Every finding on record at Tel Hai Retirement Community

Based on a review of the facility's policy, observation, clinical records review, and staff interviews, it was determined that the facility failed to ensure a pressure ulcer was identified, assessed, and treated in a timely manner, which resulted in actual harm in the development of a stage three pressure ulcer for Resident #66, and failed to ensure that a pressure ulcer that worsened was provided with an appropriate treatment in a timely manner for Resident #90, for two of fourteen residents reviewed (Resident #66, and Resident #90). Findings include: A review of the facility's policy titled, Wound Protocol, with the last revision date of October 2017, revealed that wound status must accurately be identified, and to provide appropriate treatment and follow up. It also revealed that should a new wound be discovered, the nurse shall assess the wound, follow the corresponding protocol, document assessment findings in the EMR (Electronic Medical Record), report findings to the supervisor, and inform the physician. Further review of the same policy revealed that if at any time a wound has a significant change, the nurse shall notify the supervisor and the supervisor will notify the physician if the wound care team is not available. Review of Resident #66's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident #66's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated May 18, 2019, revealed Resident R66 required extensive assistance of two-plus staff members for bed mobility and transfers. Review of Resident #66's care plan developed on May 12, 2019, revealed a plan of care for limited physical mobility related to a [MEDICAL CONDITION] heel bone, with skin preservation interventions that included a pressure-relieving mattress. Review of the Braden Scale Form (a tool used to determine risk factors for pressure sore development) completed on January 1, 2020, revealed a score of 14 which indicated the Resident #66 was at moderate risk for developing pressure sores. Resident #66's MDS dated [DATE], indicated an existing pressure ulcer, stage 4 (IV) (ulcer involving loss of skin layers, exposing muscle and bone). Review of Resident #66's clinical records revealed that the resident had an existing, stage IV pressure ulcer on the right heel, initially identified on May 28, 2019, and with ongoing wound care treatment. Review of the Treatment Administration Record (TAR) revealed an order dated December 28, 2019, to apply Nutrashield (a cream that aids in healing very dry skin) to top of the right foot. Further review of the same TAR revealed that the treatment was being completed every day and evening shifts. A wound care observation of the right heel was conducted on February 12, 2020, at 9:30 a.m., with Licensed Nurse E3 and E4. When Resident #66's sock was removed from the right foot, an intact dressing was observed covering the heel. During the same wound care observation on February 12, 2020, at 9:32 a.m., an uncovered, open wound measuring 1.6 cm x 0.8 cm, with one-fourth of the wound bed covered with yellow slough (separation of dead tissue from living tissue) was observed by the surveyor on the top of Resident #66's right foot. In an interview with the Unit Manager, Employee E4, on February 12, 2020, at 9:35 a.m., during wound care, she identified the wound as a stage three pressure ulcer (ulcer involving the full thickness of skin loss, exposing tissue). Employee E4 further stated that a wound round was done on February 7, 2020, and at that time the top of the right foot had a scab. Review of Resident #66's wound round nursing note, dated February 10, 2020, at 1:07 p.m. revealed no documentation of a scab, pressure injury, or wound of any kind, present on Resident #66's top of the right foot. A wound round nursing note dated January 31, 2020, late entry, stated resident seen by wound team this shift, tolerated assessment and application of new dressing without difficulty or s/s of pain . There was no documentation to indicate a scab or any other issues with top of right foot. A wound round nursing note dated January 24, 2020, stated resident seen by wound team for area to right heel. Area noted healing, moderate serous drainage with no foul odor . There was no documentation to indicate a scab, or any other issues with top of right foot. A wound round nursing progress note dated January 17, 2020, stated resident seen by wound team this shift for area to right heel without/s/s pain. No foul odor or active drainage observed. Skin surrounding is CDI, top of right foot is dry and facility lotion applied Review of the skin observation tool completed on February 4, 2020, revealed the presence of a pressure ulcer on Resident #66's right heel but failed to reveal presence of a scab, pressure injury, or wound of any kind present, on Resident #66 top of the right foot. Review of Resident #66's