Every finding on record at St Joseph's Manor

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in the main kitchen, two of seven resident pantries (Green Valley and the Meadows), and one of seven resident dining service areas (Green Valley). Findings include:Observation during the tour of the main kitchen, the [NAME] Valley resident serving area, and the [NAME] Valley resident pantry on January 6, 2026, beginning at 10:15 a.m., revealed the following: In the main kitchen, the floor mixer was in use and had areas of peeled paint on the front and top of the motorhead above the mixing bowl. In the [NAME] Valley resident dining service area refrigerator, there were four cups of yogurt with a use-by date of January 2, 2026. In the [NAME] Valley resident pantry refrigerator there was a carton of milk with a use-by date of January 4, 2026, and one cup of yogurt with a use-by date of January 2, 2026.Observation of the Meadows resident pantry refrigerator on January 7, 2026, at 11:23 a.m., revealed one large carton of apple juice with a use-by date of December 10, 2025. There was a large carton of opened cranberry juice that was not dated. There was a container of five pancakes that was dated use-by January 5, 2026. In an interview on January 6, 2026, at 11:00 a.m., the Executive Chef confirmed that expired food products should have been discarded. CFR 483.60(i) Food Safety RequirementPreviously cited 2/13/2528 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 36 sampled residents. (Residents 4 and 13)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included fibromyalgia (widespread body pain and fatigue) and depression. Review of the MDS assessment dated [DATE], revealed that Sections P (Restraints and Alarms) incorrectly indicated that the resident used a restraint, but less than daily. There was no documentation in the clinical record that indicated Resident 4 used any type of restraint during the review period. Clinical record review revealed that Resident 13 had diagnoses that included peripheral vascular disease and chronic embolism. Review of the MDS assessment dated [DATE], revealed that Section N (Medications) incorrectly indicated that the resident was receiving an anticoagulant medication during the previous seven days. There was no documented evidence that Resident 13 had been administered an anticoagulant medication during the review period. In an interview on January 8, 2026, at 5:14 p.m., the Registered Nurse Assessment Coordinator confirmed that Residents 4 and 13's MDS assessments were inaccurate.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 36 sampled residents. (Residents 2, 102, and 245)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included muscle weakness, end stage renal disease, and depression. The Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 2 required maximum assistance with hygiene and self-care and had no cognitive impairment. Review of the care plan revealed that staff were to assist the resident with hygiene and self-care, including nail care on bath day and as necessary. On January 6, 2025, at 12:46 p.m., the resident was observed in his room. His nails were long and dirty. He stated that he preferred short clean nails and that staff had not offered to provide nail care recently. On January 8, 2026, at 11:50 a.m., the resident was observed in his wheelchair. His nails remained long and dirt was observed underneath them. He stated that staff had not offered to provide nail care during his last shower and he would like his nails cut. Clinical record review revealed that Resident 102 had diagnoses that included muscle weakness and depression. The MDS assessment dated [DATE], revealed that Resident 102 required partial assistance with hygiene and self-care and had no cognitive impairment. Review of the care plan revealed that staff were to assist with the resident's hygiene and self care, including nail care on bath day and as necessary. On January 6, 2026, at 2:26 p.m., the resident was observed sitting in his wheelchair. His nails were long and dirty. The resident stated that staff were to cut his nails regularly but had not offered to provide nail care recently despite his repeated requests for help. On January 8, 2026, at 11:45 a.m., the resident was observed sitting in his wheelchair. His nails remained long and dirty. He stated that staff had not offered to provide nail care in several weeks, that he was very frustrated, and that he would like his nails cut and cleaned. Clinical record review revealed that Resident 245 had diagnoses that included muscle weakness, lack of coordination, and hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) affecting the left non-dominant side. The MDS assessment dated [DATE], revealed that Resident 245 was dependent on staff for hygiene and self-care and had no cognitive impairment. Review of the care plan revealed that staff were to assist with the resident's hygiene and self-care, including nail care on bath day and as necessary. On January 6, 2026, at 12:35 p.m., the resident was observed sitting in his chair. His nails were long and jagged. In an interview at this time, the resident stated that staff had not offered to trim his nails and if offered, he would not refuse. On January 8, 2026, at 11:25 a.m., the resident was observed sitting in his chair. His nails remained long and jagged. In an interview on January 9, 2026, at 12:00 p.m., the Director of Nursing confirmed that nail care was to be done on shower days and as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for three of 37 sampled residents. (Residents 5, 29 and 201)684Based on a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for three of 37 sampled residents. (Residents 5, 29 and 201)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Alzheimer's Disease, hypertensive chronic kidney disease, and type II diabetes. A physician's order dated August 21, 2024, directed staff to administer a blood pressure medication (atenolol) one time a day. The physician ordered that staff not administer the medication if the resident's heart rate was less than 55 beats per minute. Review of Resident 5's Medication Administration Records (MAR) for October, November, and December of 2025, revealed that the staff administered atenolol once each in October and November, and twice in December when Resident's 5's heart rate was less than 55 beats per minute.Clinical record review revealed that Resident 29 had diagnoses that included hypertension (high blood pressure), chronic kidney disease, and heart disease. A physician's order dated August 21, 2025, directed staff to administer a blood pressure medication (amlodipine besylate ) one time a day. The physician ordered that staff not 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 135 millimeters of mercury (mm/Hg). Review of Resident 29's Medication Administration Records (MAR) for September, October, November, and December of 2025, and January of 2026, revealed that the staff administered amlodipine 20 times in September, 15 times in October, 18 times in November, 22 times in December, and four times in January when Resident's 29's SBP was less than 135mm/Hg.Clinical record review revealed that Resident 201 had diagnoses that included Alzheimer's Disease, hypertension, and type II diabetes. A physician's order dated July 18, 2023, directed staff to administer a blood pressure medication (carvedilol) one time a day. The physician ordered that staff not administer the medication if the resident's heart rate was less than 60 beats per minute or if their SBP was less than 110mm/Hg. Review of Resident 201's Medication Administration Records (MAR) for October, November, and December of 2025, revealed that the staff administered carvedilol twice each in October, November, and December when Resident's 201's SBP was less than 110mm/Hg. In an interview on January 9, 2026, at 12:10 p.m., the Director of Nursing confirmed medications were administered outside of parameters ordered by the physician for Residents 5, 29, and 201.42 CFR Part 483.25 Quality of Care.Previously cited 4/25/2528 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, observation, and staff interview, it was determined the facility failed to implement safety interventions for one of eight sampled residents at risk for falls. (Resident 15)Findings include: Clinical record review revealed that Resident 15 had diagnoses that included abnormality of gait and mobility, muscle weakness, and difficulty in walking. The Minimum Data Set assessment dated [DATE], revealed that Resident 15 required staff assistance for bed mobility and transfers. Review of facility documentation dated September 10, 2025, revealed the resident was found on the floor after rolling out of bed, with a new intervention to place falls mats on both sides of the bed. Review of the care plan identified that the resident was at risk for falls related to gait dysfunction with an intervention that staff were to place fall mats on both sides of the bed to prevent injury. Observations on January 6, 2026, at 11:45 a.m. and 2:00 p.m., and January 7, 2026, at 12:26 p.m., revealed that Resident 15 was in bed and there was no fall mat placed on the window side of the bed. In an interview on January 9, 2026, at 11:56 a.m., the Director of Nursing confirmed that floor mats should have been in place on both sides of the bed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to notify each resident's responsible party of a significant weight loss for two of eight sampled residents. (Residents CL1 and 3) Findings include: Review of the facility policy entitled, Weight Management Guidelines, dated January 6, 2025, revealed that nursing staff were to report unexplained significant weight changes to the family/responsible party. Clinical record review revealed that Resident CL1 had diagnoses that included Alzheimer's dementia and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was rarely understood. Review of the resident's weights revealed that on February 6, 2025, the resident weighed 178.6 pounds (lbs). On March 2, 2025, Resident CL1 weighed 167.8 lbs, which was confirmed with a reweigh on March 4, 2025. This reflected a six percent weight loss in one month. There was no documented evidence that Resident CL1's family/responsible party was notified of the significant weight loss. Clinical record review revealed that Resident 3 had diagnoses that included dementia and dysphagia. Review of the MDS assessment dated [DATE], revealed the resident was rarely understood. Review of the resident's weights revealed that on January 2, 2025, the resident weighed 138.8 lbs. On February 4, 2025, Resident 3 weighed 131.2 lbs. On March 4, 2025, Resident 3 weighed 131.4 lbs. This reflected a 5.4 percent weight loss between January and February that continued through March. There was no documented evidence that Resident 3's family/responsible party was notified of the significant weight loss. In an interview on April 25, 2025, at 4:21 p.m., the Administrator confirmed that there was no documented evidence that Residents CL1 and 3's families were notified of the significant weight loss, and they should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of eight sampled residents. (Residents 3 and 5) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypertension (high blood pressure). A physician's order dated March 12, 2025, directed staff to administer a medication (lisinopril) one time a day for hypertension. Staff was not to administer the medication if the resident's blood pressure (BP) was less than 110 over 65 millimeters of mercury (mm/Hg). Review of Resident 3's medication administration records (MARs) revealed that staff administered the medication one time in March 2025, and two times in April 2025, when the resident's BP was less than 110 over 65 mm/Hg. Clinical record review revealed that Resident 5 had diagnoses that included hypertension. On April 17, 2025, the physician ordered staff to administer a medicine (metoprolol tartrate) two times a day for hypertension. Staff was 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 100 millimeters of mercury (mm/Hg). Review of Resident 5's MARs revealed that staff administered the metoprolol tartrate four times in April 2025, when the resident's SBP was less than 100 mm/Hg. In an interview on April 25, 2025, at 3:40 p.m., the Administrator confirmed that the medication was administered outside the established parameters for Residents 3 and 5. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to store and serve foods in a sanitary manner in the dietary department to prevent the potential for foodborne illness. Findings include: Review of the facility policy entitled Food Storage, last reviewed March 8, 2024, revealed that food was to be stored immediately after receipt and maintained in a manner to prevent damage, spoilage, infestation, or bacterial contamination. Observation during the initial kitchen tour on February 11, 2025, at 10:00 a.m., revealed the following: There was debris on the bottom of the stand up ice cream freezer. There were four bins of dry goods that included white rice, flour, thickened liquid product, sugar and brown rice. The scoops for the dry goods were stored inside the bins on top of the dry goods. There was a container of whipped cream in a refrigerator that was not labeled or dated. In the dry goods storage room at 10:06 a.m, there was a bag of cereal that had been opened and re-sealed, but was not labeled or dated. There was also a bag of spaghetti and a bag of penne pasta that had been opened and re-sealed but was not labeled or dated. There was a bag of long grain rice that had been opened, had not been re-sealed and was not dated. There was a bag of tortilla chips that had been opened, was re-sealed, and was not dated. In the same dry goods storage room, there was a box of kosher salt that was opened and stored on a shelf on a rack that was not sealed or dated. There was a container of old bay seasoning on the same shelf that was opened, did not have a lid on it, and was not dated. In an interview on February 11, 2025, at 10:10 a.m., the Director of Dietary Dining Services stated that all food that had been opened was to be re-sealed, labeled, and dated. In addition, he stated that the scoops for the dry goods were not to be stored inside the dry storage bins. 28 Pa.Code 201.14(a) Responsibility of licensee.

