Every finding on record at Souderton Mennonite Homes

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to maintain clinical records that were complete for three of six sampled residents. (Resident 4, 5, 43)Findings include:Review of the facility policy entitled, Pressure Ulcer Prevention Program, last reviewed January 2, 2026, revealed that a Skin Analysis Evaluation or Pressure Ulcer Potential Assessment would be completed weekly using the Point of Care Skin Evaluation task. Once weekly nursing staff were to complete a visual inspection of the resident's body and document the findings on the medical record.Clinical record review revealed that Resident 4 had diagnoses that included diabetes with foot ulcer and pressure induced deep tissue damage. On March 13, 2026, the physician ordered for staff to complete a weekly skin evaluation and to document a new evaluation in the evaluations tab weekly. Review of the clinical record revealed no completed weekly skin evaluations since March 14, 2026. Clinical record review revealed that Resident 5 had diagnoses that included hemiplegia (profound weakness or paralysis on one side of the body), squamous cell carcinoma of skin (skin cancer), and disorder of trigeminal nerve (a painful disorder of a nerve in the face). Review of the care plan revealed that the resident was at risk for skin breakdown with an intervention to monitor irritation and/or breakdown. Review of Resident 5's Weekly Skin Evaluation Task revealed a lack of documentation to support that the evaluation was completed on January 14, 2026, February 25, 2026, and March 11, 2026. Clinical record review revealed that Resident 43 had diagnoses that included thalassemia (an inherited blood disorder where the body doesn't produce enough hemoglobin leading to anemia), anxiety, and hypertension. Review of the care plan revealed that the resident was at risk for skin breakdown with an intervention to monitor for irritation and/or breakdown. Review of Resident 43's Weekly Skin Evaluation Task revealed a lack of documentation to support that the evaluation was completed on March 12 and 19, 2026. A nurse's note on March 23, 2026, revealed the resident had a deep tissue injury (soft tissue damage from pressure and/or shear) on the left heel. Review of the Resident's Weekly Skin Evaluation/Skin Problem Task revealed a lack of documentation to support that the evaluation was completed after March 23, 2026, when the deep tissue injury was first identified. In an interview on April 1, 2026, at 10:43 a.m., the Director of Nursing confirmed that there was no documented evidence that the residents' weekly skin evaluations were completed per facility policy. 28 Pa. Code 211.5(f) Medical records. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included a history of falls, muscle weakness, and lack of coordination. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident used a motorized wheelchair. Review of a therapy Discharge summary dated [DATE], revealed that the resident required distant supervision when using his motorized wheelchair outdoors. Further review of the clinical record revealed that the resident left the nursing unit daily to visit with his wife in another level of care in the building and staff were aware. Review of the care plan revealed that the resident was non-compliant with requesting staff supervision to use his motorized wheelchair outside. In an interview on October 27, 2025, at 10:57 a.m. the Director of Nursing confirmed that the resident was not compliant with requesting supervision with use of his motorized wheelchair outdoors. There was a lack of documented evidence that the facility developed an individualized care plan to meet the resident's need for supervision and implemented interventions to address his continued non-compliance with notifying staff when he desired to leave the building. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of two sampled residents who required adaptive equipment with meals. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included Parkinson's disease, dementia, and dysphagia. Review of the care plan revealed that the resident was at risk for nutrition problems with an intervention for adaptive equipment. The intervention was for staff to provide a partitioned scoop dish on blue Dycem (non-slip material that prevents objects from slipping), and weighted utensils for all meals. On March 18, 2025, from 12:15 p.m. through 12:30 p.m., and on March 19, 2025, from 12:10 p.m. through 12:20 p.m., Resident 6 was observed in the dining room without a partitioned scoop dish, blue Dycem, and weighted utensils. In an interview on March 20, 2025, at 9:27 a.m., the Director of Nursing confirmed that the resident should have received the partitioned scoop dish, blue Dycem, and weighted utensils. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 18 sampled residents. (Resident 24) Findings include: Clinical record review revealed that Resident 24 had diagnoses that included congestive heart failure and hypertension. A physician's order dated May 6, 2024, directed staff to weigh the resident daily and to call cardiology with a three pound weight gain in one day or a five pound weight gain in one week. Review of Resident 24's Medication Administration Record (MAR) for February and March 2025, revealed that Resident 24 had more than a three pound weight gain on February 2, 18, 24, and 26, 2025, and March 3 and 16, 2025. There was no documented evidence to support that the cardiologist was notified of the weight gain on the aforementioned dates. Further review of Resident 24's clinical record revealed on January 24, 2025, the physician ordered staff to administer a medication (carvedilol) twice a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters mercury (mm/Hg) or if the resident's heart rate was less than 60. Review of the MAR for February and March 2025 revealed that staff administered the medication on February 23 and 24, 2025, and March 17, 2025, when Resident 24's SBP was less than the ordered parameters. In an interview on March 20, 2025, at 9:37 a.m., the Director of Nursing confirmed that there was no documented evidence that the cardiologist was notified of the weight gain and the medication was administered outside of the ordered parameters. CFR(s) 483.25 Quality of Care Previously cited 4/4/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for one of five newly hired employees. (E2) Findings include: A review of the facility policy entitled, Resident Abuse or Suspected Abuse, dated January 8, 2025, revealed that the facility was to conduct screenings for all potential hires. This included license/registration verification. A review of the facility policy entitled, Employment Procedures 2.07, dated January 8, 2025, revealed that the facility was to check references for all potential hires. Employee 2 (E2) had been working in the facility as a Registered Nurse since January 21, 2025, a reference check was not completed until March 3, 2025, and an inquiry to the state licensure board was not completed until March 19, 2025. In an interview on March 20, 2025, at 11:12 a.m., the Director of Nursing confirmed there was no documented evidence that a reference check and the license/registry verification were done prior to start of employment. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess significant weight loss for one of two sampled residents at risk for weight loss. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included Alzheimer's disease, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of mini nutrition assessments dated December 28, 2023, and March 27, 2024, indicated that the resident was at risk for malnutrition. On October 5, 2023, the resident weighed 175.3 pounds (lbs.). On November 6, 2023, the resident weighed 164.2 lbs., which reflected a significant weight loss of 6.3%. There was no evidence that a dietitian assessed or addressed the significant weight loss until December 1, 2023. On January 8, 2024, the resident weighed 167.6 lbs. On February 5, 2024, the resident weighed 156.4 lbs., which reflected a significant weight loss of 6.6%. There was no evidence that a dietitian assessed or addressed the significant weight loss until February 19, 2024. In an interview on April 4, 2024, at 10:16 a.m., Dietitian 1 confirmed that the significant weight loss was not assessed or addressed in a timely manner. 28 Pa Code 211.12(3)(5) Nursing services.