nursing progress note dated February 10, 2020, at 11:30 a.m. stated previous dressing to right heel intact, the scant amount of tan drainage, no odor, some pain stated with treatment. Scab that was on top of the foot is now open, Nutrashield (silicone blended cream to aid in healing very dry skin) applied. Further review of the same note revealed that the note was struck out on February 11, 2020, at 7:47 a.m. for reason of incorrect documentation. Interview with Employee E5 on February 12, 2020, at 11:00 a.m., revealed that on February 10, 2020, Employee E5 identified an open area on Resident #66's top of the right foot. Employee E5 further stated that she documented it in a progress note (February 10, 2020), but was instructed by Employee E4 to remove the documentation because it was not worded appropriately. Employee E5 further stated that the documentation for the newly found wound on Resident #66 's top of the right foot had not been rewritten. Interview with Employee E4 on February 12, 2020, at 11:30 a.m., revealed that she became aware of the documentation of Resident #66's open area on top of the right foot, via twenty-four-hour report documentation on the morning of February 11, 2020. Employee E4 stated she informed Employee E5 to remove and rewrite documentation because Employee E5 used a wound note and it should not have been a wound note and it was worded wrong. Review of Resident #66's clinical records revealed no documented evidence that the physician was notified of the presence of a new open wound on Resident #66's top of right foot, originally identified by Employee E5 on February 10, 2020. Clinical records revealed physician was not notified of newly documented wound until after being observed by surveyor, and identified as a stage 3 pressure ulcer by Employee E4, during the heel wound observation on February 12, 2020. A wound care treatment was not ordered by the physician until February 12, 2020, two days after an open wound on Resident #66's top of right foot was identified by Employee E5. The facility failed to identify, assess, and provide appropriate care on Resident #66's top of right foot, in a timely manner, resulting in actual harm for this resident who acquired what was identified as a stage three pressure ulcer by Employee E4. A review of Resident #90's clinical record revealed [DIAGNOSES REDACTED]. A review of a weekly wound observation tool dated November 3, 2019, at 10:14 a.m., revealed that Resident #90 was observed with a round open area on the coccyx (commonly referred to as a tail bone) with measurement of 1x1 centimeter, scant drainage. The wound was identified as a stage two pressure ulcer (ulcer involving loss of the top layer of the skin). A review of Resident #90's physician orders [REDACTED]. A review of a weekly wound observation tool dated November 15, 2019, at 8:27 a.m., revealed that the area to Resident #90's coccyx was not improving, treatment of [REDACTED]. The coccyx wound was still assessed as stage two, with a measurement of 1x1x0.2 centimeters. A review of the skin/wound note on November 19, 2019, at 10:54 a.m., revealed that coccyx wound now appears with yellow wound bed and slight tunneling on the upper edge of the wound bed, and the unit manager was made aware. A review of the Resident #90's clinical records failed to reveal that a physician was notified of Resident #90's worsening wound on the coccyx. During an interview on February 13, 2020, at 11:00 a.m, with Employee E7, surveyor was unable to verify that the physician was made aware of the worsened condition of Resident #90's coccyx wound. A review of the clinical records revealed that Resident #90 was seen by a wound care physician on November 22, 2019, three days after a worsened coccyx wound was observed. An interview with Employee E4 on February 12, 2020, at 11:00 a.m., revealed that physician wound rounds are done weekly on Fridays. A review of the wound physician's note dated November 22, 2019, revealed that sacrum (large, triangular bone at the base of the spine) wound (previously identified by the facility as the coccyx wound), had a measurement of 1x0.5x0.2 centimeters, 50% slough (separation of dead tissue from living tissue), and was identified as a stage three wound (ulcer involving full thickness of skin loss, exposing tissue). A review of the same note revealed that the wound doctor performed a surgical excisional debridement procedure (surgical removal of unhealthy tissue from a wound to improve wound healing) to resident #90's sacral wound. Wound physician recommended applying alginate calcium (a highly absorbent, biodegradable alginate dressing that promotes healing and the formation of granulation tissue) once daily for 30 days. A review of Resident #90's treatment administration record (TAR) revealed that a new order to cleanse coccyx with normal saline, apply calcium alginate and Allevyn life (a five-layer foam dressing that absorbs fluid and redistributes pressure more evenly), change daily, and as needed, every day shift, was dated November 23, 2019, four days after Resident # 90's coccyx wound had worsened as noted in the progress note on November 19, 2020. The facility failed to timely provide appropriate wound care treatment for [REDACTED]. 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/17/19 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 9/17/19, 7/5/19 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 9/17/19, 7/5/19, 3/5/19,3/1/18