Based on review of the facility assessment and dietary policies and procedures, it was determined that the facility failed to implement the facility wide assessment to ensure that there was an inventory of resources. These resources included an adequate supply of sustenance, food and beverages, in the event of an emergency/disaster for residents and staff. Findings include: Review of the facility assessment dated [DATE], revealed that the facility was to maintain and manage a documented inventory of resources that may be needed in an emergency. There was a reference in the facility assessment to the facility emergency preparedness plan. Review of the current, referenced emergency preparedness plan revealed, the facility was to ensure that adequate sustenance needs for residents and staff were to be available during an emergency. In addition, review of the policy entitled Food and Nutrition Disaster Plan, last reviewed March 8, 2024, revealed that the purpose was to allow for advance planning in possible emergency/disaster situations. The procedure involved preparedness that included ensuring that there was an inventory of food on hand including perishable and non-perishable food. The inventory was to include adequate supplies for all current service points and additional staff and visitors. Observations in the kitchen on February 11, 2025, at 10:15 a.m., and review of facility documentation regarding the emergency food supply list revealed that the required number of listed food items were not available per the facility par listing. In an interview on February 11, 2025, at 10:30 a.m. the general manager of the dietary department stated that the facility did not have the required listed food items per the facility par listing. In an interview on February 13, 2025, at 9:30 a.m., the Administrator stated that the facility did not have the required supply of food/beverages in the event of an emergency/disaster on hand in the building as per the facility assessment, emergency preparedness plan and the dietary policy and procedure. 201.14(a) Responsibility of Licensee 201.18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for three of 36 sampled residents. (Resident 73, 185, 446) Findings include: Clinical record review revealed that Resident 73 had diagnoses that included dementia and muscle weakness. The Minimum Data Set (MDS) assessment, dated January 10, 2024, indicated that the resident was cognitively impaired and required substantial assistance for toileting. A physician's order dated November 5, 2019, directed staff to administer 30 milliliters (ml) of a laxative (milk of magnesia) if the resident did not have a bowel movement in two days, and then an enema (Fleet's) the next day if the resident still had no bowel movement. A review of the documentation revealed that no bowel movements were recorded from January 17 through 22, and from January 24 through 30, 2024. According to the Medication Administration Record (MAR) there was no documented evidence that laxatives or enemas were given as ordered. Clinical record review revealed that Resident 185 had diagnoses that included a recent joint replacement, anxiety, and depression. The MDS assessment, dated January 6, 2024, indicated the resident was alert and oriented and required assistance for toileting. On January 2, 2024, the physician ordered that staff administer 30 ml of a laxative (milk of magnesia) if the resident did not have a bowel movement in two days, and then an enema (Fleet's) the next day if the resident still had no bowel movement. A review of the documentation revealed that no bowel movements were recorded from January 7 through January 11, from January 11 through January 16, from January 16 through January 21, and from January 25 through January 29, 2024. According to the MAR there was no documented evidence that laxatives or enemas were given as ordered. In an interview on February 2, 2024, at 11:25 a.m., the DON confirmed that staff failed to administer laxatives and enemas as ordered to Residents 73 and 185. Clinical record review revealed that Resident 446 was admitted to the facility on [DATE], and had diagnoses of a recent joint replacement, osteoarthritis, and chronic kidney disease. On the date of admission, the physician ordered that staff administer 650 milligrams (mg) of a pain medication (acetaminophen) every four hours as needed for pain, but not to exceed 3,000 mg in a 24-hour period. On January 25, 2024, the physician also ordered that staff administer 1,000 mg of acetaminophen every eight hours routinely for pain and hydrocodone-acetaminophen 5/325 mg every six hours as needed for severe pain. On January 27, 2024, the physician decreased the routine acetaminophen dose to 650 mg every eight hours. According to the MARs, Resident 446 received more than 3,000 mg of acetaminophen within a 24-hour period on January 27 and 28, 2024. In an interview on February 2, 2024, at 11:14 a.m., the DON confirmed that Resident 446 received over 3,000 mg of acetaminophen on January 27 and 28, 2024, and that this was in excess of the maximum ordered daily dose. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement and develop comprehensive care plans to meet the current needs of three of 35 sampled residents. (Residents 105, 126, 158) Findings include: Clinical record review revealed that Resident 105 had diagnoses of dementia, anemia, need for assistance with personal care, dysphagia (difficulty swallowing), and Vitamin D deficiency. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required supervision for eating. A review of the care plan revealed the resident was at risk for nutrition related to dementia and increased confusion and required assistance with cueing to eat. There was an intervention for staff to cut up the resident's food into bite-size pieces. On February 21, 2023, at 12:51 p.m., and again at 1:42 p.m. the resident was observed to have been served a sandwich for lunch and it was not cut into bite size pieces. The resident did not eat any of the meal. On February 22, 2023, at 12:32 p.m., the resident was again observed to have been served a sandwich for lunch and it was not cut into bite-size pieces. In an interview on February 23, 2023, at 10:46 a.m., the licensed nurse, LPN1, confirmed that there was an intervention for staff to cut up Resident 105's food into bite-size pieces as per care plan. Clinical record review revealed that Resident 126 had diagnoses that included depression. Review of the MDS dated [DATE], identified that the resident had been administered an antidepressant four days in the review period. According to the Care Area Assessment, the facility identified the resident's antidepressant drug use was a problem and an individualized care plan with interventions was to be developed. There was no care plan intervention to address the use of antidepressant medication for Resident 126. Clinical record review revealed that Resident 158 had diagnoses that included major depressive disorder. Review of the MDS dated [DATE], identified that the resident had been administered an antidepressant three days in the review period. According to the Care Area Assessment, the facility identified the resident's antidepressant drug use and mood state were problems and an individualized care plan with interventions was to be developed for each. There were no care plan interventions to address the use of antidepressant medication and mood state for Resident 158. In an interview conducted on February 23, 2023, at 10:23 a.m., the Director of Nursing confirmed that there were no care plan interventions developed to address the use of antidepressant medication for Residents 126 and 158 and the mood state for Resident 158. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review it was determined that the facility failed to notify the residents and the residents' representative(s) of the transfers and the reasons for the moves in writing upon transfer from the facility for five of five residents sampled who were transferred to the hospital. (Residents 59, 92, 136, 138, 166) Findings include: Clinical record review revealed that Resident 59 was transferred and admitted to the hospital on June 13, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 92 was transferred and admitted to the hospital on January 19, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 136 was transferred and admitted to the hospital on January 18, 2022, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 138 was transferred and admitted to the hospital on February 6, 2022, and March 1, 2022 after changes in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfers to the hospital. Clinical record review revealed that Resident 166 was transferred and admitted to the hospital on March 1, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately assess and manage pain, and failed to attempt non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for four of 37 sampled residents. (Residents 92, 118, 144, 161) Findings include: Review of the facility policy entitled Pain Assessment Guide, dated June 24, 2020, revealed that standardized pain assessment tools such as a ten-point pain numeric pain rating scale (0 indicating no pain and 10 indicating the worst pain imaginable), were to be completed with results documented daily on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review revealed that Resident 92 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Narcotic pain medication (Percocet) was ordered by the physican on August 18, 2020, for 5-325 milligrams (mg) every four hours as needed for pain. The resident also had a physician's order dated November 5, 2019, for a non-narcotic [MEDICATION(S)] (Tylenol) 325 mg give two tablets every four hours as needed for pain. Review of the Medication Administration Records (MARs) revealed that Resident 92 received the as needed narcotic 26 times during January 2021, 24 times during February 2021, and 27 times during March 2021, for pain ranging from three to eight on the standard numerical pain scale. She also received the non-narcotic pain medication one time in January 2021, for a pain level of seven. The physician's orders did not include parameters for the level of pain to direct administration of the as needed pain medications. In addition, there was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the as needed pain medication administration. Clinical record review revealed that Resident 118 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident experienced frequent pain with an intensity of seven on the ten-point pain scale. Narcotic pain medication (Percocet) was ordered by the physican on January 28, 2021, and again on February 11, 2021, for 5-325 mg every six hours as needed for pain. Review of the MARs revealed that Resident 118 received the as needed narcotic 53 times during February 2021, and 57 times during March 2021, for pain. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the as needed pain medication administration. Clinical record review revealed that Resident 144 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated February 18, 2021, indicated that the resident was understood and understands others clearly, received as needed pain medication in the past five days, and was not experiencing pain at the time of the interview. Narcotic pain medication (oxycodone hydrochloride) was ordered by the physican on February 26, 2020, for 5mg every six hours as needed for intractable pain. Review of the MARs revealed that the resident received the as needed pain medication 78 times in February 2021, and 82 times in March 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain when the as needed narcotic pain medication was administered. Clinical record review revealed that Resident 161 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated February 25, 2021, indicated that the resident was understood and understands others clearly, received as needed pain medication in the past five days, and experienced frequent pain. Care plan interventions included that the resident be repositioned to alleviate pain. Narcotic pain medication (oxycodone hydrochoride) was ordered by the physican on November 27, 2020, for five mg every six hours as needed for severe pain which was changed to the parameter of moderate pain on March 10, 2021. Review of the MARs revealed that the resident received the as needed pain medication 47 times in February 2021, and 50 times in March 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain when the as needed narcotic pain medication was administered. In an interview on April 2, 2021, at 11:39 a.m., the Director of Nursing confirmed that physician's orders were to include parameters for the administration of as needed pain medication and staff should have provided non-pharmacological interventions prior to the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain or improve activities of daily living (walking) for one of 37 sampled residents. (Resident 157) Findings include: Clinical record review revealed that Resident 157 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], the resident was cognitively impaired and required assistance from staff to walk. The current care plan indicated that the resident had limited physical mobility related to dementia. Goals were to maintain the current level of mobility and to increase the current level of mobility by walking to and from the dining room with her walker. Interventions included a restorative nursing program for walking up to 100 feet with a rolling walker and staff assistance. A physical therapy discharge summary noted that the resident was able to walk 40 feet with staff assistance on January 26, 2021, and that staff was trained on a restorative nursing program. Review of restorative nursing documentation from March 2, 2021, through March 30, 2021, revealed a lack of documentation to support that the resident was offered assistance to walk on 21 of 29 days. In an interview conducted on April 2, 2021, at 11:19 a.m., the nurse aide (NA4) assigned to Resident 157 was unaware of the resident's restorative walking program and reported that she did not assist her to walk. In an interview on April 2, 2021, at 11:35 a.m., the Director of Nursing confirmed that the assigned nurse aide is responsible to implement the restorative nursing program as directed by the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to implement safety measures for one of nine sampled residents who were at risk for falls. (Resident 81) Findings include: Clinical record review revealed that resident had diagnoses that included Alzheimer's disease, cerebral infarction, muscle weakness, and difficulty walking. The Minimum Data Set assessment dated , December 31, 2020, indicated the resident was cognitively impaired, did not transfer out of bed or walk, and was dependent on staff for transferring between surfaces. The care plan indicated the resident required extensive assistance of staff for transfers and an intervention was to utilize a stand lift and that was initiated January 14, 2021. A nursing progress note dated January 25, 2021, revealed that the resident had a fall. A review of the facility documentation revealed that the resident had a shower on January 25, 2021. The Nursing Assistant (NA) had the resident stand after her shower to finish dressing her. The resident became weak in the knees requiring her to be lowered to the floor and into a sitting position. The resident had to be transferred back to her wheelchair with extensive assistance of two staff. The NA failed to use the stand lift in accordance with the care plan. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receiving [CONDITION(S)] drugs were provided with behavioral interventions and/or that physician orders included a duration parameter for as needed [CONDITION(S)] medication for two of 37 sampled residents. (Residents 8, 37) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included dementia and depression and was ordered by the physician to receive psychoactive drugs, including the antipsychotic [MEDICATION(S)] at bedtime for behavioral and psychological symptoms of dementia and [MEDICATION(S)] HCl every six hours as needed for anxiety. The care plan identified that the resident had a behavioral disorder and there was a goal to reduce the need for antipsychotic medication. Interventions included to encourage the resident to verbalize feelings and to provide diversional activities. Review of February 2021, and March 2021, medication administration records (MARs) revealed that Resident 8 received the antipsychotic daily and the as needed medication for anxiety 12 times. There was a lack of documentation to support that behavioral interventions were provided to the resident. Clinical record review revealed that Resident 37 had diagnoses that included dementia, anxiety disorder, and depression and was ordered by the physician on August 2, 2020, to receive the psychoactive drug [MEDICATION(S)] daily every eight hours for anxiety and every 24 hours as needed for agitation. The care plan identified that the resident had a behavioral problem related to agitation. Interventions included for staff to explain procedures before starting care, to discuss and reinforce why behavior is inappropriate (when reasonable), to divert attention, and to praise improvement in behavior. Review of February 2021, and March 2021, MARs revealed that Resident 37 received the medication daily for anxiety and the as needed medication for agitation 30 times. There was a lack of documentation to support that behavioral interventions were provided to the resident. In addition, the physician's order dated August 2, 2020, did not include the duration for the as needed [CONDITION(S)] drug. In an interview on April 2, 2021, at 11:39 a.m., the Director of Nursing confirmed that behavioral interventions were to be provided to residents receiving psychoactive drugs and that there was a lack of documentation to support their implementation. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility policy, review of manufacturer's instructions, and observations it was determined that the facility failed to store medication in accordance with the facility policy on two of 12 medication carts. (Fourth floor A/B hall, Fourth floor C/D hall). Findings include: Review of the facility policy and procedure entitled Medication Storage in the Facility dated January 26,2021, revealed medications and biologicals are to be stored safely, secrurely and properly, following manufacturer's recommendations or those of the supplier. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall date the do not use after sticker on the medication. Observations of the fourth floor A/B medication cart on March 30,2021, at 10:35 a.m., revealed one bottle of [MEDICATION(S)] (eye drops) and [MEDICATION(S)] (inhaler) with no open or expiration date. The manufacturer's instructions for the above medications indicated that medications in use more than four weeks should be discarded. There was one Incruse (inhaler) with no open or expiration date. The manufacturer's instructions indicated that medication in use more than six weeks should be discarded. The cart also contained one vial of [MEDICATION(S)] (insulin) with no open or expiration date. According to manufacturer's instructions medication in use more than six weeks should be discarded. Observation of fourth floor C/D medication cart on March 30, 2021, at 11:00 a.m., revealed one vial of [MEDICATION(S)] (insulin) with no open or expiration date. According to manufacturer's instructions medication in use more than 30 days should be discarded. There were three vials of Novolog (insulin) with no open or expiration date. According to manufacturer's instructions medication in use more than 28 days should be discarded. The cart also contained two bottles of [MEDICATION(S)] (eye drops) with no opened or expiration date. The manufacturer's instructions indicated that medication in use more than four weeks should be discarded. 28. Pa. Code 211.9 (h)(i) Pharmacy services 28. Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that hospice orders were clarified and complete for one of twelve sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a mandated assessment of resident care needs) annual assessment dated [DATE], revealed that the resident had severe cognitive impairment and was dependent on staff to meet all care needs. Review of the clinical record revealed a hospice consult dated November 11, 2019, with recommendations that included to discontinue all labs, except blood glucose checks. Review of nursing documentation dated November 16, 2019, revealed that LPN1 spoke with the resident's physician and inaccurately reported hospice recommendations that included discontinuing all labs and blood glucose checks. Based on the information provided to the physician by LPN1, the physician gave additional orders to discontinue the resident's insulin regimen. LPN1 failed to observe standards of clinical practice as referenced in section 21.145(a) Functions of the LPN of Title 49, Professional and Vocational Standards. In an interview on December 12, 2019, at 1:40 p.m., the Administror and Assistant Director of Nursing confirmed that LPN1 failed to provide the physician with accurate information to reflect resident care needs based on hospice recommendations. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 6/5/18

Based on clinical record review and staff interview, it was determined that the facility failed to designate a member of the interdisciplinary team to be responsible for coordinating resident care needs between the facility and hospice providers for nine of twelve sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9) Finding include Clinical record review revealed that nine of thirteen sampled residents (Resident 1,2, 3, 4, 5 ,6, 7, 8, 9) were receiving hospice services at the facility. During an interview on December 12, 2019, at 2:10 p.m., the Administrator and Assistant Director of Nursing stated that facility did not have a staff member designated to coordinate care between the facility and hospice service providers. 28 Pa. Code 211.5 (f) Clinical records. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 6/18/19

Based on clinical record review, observation, review of facility policy, and staff interview, it was determined that the facility failed to ensure that the interdisciplinary team assessed a resident's capabilities to self-administer medications for one of 35 sampled residents. (Resident 173) Findings include: Review of the policy entitled, Self-Administration of Medications, dated (MONTH) 13, (YEAR), indicated that a resident who desired to self-administer medications would be assessed by the interdisciplinary team to determine if the practice was safe. Based on this assessment, it would be determined if the resident was also safe to store medication at bedside. Clinical record review revealed that Resident 173 had [DIAGNOSES REDACTED]. On (MONTH) 27, 2019 at 11:05 a.m., Resident 173 was observed in her room with two tubes of pain relieving medicated cream (Aspercreme) on her bedside table in a basket. Resident 173 stated she was able to self-administer the Aspercreme and I keep it in my basket and rub it on my feet for pain. On (MONTH) 30, 2019, at 10:15 a.m., the two tubes of Aspercreme remained in the basket at the bedside in the resident's room. Review of physician's orders [REDACTED]. Further review of the clinical record documention revealed a lack of evidence to support that the interdisciplinary team completed an assessment of the resident's ability to self-administer the medication prior to the use of the Aspercreme at the bedside. In an interview on (MONTH) 30, at 1:30 p.m., the Director of Nursing confirmed that the interdisciplinary team had failed to complete the assessment for the resident to safely self-administer the Aspercreme and to keep the medication at her bedside in accordance with facility policy. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/5/18 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/5/18 28 Pa. Code 201.29(a)(d) Resident Rights.