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that catheter care and services were consistently provided for one of one sampled residents with an indwelling urinary catheter. (Resident 47) Findings included: Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia (enlarged prostate), urinary tract infection, and retention of urine. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and had an indwelling urinary catheter. Review of Resident 47's current care plan revealed that the resident had an indwelling catheter with an intervention to follow up with the urologist. In an interview on April 2, 2024, at 12:01 p.m., Resident 47 stated staff did not assist him consistently with catheter care. On November 22 and 27, 2023, the nurse practitioner documented that the resident was to have follow-up with the urologist and that staff was to assist the resident with catheter care every shift. On February 14, 2024, the nurse practitioner again documented that the resident was to follow-up with the urologist for further evaluation. Review of the catheter care task documentation from March 5, 2025 through April 3, 2024, revealed three shifts with missing documentation, 18 shifts documented as not applicable, and one shift documented as not completed. There was also a lack of documentation to support that Resident 47 had been seen by the urologist in a timely manner as recommended by the nurse practitioner. In an interview on April 4, 2024, at 11:22 a.m., the Director of Nursing confirmed that there was no documentation to support the urinary catheter care had been consistently completed and that Resident 47 had not seen by a urologist in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to implement physician's orders and follow bowel protocol for one of 18 sampled residents. (Resident 44) Findings include: Review of the facility policy entitled, Bowel Management, last reviewed January 8, 2024, revealed that staff on all shifts were to monitor a resident's bowel movements and take action to prevent complications of constipation and/or fecal impaction. The resident's bowel movements were to be charted daily in the clinical record. Staff were to administer an oral laxative for no bowel movement in nine shifts. If ineffective, staff were to administer a suppository the following shift. If the suppository was ineffective, staff were to administer an enema on the following shift. Clinical record review revealed that Resident 44 had diagnoses that included muscle weakness and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of the care plan revealed the resident had a history of constipation and staff were to administer bowel protocol medications as needed. Review of physician's orders dated February 10, 2024, directed staff to administer magnesium hydroxide suspension (an oral laxative) as needed for no bowel movement in nine nursing shifts, a Dulcolax suppository as needed if an oral laxative was ineffective, and an enema as needed if the Dulcolax suppository was ineffective. An additional physician's order dated February 19, 2024, directed staff to administer a bisacodyl suppository as needed for constipation. Review of documentation and medication administration records for March and April 2024, revealed no evidence that the resident had a bowel movement March 5 through 8 (12 shifts), March 10 through 13 (12 shifts), March 21 through 25 (15 shifts), and March 28 through April 2 (18 shifts). There was no documentation to support that physician's orders and facility policy for bowel management were implemented to address Resident 44's constipation/lack of bowel movements on the identified dates/shifts. In an interview on April 4, 2024, at 11:07 a.m., the Director of Nursing confirmed that staff did not implement the physician's orders or follow bowel protocol per the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and interview, it was determined that the facility failed to post pertinent names, addresses, and phone numbers of the Office of the State/County Long-Term Care Ombudsman Program in an area that was accessible to all residents and resident representatives. Findings include: Observation on the first day of the survey, April 2, 2024, revealed that the information to contact the Ombudsman was posted on the upper/top part of a bulletin board on the way to the main dining room on the nursing unit. The information was not at eye level nor was it accessible at eye level for someone who utilized a wheelchair. During a group interview on April 3, 2024, at 11:05 a.m., five of five alert and oriented residents, R3, R14, R40, R46 and R47, stated that they were aware that there was an Ombudsman Program: however, they did not know where the information was regarding how to contact the Ombudsman if they needed assistance from that particular advocacy agency. In addition, Resident 14 stated that she had outdated information about the Ombudsman and did not know who the current Ombudsman was for the facility. 28 Pa. Code 201.18(b)(d) Management.

