Every finding on record at Shenango Presbyterian Seniorcare

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one of 12 residents reviewed (Resident R7). Findings include: No facility policy was provided. Resident R7's clinical record revealed an admission date of 5/06/26, with diagnoses of pleural effusion (an abnormal buildup of excess fluid in the space between your lungs and chest wall), necrotizing fasciitis (a bacterial infection that destroys tissue beneath the skin), malignant neoplasm of prostate (prostate cancer), and neoplasm of bone (bone cancer). Resident R7's clinical record revealed he/she was transferred to the hospital on 5/15/26. Resident R7's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/13/26, at 3:00 p.m. the Director of Nursing confirmed that Resident R7's clinical record lacked evidence that required documents were communicated to the hospital when transferred on 5/15/26. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c.3)(2) Resident rights

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to maintain resident dignity for one of two residents reviewed with a catheter (tube inserted into the bladder to drain urine) (Resident R17). Findings include: Review of Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movements, and often includes tremors), presence of right artificial hip joint, altered mental status, benign prostatic hyperplasia (a condition that alters the ability to urinate leading to infections), dysphasia (impairment of speech production resulting from brain disease or damage) and urinary tract infection. Upon request, the facility was unable to produce a policy regarding the care of urinary catheters and catheter bags Observations on 9/20/2023, at 10:45 a.m. and 2:45 p.m., revealed Resident R17's urinary catheter bag was uncovered and easily visible to to anyone who entered the room or pass by the room from the corridor. During an interview and observation on 9/20/2023, at 3:00 p.m. the Director of Nursing confirmed that Resident R17's urinary catheter bag should always be covered to maintain privacy/dignity for the resident. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records, observations, and resident, resident representative, and staff interviews, it was determined that the facility failed to assure their call bell system was functional and within reach for one of 12 residents reviewed (Resident R6). Findings include: Review of Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included [CONDITION(S)] (a disorder of the central nervous system that affects movement, often including tremors), [CONDITION(S)] of knee (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), obesity, and asthma. Review of the Quarterly Minimum Data Set (MDS-periodic assessment of resident care needs), dated 9/29/22, revealed that Resident R6 was alert and oriented with a BIMS (Brief Interview for Mental Status) score of 13/15. A review of Resident R6's care plan dated 7/12/22, stated a goal as Ask and encourage me to use my call light or request assistance for toileting. A care plan dated 2/12/21, related to Resident R6 at risk for skin breakdown stated, I need to keep a call light within reach. Observations on 10/04/22, at 9:30 a.m. and 10/5/22, at 3:05 p.m. revealed that Resident R6's call bell was wrapped and hung on the wall behind Resident R6. A tap bell was observed on Resident R6's bedside table but was not within Resident R6's reach. Observation on 10/06/22, at 2:55 p.m. revealed that Resident R6's tap bell was pushed several times and no staff responded during the time of observation from 2:55 p.m. through 3:10 p.m. An interview with Nursing Assistant (NA) Employee E1 in the hallway adjacent to Resident R6's room on 10/06/22, at 3:11 p.m. revealed that the tap bell was not heard by staff. NA Employee E1 indicated that Resident R6 is to push the tap bell to alert staff for assistance, but NA Employee E1 confirmed he/she did not hear Resident R6's tap bell minutes earlier. Resident R6's room is located at the end of a hallway. An interview on 10/05/22, with Resident R6's spouse, revealed that the tap bell is pushed often, but no staff respond due to not hearing the tap bell. Resident R6's spouse then indicated he/she goes to the nurse's station to alert staff of Resident R6's need for staff assistance. During an interview on 10/07/22, at 2:30 p.m. the Director of Nursing confirmed that Resident R6's call bell should not have been wrapped and hung on the wall and should have been always within his/her reach. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of 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 one of five residents reviewed for unnecessary medications (Resident R13). Findings include: Review of Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, high blood pressure, and [CONDITION(S)] (a brain disorder that causes unintended or uncontrollable movements). Review of Resident R13's clinical record revealed physician's order dated 4/28/22, for [MEDICATION(S)] (medication used to treat anxiety) 0.5 milligrams (mg) every 6 hours PRN for anxiety for 13 days; physician's order dated 5/10/22, for [MEDICATION(S)] 0.5 mg every 6 hours PRN for anxiety for 28 days; physician's order dated 6/7/22, for [MEDICATION(S)] 0.5 mg po (by mouth) every 6 hours PRN for anxiety for 34 days; and physician's order dated 7/11/22, for [MEDICATION(S)] 0.5 mg po every 6 hours PRN for anxiety indefinitely. Review of the May 2022 Medication Administration Record (MAR) for Resident R13 revealed that the PRN [MEDICATION(S)] was used seven 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 of non-pharmacological interventions attempted prior to the administration of the PRN [MEDICATION(S)] for seven of the seven times the [MEDICATION(S)] was utilized in May 2022. Review of the June 2022 MAR for Resident R13 revealed that the PRN [MEDICATION(S)] was used twelve times between 6/1/22, and 6/30/22. Review of the June 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 twelve of the twelve times the [MEDICATION(S)] was utilized in June 2022. Review of the July 2022 MAR for Resident R13 revealed that the PRN [MEDICATION(S)] was used nine times between 7/1/22, and 7/31/22. Review of the July 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 nine of the nine times the [MEDICATION(S)] was utilized in July 2022. Review of the August 2022 MAR for Resident R13 revealed that the PRN [MEDICATION(S)] was used nine times between 8/1/22, and 8/31/22. Review of the August 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 nine of the nine times the [MEDICATION(S)] was utilized in August 2022. Review of the September 2022 MAR for Resident R13 revealed that the PRN [MEDICATION(S)] was used 18 times between 9/1/22, and 9/30/22. Review of the September 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 18 of the 18 times the [MEDICATION(S)] was utilized in September 2022. Review of the October 2022 MAR for Resident R13 revealed that the PRN [MEDICATION(S)] was used one time between 10/1/22, and 10/7/22. Review of the October 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 one of the one times the [MEDICATION(S)] was utilized in October 2022. During an interview on 10/7/22, at 2:28 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN [MEDICATION(S)] 56 of the 56 times it was administered between 5/1/22, and 10/7/22, for Resident R13. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy, observations, review of clinical records and staff interview, it was determined that the facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment according to physician orders [REDACTED]. Findings include: Resident R6's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R6's physician orders [REDACTED]. Observations on 4/22/19, at 12:03 p.m. revealed Resident R6's oxygen concentrator unit dated as cleaned 3/27/19, a period of 26 days. The filters on both sides of the concentrator had a build up of white dust & debris. Resident R18's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Observation on 4/22/19, at 11:50 a.m. revealed Resident R18's oxygen concentrator unit dated as cleaned 4/06/19, a period of ten days. The filters on both sides of the concentrator had a build up of white dust & debris. During an interview on 4/22/19, at 12:15 p.m. the Director of Nursing, confirmed that Residents R6 and R18's oxygen concentrators were not cleaned as per the ordered frequency and they both had a build up of dust/debris in the filters. The facility policy entitled Oxygen Therapy dated 10/12/18, revealed that the nasal cannulas and masks will be changed every two weeks; date the cannula or mask when changed; oxygen supply tubing will be changed monthly. Date tubing when changed. Humidifier bottles (bottle of distilled water attached to the oxygen concentrator to moisten the oxygen before it goes to the patient) will be changed monthly. Date the humidifier bottle when changed. The filter on the oxygen concentrator is washed with soap and water every two weeks. Resident R28's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Observation on 4/22/19, at 12:13 p.m. revealed an oxygen concentrator in Resident R28's room. The oxygen tubing was not dated and the concentrator filter was covered with a build-up of white dust and debris. During an interview on 4/22/19, at 12:30 p.m. Registered Nurse Employee E4 confirmed that the oxygen tubing was not dated and that the filter needed cleaned. Resident R21's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observation of Resident R21 on 4/22/19, at 1:44 p.m. revealed an oxygen concentrator in Resident R21's room. The oxygen humidifier bottle and oxygen tubing were not dated. During an interview on 4/22/19, at 2:34 p.m. the Director of Nursing confirmed that the oxygen humidifier bottle and the oxygen tubing were not dated. 28 Pa. Code 211.5(f)(h) Clinical records Previously cited 5/25/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/25/18