Based on observation, review of facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to provide supervision and monitoring of food temperatures related to microwave use on seven of eight nursing units and left medication unattended for one of 41 residents reviewed (Resident R43.) This failure to monitor food temperatures of food reheated in microwaves put residents at high risk for a burn injury, and resulted in an Immediate Jeopardy situation. Findings include: During an observation on (MONTH) 31, (YEAR), at approximately 12:13 p.m. Employee E44 (dietary worker) was observed heating up a pasta entree that was brought in by Resident R38's daughter. The pasta entree was carried from the food serving pantry on Unit 2A and placed in the microwave by Employee E44 which was in the dining room on Unit 2A. This surveyor walked over to the microwave after observing Employee E44 place the food in microwave. When this surveyor walked over to the microwave, the cooking time on the microwave was one minute and twenty-two seconds. After the microwave stopped, Employee E44 took the plate out of the microwave and placed the plate in front of Resident R38 who proceeded to eat the food. An interview on (MONTH) 31, (YEAR), at 11:30 a.m. with Resident R88's representative revealed that there was a microwave available in the 2 Bridge Unit's activity room that was available for use to residents and their families at any time without supervision from facility staff. An observation of the 2 Bridge Unit activity room after the interview revealed a microwave on the counter that was plugged in and operational. No staff were present in the room at the time of the observation. During a continued observation on (MONTH) 31, (YEAR), at 1:45 p.m. of the 2 Bridge Unit activity room revealed the same microwave on the counter that was plugged in and operational. No staff were present in the room at the time of the observation. A staff member then briefly entered the room to refill Styrofoam cups and stated that, residents can help themselves to anything in the room. After refilling the cups, the staff member left the room. During an interview with Employee E44, (host/hostess) on 2A at approximately 2:50 p.m. on (MONTH) 31, (YEAR), Employee E44 confirmed that Resident R38 asked her to heat up the pasta entrée that her daughter brought in for her so that she could eat it for lunch. She confirmed that she did not test the temperature of the food after she took it out of the microwave and gave it to the resident to eat. During an interview with Employee E47 (Food Service Worker) on 2A at approximately 2:53 p.m. on (MONTH) 31, (YEAR), regarding the process and procedures for heating food in the microwave for residents, Employee E47 reported that when a resident makes a request to have their food heated in the microwave, Employee E47 stated that she uses a thermometer to test the temperature of the food prior to giving it to the resident. During an interview on (MONTH) 31, (YEAR), at approximately 3:00 p.m. with Employee E19, (Licensed Practical Nurse), revealed that the microwaves on the 2 Bridge Unit are self-serve and that resident's families often bring in food. During a continued interview with Employee E19 employee stated that she, doesn't know the process for reheating residents' food. During an interview with Employee E46 (Nurse Aide) on 2A at approximately 3:00 p.m. on (MONTH) 31, (YEAR), regarding the process and procedures for heating food in the microwave for resident, Employee E46 reported that when a resident makes a request to have their food heated in the microwave, Employee E46 reported that she heats it up in the microwave until she thinks it is hot enough, and then she gives it to the resident to eat. When asked if she takes the temperature of the food, Employee E46 stated that she does not take the temperature. She stated, there are no thermometers up here. The thermometers are downstairs in the kitchen. During an interview on (MONTH) 31, (YEAR), at approximately 3:10 p.m. with Employee E18 (Unit Manager), revealed that there was no policy available related to the reheating of residents' food and that there were no thermometers available on the 2 Bridge Unit for checking food temperatures. A continued interview with Employee E18 revealed that resident families often use the microwave to heat up food, unsupervised by staff. Employee E18 stated that staff are, unaware of when residents or families use the microwave, and that since the use of the microwaves is unsupervised that any resident could be at risk [MEDICAL CONDITION] there is no method in place for checking the temperature of foods reheated in the microwaves by residents or their families. During an interview on (MONTH) 31, (YEAR), at approximately 3:14 p.m. with Employee E38 (Nurse Aide), employee stated that, staff are not allowed to heat residents' food in the microwave. Continued interview with Employee E38 revealed that resident family members use the microwave to reheat food and confirmed that there were no thermometers available on the 2 Bridge Unit for checking food temperatures. During an interview with Employee E48 (Activity Staff) on 2A on (MONTH) 31, (YEAR), at approximately 3:15 p.m. regarding the process and procedures for heating up food in the microwave for resident, Employee E48 reported that when a resident makes a request to have their food heated in the microwave, Employee E48 reported that she would ask the nurse to makes sure that the resident was able to have the food, and then if the nurse stated that resident could have the food, she would warm the food in the microwave and then give the food to the resident to eat. When Employee E48 was asked if she would do anything else prior to giving the food to the resident, she stated that she would put gloves on. During an interview on (MONTH) 31, (YEAR), at approximately 3:16 p.m. with Employee E39 (Registered Nurse), employee stated that she uses the microwave on the 2 Bridge Unit to reheat residents' food. Employee E39 confirmed that there were no thermometers available on the 2 Bridge Unit for checking food temperatures. During a continued observation on (MONTH) 31, (YEAR), at approximately 3:23 p.m. of the 2 Bridge Unit revealed a door labeled Pantry that was open and unattended. No staff were present in or near the pantry at the time of the observation. Inside the pantry were two microwaves, one sitting on the counter and the other mounted on the wall, and an oven. Both the microwave on the counter and the oven were able to be activated/turned on by this surveyor. During an observation on Thursday, (MONTH) 31, (YEAR), at 1:50 p.m. on unit 4A revealed a stainless-steel microwave and a conventional oven built into the wall in the 4A dining area, as well as a white free-standing microwave plugged in and operational on the counter in the 4A dining area. There were a few residents in the area and Employee E23 (Food Service Worker), who was still cleaning up from lunch. During an interview with Employee E23 at 1:50 p.m. on Thursday, (MONTH) 31, (YEAR), it was confirmed that the microwave and oven built into the wall in the 4A dining area and the free-standing microwave on the counter were all operational. She demonstrated that both wall units were working and turned them on using the buttons on the front of the units. She also demonstrated that the white microwave on the counter was also operational. When asked what to do if a family brought in food from outside to be reheated for a resident, she stated that the nurse aide had to heat it up. Review of facility policy, Use and Storage of Food Brought to Patient/Residents from Outside Guidelines, stated, If the prepared food must be reheated before service, it may be reheated in a microwave available on the resident's unit. These foods may not be brought into, or reheated in, the Dining Services Department. The FDA Food Code requires that all leftover for foods that have been precooked or leftover food as an ingredient be reheated to 165 degrees F. Thermometers will be available on resident units and must be sanitized between each use. There was no statement about checking the temperature of the reheated food before serving to a resident to avoid burning the resident. During an interview with Employee E24 (3A Unit Manager), at 2:50 p.m. on Thursday, (MONTH) 31, (YEAR), revealed when asked how many residents could possibly ambulate or self-propel to the microwave and heat something and accidently burn themselves, he/she confirmed that the census on 3A was 49 residents, and that 4 of the residents were bed fast, and another 35 residents would be unable to get to the microwave on their own, leaving 14 residents out of 49 on unit 3A at risk of getting burned by improper use of the unattended microwaves. During a further interview with Employee E24, it was confirmed that when food was brought in from outside the facility and it is reheated, the nurse should use a thermometer to check to make sure the food is not too hot and thought that 135 degrees would be appropriate. Employee E24 pulled a thermometer out of her shirt pocket as she was explaining how she would take the temperature of the food. During an interview with Employee E25 (Licensed Practical Nurse) at 3:00 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated, she stated that staff were not to be involved and the family could heat the food if they wanted to do that. When asked what to do if a resident was eating and wanted the food heated, she stated she would go to the dietary staff and ask for hot food. Asked about heating coffee, she said that there was a coffee machine on the unit which dispensed coffee at the appropriate temperature and that she would just get a new cup hot coffee from the machine. When asked further about reheating food she insisted that she had never done this and had never been asked to heat food by any family members. During an interview with Employee E26 (Nurse Aide) at 3:05 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated, he stated that if a family brings in food, I would just heat it up and check the temperature. When asked how to check the temperature, he stated he did not know where to get a thermometer. During an interview with Employee E27 (Dietary Aide) at 3:07 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated, she stated that it was up to the family to reheat the food and only the family could give it to the resident. During an interview with Employee E34 (Dietary Aide) at 3:10 