Based on observation, it was determined that the facility failed to ensure that the facility environment remained free of accident hazards in the shower room. (Spa 3665) Findings include: During multiple observations of the shower room from May 16, 2023, at 11:50 a.m., to May 17, 2023, at 12:55 p.m., a cabinet was unlocked and contained a package of disposable razors, shaving cream, deodorant, barrier cream, body lotion, anti-itch cream, a hairdryer and toothpaste. There was no locking mechanism on the door to the shower room to prevent a resident from entering the room. In an interview on May 16, 2023, at 1:00 p.m., the Director of Nursing stated that there were eight residents that resided on the nursing unit that were ambulatory and cognitively impaired. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adequate treatment and services to increase range of motion or prevent further decrease in range of motion for one of four sampled residents with impaired range of motion. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive staff assistance for activities of daily living, and had limited range of motion of one upper extremity. There was a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 15 revealed that the left hand was held in a fist and the splint was not applied as ordered (between meals) on June 8, 2021, at 10:36 a.m. and June 9, 2021, at 10:45 a.m. and 1:15 p.m. through 1:28 p.m. In addition, the resident was observed out of bed in her chair and was not wearing the hip abduction brace as ordered on June 8, 2021, from 10:36 a.m. through 12:40 p.m. and on June 9, 2021, at 10:45 a.m. and 1:15 p.m. through 1:28 p.m. During an interview while observing Resident 15 on June 9, 2021, at 1:15 p.m., a physical therapist (PT 1) confirmed that the resident required the left hand splint and hip abduction brace as ordered by the physician. At this time, both pieces of equipment were located on top of the resident's bed side cabinet. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store medications on one of three nursing units. (Rambler Unit) Findings include: Review of facility policy entitled, Disposal of Medications and Medication related supplies, dated (MONTH) 2019, revealed that staff were to ensure all unused, unwanted, and all non-returnable medications were to be removed from their storage area and secured until destroyed. Observation in the Rambler Medication room on (MONTH) 20, 2019 at 11:02 a.m., revealed that there was one bottle of Digest Smart Hi Potency tablets with an expiration date of (MONTH) 2019 and five [MEDICATION NAME] AG wound dressings that expired in (MONTH) 2019. In an interview on (MONTH) 20, 2019, at 3:15 p.m., the Director of Nursing confirmed that expired medication supplies should have been removed during monthly audits. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE]