Based on observations, review of facility policy and staff interview it was determined that the facility failed to properly follow hand hygiene procedures during the administration of medications for three of 16 residents (Residents R16, R81, and R82). Findings include: The current facility policy entitled, Infection Control Manual indicated that hands must be washed with soap and water after removal of gloves and before and after resident contact. Observation on 4/22/19, at 3:55 p.m. revealed that Licensed Practical Nurse (LPN) Employee E5 administered an eye drop to Resident R82, removed gloves and did not wash his/her hands after removal of gloves. Observation on 4/22/19, at 4:05 p.m. revealed that LPN Employee E5 administered three oral medications to Resident R81, had resident contact and did not wash his/her hands before and after administering the oral medications. Observation on 4/22/19, at 4:58 p.m. revealed that LPN Employee E5 administered one oral medication to Resident R16, had resident contact and did not wash his/her hands before and after administering the oral medication. During an interview at 4:10 p.m., LPN Employee E5 confirmed that he/she did not follow proper hand hygiene procedures and did not wash his/her hands before and after administering medications with resident contact and after removing gloves. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/25/18

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to assure physician orders [REDACTED]. Findings include: The facility policy Resident Rights-Advance Directives POLST Resuscitation Code Status dated [DATE], revealed that the facility would respect the right of each person served to participate in decisions concerning his/her care and have the right to accept or refuse medical care and treatment. Resident R18's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R18's POLST dated [DATE], revealed that Resident R18 requested Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after [MEDICAL CONDITION]), Attempt Resuscitation, Limited Additional Interventions. Current physician orders [REDACTED]. During an interview on [DATE], at 10:30 a.m. the Director of Nursing confirmed that Resident R18's physician order [REDACTED]. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited [DATE] 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE] 28 Pa. Code 211.10(c) Resident care policies

Based on observations, review of clinical records, facility policy and the Skilled Nursing-Bed and the Long-Term Care Facility Resident Assessment User's Manual (guide to complete Minimum Data Sets (MDS - periodic assessment of resident care needs)), and staff interview, it was determined that the facility failed ensure that MDS assessments accurately reflected the resident's status for one of 14 residents (Resident R24). Findings include: The facility policy entitled Skilled Nursing-Bed Rail, dated 10/18/17, indicated that bedrails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). Resident R24's clinical record revealed an admission date of [DATE], [DIAGNOSES REDACTED]. to assist with self positioning. An assessment of the rails dated 3/27/18, indicated that Resident R24 could safely use the rails and the bed was assessed to have no zones of entrapment. Observations on 5/23/18, 11:30 a.m. revealed quarter rails on Resident R24's bed that were level with the mattress on the upper sides of the bed. During an interview at the time of the observation, Resident R24 stated that the facility requested to remove the rails stating they could be dangerous, but Resident R24 stated they're just the opposite, I can move in bed better and indicating that they didn't prevent movement of his/her legs out of bed. The Long Term Care Facility Resident Resident Assessment User's Manual, dated (MONTH) (YEAR), revealed that the intent of Section P, related to Restraints, was to determine whether or not an item listed in section P0100 (bedrail, trunk or limb restraint or other) is a physical restraint; was used during the 7-day look-back period; and code the frequency of use that the resident was restrained by any of the listed devices during the 7-day look-back period. Section P defined a restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Section P of Resident R24's Quarterly MDS, dated [DATE], indicated that Resident R24's bedrails were coded as meeting the definition of a restraint and used on a daily basis during the seven day look-back period. During an interview on 5/24/18, at 3:30 p.m. the Director of Nursing confirmed that Resident R24's bed rails were coded as a restraint on the current MDS, were applied to assist movement, and that they weren't assessed or monitored as a restraint. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/07/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 9/19/17, 4/07/17