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated, he stated that he would heat the food, but not take the temperature of the food. During an interview with Employee E35 (Nurse Aide) at 3:12 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated stated he would tell them to go to the microwave themselves, or he would give it to the kitchen staff so they could take the temperature. During an interview with Employee E36 (Nurse Aide) at 3:15 p.m. on Thursday, (MONTH) 31, (YEAR), revealed that when asked what to do if a family brought in food from outside to be reheated she stated that we are not allowed to heat the food, and that she would guide them to the microwave or direct them to the nurse manager if she was not sure what to do. During an interview with Employee E40 (3 Bridge Charge Nurse), who was a Registered Nurse, at 3:00 p.m. on Thursday, (MONTH) 31, (YEAR), revealed when asked how many residents could possibly ambulate or self-propel to the microwave and heat something and accidently burn themselves, she confirmed that the census on 3 Bridge was nine residents and that they would be unable to get to the microwave on their own. During a further interview with Employee E40, confirmed that when food is brought in from outside the facility and if they want to reheat it, the staff would take it to kitchen to reheat it, and would make sure that the food is not too hot. Employee E40 said that she had not seen anybody heating food in the microwave in 3 Bridge Unit. During an interview with Employee E41 (4 Bridge Unit Manager), who is a Registered Nurse, at 3:30 p.m. on Thursday, (MONTH) 31, (YEAR), revealed when asked how many residents could possibly ambulate or self-propel to the microwave and heat something and accidently burn themselves, he/she confirmed that the census on 4 Bridge was 26 residents and that 24 residents would be unable to get to the microwave on their own. During a further interview with Employee E41, it was confirmed that she had not seen anybody heating food in the microwave in 4 Bridge Unit. During an observation on (MONTH) 31, (YEAR), of the 4a Nursing Unit revealed the Nursing Unit contained two microwaves in the resident's dining room that were accessible to resident's and staff. During an interview on (MONTH) 31, (YEAR), at 3:01 p.m. with Employee E15 (Nurse Aide), she stated that she uses the microwave to heat up resident food and drinks and she confirmed that she does not use a thermometer to test the food and drink. During an interview on (MONTH) 31, (YEAR), at 3:10 p.m. with Employee E11 (Registered Nurse), she identified 23 residents as being able to ambulate and self propel their wheelchairs and not being cognitively intact and potentially in harm when using the microwave creating an immediate jeopardy situation. The following was a list that was compiled after interviewing staff, as mentioned above, of the nursing units with the number of unattended microwaves and the census with the number of residents at risk of injury due [MEDICAL CONDITION] unsupervised heating of food on each unit: 1 Bridge no unattended microwaves. 2 Bridge had 2 unattended microwaves, a census of 30 with 3 residents at risk. 3 Bridge had 1 unattended microwave, a census of 9 and no residents at risk. 4 Bridge had 1 unattended microwave, a census of 26 with no residents at risk. 2A had one built in microwave/oven combo, a census of 49 with 14 residents at risk. 3A had one built in microwave/oven combo, a census of 49 with 14 residents at risk. 4A had one built in microwave/oven combo, a census of 45 with 21 residents at risk. There was a total of 256 residents on units with unattended/unsupervised microwaves with 75 of those residents at risk of burning themselves due to improper use of the microwave. Based on these findings, Immediate Jeopardy to the health and safety of the residents on the above nursing units was identified to the Nursing Home Administrator at 4:35 p.m. on Thursday, (MONTH) 31, (YEAR). The facility's immediate corrective action plan, Thursday, (MONTH) 31, (YEAR), at 6:30 p.m. included: 1. Protection of all residents at risk: All microwaves will be taken out of service. 2. How did we remove the danger: All microwaves will be removed from units; microwaves that cannot be removed have been disarmed on the electrical panel which is not near the microwave; Out of service signs will also be placed on these units. 3. Protection of all residents: The above steps will protect all residents. 4. Department heads and unit managers have received immediate education that microwaves are no longer in service. 5. Create a new microwave reheating policy to address heating food. 6. Education of all departments on reheating food prior to placing microwaves back in service. 7. In summary, microwaves have been removed and disarmed and will not be placed back in service until all staff in all departments have been educated. The Immediate Jeopardy was lifted on Friday, (MONTH) 1, (YEAR), at 2:00 p.m. after it was verified that the corrective action plan was fully implemented. The facility failed to provide supervision and monitoring of food temperatures related to microwave use on seven of eight nursing units. Review of Resident R43's clinical record revealed physician orders which included Oyster Calcium 500 mg (Calcium Supplement), [MEDICATION NAME] 250 mg (Benefical Bacteria and Yeast), Slow-mag 20 mg (Magnesium Supplement), Thera-m tablet (multi vitamin with mineral), and [MEDICATION NAME] 320 mg tablet (anti-hypertensive medication. Further, review of Resident R43's clinical record revealed no physician order or documentation that the Resident was assessed to self administer medications. During an observation on (MONTH) 31, (YEAR), at 10:03 a.m. of Resident R43's room revealed medication stored in a souffle cup were on the Resident's overbed table without staff supervision. During an interview on (MONTH) 31, (YEAR), at approximately 10:30 a.m. with Employee E11 (Registered Nurse), she confirmed that the medications were left unattended in the resident's room and she confirmed that the resident is not supposed to have medications left unattended in her room. The facility failed to provide adequate supervision related to having medications left unattended in a Resident's room. The facility failed to ensure each resident received adequate supervision to prevent accident hazards and failed to ensure the resident environment remained free of accident hazards related to unattended/unsupervised microwaves on seven of eight nursing units and staff having the training to safely heat food in the microwave oven, which placed residents at risk for potential harm identifying an Immediate Jeopardy situation. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 08/29/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/30/18, 07/10/17, 04/21/17, 08/29/16 28 Pa. Code 201.18(a) Management Previously cited 07/10/17 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 04/30/18, 07/10/17, 04/21/17, 08/29/16 28 Pa. Code 201.18(b)(3) Management Previously cited 04/30/18, 07/10/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/10/17, 04/21/17, 08/29/16 28 Pa. Code 211.12(c) Nursing services Previously cited 04/30/18, 04/21/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/30/18, 07/10/17, 04/21/17, 08/29/16 28 Pa Code 211.12(d)(3) Nursing services Previously cited 04/30/18, 08/29/16

Based on a review of clinical records, facility documentation and interviews with staff, it was determined the facility failed to provide the appropriate diet for one of 12 residents reviewed that resulted in actual harm to that resident (Resident (CL1) who expired following a choking episode. Findings include: Resident CL1 was admitted to the facility on (MONTH) 19, (YEAR), at approximately 14:30 (2:30 PM) from an acute care hospital. The resident's [DIAGNOSES REDACTED]. that supply blood to the heart muscle become hardened and narrowed) and hypertension (high blood pressure). Documentation identified the resident as alert and oriented. Review of the resident's clinical record revealed that the resident was alert and oriented. A review of the resident's clinical record revealed that on (MONTH) 19, (YEAR), at approximately 17:50 (5:50 PM) the resident was noted to be unresponsive. A Code was called (a term for a cardiopulmonary arrest happening to a patient, requiring a team of providers (sometimes called a code team) to rush to the specific location and begin immediate resuscitative efforts), and interventions including CPR (cardiopulmonary resuscitation- a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) were initiated. The resident was pronounced dead by the physician at 18:43 (6:43 PM). The coroner was notified. A review of the facility investigation into the death was conducted and revealed the following: A witness statement from Employee E1, Licensed Nurse, signed and dated (MONTH) 20, (YEAR), stated she called the transferring hospital and obtained a full report for the resident's admission. This information was relayed to the on-coming ,[DATE] shift. Staff giving the information from the hospital explained to Employee E1 that Resident CL1 was on a pureed diet, thin liquids but might possibly be advanced to a chopped diet, however their speech therapist had not made that official. Employee E1's statement noted she was not told the resident required assistance with feeding. Employee E1 stated she read back the full report to the oncoming nurse, Employee E2, a Registered Nurse (RN). Per Employee E1's statement, Employee E2 stated he needed to put in a diet order and she stated that the resident was on a pureed diet and explained the speech situation. Employee E1 then stated she left. She also stated in her witness statement that there is a hand-off form used to update the next shift, but she did not fill it out at that time. A witness statement from Employee E2, a Registered Nurse signed and dated (MONTH) 19, (YEAR), stated that he received the hand-off report at 15:00 (3:00 PM) from Employee E1 about resident CL1. Employee E2 stated he went to the resident's room at 15:30 (3:30 PM) to introduce himself, and that the resident was alert and oriented. At 16:00 (4:00 PM) Employee E2 contacted the physician and was told another physician was on call. The statement continued that at 16:40 (4:40 PM) a physician called back and verified medications and all orders. The physician asked Employee E2 to ask the resident if he took [MEDICATION NAME] for pain in the