Based on clinical record review and review of incident reports, it was determined that the facility failed to provide adequate supervision and assistance in order to prevent falls for one of four sampled residents who were at risk for falls. (Resident 37) Findings include: Clinical record review revealed that Resident R37 had [DIAGNOSES REDACTED]. Review of the fall risk evaluation dated (MONTH) 5, 2019, revealed that the resident was at a high risk for falls, had a history of [REDACTED]. The Minimum Data Set assessment dated (MONTH) 26, 2019, indicated that the resident had memory impairment, exhibited physical, verbal and other types of behavior, utilized a wheelchair and had a history of [REDACTED]. The assessment further indicated that the resident required assistance from staff for activities of daily living including transfers and toileting. Review of the current care plan identified that the resident was at risk for falls due to a [DIAGNOSES REDACTED]. Review of nursing documentation dated (MONTH) 1, 2019, revealed that the resident had increased agitation between 1:00 p.m., and 1:30 p.m Further review of behavior monitoring sheets revealed that on (MONTH) 2, 2019, the resident was noted as being anxious all day. The resident was yelling help, help let me go back there (in her room ), between 2:00 p.m., and 6:00 p.m On (MONTH) 3, 2019, the behavior monitoring documentation revealed that between 2:00 p.m., and 6:00 p.m., the resident had been yelling out during supper help, help. Review of a medication management assessment from a certified nurse practioner dated (MONTH) 1, 2019, revealed that Resident 37 had a [DIAGNOSES REDACTED]. The assessment further indicated that the resident had increased afternoon activity, wandering about the unit, unable to focus on activities and anxiety. Review of an incident report dated (MONTH) 4, 2019, at 4:00 p.m., revealed that the resident had propelled herself into her room and attempted to toilet herself. A loud thud was heard and the resident was then observed in her bathroom sitting against the door which had been closed. The incident report further indicated that the resident had been restless and had been attempting to ambulate independently. Review of an incident report dated (MONTH) 5, 2019, at 2:00 p.m., revealed that the resident had again fallen and was observed on the floor next to her bed. Review of an incident report dated (MONTH) 7, 2019, at 2:00 p.m., revealed that the resident had again been found on the floor in her room and that the resident had been attempting to transfer herself into bed. The facility failed to provide adequate supervision and assistance in order to prevent a resident's repeated falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/28/18

Based on clinical record review and staff interview, it was determined that the facility failed to assess and document the status of a pressure ulcer for one of four sampled residents with pressure ulcers. (Resident 38) Findings include: Interview with the Director of Nursing, on (MONTH) 21, 2019, at 12:35 p.m., revealed that when a resident develops a pressure ulcer, staff was to notify the wound nurse and physician. Staff was to assess pressure ulcers weekly. Clinical record review revealed that Resident 38 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the ongoing care plan revealed that the resident was at risk for skin breakdown and had a history of [REDACTED]. Review of the nursing notes revealed that on (MONTH) 22, 2019, the resident's left upper thigh was noted to have a new open area measuring 2 centimeters (cm) x 0.5 cm. On (MONTH) 4, 2019, her coccyx wound was noted to have reopened and there was no assessment of the wound at that time. There was no further documentation to support weekly assessments of the wounds were completed and that the wound care nurse and physician were notified of the wounds in accordance with the care plan. In an interview on (MONTH) 22, 2019, at 12:40 p.m., the Director of Nursing confirmed that there was no further documentation to support that Resident 38's pressure ulcers were assessed weekly and that the wound care nurse and physician were notified. 28 Pa Code 211.10(a)(d) Resident care policies. 28 Pa Code 211.12 (d)(1)(5) Nursing services. Previously cited 12/28/18