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to ensure that a lap buddy was assessed as the least restrictive device for one of three residents (Resident R11). Findings include: Resident R11's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/11/18, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. and personal hygiene. The MDS also indicated that Resident R11 sustained two falls without injury since the prior assessment and used a restraint in a chair/out of bed on a daily basis. On 5/22/18, at 4:04 p.m. Resident R11 was observed seated at the central nurse station in a wheel chair with a lap buddy (a padded removable tray fitted in the front of a chair) in place. Resident R11's current physician orders, dated 5/23/18, included an order for [REDACTED]. The original Physical Device Evaluation/Reduction Plan form, dated 3/05/18, indicated that Resident R11 was not able to consistently remove the lap buddy; was used due to an unsteady gait, a recent fracture/sprain or amputation and poor safety awareness; and that the device enabled/increased independence, allowed for nutrition/hydration, and enabled participation in activities otherwise could not. The evaluation also indicated the device restricted the resident's freedom of movement, meeting the form's definition as a restraint. The evaluation lacked reference to prior less restrictive interventions/devices utilized or documentation to support that the lap buddy was the least restrictive device. Resident R11's Interdisciplinary Notes, identified falls on 3/04/18 (found on the floor) and on 3/05/18 (fell in dining room), followed by an emergency room visit. Interdisciplinary Notes dated 3/07/18, indicated that a lap buddy was in place on Resident R7's wheel chair. Interdisciplinary Notes did not reference rationale for the use of the lap buddy over other devices, or other interventions or less restrictive devices attempted prior to the institution of the lap buddy. During an interview on 5/24/18, at 3:30 p.m. the Director of Nursing indicated that Resident R11's lap buddy was instituted due to repeated falls, met the definition of a restraint and that other prior, less restrictive measures attempted were not reflected in the clinical record. 28 Pa. Code 201.18(b)(1) Management Previously cited 9/19/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 9/19/17, 4/07/17

Based on review of clinical records and staff interview, it was determined that the facility failed to document the rationale for continuing an order for [REDACTED]. Findings include: Resident R11's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/11/18, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R11's current physician orders [REDACTED]. During an interview on 5/25/18, at 10:00 a.m. the Director of Nursing confirmed that the prn [MEDICATION NAME] order exceeded 14 days and was not evaluated for ongoing use by the physician. 28 Pa. Code 211.10(d)(1)(5) Nursing services Previously cited 9/19/17, 4/07/17

Based on observation, review of clinical records and staff and family interviews it was determined that the facility failed to revise care plans to reflect the current condition of two of 14 residents reviewed (Resident R11 and R7). Resident R11's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/11/18, revealed an admission date of [DATE]; [DIAGNOSES REDACTED]. into the bladder for the collection of urine). Resident R11's Interdisciplinary Notes indicated that Resident R11 had a urinary catheter present on admission that was removed on 1/05/18. Resident R11's current nursing care plans included a problem related to an alteration in elimination related to use of a Foley (brand name) catheter. Observations on 5/22/18, at 3:53 p.m., revealed Resident R11 seated in the central lounge area sleeping in a chair without a urinary catheter present. During an interview on 5/25/18, at 10:20 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that Resident R11's care plan was not updated to reflect the removal of the urinary catheter in (MONTH) (YEAR). Resident R7's Quarterly MDS, dated [DATE], revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. During an interview on 5/22/18, at 1:42 p.m. Resident Family Member RF7 indicated that Resident R7 had a history of [REDACTED]. Resident R7's clinical record included a Suspected UTI (Urinary Tract Infection) SBAR (Situation, Background, Assessment, Recommendation) form dated 4/20/18, indicating that Resident R7 had developed foul smelling urine, was urinating frequently and was incontinent. The Request for Orders section of the form included an order for [REDACTED]. Resident R7's current nursing care plans did not reference the new urinary tract infection or the instituted medical and nursing treatment to address the infection. During an interview on 5/25/18, at 10:20 a.m., RNAC Employee E1 confirmed that Resident R7's care plan was not updated to include measures to address the UTI. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/07/17 28 pa. Code 211.12(d)(1)(5) Nursing services Previously cited 9/19/17, 4/07/17

