitation and may give intramuscularly every four hours PRN for agitation if resident refuses oral medication. Review of the November 2021 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used eight times between 11/4/22, and 11/30/22. Review of the November 2021 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the eight times the [MEDICATION(S)] was utilized in November 2021. Review of the December 2021 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used ten times between 12/1/21, and 12/31/21. Review of the December 2021 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the ten times the [MEDICATION(S)] was utilized in December 2021. Review of the January 2022 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used one time between 1/1/22, and 1/4/22. Review of the January 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the one time the [MEDICATION(S)] was utilized in January 2022. Review of the March 2022 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] intramuscular was used three times and the [MEDICATION(S)] orally was used sixteen times between 3/8/22, and 3/31/2022. Review of the March 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the nineteen times the [MEDICATION(S)] was utilized in March 2022. Review of the April 2022 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used nineteen times between 4/1/22, and 4/30/22. Review of the April 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the nineteen times the [MEDICATION(S)] was utilized in April 2022. Review of the May 2022 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used seventeen times between 5/1/22, and 5/31/22. Review of the May 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the seventeen times the [MEDICATION(S)] was utilized in May 2022. Review of the June 2022 MAR for Resident R35 revealed that the PRN [MEDICATION(S)] was used one time between 6/1/22, and 6/2/22. Review of the June 2022 MAR and clinical record progress notes revealed that there was no evidence that non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION(S)] for the one-time [MEDICATION(S)] was utilized in June 2022. During an interview on 6/3/22, at 9:09 a.m. the Nursing Home Administrator confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN [MEDICATION(S)] for Resident R1 or PRN [MEDICATION(S)] for Resident R35. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and staff interview, it was determined that the facility failed to maintain a qualified individual as the Infection Preventionist (IP) with proper training/education in infection control for the facility. Findings include: Review of facility policy entitled Infection Control Program dated 7/21/21, identified that the designated IP serves as a consultant to the staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. During a review of the facility's infection control program, it was identified that the individual designated as the facility IP was the Director of Nursing (DON) and he/she was unable to provide evidence of being qualified by education/training and/or certification. During an interview on 6/2/22, at 12:50 p.m. the DON confirmed that he/she had not completed the infection control training/education, and also confirmed that currently, the facility did not have a qualified IP. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and manufacturer's instructions, observation, and staff interview it was determined that the facility failed to label prefilled insulin pens with the date they were opened and discard prefilled insulin pens within the use by timeframe for one of two medication carts reviewed (Team 1). Findings include: The policy entitled Policy on Medication Storage, dated [DATE], indicated that expired, deteriorated, or contaminated medications are disposed of properly. The policy entitled General Guidelines for Safe and Accurate Medication Administration dated [DATE], indicated that Flex Pens / Insulin - date when open. Manufacturer's instructions for the prefilled insulin pens directed that once in use, they were to be used within 28-days, then discarded. Observation of Team 1 medication cart on [DATE], at 11: 17 a.m. revealed that Resident R34's Novolog (type of insulin) Flex Pen was currently in use, but not labeled with an open date and Resident R14's [MEDICATION(S)] (type of insulin) Flex Pen was currently in use, but not labeled with an open date. Resident R13's Novolog Flex Pen had an open date of [DATE], was currently in use, or 50 days past the open date. During an interview at the time of observation, Registered Nurse Employee E1 confirmed Resident R34's and R14's Flex Pens were in use and not labeled with an open date and Resident R13's Flex Pen was being used past the 28-days. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility documentation and staff and resident interviews, it was determined that the facility failed to follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident's R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of information submitted by the facility dated 6/26/21, identified that Resident R1 was in the bathroom with Nurse Aide (NA) completing care after using the bathroom. When NA had resident stand, his/her leg buckled and he/she was unable to stand and was lowered to the floor. An interview with Resident R1 on 7/14/21, at 12:05 p.m. revealed that he/she was transferred with assist of one staff prior to 6/27/21. An interview with NA Employee E1 on 7/13/21, at 12:00 p.m. revealed that Resident R1 was transferred with assist of one prior to 6/27/21. During an interview on 7/13/21, at 1:00 p.m. the Director of Nursing confirmed that Resident R1 was not transferred correctly with an assist of two on 6/26/21, as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records and facility policies and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of 18 residents (Resident R163). Findings include: The Oxygen Administration policy, dated 11/20/19, revealed if a resident is in respiratory distress, oxygen may be applied at 2L (liters) nasal cannula per facility protocol. Physician is to be notified and an order obtained to continue oxygen if needed. The clinical record revealed that Resident R163 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The clinical record revealed a nursing note dated 12/15/19, at 6:30 a.m. indicating that Resident R163 complained of shortness of breath at 5:15 a.m. with respirations labored at 30 respirations per minute, Registered Nurse notified. Oxygen applied at 2L. Observation on 12/21/19, at 5:20 p.m. revealed Resident R163 with oxygen on at 2L. The clinical record lacked evidence that the physician was notified of Resident R163's change in condition when the resident was experiencing shortness of breath or for the continued use of oxygen. During an interview on 12/22/19, at 2:36 p.m. the Director of Nursing confirmed that the physician should have been notified regarding Resident R163's change in condition with the shortness of breath and oxygen use. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 2/07/19