Based on clinical record review and interview, it was determined that the facility staff failed to shampoo a resident's hair and provide his scheduled showers in accordance with the resident's preference for one of 22 sampled residents. (Resident 211) Findings include: Clinical record review revealed that Resident 211 was admitted on (MONTH) 27, 2019, had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 23, 2019, indicated that the resident was able to make his needs known and required extensive assistance from staff for personal hygiene and bathing. The resident reported during an MDS assessment on (MONTH) 5, 2019, that it was very important to him to be able to choose between a shower and a bed bath, or sponge bath. In the above mentioned interview with the resident, he also expressed it is his preference to have a shower and wash his hair. Review of the current care plan revealed that staff were to assist with daily hygiene and grooming. In an interview on (MONTH) 20, 2019 at 11:02 a.m., Resident 211 stated that he had his hair washed two to three times and only showered three times during his entire stay at the facility. Review of clinical documentation revealed that the resident's scheduled shower days were Mondays and Thursdays. Further review revealed that from (MONTH) 27, 2019 through (MONTH) 19, 2019, the resident had not received showers or had his hair washed on thirteen occasions out of the 19 scheduled shower days. In an interview on (MONTH) 20, 2019 at 3:15 p.m., the Director of Nursing confirmed that the resident's medical condition did not preclude him from receiving showers and that there was no documented evidence that the resident had his hair washed on the thirteen occasions. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/28/18

Based on clinical record review and observation, it was determined that the facility failed to ensure that a resident's dignity was promoted for one of 22 sampled residents. (Resident 37) Findings include: Clinical record review revealed that Resident 37 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 13, 2019, indicated that the resident had memory impairment and required extensive assistance from staff for activities of daily living that included dressing, toileting and grooming. Review of the current care plan revealed the resident required extensive assistance from staff for activities of daily living related to dementia and general muscle weakness. Observation on (MONTH) 19, 2019, at 10:05 a.m., revealed that Resident 37 was in her wheelchair in a common area near the nurse's station. Resident 37 was dressed in a hospital gown. Her hair had not been combed and her nail beds were dirty. Resident 37 remained in this common area until 11:35 a.m., and she had been restless in her chair between 10:05 a.m., and 11:35 a.m., and had been repeatedly asking to go to the bathroom. Observation from 12:00 p.m., through 1:00 p.m., revealed Resident 37 was in the dining room and her hair had still not been combed and she was still dressed in a hospital gown. Throughout both observations, there were staff, visitors and residents in the common area and in the dining room. Pa. Code 201.29(j) Resident rights.