Based on review of clinical records, and staff interview it was determined that the facility failed to ensure that a written summary of the baseline care plan including medications, dietary instructions and initial goals was provided to the resident and their representative for one of nine newly admitted residents (Resident R126). Resident R126's Admission Minimum Data Set (MDS - periodic assessment of resident care needs), dated 5/21/18, revealed an admission date of [DATE], [DIAGNOSES REDACTED]. Resident R126's clinical record revealed a baseline care plan, but lacked evidence that Resident R126 and his/her representative were provided with a care plan summary including medications and dietary instructions. During an interview on 5/25/18 at 9:40 a.m., the Director of Nursing confirmed that newly admitted residents were not provided with a care plan summary. 28 Pa. Code 201.18(1) Management Previously cited 9/19/17 28 Pa. Code 211.11(e) Resident care plan

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to comprehensively assess an injury and obtain physician ordered treatment in a timely manner for one (closed record) of three residents reviewed (Resident CR1). Findings include: The facility policy Resident Incident Report dated 10/12/16, indicated that following an incident, defined as any occurrence which is not consistent with the routine care of a particular resident, the nature, location, time and date of the incident should be recorded in the Nurses Notes and any action taken. The policy further indicated if the incident is of a serious nature the physician should be called immediately, or if not of a harmful nature the physican can be called during reasonable business hours. Resident CR1's Admission Minimum Data Set (MDS - periodic assessment of resident care needs), dated 6/15/17, revealed an admission date of [DATE], [DIAGNOSES REDACTED]. Resident CR1's Interdisciplinary Notes, dated 7/06/17, revealed that Resident CR1 was found on the floor of the facility dining room,with the wheelchair next to him/her. The note further indicated that Resident CR1 had no complaints of pain or discomfort and was able to move all extremities with the noted limitation of movement on the left side related to a history of a stroke. The note lacked any evidence of injury. A fall investigation document, dated 7/06/17, related to Resident CR1's fall in the dining room indicated that Resident CR1 had sustained a skin tear to the left forearm and small laceration above the left eye. There was no description of the wounds and the section of the form related to notification of the primary care provider was blank. The clinical record included a correspondence sheet submitted to Resident CR1's primary care provider, dated 7/08/17 (two days after the fall), requesting a treatment order for a skin tear described as new development since recent fall. Resident CR1's Interdisciplinary Notes, dated 7/07/17, included reference to dressing dry/intact to left arm no further bleeding from laceration above left eye; and a note dated 7/08/17, with a reference to skin tear to left upper forearm with dressing in place . moderate amount of bleeding noted to dressing . dressing change completed . skin tear is large . length is 8.5 centimeters (cm) by 6 cm (3.3 inches by 2.3 inches) . remaining skin flap is jagged in nature . area cleansed with NSS (normal saline solution), steri strips (tape devices to stabilize wounds of the skin) applied, non-adherent [MEDICATION NAME] pads x 2 and cling wrap applied. During an interview on 9/18/17, at 1:30 p.m. Registered Nurse Employee E1 confirmed that the clinical record lacked evidence of a comprehensive assessment of Resident CR1's wounds at the time of the fall and lacked evidence that physician orders [REDACTED]. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/07/17