hospital. Employee E2 went to the resident's room, asked him about the [MEDICATION NAME] and asked him what diet he had while at the hospital. Resident CL1 told Employee E2 he was on a regular diet. The statement concluded stating that Employee E2 was called by a nurse aide at 17:50 (5:50 PM) to check the resident and he found the resident upright and unresponsive. The resident had food in his mouth and a food tray was in front of the resident. Another witness statement taken from Employee E2, by Employee E3, a Registered Nurse, and Employee E4, the Director of Nursing, signed and dated (MONTH) 19, (YEAR), by Employee E2, revealed the following information: Employee E2 stated he did receive report at the change of shift from Employee E1, and that the report was verbal but there was also a written report on the front of Resident R1's medical record. That report was the nursing report from the hospital. Employee E2 stated there was no diet on the transfer form so he asked the resident what diet he was on in the hospital. The resident replied regular. Employee E2 believed the resident to be alert and oriented. Employee E2 placed the diet order into the dietary system as regular. He stated that he verified the orders with the physician. He stated he reviewed all the transfer paperwork but did not see a diet order. In a witness statement from Employee E5, a Nurse Aide, signed and dated (MONTH) 19, (YEAR), the nurse aide stated that the dinner trays arrived on the unit from dietary, about 17:00 (5:00 PM) and that Resident CL1 received his tray last. She set the resident up for dinner because he only had the use of his right hand. The nurse aide set up his coffee, cut up his chicken and told him to call if he needed her. A review of the resident's clinical record revealed two sets of documentation from the transferring hospital. The first document was nine pages in length and titled, Summary of hospitalization . On page 2 of the document, the section titled, Diet instructions, was blank. The second document was a 40-page document and contained the resident's history and physical and course of care while hospitalized . The top of page 13 was labeled Assessment/Plan and under that section the diet per speech therapy was noted as currently on pureed, thin liquid diet, vitamin supplements for wound healing per nutritionist. Page 34 of the document under the heading Diet orders, revealed an order dated (MONTH) 14, (YEAR), for pureed, thin liquids - diet effective now. Review of a copy of the cause of death document from the office of the coroner noted the cause of death to be, choking on a bolus (a small rounded mass of a substance, especially of chewed food at the moment of swallowing) of food. During an interview with Employee E4, the Director of Nursing, she verified that the hand-off report was delivered verbally from Employee E1 to E2; that Employee E2 obtained information about the type of diet the resident was on directly from Resident CL1, and that the 40-page document from the transferring hospital, which contained the resident's diet order while in the hospital, was included in the information sent by the transferring hospital at the time of admission. She verified that the order to serve the resident a regular diet was placed and the resident was served a regular diet at the dinner meal. The facility failed to provide the appropriate diet for one resident who expired following a choking episode. CFR: 483.25 Quality of Care Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.5(h) Clinical records Previously cited [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE]

Based on observations, clinical record review, review of facility policy and procedure, review of facility documentation and interviews with facility staff, it was determined that the facility failed to accurately monitor and assess skin integrity to prevent the development of a pressure ulcer for one of 4 residents reviewed (Resident R1). Findings include: Review of the facility policy titled, Skin Condition Guidelines, revised on November 25, 2013, stated entry into the medical record will be initiated on all residents with skin conditions which may include, but not limited to, pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure), open incisions (cuts), leg ulcers, abscesses (a collection of pus that has built up within the tissue of the body), foot ulcers, traumatic injuries, cancerous [MEDICAL CONDITION], burns, etc. Other skin conditions will be recorded in the nurses' notes during the time of the event or admission/re-admission to the facility. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. sadness, loss, anger, or frustration interfere with daily life.) An annual Minimum Data Set assessment (MDS - an assessment of resident care needs), dated October 6, 2016, indicated that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool used to assess a resident's cognitive status) score of 13 (a score of 13-15 is considered cognitively intact). This MDS also identified Resident R1 as requiring extensive assistance of one staff member for dressing and hygiene, extensive assistance of two staff members for transfers and bathing and having impairment on both sides of the lower extremities. A nurses' note dated January 13, 2017, stated that Moisture Associated Skin Damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration - characterized by inflammation of the skin, occurring with or without erosion) was noted to the left posterior upper thigh where the resident's brief (an incontinence product) was positioned. Further review of the nurses' note indicated to cleanse the area with wound cleanser and to cover with [MEDICATION NAME] border (foam dressing used to minimize pain and trauma to the wound). Review of the, Skin Observation/Bathsheet form initiated by the staff dated January 13, 2017, reflected this same information, however, there were no measurements of the area and there was no description of what the affected area looked like on the resident's left posterior upper thigh. A physician's order was obtained on January 13, 2017, to, cleanse left posterior (in the back) upper thigh with wound cleanser, pat dry and apply [MEDICATION NAME] boarder every 3 days and as needed until healed. Review of the facility's monthly wound tracking reports and the weekly Wound Assessment forms completed by Employee E3, the Wound Care Nurse, revealed that Resident R1 was consulted for and then followed/assessed by Employee E3 weekly due to a stasis wound (a wound that develops in an area in which the circulation is sluggish) to the resident's right second toe. This wound was identified on October 11, 2016. Further review of the Wound Assessment forms revealed that the Wound Care Nurse assessed Resident R1's right foot wound weekly from the onset in October 2016 until March 3, 2017, when it was documented on the Wound Assessment form as wound healed and no further documentation needed. An interview with Employee E3 on April 21, 2017, at 11:45 a.m. revealed that wound rounds are completed weekly and each nursing unit has a specific day of the week. Review of the documentation on the weekly Skin Observation/Bathsheet forms dated January 18 and 25, 2017, February 1, 8, 15, and 22, 2017, and March 1, 8, 15, 22, and 29, 2017, revealed under the heading Observations, the staff were documenting, all wounds previously identified. See wound assessment. Review of the weekly Wound Assessments forms dated January 20, 2017, February 2, 8, 16, and 24, 2017, and March 3, 2017, revealed that Employee E3 only assessed Resident R1's right second toe wound. There was no documentation available for review to show that a Wound Assessment form had been completed for the MASD area noted to Resident R1's left posterior upper thigh on January 13, 2017. An interview with Employee E3 on April 21, 2017, at 11:45 a.m. confirmed that the stasis wound to Resident R1's right toe was the only area assessed during the weekly wound rounds during that time period. There were no indications in the nursing documentation that the nursing staff noted any changes to the MASD area to Resident R1's left posterior upper thigh during wound care treatments from the time it was identified in January 2017 until March 2017. There was no documentation to indicate that the wound nurse had been notified of wound on the resident's left upper thigh. This was confirmed in an interview with Employee E2, the Assistant Director of Nursing, on April 21, 2017, at 11:00 a.m. Review of a nursing note dated March 30, 2017, stated, masd worsened on left ischium (the back lower portion of the hip bone; left lower buttocks). Seen by wound nurse and [MEDICATION NAME] treatment set up to change every 2 days and prn (as needed). Also Balmex (a skin protectant) for peri-area (the perineal area/genital area) and oob (out of bed) for lunch (2 hrs) only. A physician's order was obtained on March 30, 2017, for, [MEDICATION NAME] border to left ischium-change every 2 days and prn; apply Balmex to peri-area every shift. A Wound Assessment form dated March 30, 2017, identified the wound as left ischium, pressure, unstagable (full thickness loss in which the base of the ulcer is covered by slough (necrotic {dead} [MEDICATION NAME] tissue either yellow, tan, green gray or brown and/or eschar (dead tissue, brown, black, leather, scab-like)) slough and necrotic tissue present, with scant serous (bloody) drainage, measuring 5.5 centimeters in length, and 4.5 centimeter width and 0.0 depth. Review of the nursing documentation revealed that Resident R1 was sent to the Wound Center on April 20, 2017, and a wound debridement (process of removing dead tissue from a wound to promote healing) was performed and Resident R1 returned to the facility with new orders to apply [MEDICATION NAME] Ag (a dressing covering with ionic silver for killing wound related microbes) to the wound and cover with [MEDICATION NAME] daily. Observation of Resident R1 during wound care on April 21, 2017, at approximately 12:30 p.m. revealed that the resident was in her room in bed. The resident was laying on her left side with a pillow behind her back to relieve pressure from her right side. The resident was noted to have an open area to the left ischium with moderate bloody drainage, with ecchymosis around the wound edges (discoloration of the skin resulting from bleeding underneath). Employee E3 stated that the wound was measured yesterday at the Wound Center as 3.5 centimeters by 4.5 centimeters by 1.4 centimeters. The facility failed to accurately monitor and assess skin breakdown that resulted in harm to a resident as evidenced by the development of a pressure sore. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/29/16 28 Pa. Code 201.18(b)(1) Management Previously cited 09/11/15, 08/29/16 28 Pa. Code 201.18(e)(1) Management Previously cited 08/29/16 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 08/29/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 06/26/15, 08/29/16 28 Pa. Code 211.12(d)(1)(5) Nursing services previously cited 06/26/15, 01/19/16, 08/29/16