Based on clinical record review and observation, it was determined that the facility failed to implement and develop comprehensive care plans for two of 18 sampled residents. (Residents 25, 33) Findings include: Clinical record review revealed that Resident 25 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 26, (YEAR), indicated that the resident required extensive assistance from staff for most activities of daily living including eating and had a history of [REDACTED]. An intervention since (MONTH) (YEAR), was for staff to have the resident up out of bed, washed and dressed and placed by the nursing station at 7:00 a.m. Review of a nursing note dated (MONTH) 20, (YEAR), at 7:25 a.m., revealed that the resident was noted to be on the floor in her bedroom. Review of the incident report revealed that the resident was observed at 7:25 a.m., crawling on the floor facing the bathroom in her bedroom. The facility failed to implement the intervention to have the resident up and out at the nurses station by 7:00 a.m. In addition, Resident 25 also had a current care plan for altered nutrition due to [MEDICAL CONDITION] and difficulty with self feeding. There was an intervention for staff to provide extensive assistance to the resident at meals for eating. Resident 25 was observed on (MONTH) 26, (YEAR), from 12:00 p.m., through 1:00 p.m., in the dining room at a table with her food in front of her The resident was observed sleeping and staff was not assisting her to eat. Clinical record review revealed that Resident 33 was admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED]. Review of nursing notes dated (MONTH) 25, (YEAR), indicated the resident was admitted with STAPH (infection) in the left lower extremity wound. A nursing note dated (MONTH) 15, (YEAR), indicated that the resident [MEDICAL CONDITION] to the left lower extremity and was receiving an antibiotic intravenously. A nursing note dated (MONTH) 23, (YEAR), indicated that the resident continued on an antibiotic for the infection. There was no care plan developed with interventions to identify the area of infection. In an interview on (MONTH) 28, (YEAR), at 11:54 a.m., the Director of Nursing confirmed that the facility had failed to develop a specific care plan with interventions to address the area of infection of the left lower extremity at the surgical site. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/9/17

Based on observation, clinical record review and staff interview it was determined that the facility failed to ensure that physician's orders were implemented for one of two sampled residents receiving oxygen therapy. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had [DIAGNOSES REDACTED]. On (MONTH) 10, (YEAR), the physician ordered oxygen to be dispensed to the resident via nasal cannula at a rate of two liters per minute. On (MONTH) 26, (YEAR) at 12:04 p.m., the resident's oxygen was observed at 1 liter per minute, below the physician's ordered rate of two liters per minute. Subsequent observations at 1:32 p.m., and 1:52 p.m., revealed the oxygen was at 3 liters per minute which is above the physician's ordered rate of two liters per minute. In an interview on (MONTH) 26, (YEAR) at 1:52 p.m., the Director of Nursing confirmed that the resident's oxygen setting was not at the rate ordered by the physician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 11/09/17

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement physician's orders for one of 18 sampled residents. (Resident 33) Findings include: Clinical record review revealed that Resident 33 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated (MONTH) 5, (YEAR), indicated that the resident was alert and oriented and required extensive assistance from staff for most activities of daily living including dressing. On (MONTH) 20, (YEAR), a physician ordered for staff to apply a tubi-grib sleeve to her left arm in the morning and remove at bedtime. A nursing note dated (MONTH) 20, (YEAR), indicated that the resident had a dressing to her left forearm due to weeping of serous fluid on her arm. Observation on (MONTH) 26, (YEAR), at 12:15 p.m., 1:15 p.m., and 2:00 p.m., revealed that the resident was dressed and seated in a chair near the nurse's station. The resident did not have the tubi-grip on her left arm in place and her left hand appeared [MEDICAL CONDITION]. Observation again on (MONTH) 28, (YEAR), at 9:30 a.m., revealed that the resident was dressed and lying in bed without the tubi-grip on her left arm. Resident stated my left hand has been swollen. In an interview on (MONTH) 28, (YEAR), at 10:52 a.m., RN1 stated that the tubi-grip was to be in place on her left arm to reduce the [MEDICAL CONDITION] as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 11/9/17

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services in order to restore bladder function for two of six sampled residents with urinary incontinence. (Residents R23, R29) Findings include: Clinical record review revealed that Resident R23 had [DIAGNOSES REDACTED]. There was no documented evidence that the facility had identified the type of urinary incontinence or provided the resident with a specific toileting program in order to attempt to restore the resident's bladder function. Clinical record review revealed that Resident R29 had [DIAGNOSES REDACTED]. The MDS assessments dated July 21, 2017, and October 19, 2017, indicated that the resident had memory impairment, required extensive assistance from staff to use the toilet and was frequently incontinent of urine. There was no documented evidence that the facility had identified the type of urinary incontinence or provided the resident with a specific toileting program in order to attempt to restore the resident's bladder function. In an interview on November 8, 2017, at 1:15 p.m., the Director of Nursing confirmed that there was no documented evidence that the type of incontinence or a specific toilieting program had been identified for the aforementioned residents. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.