Based on review of facility policies and clinical records and staff interview, it was determined that facility staff failed to notify the physician in a timely manner of a fall with resulting injury for one (closed record) of three residents reviewed (Resident CR1). Findings include: The facility policy Notification of Changes in Resident Status dated 10/12/16, indicated that nursing staff will notify the resident's physician within 24 hours of a change in condition including an accident involving the resident which results in injury. Resident CR1's Admission Minimum Data Set (MDS - periodic assessment of resident care needs), dated 6/15/17, revealed an admission date of [DATE], [DIAGNOSES REDACTED]. Resident CR1's Interdisciplinary Notes, dated 7/06/17, revealed that Resident CR1 was found on the floor of the facility dining room, with the wheelchair next to him/her. The note further indicated that Resident CR1 had no complaint of pain or discomfort and was able to move all extremities with the noted limitation of movement on the left side related to a history of a stroke. The note lacked documentation that the physician was notified of the fall. A fall investigation document, dated 7/06/17, related to Resident CR1's fall in the dining room indicated that Resident CR1 had sustained a skin tear to the left forearm and small laceration above the left eye. A section of the investigation form related to notification of the primary care provider was blank. Resident CR1's clinical record lacked evidence of physican notification related to the 7/06/17, fall with injuries until 7/08/17, two days later, when a correspondence sheet was faxed to Resident CR1's primary care provider, requesting a treatment option for a skin tear described as new development since recent fall. During an interview on 9/18/17, at 2:00 p.m. the Director of Nursing confirmed that the clinical record lacked evidence that Resident CR1's primary care provider was notified in a timely manner of the fall with resulting injuries sustained on 7/06/17. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 4/07/17

Based on review of clinical records and the Resident Assessment Instrument (RAI) User's Manual (provides direction for the completion of the Minimum Data Set (MDS) - periodic assessment of resident care needs) and staff interview, it was determined that the facility failed to document the required supporting date with the location of the clinical information related to the Care Area Assessment (CAA - potential areas of resident problems) for 9 of 10 residents (Residents R1 through R9). The findings include: The RAI User's Manual provides the instruction that the documentation related to the CAA's should indicate the basis for the care plan decision, why the finding requires an intervention, and the rationale for selecting specific interventions. For each triggered care area, the facility must indicate the date and location of where the information related to the CAA's can be found in the resident's clinical record. Resident R1's Annual MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R2's Significant Change MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R3's Annual MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R4's Admission MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R5's Annual MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R6's Admission MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R7's Admission MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R8's Annual MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. Resident R9's Annual MDS assessment dated [DATE], revealed that the CAA summary did not indicate the date of the supporting information within the clinical record that related to the CAA. During an interview on 4/7/17, at 9:05 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that the CAA summaries did not contain all the required information as related to the date of the supporting information from the resident records. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 6/10/16

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive, resident centered care plan related to pressure ulcers for one of 10 residents (Resident R7) and related to depression for one of 10 residents (Resident R5). Findings include: Resident R7's Admission Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/22/17, revealed an admission date of [DATE]; [DIAGNOSES REDACTED]. Section V of the MDS related to areas of care concern, revealed that pressure ulcers were an area of concern for Resident R7 and that a plan of care would be developed by the facility. The facility policy related to care plans, dated 10/12/16, revealed that assessment data would be utilized to develop plans of care that are I centered to address resident needs. Review of Resident R7's current plan of care related to pressure ulcers, indicated that I have a pressure ulcer, and included generalized approaches for adequate protein in the diet, avoiding skin-on-skin contact, keeping skin clean and dry, using pressure relieving devices and offering fluids. The care plan lacked evidence of approaches specific to Resident R7's pressure ulcers such as the number of pressure ulcers, their location, stage, or treatments and changes in treatment. During an interview on 4/06/17, at 12:30 a.m., Registered Nurse Employee E1 confirmed that the care plan lacked intervention related to the care and treatment of [REDACTED]. The admission record revealed that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R5's MDS dated [DATE], revealed that resident R5 received an antidepressant (drugs that are used in the treatment of [REDACTED]. Review of Resident R5's current plan of care related to depression, revealed no care plan for depression. During an interview on 4/7/17, at 10:35 a.m., Registered Nurse Employee E1 confirmed that Resident R5 should have had a care plan for depression. 483.21(b) Previously cited state deficiency 6/10/16 28 Pa. Code 211.5(f) Clinical records Previously cited 6/10/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 6/10/16

