Every finding on record at Saint Paul Homes

Based on review of clinical records and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R114). Findings include: Upon request, the facility was unable to provide a policy regarding non-pharmacological interventions prior to the administration of psychotropic medications. Resident R114's clinical record revealed an admission date of 9/18/23, with diagnoses that included dementia (loss of cognitive functioning affecting a person's memory and behaviors), gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and high blood pressure. Resident R114's clinical record revealed a physician's order dated 5/18/25, with a discontinuation date of 11/18/25, that identified to administer Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth daily PRN for increased behaviors / anxiety. Resident R114's May 2025 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used five times (5/20/25, 5/21/25, 5/22/25, 5/27/25, and 5/28/25). Review of May MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam four of the five times it was used. Resident R114's June 2025 MAR revealed that the PRN Lorazepam was used four times (6/3/25, 6/10/25, 6/12/25, and 6/23/25). Review of June MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam three of the four times it was used. Resident R114's July 2025 MAR revealed that the PRN Lorazepam was used six times (7/3/25, 7/8/25, 7/18/25, 7/28/25, 7/30/25, and 7/31/25). Review of July MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam six of the six times it was used. Resident R114's August 2025 MAR revealed that the PRN Lorazepam was used one time (8/5/25). Review of August MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam one of one time it was used. During an interview on 8/7/25, at 1:47 p.m. the Director of Nursing confirmed that the facility lacked evidence of non-pharmacological interventions being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety on three of three kitchenettes observed ([NAME], Gardens, and Springs). Findings include: Review of manufacturer's instructions for the facility dishwashing machine revealed that the hot water sanitizing mode minimum wash temperature and recommended wash temperature was 150 degrees Farenheit (F). Review of the Dishwashing/Warewashing machine temperature log sheet revealed that the temperature requirements for the wash cycle was: Wash 150 degrees F. If temperatures were not met per standard, fill out work order and notify management. Observations of the dishwashing machine operation on 10/11/2023, at 1:10 p.m. on the [NAME] unit, in the presence of the Dietary Aide Employee E1, revealed a dishwasher temperature of 144.2 degrees F during the wash cycle. Dietary Aide Employee E1 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Observations of the dishwashing machine operation on 10/11/2023, at 1:12 p.m. on the Gardens unit, in the presence of the Dietary Aide Employee E2, revealed a dishwasher temperature of 147.6 degrees F during the wash cycle. Dietary Aide Employee E2 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Observations of the dishwashing machine operation on 10/11/2023, at 1:15 p.m. on the Springs unit, in the presence of the Dietary Aide Employee E3, revealed a dishwasher temperature of 146.3 degrees F during the wash cycle Dietary Aide Employee E3 confirmed, at the time of observation, that the wash cycle was lower than the required 150 degrees F. Review of Dishwashing/Warewashing machine temperature logs for the Springs, [NAME], and Gardens kitchenettes revealed that Springs kitchenette dishwashing machine logged wash temperatures below 150 degrees F for multiple days and shifts in the months of September and October 2023. During an interview on 10/11/2023, at 1:30 p.m. the Dining Manager confirmed that dishwashing machine temperatures are supposed to meet the 150 degrees F during the wash cycle. Staff recording and observing the dishwashing machine temperatures are to inform management and maintenance if the dishwashing machines do not meet the required temperatures for wash and rinse cycles. The facility did not produce a policy on monitoring and documenting dishwashing machine temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were accurate and reflected the status and care provided to one of 24 residents reviewed (Resident R8). Findings include: Review of a facility policy entitled, Special Locking Arrangement (SLA) and Secure Care Systems, dated 1/27/22, indicated that With a signed consent and a physician's order, residents considered at risk for elopement, will be properly fitted with an ankle transmitter to be worn . Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle weakness, and anemia. Review of Resident R8's clinical record revealed an elopement risk assessment completed on 11/6/22, at 3:23 p.m. that identified a transmitter was fitted to the resident on 11/6/22, due to history of wandering and making statement that they are leaving or seeking to find someone/something. Further review of Resident R8's clinical record revealed there was not a physician's order for the secure band/ankle transmitter. Observation of Resident R8 on 11/9/22, at 10:11 a.m. revealed a secure band/ankle transmitter to his/her left ankle. During an interview on 11/9/22, at 2:35 p.m. Registered Nurse (RN) Employee E1 and Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R8 had a secure band/ankle transmitter to his/her left ankle. On 11/9/22, at 2:40 p.m. RN Employee E1 and LPN Employee E2 confirmed that there was no physician's order for use of the secure care/ankle transmitter band for Resident R8. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide a date of duration and clinical rationale for the continued use of a PRN (as needed) [CONDITION(S)] (affecting the mind) medication beyond 14-days for one of 27 residents reviewed (Resident R52) and failed to ensure that drug regimens were free of unnecessary [CONDITION(S)] medications for one of 27 residents reviewed (Resident R16). Findings include: Review of the facility policy entitled Chemical Restraints and/or Antipsychotic Medications (drugs used to treat severe mental states such as delusions and hallucinations), dated 1/27/21, indicated that residents who use antipsychotic medications will be evaluated to determine their effectiveness; the consultant pharmacist will review all ordered [CONDITION(S)] medications and make recommendations as to the need for drug and gradual dose reductions (GDR); and that dose reductions will be attempted on all residents who receive antipsychotic medications unless clinically contraindicated, with contraindications to GDR's described in the resident's medical record. Review of Resident R52's clinical record revealed an admitted [DATE], and diagnoses that included unspecified dementia without behavioral disturbance (a loss of memory/thought processing without behaviors such as verbal or physical aggression or excessive wandering), history of a fractured right humerus (bone in the upper arm), [CONDITION(S)] (inadequate pumping of the heart muscle) and kidney disease. Review of current physician's orders included an order for Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), three times a day, and a second order for Lorazepam 0.5 mg, every two hours PRN for restlessness, agitation. Review of a Note to Attending Physician/Prescriber, dated 10/01/21, revealed a request from the facility's consultant pharmacist for the physician to review Lorazepam 0.5 mg, scheduled twice a day (4/20) and Lorazepam 0.5 mg every two hours as needed (7/21). The physician response indicated a reduction was not appropriate, as Hospice care, tolerates well, no adverse reactions. The response lacked clinical rationale for the continued use of both orders and lacked a date of duration for use of the as needed Lorazepam order. Review of Resident R16's clinical record revealed an admitted [DATE], and diagnoses that included Alzheimer's disease, a major depressive disorder, and unspecified dementia without behavioral disturbance. Review of Resident R16's current physician's orders included an order for [MEDICATION(S)] (an antipsychotic medication) 25 mg, daily in the evening. Review of a Note to Attending Physician/Prescriber, dated 10/22/20, revealed a request from the facility's consultant pharmacist for the physician to review [MEDICATION(S)] 25 mg every HS (evening) (05/19) for a trial dose reduction. The physician response indicated a reduction was not appropriate as no adverse reactions, continue dose. The clinical record lacked evidence of any other review of the [MEDICATION(S)] for a possible dose reduction since the 10/22/20 review (14 months). During an interview on 12/27/21, at 12:26 p.m. the Director of Nursing confirmed there was no evidence that Resident R52's PRN Lorazepam order was reviewed for a duration date or that Resident R16's [MEDICATION(S)] was reviewed in the last 12 months for a possible gradual dose reduction. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement measures to prevent the potential for cross contamination (transfer of germs/organisms from one location to another) during a dressing change for one of three residents reviewed with wounds (Resident R88). Findings include: Review of the facility policy entitled Dressing Change Procedure, dated 1/27/21, indicated that after cleansing a wound with normal saline, staff are to remove gloves and perform hand hygiene, apply gloves and apply treatment as ordered. Review of Resident R88's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record further revealed Resident R88 was ordered contact isolation (techniques to decrease the likelihood of the transfer of organisms that can cause disease through direct/indirect contact - use of gloves, gowns, frequent environmental cleaning) due to a [CONDITION(S)] ([CONDITION(S)]-Resistant Staphylococcus Aureus)/VRE ([MEDICATION(S)]-Resistant Enterococcus) infection in the buttock wound. Resident R88's current physician's orders included an order to cleanse the right buttock wound with saline (salt solution), apply [MEDICATION(S)] (a collagen/cellulose/antimicrobial product that promotes healing) to the wound bed then gauze soaked with 0.125% Dakin's solution (antiseptic/diluted bleach product) wet to dry overlay, moisture barrier to skin around the wound and cover with a [MEDICATION(S)] border (a dressing with an adhesive border) to be applied every other