Based on observations, review of clinical records, facility documentation, policies and procedures, and interviews with facility staff, it was determined that the facility failed to ensure that the staff provided adequate supervision to prevent accident hazards and failed to follow proper procedures while administering medication which resulted in actual harm to two of 30 residents reviewed (Resident R37 and R102) and the facility failed to properly store medications to prevent accident hazards on one of 8 nursing units (4A Nursing Unit). Findings include: Resident R37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record for Resident R37 revealed that the resident was admitted to the hospital on August 13, 2016, due to ingestion of multiple medications. Review of the information submitted by the facility dated August 13, 2016, revealed that on August 13, 2016, at around 5:30 p.m. Resident R37 ingested medications intended for another resident. The documentation stated that Resident R37 had received his/her medication prior to the event. The other resident's medications were mixed in Pepsi cola. The nurse put the cup containing the medications and the Pepsi cola on the dining room table where Resident R37 and Resident R28 were seated. According to the conclusions of the PB-22 (Provider Bulletin-22, a form for investigation of alleged abuse and neglect), when the nurse stepped away from the medication cup to obtain a spoon to stir the settling medication, Resident R37 drank the Pepsi cola with the medications. Resident R37 was transferred and admitted to the hospital. According to the written statement about the incident given by Licensed Practical Nurse (LPN), Employee E4, on August 13, 2016, Resident R37 had ingested 75% of the medications in the cup. According to the statement, Resident R37 had taken her own medication prior to the incident, which included gas relief chewable tablet 125 milligram (mg), Dicyclomine 20 mg (a medication for stomach cramps), Florastor 250 mg (a probiotic supplement), Gabapentin 300 mg (a medication for seizures), Metoprolol 25 mg (a medication for blood pressure), Reguloid (a medication for constipation), Betimol solution 0.5% (a medication for glaucoma) and Latanoprost solution 0.005% (a medication for glaucoma), According to Employee E4's written statement, included in the facility's investigation report, the medications mixed in the Pepsi cola that were intended for Resident R28, but were actually ingested by Resident R37 included: Calcium carbonate (a calcium supplement) 600 mg (milligrams), Carbidopa-levodopa 25-100 mg (a medication for Parkinson's disease), Carbidopa-levodopa 10-100 mg (a medication for Parkinson's disease), Memantine 10 mg (a medication for dementia), Polyeth glycol powder 3350 (a medication for constipation), Pyridostigm 60 mg (a medication for orthostatic blood pressure), Quetiapine 100 mg (a medication for behaviors), Senna 8.6 mg (a medication for constipation), Trazodone 50 mg (a medication for depression), Midodrine 10 mg (a medication for hypotension), Fludocort 0.1 mg (corticosteroid), and Keppra 250 mg (a seizure medication) and Metoprolol 25 mg (a medication for blood pressure). Following the incident, Resident R37 was sent to hospital. The hospital record on August 13, 2016, at 9:43 p.m. stated, Per NH (nursing home), patient ingested fell ow residents medication. Medication include Calcium, Carbidopa-levodopa 10-100 mg and 25/100 mg, Fludocort 0.1 mg, Keppra 250 mg, Mementine 10 mg, Metoprolol 25 mg, Midodrine 10 mg, Pyridostigm 60 mg, Seroquel (Quetiapine) 100 mg, Senna 8.6 mg, and Trazodone 50 mg. NH states patient took at least one of each of the listed medications------ The doctor's note stated, multiple sedative meds ingested by patient and also double dose of unknown if long lasting BP med------ The final [DIAGNOSES REDACTED]. Further review of the hospital documentation related to Resident R37 revealed that Resident R37 was triaged (process of deciding which patients should be treated first based on how sick or seriously injured they are) in the hospital as ESI 3 (Emergency Severity Index 3 which means the patient needed urgent care). The hospital records stated that Resident R37 arrived lethargic (state of sluggishness and fatigue). It also stated that Resident R37's blood pressure was high, mucous membranes were dry and that the total GCS (neurological scale to determine level of consciousness with scale ranging from 3 to 15 where 3 is coma stage and 15 is fully conscious stage) was 10, indicating an altered mental status. The electrocardiogram (EKG-a test that checks for problems with electrical activity of heart) done at the hospital on August 13, 2016, stated that abnormalities (the heart was not in the rhythm that it should be/or beating in the normal order) were seen in the EKG. The history and physical done in the hospital indicated that Resident R37 was extremely lethargic and was at risk of hypercalcemia (excess calcium), [DIAGNOSES REDACTED] (insufficiency of magnesium), cramping, dyskinesia (involuntary muscle movement), acute [DIAGNOSES REDACTED] (uncontrollable muscle spasm) and high blood pressure. The history and physical note stated that Resident R37 was still lethargic even the next morning and recommended to keep Resident R37 under observation until the third day. The admission [DIAGNOSES REDACTED]. Resident R37 was discharged from the hospital on August 15, 2016. Review of the clinical documents of Resident R37 and R28 revealed that both of the residents had severe cognitive impairment. During an interview on August 24, 2016, at 3:28 p.m. with the LPN who administered the medication, Employee E4, he/she stated that Resident R37 was sitting with Resident R28 at a table. When Employee E4 was asked how many residents were sitting at the table with Residents R28 and R37, he/she stated that there might have been a third resident, but he/she was not sure. Employee E4 stated that he/she prepared the medication for Resident R28 and crushed the medication and put them in Pepsi cola, placed it in front of Resident R28, and left the dining room to get a spoon to stir the contents in the cup. When Employee E4 was asked why the medication was mixed in Pepsi cola, Employee E4 stated that Resident R28 was care planned to receive medication in Pepsi cola. When Employee E4 was asked how long he/she was away after leaving the medication on the table in front of Residents R37 and R28, he/she stated that it was about one minute and that by that time Resident R37 had finished 75% of the Pepsi cola-medication mixture in the cup. Review of the care plan for Resident R28 revealed that Resident R28 was not care planned to receive medications in Pepsi cola. Observation of Resident R37 drinking liquid from a cup during lunch while assisted by the Unit Manager, Employee E3, on August 24, 2016, at 12:29 p.m. revealed that Resident R37 took 10 to 15 seconds to take a sip and took three minutes to drink 1/3 of the ice tea in the cup. Review of the clinical record for Resident R102 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment (MDS- an assessment of resident care needs) dated July 20, 2016, indicated that the resident had a moderate cognitive (cognition-ability to think, judge and reason for oneself) impairment, was physically impaired on one side of her/his lower leg and required extensive physical assistance from one or more staff persons to transfer from one area to another. The MDS further indicated that the resident had identified care needs in the areas of Cognitive Loss and/or Dementia. Nursing progress notes dated July 2, 2016, indicated that at approximately 3:00 p.m. Resident R102, who had been left alone in the bathroom, attempted to transfer independently from the toilet to the wheelchair and sustained a laceration to the right lower leg. Further review of the progress notes dated July 2, 2016, indicated that the resident had been transferred to the emergency room for evaluation and treatment of [REDACTED]. Interview with the Director of Nursing on August 26, 2016, at 10:00 a.m. confirmed that Resident R102 had received 26 stitches to the laceration while in the emergency room . Further interview with the Director of Nursing revealed that the facility had not investigated if possible employee neglect had occurred when the NA (Nursing Assistant) left Resident R102, who had documented cognitive impairments, in the bathroom unattended. Further interview with the Director of Nursing confirmed that the facility had not looked into whether this cognitively impaired resident was capable of remembering to ring a call bell for assistance. Observation of medication administration on the 4A Nursing Unit on August 25, 2016, at approximately 8:40 a.m. revealed Employee E6, a Licensed Nurse, administering morning medications to Resident R175. After medicating Resident R175, the employee entered the resident's bathroom and washed his/her hands. Continued observation of the bathroom revealed the presence of a corner cabinet mounted on the wall of Resident R175's bathroom. Inspection of the corner cabinet revealed the presence of an eight ounce bottle of Dimetapp (over the counter medication) cough and cold syrup, one bottle of Hydrocodone-acetaminophen (a liquid narcotic with Tylenol used for the treatment of [REDACTED]. The bottle was labeled 7.5-325/15 ml (7.5-325 concentration of liquid and/or dosage) (ml-milliliters-volume). Take 15 ml q (every) hours prn (as needed). The bottle was labeled with another person's name and not that of Resident R175. Additionally, there was one tube of Clotrim-Beta (an anti-infective used to treat fungal infections) cream and one blister pack of Extra-Strength Simethicone (used to treat gas) 125 mg (milligram) tablets. An interview with Employee E6 at the time of the observation revealed that the employee was unaware that the above listed medications had