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to accurately assess and implement physician ordered treatment for [REDACTED]. Findings include: The facility policy entitled Skin Care Prevention Protocol, dated 10/12/16, indicated that residents with an open skin area would receive Remedy Olivamine [MEDICATION NAME] Skin Protectant Paste (a protectant zinc oxide paste with a higher thickness than other skin pastes) to compromised skin on a daily and prn (as needed) basis. Resident R7's Admission Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/22/17, revealed an admission date of [DATE]; [DIAGNOSES REDACTED]. Initial wound care documentation dated 3/16/17, revealed that Resident R7 had two pressure ulcers, one of the left buttock and one of the right buttock, that were assessed under the category section as full thickness (Stage III) skin loss. Descriptive documentation related to the the left and right buttock pressure ulcer under the same assessment indicated Stage II (partial thickness skin loss) and the treatment for [REDACTED]. physician progress notes [REDACTED]. The 3/16/17, assessment indicated the presence of a rash under the integumentary system, and the 3/22/17 and 3/27/17, integumentary sections were marked NL (normal) . Physician admission orders [REDACTED]. During an interview on 4/07/17, at 10:15 a.m., the Director of Nursing confirmed that Resident R7's pressure ulcers were Stage II on admission, not Stage III, that the clinical record lacked review or assessment of the pressure ulcers by the physician and that the physician orders did not include an order for [REDACTED].>28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 6/10/16

Based on review of clinical records and staff interview, it was determined that the facility failed to properly assess for self-administration of medications for one of 10 residents (Resident R4). Findings include: The admission record revealed that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that no formal assessment was completed to determine that it was safe for Resident R4 to self-administer medications. In addition, the care plan for self-administration of medications for Resident R4 lacked detail regarding the location of where medications will be administered. During an interview on 4/7/17, at 11:15 a.m., Registered Nurse Employee E1 confirmed that there was no formal assessment for self-administration of medications and the care plan did not state where the medication was to be administered. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/10/16

Based on review of clinical records and and staff interview, it was determined that the facility failed to adequately provide evidence to warrant the use of [MEDICAL CONDITION] (medications to treat mental disorders) medication for one of two closed records (Resident CR11) and failed to develop a care plan to address the [MEDICAL CONDITION] medication for one of two closed records (Resident CR11). The facility also failed to implement a gradual dose reduction (GDR-a gradual reduction of [MEDICAL CONDITION] medications in an attempt to achieve the lowest possible dose or possible discontinuation of the medication) for [MEDICAL CONDITION] drug for one of 10 residents (Resident R5). Findings include: Resident CR11's admission face sheet revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The facility Archived Daily Charting Details for November and December 2016 revealed one episode of Resident CR11 being upset/aggitated on 11/21/16, and one episode of screaming for no reason on 12/06/16. Interdisciplinary (ID) Notes for December 2016, revealed one episode of paranoid on behavior by Resident CR11 on 12/07/16, with subsequent orders for an antidepressant medication and for a psychiatry consult. Additional notes referenced some periods of confusion, pleasant and mostly compliant, cooperative with an ID note dated 12/16/16, that Resident CR11 was being treated for [REDACTED]. There was no further documentation regarding paranoid behavior or screaming. Resident CR11 was seen by the psychiatrist on 12/19/16, with the [MEDICAL CONDITION] medication, [MEDICATION NAME], ordered at 12.5 milligrams (mg) every evening (hs) for one week then to increase to 25 mg hs ongoing to address paranoia. Resident CR11 continued to receive [MEDICATION NAME] 25 mg through 2/04/17. Resident CR11's clinical record also lacked the development of a care plan to address the use of [MEDICATION NAME]. During an interview on 4/7/17, at 12:30 p.m. the Director of Nursing and Registered Nurse Assessment Coordinator respectively confirmed that there was a lack of detailed supporting evidence in the clinical record for the use of [MEDICAL CONDITION] medication and the lack of a care plan for the use of [MEDICATION NAME] for Resident CR11. The admission orders [REDACTED]. Review of the clinical record revealed that on 3/28/16, [MEDICATION NAME] 1 mg was discontinued at bedtime due to no [MEDICAL CONDITION] being documented since admission. On 5/9/16, [MEDICATION NAME] 1 mg was restarted at bedtime. The behavior flow records for Resident R5 revealed that there was no [MEDICAL CONDITION] noted until 5/9/16. On 5/9/16, Resident R5 was shown to have two occurrences of [MEDICAL CONDITION]; however, the clinical record lacked any notes detailing Resident R5's [MEDICAL CONDITION] behaviors. In addition, review of the clinical record lacked a second GDR attempt and lacked any justification from the physician why a second GDR would not be recommended. During an interview on 4/7/17, at 10:30 a.m. Registered Nurse Employee E1 confirmed that the clinical record lacked a second GDR or physician justification why a second GDR would not be recommended. 28 Pa. Code 201.14(a) Responsibility of license Previously cited 6/10/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 6/10/16