Based on policy review, clinical record review, review of facility documentation, and staff interview, it was found that the facility failed to ensure residents are free from accidents hazards by not following the resident's plan of care for the use of a walker for one of three residents reviewed (Resident 2) resulting in actual harm to Resident 2 who was transferred without the use of a walker and fell , was transferred to the emergency room and sustained a right humerus fracture. Findings include: Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 2's annual Minimum Data Set (MDS - periodic assessment of resident care needs) dated (MONTH) 29, 2019, revealed that the resident required extensive assistance from one staff person for transfers and utilized a walker. Review of Resident 2's care plan identified the resident as requiring assistance with transfers due to poor balance and safety with an intervention revised on (MONTH) 8, 2019, for the resident to transfer using an assist of one staff person and a rolling walker. Review of Resident 2's progress notes revealed a nurse's note dated (MONTH) 12, 2019, at 10:30 a.m. which stated called to residents room and found resident laying on the floor in her bathroom. Resident was assisted into her wheelchair x 2 assist, assessed by charge nurse on unit, ROM ((range of motion)) to upper extremities, resident c/o ((complained of)) pain to right upper arm, vital signs obtained, PRN ((as needed)) Tylenol administered, and resident requested to lay in her bed, right arm elevated on pillows. Daughter made aware of incident, Physician made aware. Review of Resident 2's radiology report obtained at the facility dated (MONTH) 12, 2019, at 2:31 p.m. revealed there is a fracture involving humeral neck ((top of the long bone that connects the shoulder to the elbow)) with displacement. The fracture was described as acute (recent onset). Further review of Resident 2's progress notes revealed a nurse's note dated (MONTH) 12, 2019, at 4:35 p.m. which stated Resident was assisted into her wheel chair, head to toe assessment complete, vital signs obtained, and PRN Tylenol administered for c/o right arm pain. Neuro checks initiated and WNL ((within normal limits)). (Physician) notified for xray new order noted, resident transferred (to hospital) for eval at (4:35 p.m.). Review of Resident 2's hospital records revealed the resident was discharged back to the facility from the emergency roiagnom on (MONTH) 12, 2019, with [DIAGNOSES REDACTED]. Review of the facility's investigation into Resident 2's fall revealed Staff stated walker was not utilized during transfer. Nursing assistant Employee E3 stated I was assisting (Resident 2) off of the toilet and while she was standing at the towel bar, she was holding it with both hands/arms. As I was reaching down with my right hand to pull up her pants, with my left hand on her back, her right arm gave out and she fell against the wall with her right shoulder landing at an angle on her bottom onto the floor. She bumped her head on the door frame. I went to inform the nurse. During the facility investigation, Employee E3 was asked if the resident's Kardex (reference tool to guide resident's care based off of information on the care plan) was reviewed prior to providing care. Employee E3 stated I never looked at a Kardex, I don't know how to have access to it. Review of paperwork provided by the Director of Nursing revealed evidence that Employee E3 knew how to log in to the charting system to review residents' Kardex. Interview with the Director of Nursing and licensed nurse Employee E4 on (MONTH) 17, 2019, at approximately 1:20 p.m. confirmed that nursing assistant E3 did not use a rolling walker when transferring Resident 2 and revealed that staff were expected to look at the Kardex prior to providing care to residents. The facility failed to ensure that Resident 2 was transferred with a rolling walker as per the resident's plan of care resulting in actual harm with a transfer to the hospital and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 3/1/18, 3/5/19 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 3/5/19 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/5/19 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 3/1/18, 3/5/19