Based on review of clinical records and facility policies and staff interview, it was determined that the facility failed to demonstrate that care for an indwelling catheter (tubing to drain urine from the bladder) was performed for one of four residents with a catheter (Resident R163). Findings include: The Catheter Care policy, dated 11/20/19, revealed that indwelling catheters are to be changed every month unless otherwise ordered by the physician and if blocked whether the physician has ordered the catheter to be irrigated. The clinical record revealed that Resident R163 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility Admission Assessment revealed that Resident R163 was admitted to the facility with an indwelling catheter. As of 12/22/19, Resident R163's clinical record lacked evidence to identify that catheter care was provided since admission, a period of 12 days. During an interview on 12/24/19, at 9:57 a.m. the Director of Nursing confirmed that there was no evidence to demonstrate that catheter care was provided to Resident R163. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 2/07/19

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to maintain infection control practices to prevent cross contamination during a dressing change for one of 19 residents (Resident R71). Findings include: The Record of Admission revealed Resident R71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS-periodic review of resident care needs), dated 1/08/19, revealed Resident R71 had a pressure ulcer (injury to skin and underlying tissue due to prolonged pressure on the skin). physician's orders [REDACTED]. Observation of the wound dressing change on 2/07/19, at 10:10 a.m. revealed that Licensed Practical Nurse (LPN), Employee E2 donned gloves, removed the old dressing and cleaned Resident R71's left heel wound, then removed their gloves and donned new gloves without first washing or sanitizing their hands. During an interview on 2/07/19, at 10:55 a.m. the Director of Nursing confirmed that the LPN should have washed their hands after removing their gloves before donning new gloves. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/07/17

Based on review of facility menus, observations, and staff interviews, it was determined that the facility failed to provide a variety of foods to ensure resident satisfaction for three of 21 sampled residents (Residents R24, R53 and R72). Findings include: During interviews conducted in a group setting on 12/04/17, at 4:00 p.m., Residents R24 and R53 stated in response to questions regarding dining services that it was the same food throughout the weeks. Observations of dining, conducted on 12/04/17, at 5:30 p.m., in the East Dining Room revealed meal service including a steak sandwich with peppers and onions, peas, potatoes and cherry pie. Resident R12 stated during an interview, conducted at the time of the observation, that you can't tell me that's steak - looks like beef to me. During an interview on 12/05/17, at 1:47 p.m., Resident R72 stated that they received too much of the same food. During an interview conducted on 12/07/17, at 8:50 a.m., Dietary Employee E2 confirmed that the facility utilized a one month rotation of meals for six months (fall/winter) and a one month rotation for the next six months (spring/summer). The monthly, repeating menu revealed that on 12/04/17, residents were served an open-face roast beef sandwich for lunch, and a steak sandwich for supper. The menus further reflected beef, in some form, served during lunch and/or dinner 19 times; pasta/pizza served nine times, chicken served nine times, pork served seven times and fish served five times. During an interview conducted on 12/05/17, at 2:00 p.m., Dietary Employee E3 confirmed that the meal schedule repeated every month for six months before changing, and that the facility was aware residents wanted more variation. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a resident or the responsible party with a notice of bed-hold policy when transported to the hospital for one of 21 residents (Resident R66). Findings include: The Record of Admission indicated that Resident R66 was admittted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurse's note, dated 8/27/17, revealed that the resident was shaking with an elevated temperature. The physician was notified and an order was received to send Resident R66 to the hospital for evaluation and treatment. 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 12/07/17, at 10:33 a.m. the Nursing Home Administrator confirmed that the written notification of the bed hold policy was not sent with Resident R66 when discharged to the hospital. Pa. Code. 211.5(f) Clinical records Previously cited 2/24/17 Pa. Code. 211.12(d)(1)(3)(5) Nursing services Previously cited 2/24/17

Based on review of clinical records, Minimum Data Sets (MDS - periodic assessment of resident care needs) and the Resident Assessment Instrument Manual (RAI Manual - directions for completion of the MDS) and staff interview, it was determined that the facility failed to accurately assess one of 21 residents (Resident R1). Findings include: Resident R1's clinical record revealed [DIAGNOSES REDACTED]. Resident R1's physcian's orders dated 10/18/17, revealed an order May release body to John(NAME)Funeral Home. Review of Resident R1's MDS's revealed an Entry MDS dated [DATE], in Section A0310. During an interview on 12/07/17, at 12:15 p.m., Resident Nurse Assessment Coordinator Employee E1 confirmed the facility failed to identify death in facility for Resident R1 on 10/18/17, in Section A0310 of the 10/18/17, MDS. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 2/24/17