Based on review of clinical records and facility policies staff interview, it was determined that the facility failed to identify the type of incontinence that residents experienced for six of 10 residents (Residents R1, through R6) and failed to determine the type of behavior management toileting required for five of ten residents (Residents R1, R2, R3, R4, R5, and R6). The findings include: The Bowel and Bladder Assessment form completed by the facility presented a rating scale that indicated the following, either a resident was rated, fully incontinent or rated 18-24-initiate bowel and bladder program, 10-17- initiate habit toileting or prompted toileting or scheduled toileting based on individualized needs, and 0-9- initiate check resident every 2 hours and prn (as needed) to provide incontinence care with brief change. The quarterly Minimum Data set (MDS-periodic review of resident care needs), dated 3/23/16, revealed that Resident R1 was always incontinent. The bladder assessment lacked the type of incontinence that Resident R1 experienced. The 10/26/15, Bowel and Bladder Assessment form indicated that Resident R1 was rated at a 15, indicating to initiate habit, prompted or scheduled toileting. There was no evidence to indicate Resident R1's initiated toileting program or that the resident was currently always incontinent. The quarterly MDS, dated [DATE], revealed that Resident R2 was always incontinent The bladder assessment lacked the type of incontinence that Resident R2 experienced. The 9/09/15, Bowel and Bladder Assessment form indicated that Resident R2 was rated at a 11, indicating to initiate habit, prompted or scheduled toileting. There was no evidence to indicate Resident R2's initiated toileting program. There was no evidence to indicate Resident R2's initiated toileting program or that the resident was currently always incontinent. The quarterly MDS, dated [DATE], revealed that Resident R3 was always incontinent The bladder assessment lacked the type of incontinence that Resident R3 experienced. The 11/16/15, Bowel and Bladder Assessment form indicated that Resident R3 was rated at a 13, indicating to initiate habit, prompted or scheduled toileting. There was no evidence to indicate Resident R3's initiated toileting program. There was no evidence to indicate Resident R3's initiated toileting program or that the resident was currently always incontinent. The quarterly MDS, dated [DATE], revealed that Resident R4 was admitted to the facility on [DATE] and was always incontinent. The bladder assessment lacked the type of incontinence that Resident R4 experienced. The quarterly MDS, dated [DATE] revealed that Resident R5 was always incontinent. The bladder assessment lacked the type of incontinence that Resident R5 experienced. The 10/15/15, Bowel and Bladder Assessment form indicated that Resident R5 was rated at a 10, indicating to initiate habit, prompted or scheduled toileting. There was no evidence to indicate Resident R5's initiated toileting program or that the resident was currently always incontinent. The annual MDS, dated [DATE], revealed that Resident R6 was frequently incontinent. The bladder assessment lacked the type of incontinence that Resident R6 experienced. The 3/18/16, Bowel and Bladder Assessment form indicated that Resident R6 was rated at an 11, indicating to initiate habit, prompted or scheduled toileting. There was no evidence to indicate Resident R6's initiated toileting program. There was no evidence to indicate Resident R6's initiated toileting program. During an interview on 6/09/16 at 10:15 a.m., the Director of Nursing confirmed that the bladder assessments lacked the type of incontinence Residents R1 through R6 experienced and that the assessment did not identify which program (habit, prompted or scheduled) Residents R1, R2, R3 R5 and R6 were placed. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.