Based on observation, clinical record review and staff interview, it was determined that the facility failed to maintain an environment that was hazard-free during medication pass on one out of two nursing units ( First floor nursing unit) Findings include: Review of clinic record for Resident, R50 revealed [DIAGNOSES REDACTED].{nonreversible decline in mental function} caused by impaired blood supply to brain which can lead to inappropriate behaviors) and Alzheimer's (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability). Observations conducted during the initial tour of the First floor nursing unit, C wing on (MONTH) 27, 2019, at approximately 4:55 p.m. revealed that Employee E3, Licensed Nurse, was exiting the(NAME)Gardens dining room with arms laden with treatment supplies and placing the supplies into the drawer of the treatment cart, which was positioned against wall outside of dining room. Surveyor observed Resident R50 propelling self haphazardly around the Health Gardens dining room. On a table near the door approximately 10 feet away from Resident R50, was a plastic medication cup. Standing in the doorway of the(NAME)Gardens dining room with their back to the resident in the dining room was non-licensed Employee, E4. As non-licensed Employee, E4 started to walk out into hallway, licensed Employee, E3 turned to non-licensed Employee, E4 and ask that she watch medication cup in dining room. Licensed Employee, E3 then re-entered(NAME)Gardens dining room, picked up clear plastic medication cup and proceeded to walk across the hallway to room C111, where he administered the medications to Resident R29. Interview conducted with licensed nursing staff Employee, E3 on (MONTH) 27, 2019 at approximately 5:00 p.m. confirmed that the clear plastic medication cup observed on a table in the Health Gardens contained medications mixed with applesauce. Employee E3 indicated that he just poured them. Employee E3 confirmed medications in the clear plastic cup were [MEDICATION NAME] 3mg (blood thinner to treat/prevent clots), Edecrin tablet 50mg ( for treating [MEDICAL CONDITION]), and [MEDICATION NAME] Acid 250mg (helps to maintain levels of vitamin C). The facility failed to maintain an environment that was hazard-free during medication pass. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 3/1/18, 1/31/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 1/31/17 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 1/31/17, 3/1/18

Based upon review of facility policy and procedures and observation, it was determined that the facility failed to maintain appropriate transmission based precautions for one of one resident reviewed (Resident #51). Findings include: Review of facility policy and procedure entitled [MEDICAL CONDITIONS], revised (MONTH) (YEAR) revealed Residents with [MEDICAL CONDITION] ([MEDICAL CONDITION] - a contagious internal bacteria that causes chronic diarrhea) shall be placed on contact isolation. Further review of this policy revealed Wear gowns and gloves when entering the resident's room even to care for the roommate the whole room is an isolation room. Further review of this policy revealed Employees shall wash their hands after resident and/or room contact. Review of facility policy and procedure entitled Transmission-based Precautions revealed Transmission-based isolation precautions will be used for residents with uncontained or suspected infectious material or communicable diseases that can be transmitted by airborne or droplet transmission or by contact with skin or contaminated surfaces. Transmission based isolation precautions are to be used in addition to Standard Precautions. Further review of this policy revealed Isolation precautions encompass the entire room due to the risk of potential exposure while in the room. Even if not working with the infected individual, but with the roommate. Further review of this policy revealed Remove gloves before leaving the room and wash hands immediately or use a waterless antiseptic agent and wear a gown (clean, nonsterile) when entering room; remove the gown before leaving the resident's environment. Review of Resident #51's [DIAGNOSES REDACTED]. Observation on (MONTH) 28, 2019 at 9:53 a.m. of Resident #51's room revealed a housekeeper cleaning the residents' bathroom without wearing a cover gown. Further observation revealed the housekeeper left Resident's #51's room, removed the used, contaminated gloves in the hallway and entered another resident's room across the hall without washing hands. Further observation on (MONTH) 28, 2019 at 9:55 a.m. revealed a caregiver assisting Resident #51's roommate with getting dress. This observation further revealed that the caregiver was not wearing a cover gown or gloves while in the residents' room. The facility failed to maintain appropriate transmission-based precautions while caring for a resident on contact isolation precautions. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c) Nursing services Previously cited 3/1/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/1/18