day. Observation on 12/16/21, at 9:05 a.m. of wound care to Resident R88's right buttock wound revealed that Licensed Practical Nurse (LPN) Employee E3 proceeded, with gloved hands, to cleanse Resident R88's undressed wound with saline solution, while Registered Nurse (RN) Employee E2 assisted to position Resident R88 on his/her left side. After cleansing the wound, drying the area and applying a moisture barrier to the surrounding wound, LPN Employee E3 removed the glove on his/her right hand, keeping the left gloved hand positioned on Resident R88's hip. Then, without the benefit of performing hand hygiene to the right-hand, LPN Employee E3 applied a new glove and with the gloved right hand proceeded to insert [MEDICATION(S)] to the wound bed, a gauze soaked with Dakin's solution and lastly applied a [MEDICATION(S)] border dressing. During an interview on 12/16/21, at 10:05 a.m., LPN Employee E3 confirmed that after cleansing Resident R88's infected buttock wound, only his/her right-hand glove was changed and without first performing hand hygiene, increasing the potential for cross contamination. 28 Pa. Code 211.10(D) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review and staff interview, it was determined that the facility failed to follow a physician order [REDACTED]. Findings include: Resident R85's physician's orders [REDACTED].>During an observation on 1/26/21, at 11:20 a.m. of medication storage of Cart A on The Springs unit with RN Supervisor Employee E1, it was discovered that Resident R85's number of [MEDICATION NAME] (medication to relieve anxiety) was identified as 85 tablets in the computer system and 84 tablets in the cart. Upon further investigation, it was discovered that Resident R85's [MEDICATION NAME] doses in the cart were 12 but the number of doses represented in the computer system was 11.5 doses. During the observation with RN Supervisor Employee E1, it was confirmed that [MEDICATION NAME] was administered in error to Resident R85 at 7:48 a.m. when [MEDICATION NAME] was the medication that should have been administered. At the time of the observation, at 11:20 a.m. it was past the ordered time frame for Resident R85 to be administered [MEDICATION NAME] between 5:00 a.m. and 10:30 a.m. Resident R85 was not administered [MEDICATION NAME] as ordered by the physician resulting in only receiving the two of three doses ordered for that day. 28 PA Code 211.12(d)(1)(2) Nursing services

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to provide physician ordered adaptive dining equipment for one of eight residents reviewed (Resident R86). Findings include: Resident R86's clinical record revealed an admission date of [DATE], with current [DIAGNOSES REDACTED]. Resident R86's current care plan entitled Nutritional Status indicated Resident R86 had a history of [REDACTED]. Interventions for the nutritional problem included an approach to provide, per occupational therapy (OT) recommendation, small built up utensils, skinny juice glasses and a red plate at all meals. Current physician orders [REDACTED]. On 6/06/19, at 9:00 a.m. Resident R86 was observed seated in the unit's dining room with a dietary placard posted at the setting for Red Plate, Built-up (BU) utensils, and a Skinny Juice Glass. Resident R86's place setting included eggs and toast on a regular plate with regular silverware. On 6/06/19, at 9:10 a.m. Licensed Practical Nurse Employee E1 proceeded to feed Resident R86 and confirmed that the physician ordered plate and built up utensils were not available to Resident R86 to enhance his/her ability to eat independently. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/02/18, 5/11/18

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to discard expired medications per manufacturer's recommendations on one of five medication carts reviewed for drug storage (Unit Orchards A). Findings include: The facility policy entitled Administration of Medications - General guidelines, dated 1/29/19, indicated that the first person to use a multi-dose vial/pen was to write the date opened on the vial/pen and that all vials and pens of insulin were to be discarded after 28 days. Manufacturer's recommendations for [MEDICATION NAME] (a long acting insulin) storage, indicated that opened pens of [MEDICATION NAME] are to be stored at room temperature and discarded 28 days after opening. Manufacturer's recommendations for [MEDICATION NAME] (a rapid acting insulin) storage, indicated that opened pens of [MEDICATION NAME] are to be stored at room temperature and discarded 28 days after opening. Observations of drug storage on 6/06/19, at 1:15 p.m. on Orchards A nursing unit, revealed opened pens of [MEDICATION NAME] and [MEDICATION NAME]stored in the medication cart, labeled for Resident R59, and marked with an open date of 5/06/19 (a period of 31 days after opening). During an interview, at the time of the observation, Licensed Practical Nurse Employee E1 and Registered Nurse Employee E2 confirmed that Resident R59's [MEDICATION NAME] and [MEDICATION NAME] were outdated based on the open date and should be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/02/18, 5/11/18