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: The Record of Admission sheet revealed that Resident R41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order, dated 9/03/17, revealed that Resident R41 was to have tubi-grips(elastic stockings) bilateral lower extremities (both legs)-knee high 24 hours/day. A nurse's note, dated 9/04/17, at 06:42 a.m. stated continues with 2-3 plus [MEDICAL CONDITION] from arch to ankle. Tubi-grips previously placed only single layer and not covering arch. Instructed CNA (nurse aide) on application of double-layer tubi-grips from arches to knees. There was no evidence that the order obtained on 9/04/17 had been changed to layer the two tubi-grips. During an interview on 12/06/17, at 2:37 p.m., the Director of Nursing confirmed that the physician's orders [REDACTED]. Pa. Code. 211.12(d)(1)(3)(5) Nursing services Previously cited 2/24/17

Based on observation, review of facility policies and staff interview, it was determined that the facility failed to maintain appropriate infection control measures related to handwashing after the administration of medication for three of seven employees observed (Employees E2, E3 and E4). The findings include: The Intravenous (adminstered into a vein) Infusions policy, dated 10/11/16, revealed that when disconnecting an intravenous infusion to swab the end cap with alcohol, allow to air dry, flush with saline . The Hand Washing Policy and Procedure, dated 10/11/16, revealed after washing one's hands, to dry the hands and use disposable hand towel to turn off the water faucet. During observation of medication administration on 2/21/17, at 2:30 p.m., Registered Nurse Employee E2 disconnected an intravenous medication from Resident R1 but had not swabbed the end cap with alcohol prior to flushing the site with saline. During the observation of medication administration on 2/22/17, between 8:45 a.m. and 9:40 a.m., Licensed Practical Nurse Employees E3 and E4 were observed turning the faucet off with their bare hands instead utilizing a paper towel. During an interview on 2/22/17, at 10:12 a.m., the Director of Nursing confirmed that the end caps of the intravenous site should be swabbed with alcohol prior to flushing the intravenous line and that the water faucets should be turned off with a paper towel. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/04/15

Based on review of clinical records, facility policies and staff interviews, it was determined that the facility failed to follow up on laboratory testing in a timely manner, monitor and evaluate the response to pain interventions, provide an agreement/arrangement concerning how [MEDICAL TREATMENT] residents care is managed and provide care as the physician ordered for four of 17 residents (Resident R2, R3, R5, and R11). The findings include: The Change in Condition, Physician Notification and Faxing Policy and Procedure, dated 10/11/16, revealed a phone call must be made in the following conditions: any abnormal/significant change in lab work, cultures, xrays, ect . The Record of Admission revealed that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order, dated 1/18/17, ordered a [MEDICAL CONDITION] stimulating hormone (TSH) blood test every month. The 2/17/17, TSH was verified by the laboratory as below the normal range. The information was faxed to the physician on 2/17/17, at 11:59 a.m. There was no evidence to indicate that the physician was aware of the TSH results or that a response was received from the physician by 2/22/17 (five days later). During an interview on 2/22/17, at 11:00 a.m., the Registered Nurse Employee E2 had confirmed that there was no evidence to indicate that the physician received the notification that Resident R2's TSH was low or that any follow up by the facility was completed to address the low TSH found from Resident R2's laboratory results. There was no evidence that a phone call was made to the physician office to address the low TSH from Resident R2 before 2/22/17. The Policy and Procedure for Non-Pharmacological Approaches to Pain, dated 10/11/16, revealed that the charge nurse must document the effectiveness of the pain medication in the MAR (medication administration record). The Record of Admission revealed that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MAR revealed that Resident R3 was medicated for pain on three occasions in January 2017. There was no documented evidence to indicate the effectiveness of the administation of the pain medication administered on 1/04/17, at 9:35 a.m., and 1/13/17, at 5:00 a.m. During an interview on 2/23/17, at 10:10 a.m., the Director of Nursing confirmed that the effectiveness of the pain medication is either documented on the MAR or in the computer under nursing progress notes and there was no documentation found on those two days concerning the effectiveness of the medication The Record of Admission revealed that Resident R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R11 received [MEDICAL TREATMENT] services on Tuesdays, Thursdays and Saturdays. There was no evidence that a facility arrangement/agreement had been developed to address how resident care was managed including medical and non-medical emergencies and how information would be interchanged regarding the necessary care of the resident between the facility and the [MEDICAL TREATMENT] center. During an interview on 2/23/17, Registered Nurse (RN) Employee E2 revealed that they were not aware of a communication record being utilized between the facility and the [MEDICAL TREATMENT] center. During an interview on 2/23/17, at 1:45 p.m., the Nursing Home Administrator confirmed that the facility did not have a written agreement/arrangement with the [MEDICAL TREATMENT] center. Resident R5's clinical record revealed an admission date of [DATE], [DIAGNOSES REDACTED]. Current physician orders, dated 1/21/17, included an order for [REDACTED]. Resident R5's Treatment Records from November 1, 2016, through January 31, 2017, revealed that Resident R5's vital signs were not obtained, or recorded on seven of fourteen ordered occasions (11/08/16; 11/15/16; 11/29/16; 12/06/16; 12/20/16; 1/10/17; 1/31/17). During an interview on 2/22/17, at 11:00 a.m., RN Employee E5 confirmed that Resident R5's vital signs were not consistently obtained per physician order. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/04/15