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to provide a diet consistent with physician's orders [REDACTED]. Findings include: Review of Resident R116's admission MDS (Minimum Data Set - periodic assessment of resident needs) assessment dated (MONTH) 29, (YEAR), indicated that the resident had severe cognitive impairment. [DIAGNOSES REDACTED]. The resident required a mechanically altered diet and extensive assistance of one person for eating. Review of physician's orders [REDACTED]. ground or minced) was ordered. Review of speech therapy note of (MONTH) 6, (YEAR), indicated that the resident participated in skilled speech therapy which included assessment and intervention for dysphagia. The resident presented with moderate impulsive behaviors characterized by rapid intake of all foods within arm's reach immediately upon being seated at the dining table. Caregiver education completed related to the benefit of remaining with resident at all times in the presence of food. Resident requires full cues/assistance to moderate rate of po (by mouth) intake to facilitate increased bolus (soft mass of chewed food) control and to decrease risk of aspiration (drawing of food/fluid into the lungs). Assessed safety and tolerance of diet level upgrade to mechanical soft dysphagia diet level. Review of nursing note dated (MONTH) 7, (YEAR), revealed that licensed nursing staff was alerted that the resident was in the dining room choking on his dinner. Upon entering the room resident was noted to be cyanotic (a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood), nose running clear fluid and a [MEDICATION NAME] sound coming from residents throat. A nursing assistant was noted to be pressing their fist into resident's abdomen to attempt abdominal thrusts. The resident was immediately transferred to his room via his wheelchair. Abdominal thrusts, alternate suctioning and mouth sweeping provided by this nurse and 3 staff members. O2 applied. Physician and 911 (Emergency Medical Services) alerted. Nurse was able to digitally remove several pieces of ham from oral cavity. After approximately 15 minutes of abdominal thrusts, resident was able to dislodge remaining pieces of food from the throat and exchange air as medics entered the room. Resident continued with strong pulse throughout the entire episode. Resident then returned to normal skin color but was lethargic and did not answer questions. Did arouse to sternal rub. Left facility with medics, O2 via mask in place at 1845. Report given. Review of facility investigation into Resident 116's incident revealed that the resident was to receive manicotti, but the kitchen was out of manicotti. The resident was provided ham and potato casserole of regular consistency. Review of Resident 116's hospital discharge instructions dated (MONTH) 9, (YEAR), indicated a discharge [DIAGNOSES REDACTED]. Review of Resident 116's physician's readmission note of (MONTH) 11, (YEAR), indicated that the resident choked on food, became hypoxic and went out to the hospital via 911. The resident was stabilized, treated for [REDACTED]. Interview with the Director of Nursing on (MONTH) 1, (YEAR), at 12:43 p.m. revealed that the resident's diet was on the ticket. There was supposed to be a double check with both nursing staff and dietary staff checking the ticket to ensure that the resident received the correct diet. The Director of Nursing confirmed that this did not happen, resulting in the resident receiving the wrong diet consistency. This led to a choking episode and hospitalization . The facility failed to ensure that Resident R116 was provided a meal consistent with the prescribed diet, resulting in a choking episode and actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/31/17, 03/25/16 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 01/31/17, 03/25/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/31/17, 03/25/16

Based on observation and staff interview, it was determined that the facility failed to provide nursing care which maintained dignity and respect for four of 25 residents reviewed. (Residents 6, 66, 78 and 91) Findings include: Observations conducted on (MONTH) 26, (YEAR), at approximately 1:00 p.m. revealed Resident 6 sitting on the bed in her room naked from the waist down, with the door open and the privacy curtain not drawn, which left the resident's buttocks exposed to staff and visitors passing in the hallway. The aforementioned observations were reported to the administrator on (MONTH) 1, (YEAR), at approximately 3:00 p.m. Review of Resident 66's quarterly Minimum Data Set (MDS- periodic assessment care needs) assessment dated (MONTH) 29, (YEAR), revealed that Resident 66 required extensive assistance for transferring and ambulation. Review of Resident 66's care plan revealed that Resident 66 required supervision