Based on observations, review of facility policies and resident clinical records and staff interviews, it was determined that the facility failed to provide care and services to prevent potential complications and infections associated with the use of an indwelling, urinary catheter (a tube inserted into the bladder and attached to a bag to promote urine drainage) for one of 28 residents (Resident 28). Findings include: The facility policies related to urinary catheter insertion and urinary catheter care, dated 1/19/17, revealed that during male catheter care, the head of penis is to be cleansed in a circular fashion toward the base of the penis, the catheter tubing cleaned in a downward direction and the catheter tubing connected to the inner aspect of the leg, allowing some slack to guard against trauma to the urethra (anatomical tube through which urine leaves the bladder). Resident R28's clinical record revealed an admission date of [DATE], [DIAGNOSES REDACTED]. The clinical record also included current physician orders [REDACTED]. The nursing care plan associated with Resident R28's indwelling urinary catheter included a goal to not exhibit sings of infection or trauma, and interventions including but not limited to the provision of catheter care and reporting signs of infection such as back pain, fever, and foul smelling urine. On 6/14/17, at 8:45 a.m., prior to an observation of care to Resident R28's indwelling urinary catheter, it was noted that Resident R28's bed was in the lowest position, with the urinary catheter bag resting directly on the floor without a cover. It was also noted there was no device in place to secure the catheter to the inner leg. Nursing Assistant (NA) Employee E1 proceeded to provide urinary catheter care and upon completion, cleaned the emptying spout attached to bag with a wash cloth, dropped the cloth on the floor, and after picking it up from the floor, finished cleaning the spout. During an interview on 6/14/17, at 9:00 a.m., NA Employee E1 confirmed that the urinary drainage bag resting on the bed and that utilizing the wash cloth to clean the spout after coming in contact with the floor violated infection control practices. NA Employee E1 also confirmed that Resident R28 did not have a securing device for the urinary catheter to prevent trauma to the urethra. During an interview on 6/15/17, at 1:30 p.m., the Director of Nursing confirmed the facility practice to apply a securing device to prevent trauma to the urethra for residents with indwelling catheters and the Resident R28 did not have such a device. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Previously cited 5/13/16

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to demonstrate that proper procedure was followed for one of 28 residents reviewed (Resident R3) and failed failed to follow physician orders for one of 28 residents reviewed (Resident R20). Findings include: The Face Sheet showed that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's order dated 6/12/17, directed the removal of Resident R3's PICC line (Peripherally Inserted Central Catheter used for the administration of antibiotics directly into the vein). The Lippincott Nursing Procedures reference manual (a common, widely used and accepted reference guide for nursing procedures) instructions for removing a PICC line includes the following: Measure the catheter after you remove it to ensure that the line has been removed intact. It again directs Measure and inspect the catheter. If any part has broken off during removal, notify the practitioner immediately, and monitor the patient for signs of distress. The manual warns that that catheter breakage on removal is the most common complication and that the entire procedure should be documented. There was no evidence to indicate that the PICC line was inspected for damage or measured to ensure that it remained completely intact when removed and/or whether Resident R3 was assessed for any indication of complications related to the procedure. During interview on 6/16/17, at 11:00 a.m., the Director of Nursing confirmed that the PICC line had been removed, but that there was no measurements of the PICC line length or condition following removal. The facility policy, Administration of Medications- General Guidelines, with a facility review date of 1/15, stated, St. Paul's administers medications as prescribed by the attending physician . Resident R20's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A physician order dated 5/29/17, directed that [MEDICATION NAME] antibiotic be given orally three times a day. Resident R20's Medication Administration Record [REDACTED] 05/29/17 1:00 PM, Not Administered: Resident unavailable. 05/31/17 1:00 PM, Not Administered: Resident unavailable. 06/2/17 1:00 PM, Not Administered: Resident unavailable. There was no evidence to indicate that the staff were directed by the physician to withhold the above doses of the antibiotic medication. During an interview on 6/16/17, at 10:00 a.m., the Assistant Director of Nursing confirmed that the antibiotic medication was not administered as physician ordered on the above dates and that there was no physician order to withhold the antibiotic doses. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 5/13/16.