Based on review of clinical records and facility documentation and staff and family interview, it was determined that the facility failed to provide showers as scheduled for one of 17 residents (Resident R2). The findings include: During an interview on 2/21/17, at 5:45 p.m., Resident Family Member (RF2) indicated that they did not feel showers were done as scheduled. The Record of Admission revealed that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation presented by Registered Nurse Assessment Coordinator (RNAC) Employee E7 on 2/23/17, at 11:10 a.m., confirmed that Resident R2's bathing schedule was on Wednesdays and Saturdays. Review of the Bath Type Detail report revealed that from 12/26/16 through 2/23/17, Resident R2 was not showered on five of 17 scheduled shower days. (12/31/16, 1/07/17, 1/21/17, 2/01/17, and 2/15/17). There was no evidence to indicate the reason the showers were not provided to Resident R2 when scheduled. During an interview on 2/23/17, at 11:10 a.m., RNAC Employee E7 confirmed that there was no evidence to indicate why Resident R2 was not provided a shower as scheduled. 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited 12/04/15

Based on a resident family interview, review of facility policy and clinical records and staff interview, it was determined that the facility failed to investigate an injury of unknown origin for one of 17 residents (Resident R7). Findings include: The facility policy entitled Incident/Accident Policy, dated 10/11/16, indicated that all incidents and accidents, regardless of how minor they present, must be reported to the Clinical Care Coordinator and/or Registered Nurse (RN) Supervisor upon discovery and noted in the Nurses 24-Hour Report Sheet. For unwitnessed falls an Incident/Accident Investigation form is to be completed for the shift during which the unwitnessed fall occurred and for injuries of unknown origin, the Incident/Accident Investigation form is to be completed for three shifts prior to the discover of the injury, or longer, if deemed necessary. Following incidents/accidents, documentation related to the resident's status following the event is required every shift for 72 hours. Resident R7's clinical record revealed an admission date of [DATE], [DIAGNOSES REDACTED]. The record further revealed Resident R7 had cognitive impairment (a decline in memory and reasoning ability) and was at high risk for falls. During an interview on 2/22/17, at 10:00 a.m., Resident Family Member RF7 indicated that R7 left the facility to spend Thanksgiving day at home and sustained a fall during the visit. A week later, RF7 indicated that R7 was black and blue from under the left arm to the middle of the chest, and the area was hard. RF7 stated that he/she didn't understand how the area could get that bad in a week and no one noticed it and questioned did some other injury occur. Clinical record documentation indicated that Resident R7 was out of the facility on 11/24/16, with family. On 11/26/16, during a routinely schedule skin assessment, new bruising to left breast was noted. The clinical record revealed no further documentation related to the bruising until 12/01/16, when documentation reflects that Resident R7 was experiencing left breast discomfort and examination revealed the breast was bruised dark blue, purplish and black spreading from the middle of the chest to under the arm pit and down to the nipple. Resident R7 stated that he/she does not remember how the injury occurred. A Nurse's Note entered on 12/03/16, but post dated to 11/24/16, indicated that when Resident R6 returned to the facility on [DATE], the family reported that Resident R7 had sustained a fall on the stairs during the visit home and that family had an extremely difficult time attempting to assist the resident up up off the ground . zero injuries noted . family stated that Resident R7 may experience some bruising under the arms. Resident R7's clinical record lacked evidence that an assessment was completed at the time the facility was made aware of the fall or follow-up documentation completed on each shift for 72 hours following the accident. During an interview on 2/23/17, at 1:30 p.m., the Director of Nursing confirmed that the facility failed to follow the facility policy and procedure related to incidents/accidents by not assessing Resident R7 upon return to the facility, initiating an incident report in a timely manner, or documenting Resident R7's status every shift for 72 hours following the fall. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.29(a)(d) Resident rights 28 Pa. Code: 211.10(d) Resident policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 12/04/15