been stored in Resident R175's corner cabinet. Continued observation of medication administration on the Four A Nursing Unit on August 25, 2016, at 9:10 a.m. revealed Employee E12, a Licensed Nurse, preparing to administer medications to Resident R146. Observation of Resident R146's bathroom revealed the presence of a tub of Vitamin A and D ointment sitting on the floor of the bathroom along with a bottle of Bausch and Lomb Eye wash and a 16 ounce bottle of Isopropyl Alcohol (rubbing alcohol). An interview with Employee E7, 4A Unit Manager, on August 25, 2016, at approximately 9:50 a.m. revealed that the employee was unaware of the presence of the medications in Resident R175's cabinet. Employee E7 indicated in the interview that Resident R175 was able to walk freely with the aide of a walker and had free access to the medications stored in the cabinet. Additionally, Employee E7 was unaware of the presence of the tub of A and D ointment and the bottle of eye wash in Resident R146's bathroom. Continued interview with Employee E7 revealed that he/she was unaware if Resident R146 had been assessed for the safe self administration of medications. Further interview with Employee E7 confirmed that the facility has no current process in place to monitor the contents of resident's bathroom cabinets. Observation of Resident R179's bathroom cabinet on August 25, 2016, at approximately 2:00 p.m. revealed the presence of one bottle of Refresh Tears (liquid eye drops), one bottle of Tums tablets, one tube of Neosporin (an antibiotic ointment) and two bottles of Isopropyl Alcohol in the cabinet. The facility failed to ensure that the facility provided adequate supervision and security of medications to prevent accident hazards. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 09/11/15, 08/05/14 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/05/14 28 Pa. Code 201.18(b)(1) Management Previously cited 09/11/15, 08/05/14 28 Pa. Code 201.18(e)(1) Management Previously cited 08/05/14 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 01/19/16, 06/26/15, 08/05/14 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/26/15, 08/05/14

Based on observations, review of facility documentation, and interviews with facility staff, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of a resident who suffered first (superficial) and second degree burns (damage extends beyond the top layer of skin) from hot coffee (Resident R1). Findings include: Review of the information, dated September 9, 2015, submitted by the facility revealed that Resident R1, a [AGE] year old female resident, sustained a burn to the right and left thighs, after a coffee spill during the supper meal. Review of nurses' notes, for September 9, 2015, revealed that they heard the resident scream from spilled coffee and resident was taken to the bathroom and cold compresses were applied to red and open areas on top of both thighs, groin and inner thighs. The resident was sent to the emergency room for evaluation since skin was already open. Resident R1 was treated in the emergency room for burns to resident's upper legs from coffee at dinner time. Bacitracin (antibiotic ointment) was ordered with non-stick dressing and kling; also ordered was 650 mg Tylenol and tetanus shot (a recommended injection after trauma). A wound evaluation, on September 10, 2015, from Holy Redeemer Wound Care Center revealed a [DIAGNOSES REDACTED].<0.1 centimeters depth with a wound base that was 85% pink and 15% slough (a layer dead tissue); a right middle thigh, full thickness wound that measured 4 centimeters long by 5 centimeters wide with a wound base of 50% pink and several fluid-filled blisters (a small bubble caused by a burn); a left middle thigh, full thickness wound that measured 5 centimeters long by 8 centimeters wide with a wound base of 50% pink. Each wound had 90% necrotic (dead) tissue excised (a surgical removal). The resident returned with orders for a non-stick wound dressing to be changed daily and as necessary. Observation of the lunch meal service, on 3E - Four Seasons, where Resident R1 resides, on September 11, 2015, at approximately 12:45 p.m. revealed that staff did not test the coffee temperature before serving it to the residents. This surveyor initiated temperatures of the coffee, with Employee E3, Clinical Nutrition Manager, who used a digital thermometer. The temperature of the coffee on cart #1, at 12:43 p.m., revealed a temperature of 169.8 degrees Fahrenheit; cart #2, at 12:55 p.m., was 165.1 degrees Fahrenheit; and cart #3, at 1:00 p.m., was 172.2 degrees Fahrenheit. Resident R1's tray was on Cart #3, as revealed by Employee E4. The temperature of the coffee, on September 9, 2015, at 5:55 p.m., (when the resident was injured from the hot coffee) revealed a temperature of 174 degrees Fahrenheit. Interview with Employee E3, on September 11, 2015, at approximately 1:15 p.m., revealed that there was no policy or parameters for the acceptable temperature range of hot beverages. A sample meal test tray audit only indicated that temperatures of hot beverages are to be equal to or greater than 155 degrees Fahrenheit. There were no test tray audits completed and no evaluation completed by occupational therapy for the safe use of a coffee mug, for Resident R1 as of September 11, 2015. The facility failed to consistently supervise and monitor Resident R1 and other residents to prevent burns from hot beverages and ensure the resident's safety, resulting in actual harm to resident R1. 28 Pa Code:211.6(c) Dietary services. 28 Pa Code: 201.18(b)(1) Management. Previously cited 8/5/2014.

Based on observation, clinical record review, review of facility policy and documentation and interviews with staff, it was determined that the facility did not accurately identify, assess and monitor two of 28 residents reviewed for the development of pressure ulcers (Residents R118 and R160), resulting in actual harm to one resident (Resident R118). Findings include: A review of Resident R118's physician's orders [REDACTED]. A skin assessment (Braden Scale) dated July 20, 2011 indicated that the resident was at a low risk of developing a pressure ulcer The resident's admission MDS (Minimum Data Set-assessment) dated July 24, 2011, revealed that the resident required extensive assistance with transfers, ambulation and personal hygiene. Nursing documentation dated July 23, 2011 at 11:30 a.m. indicated that the resident complained of a 'lump' on the right hip. The nurse identified a 2 cm. x 2 cm. x 0.1 cm. area with serosanguineous (blood and serum) drainage and dark slough (dead or necrotic tissue separated from the living tissue) covering the ulcer and tender to touch. The physician was notified and ordered to cover the wound with [MEDICATION NAME] (a foam guaze) and send the resident to the wound center for evaluation. A review of the initial wound consultation report, dated July 26, 2011, revealed that the area was now described as a necrotic, unstageable 2.2 cm. x 3.2 cm. x 1.2 cm. wound with moderate discharge that required debridement (an outpatient surgical procedure to remove dead or damaged tissue). The physician also ordered a wound culture to be completed, started the resident on an oral antibiotic and changed the treatment of [REDACTED]. There was no documentation that the physician had been notified of the deterioration of the wound or the increase in size from July 23, 2011 to July 26, 2011. A review of the lab results, dated July 26, 2011, revealed that the wound was positive [MEDICAL CONDITION] infection. Observation of the wound treatment on August 15, 2011, at 11:30 am revealed the wound exposed and rubbing on the residents brief and shorts when the treatment began. During the observation, the nurse packed the wound with the mesalt gauze and there was a large area of the wound edge that appeared to be undermining/tunneling (separation of the tissue lying beneath the healthy tissue at the wound edges). This separation was confirmed with Employee E2 during the treatment observation. There was no documentation to indicate that the physician had been notified of the change in the resident's wound or that the facility had documented the deterioration since the prior wound clinic consult on August 11, 2011. After the treatment, the physician was called and ordered the resident to be seen by the wound consultant. A wound consult report, dated August 16, 2011, revealed the wound had increased in overall size and that there was undermining around the entire circumference of the wound. There was no evidence that the this pressure ulcer was identified prior to finding it at an advanced stage. There was no evidence that the facility assessed the resident's wound in a timely or consistent basis or that the physician was notified of the changes to the wound, which resulted in actual harm to the resident. An interview with Employee E6 on July 16, 2011 at 11:00 am confirmed that there was no additional documentation that indicated that the wound was being accurately monitored in a timely fashion. Review of the clinical record for Resident R160 revealed that the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an annual MDS (Minimum Data Set-assessment tool) dated February 19, 2011, indicated that the resident had been identified with care needs in the area of pressure ulcers. A comprehensive plan of care for Resident R160 related to skin integrity revealed that facility staff was to reassess the resident's pressure ulcer weekly and document the findings in the accunurse system. Review of the accunurse system for Resident R160 revealed no documented assessment of the resident's posterior sacral ulcer for a period of five weeks, from April 28, 2011, through June 7, 2011. Review of facility policy, "Pressure Ulcer Prevention & Treatment Guideline," dated effective August 30, 1998, indicated that "...Documentation of wounds will be updated at least weekly in the accunurse. ..." An interview with Employee E1, unit manager, on August 16, 2011, at 11:20 a.m., confirmed that per facility policy nursing staff are expected to document weekly assessments of all residents' pressure ulcers into the accunurse system. Further interview with Employee E1 confirmed there were no assessments documented in the accunurse system for Resident R160's posterior sacral ulcer from April 28, 2011, to June 7, 2011. 28 Pa. Code:201.18(b)(1) Management Previously cited 7/1/10 28 Pa Code: 211.12 (d)(5) Nursing Services Previously cited 7/1/10