Based on facility records and staff interview, it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the attendance of a the Medical Director or a facility designated physician at the required number of meetings. Findings include: Review of the QAA Committee attendance present portion of the minutes dated 7/16/15, through 4/21/16, revealed that the Medical Director or a physician designated by the facility attended the meetings on 7/16/15, and 1/21/16, and then was not in attendance during the quarterly QAA meetings of 10/19/15 and 4/21/16 and was not in accordance with the Medical Director or a facility designated physician attending the required minimal number of meetings. During an interview on 5/12/16, at 10:15 a.m., the Director of Nursing confirmed that the Medical Director or a facility designated physician did not attend two of the four required number of QAA Committee Meetings from 7/16/15, through 4/21/16. 28 Pa. Code 201.18(e)(1)(2)(3) Management.

Based on observations, review of facility policies and staff interview, it was determined that the facility failed to serve food under sanitary conditions in one of five kitchenettes. (Orchard Unit). Findings include: The Dress Code policy, dated 2/01/16, revealed, hairnets or appropriate head covering are required for all personnel in the food production or storage areas of the Dining and Nutritional Services Department. Observation of meal service on 5/09/16, between 5:15 - 5:30 p.m., the following was noted: Dietary Employee E1 grilled sandwiches without wearing a hair restraint. During an interview on 5/13/16, at 8:30 a.m., the Registered Dietician, Dining Service Director confirmed that Dietary Employee E1 should have had a hair restraint on while in the kitchenette. 28 Pa. Code: 201.18(a)(b)(1) Management. Previously cited 6/12/15. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/12/15.

Based on review of the Resident Assessment Instrument (RAI) Manual (instructions to complete Minimum Data Sets Assessments (MDS - periodic assessment of resident care needs)), resident records and facility policy and staff interviews, it was determined that the facility failed to accurately assess three of 29 residents (Residents R10, R11, and R13). Findings include: The facility policy related to completion of MDS Assessments, dated 1/22/16, indicated that assessments would be completed as required in the RAI Manual. The RAI Manual instructions related to the completion of Section A0310, entitled Type of Assessment, instructs the facility to indicate if this is the first assessment completed since admission or re-entry to the facility. The RAI Manual instructions related to the completion of Section HO500, entitled Bowel Toileting Program (a systematically implemented program to decrease or prevent loss of bowel control) instructs the facility to indicate no or yes if a bowel toileting program is in use. Resident R10's Significant Change MDS dated [DATE], indicated that this was not the first assessment completed since Resident R10's most recent re-entry to the facility. The assessment also indicated that Resident R10 was always incontinent of bowel movements and was on a bowel toileting program. Review of Resident R10's clinical record revealed that Resident R10 was discharged from the facility on 3/01/16, readmitted on [DATE], and lacked evidence that another MDS Assessment was completed prior to the Significant Change MDS of 3/11/16. The record also lacked evidence that Resident R10 was on a bowel toileting program during the assessment period. The RAI Manual instructions related to the completion of Section M0300B, entitled Stage 2 Pressure Ulcers (partial thickness loss of skin presenting as a shallow ulcer), instructs the facility to enter the number of Stage 2 pressure ulcers present based on resident skin assessments. Resident R13's Annual MDS dated [DATE], indicated that Resident R13 had [DIAGNOSES REDACTED]. The MDS also indicated that Resident R10 had a Stage 2 pressure ulcer. Review of Resident R13's clinical record lacked evidence that Resident R13 had a pressure ulcer during the assessment period for the 8/13/15 Annual MDS. During an interview on 5/11/16, at 1:45 p.m., the Director of Nursing (DON) confirmed that Resident R10's Significant Change MDS dated [DATE], inaccurately reflected that Resident R10 was on a bowel toileting program and that the assessment was not the first assessment completed since re-entry to the facility. The DON also confirmed that Resident R13's Annual MDS dated [DATE], inaccurately reflected the presence of a Stage 2 pressure ulcer. The RAI Manual instructions related to completion of Section H0200, entitled Urinary Toileting Program (an individualized, resident-centered, program to decrease or prevent the loss of urinary control) instructs the facility to indicate no or yes if a urinary toileting program is in use. Resident R11's Annual MDS dated [DATE], indicated that Resident R11 had [DIAGNOSES REDACTED]. The MDS also indicated that Resident R11 was occasionally incontinent of urine and was not on a urinary toileting program. Review of Resident R11's clinical record revealed a Restorative Nursing Note dated 11/05/15, indicating that Resident R11 was on a urinary toileting program; a current physician order, originally written 8/29/15, to toilet the resident every three hours while awake per a urinary toileting program; and nursing assistant documentation that the resident was toileted daily per the program orders during the 11/17/15, assessment period. During an interview on 5/12/16, at 2:00 p.m., the DON confirmed that Resident R11's Annual MDS, dated [DATE], inaccurately reflected that a urinary toileting program was not in place. 28 Pa. Code 211/12(d)(1)(3) Nursing service. Previously cited 6/12/15.

Based on review of a facility policy and clinical records, observations and staff interview, it was determined that the facility failed to utilize infection control practices during a dressing change, creating the potential for cross contamination for one of 29 residents (Resident R1). Findings include: The facility policy entitled Dressing Change Procedure, dated 1/22/16, indicated that the facility would provide wound care in a manner to decrease the potential for nosocomial (developing in the facility) infections and that during dressing changes a clean field (area) would be utilized for the placement of all dressing items. Resident R1's Admission Minimum Data Set assessment (MDS - periodic assessment of resident care needs), dated 4/21/16, revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. The MDS further revealed the presence of a Stage 2 (partial loss of skin thickness presenting as a shallow open area) pressure ulcer. Resident R1's current physician orders, included an order dated 5/03/16, for contact precautions (infection control practices to prevent the spread of disease producing organisms) to be utilized due to a positive Methicillin Resistant Staphylococcus Aureus (MRSA) culture of the nasal area; and an order dated 5/04/16, to cleanse an open area of the coccyx with normal saline, apply [MEDICATION NAME] (an absorbent, antibacterial dressing) and a [MEDICATION NAME] border (a foam covering with adherent edges) to the area every day. During an observation of wound care to Resident R1's coccyx on 5/09/16, at 4:20 p.m., Licensed Practical Nurse (LPN) Employee E2 proceeded to enter Resident R1's room, which was posted with a notice that contact precautions were to be observed. LPN Employee E2 then gowned and gloved and proceeded to open the [MEDICATION NAME] and [MEDICATION NAME] packaging and placed the open packages on the bed. LPN Employee E2 then cleaned a pair of scissors and placed them on the sheet of the bed. After cleansing the wound, LPN Employee E2 utilized the potentially contaminated scissors to cut the [MEDICATION NAME] dressing to fit the wound. LPN Employee E2 then returned the potentially contaminated dressing material to the original packaging. During an interview on 5/09/16, at 4:30 p.m., LPN Employee E2 confirmed that the scissors should have been placed on a clean field after cleansing, and prior to cutting the dressing, to prevent the potential for cross contamination of the dressing prior to use. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/12/15.

Based on observations and staff interview, it was determined that the facility failed to monitor residents personal refrigerators for four of 33 residents (Residents R4, R31, R32 and R33). The findings include: Observation on 6/09/15, at 11:45 a.m., revealed a personal refrigerator in Resident R31's room that contained several food items and lacked a thermometer. During an interview on 6/09/15, at 11:45 a.m., Registered Nurse Employee E1 stated that the temperatures of the residents personal refrigerators were not monitored. Observation on 6/11/15, at 2:25 p.m., revealed a personal refrigerator in Resident R33's room with a build up of ice in the freezer section. During an interview, on 6/09/15 at 2:15 p.m., the Director of Nursing confirmed that Residents R4, R31, R32 and R33 all had personal refrigerators and that the facility had no policy and procedure in place to monitor the personal refrigerators to ensure that they were cleaned and that the food was stored at a safe temperature, was not outdated and was safe for the resident and roommate if applicable. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of the facility policy, clinical records and staff interview, it was determined that the facility failed to perform bladder assessments and/or implement measures to restore bladder function for one of 29 residents (Resident R13). The findings include: The Bladder & Bowel Assessment dated 1/15/15. revealed that an assessment form is completed on admission and quarterly and that a bladder assessment is implemented on all residents noted to be incontinent at the time of admission or whenever there is a change in cognition, physical ability or urinary tract function. Resident R13 was admitted to the facility on [DATE]. The physician order report indicated that Resident R13 had a [DIAGNOSES REDACTED]. The Significant Change MDS, dated [DATE], revealed that Resident R13 had a slight change in bladder function, revealing a change from always continent too occasionally incontinent. The Quarterly MDS, dated [DATE], revealed that Resident R13 had gone from occasionally incontinent to frequently incontinent. There was no evidence that a comprehensive bladder assessment was completed to indicate the type of incontinence that Resident R13 was experiencing when the resident changed from continent to occasionally incontinent and then to frequently incontinent. During an interview on 6/10/15, at 11:20 a.m., the Director of Nursing confirmed that a comprehensive bladder assessment was not completed on Resident R13 to include the type of incontinence experienced after a decline in bladder function. 28 pa. Code 211.12(d)(1)(3)(5) Nursing Services. Previously cited 5/22/14.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to provide privacy and confidentiality for one of 30 residents with a pacemaker (Resident R30). The findings include: The facility policy Privacy, dated 1/15/15, indicated that medical treatments that has potential for exposure of any portion of the residents body will be provided for in the privacy of the resident's room. Observation on 6/10/15, at 10:40 a.m., revealed Resident R30 seated at the Nurses' station with a machine attached to her partially exposed chest in full view and close proximity of individuals using the main hall or leaving the dining area. During an interview at the same time, the Unit Manager Registered Nurse Employee E1 confirmed that pacemaker checks were always done at the Nurses' station and not in a private area. 28 Pa. Code 201.29(a)(d) Resident rights.

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to comprehensively assess pressure ulcers upon discovery for 2 of 29 residents (Resident R15 and R11). The findings include: The facility policy entitled Pressure Ulcers/Protocol, dated 1/15/15, indicated that pressure ulcers are to be assessed by a wound care team on a weekly basis and that the location and staging (a four stage system to systematically identify severity); size including length, width, and depth; exudate (drainage), pain, wound bed, and description of wound edges and surrounding tissue are to be documented. Resident R15's electronic clinical record revealed an admission date of [DATE], and current diagnoses, including but not limited to, of debility (physical weakness), dementia and abnormal posture. Physician orders, dated 12/03/14, indicated that [MEDICATION NAME] (a foam, padded dressing with an adhesive border) was to be applied to a bony prominence on the middle of Resident R15's spine and changed every three days. Nurses Notes, dated 2/12/15, revealed that Resident R15 developed an open area on a bony area of the spine that had been protected by the [MEDICATION NAME] dressing. The note further indicated the area was 0.5 centimeters (cm) in length, by 1.0 cm in width, with no depth documented or assessment of stage, surrounding tissue, wound bed or the edges and surrounding tissue. The note indicated the wound team was consulted to assess the wound. On 2/16/15, (four days later) an assessment of Resident R15's wound by the wound team indicated the open area was a Stage III (full thickness tissue loss) pressure ulcer with measurements of 0.8 cm in length, by 0.6 cm in width, by < (less than) 0.1 cm in depth. Physician orders [REDACTED]. Wound assessments by the wound team revealed the wound was healed on 2/23/15. Resident R15's electronic clinical record included a second consult to the wound team on 4/30/15, requesting an evaluation of an open area on the spine . The clinical record lacked a full assessment of the wound at the time of discovery. An assessment of the wound on 5/04/15, (four days later), indicated the wound was a Stage II (partial thickness loss of upper skin tissue) with mid spine documented in the area designated to include the wound size. Physician orders [REDACTED]. During an interview on 6/11/15, at 10:30 a.m., the Assistant Director of Nursing confirmed that Resident R15's wounds were not fully assessed at the times of discovery on 2/12/15, and 4/20/15, to establish a baseline of reference for worsening or improvement of the wound. The Resident Admission Record, dated 6/11/15, revealed that Resident R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS-periodic review of resident care needs), dated 4/14/15, revealed Resident R11 had no pressure ulcers. The Nursing note, dated 4/29/15, revealed that a 3cm by 4cm purple area was discovered on Resident R11's left heel. A full assessment of the area was not completed until 5/04/15, with the assessment identifying the left heel as unstageable. During an interview on 6/12/15, at 10:50 a.m., the Assistant Director of Nursing revealed that nursing on the units do not complete a full in depth assessment on wounds at the time of discovery. A full assessment is initiated on wound round days, usually on Mondays. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/22/14.

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly store foods in the main kitchen area under optimal sanitary conditions and failed to follow sanitary practices in one of five unit kitchens (Gardens). The findings include: Observations on 5/19/14, at 6:10 p.m., revealed the following: In one walk-in cooler, there were two large uncovered plastic basins with cut up sweet potatoes soaking in water. On top of one of the basins was a large metal sheet pan, with packages of food on it, that was angled into the basin of potatoes. In a second walk-in cooler, there were three large uncovered plastic basins with cut up potatoes soaking in water. In a walk-in freezer, there was one box each of pancakes, cookie dough, and muffins all stored directly on the floor. Observation on 5/20/14, at 9:05 a.m., revealed the boxes of pancakes, cookie dough and muffins remained directly on the floor. During an interview, on 5/20/14, at 9:05 a.m., the Director of the Food and Nutrition Department confirmed that the above food items were not stored correctly. The "Hand Hygiene in the Long Term Care Setting" policy, dated January 2014, stated that appropriate hand hygiene was important to reduce the risk of transmission of infection and instructed staff to dry the hands with a paper towel, then turn off the faucet with the paper towel. Observation of meal service in Gardens kitchen on 5/20/14, from 11:15 a.m. to 11:30 a.m., revealed that, during preparation for tray line, Dietary Employee E1 touched the garbage can on two occasions and on one occasion dropped a piece of aluminum foil onto the floor and retrieved it, then proceeded with food preparation without the benefit of handwashing. Observation of handwashing in the Gardens kitchen on 5/20/14, at 11:50 a.m., revealed that Dietary Employee E2 washed hands, then turned off the faucet with bare hands rather than using a paper towel. During an interview, on 5/22/14, at 2:15 p.m., The Director of Nursing confirmed that Dietary Employee E1 should have washed the hands after touching the garbage can and after retrieving an item from the floor, and that staff should not turn off the faucet with bare hands. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations, review of facility policy and manufacturer recommendations and staff interviews, it was determined that the facility failed to prevent the opportunity for unauthorized access to medications and failed to discard open expired medication on one of five units (Gardens). The findings include: The "Access to Drug Storage Areas" policy, dated [DATE], stated that medication carts are kept locked at all times when unattended. Observations of Gardens A, on [DATE], at 9:15 a.m., revealed a medication cart left unlocked and unattended, with two medication cups that contained pills located on the top of the cart. During an interview, on [DATE], at 9:17 a.m., Licensed Practical Nurse (LPN) Employee E3 confirmed that the medication cart was left unlocked and unattended. Review of manufacturer recommendations for Novolog (a type of insulin, used to treat elevated blood sugar) revealed that once opened, "a vial may be kept...for up to 28 days." Observation of drug storage on Gardens B, on [DATE], at 9:55 a.m., revealed a multi-dose vial of Novolog with a date opened of [DATE], six days past the expiration date. During an interview on [DATE], at 9:55 a.m., LPN Employee E5 confirmed that the Novolog vial was expired and should have been discarded. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited [DATE].