and staff assistance for ambulating with the use of walker and gait belt. On (MONTH) 28, (YEAR), at approximately 7:55 a.m. Resident 66 was observed ambulating in hallway, outside the dining area heading to the dining room for breakfast using a walker and wearing a gait belt (a device used to assist with transfers with those who have problems with balance/mobility) around the waist. Resident 66 ambulated to the table, sat down and ate breakfast with the gait belt secured around the waist. On (MONTH) 28, (YEAR), at approximately 12:05 p.m. Resident 66 was observed sitting at the table during lunch with a gait belt secured around the waist. Resident 66 completed the meal with the gait belt around the waist and ambulated back to the room with a family member walking next to them and the gait belt still secured around the waist. Interview with non-licensed nursing staff, Employee E7, on (MONTH) 28, (YEAR), at approximately 11:30 a.m. revealed that after a transfer with a gait belt, the gait belt should be removed from around the resident's waist. An additional interview with non-licensed nursing staff, Employee E8, at approximately 11:50 a.m. revealed that the gait belt was not to be left on a resident after moving the resident from one place to another. On (MONTH) 27, (YEAR), at approximately 7:50 a.m. during medication administration observation it was revealed that licensed Employee, Employee E5 was observed administering medication to Resident 91. Licensed nursing staff, Employee E5 went into Resident 91's room and advised the resident to sit at the edge of the bed. Resident 91's door was left open and the privacy curtain was not drawn. A housekeeper staff was observed to be present in the resident's room cleaning the roommate's bed. Licensed nursing staff, Employee, E5 was observed administering a [MEDICATION NAME] injection (medication used to help control blood sugars in residents with diabetes) to Resident 91's right arm without pulling curtain or closing door. Licensed nursing staff Employee E5 failed to ensure Resident 91 privacy during insulin administration On (MONTH) 27, (YEAR), at approximately 8:05 a.m. during a medication administration observation, it was revealed that Licensed nursing staff, Employee E6 was observed administering medication to Resident 78. Licensed nursing staff, Employee E6, went into Resident 78's room. The resident was asleep in personal wheelchair, semi reclined watching television. Without closing privacy curtain or closing door, Licensed nursing staff, Employee E6 pulled up Resident 78's shirt, exposing the stomach and administered Humalog injection (medication used to help control blood sugars in residents with diabetes). Licensed nursing staff, Employee E6, failed to ensure Resident 78's privacy during insulin administration. Observations conducted on (MONTH) 27, (YEAR), at approximately 9:45 a.m. revealed that Resident 78 was observed sleeping in his personal wheelchair with the head of wheelchair reclined to about a 45-degree angle. The resident's television was on in the resident's room. Resident 78's foot was hanging down, not on footrest of wheelchair. Resident #78's stomach was exposed as their shirt was tight and pulled up. Their upper body was slouched to the right side with hand hanging down off wheelchair which appeared to be missing right arm rest. Head was hanging slightly to the right with minimal pillow support. Resident #78 was observed every fifteen minutes and remained in this position for an hour and thirty minutes. The facility failed to maintain Residents 6, 66, 78 and 91 dignity. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 01/31/17, 03/25/16

Based on clinical record review and staff interview it was determined that the facility failed to follow physician's orders for one of 25 residents reviewed (Resident 60). Findings include: Review of Resident 60's (MONTH) (YEAR) physician's orders revealed an order obtained on (MONTH) 6, (YEAR), for the resident to wear gerisleeves (protective sleeves worn on the arms to protect from skin tears) to both arms when out of bed as tolerated every day and every evening shift for skin protection. Review of Resident 60's nursing notes revealed a nursing entry on (MONTH) 18, (YEAR), at 9:36 p.m. stating that during p.m. care (care provided for the resident before they go to bed) a 4 centimeter by 3 centimeter skin tear was noted to the left elbow. Review of Resident 60's facility incident report, dated (MONTH) 18, (YEAR), for the skin tear sustained by Resident 60 revealed the action plan was to re-educate the staff on making sure the gerisleeves were on. Interview with the Director of Nursing on (MONTH) 1, (YEAR), at 11:30 a.m. revealed the staff were educated because Resident 60 did not have the gerisleeves on as ordered by the physician when the skin tear was discovered on (MONTH) 18, (YEAR). Quality of Care CFR(s): 483.25 Previously cited 01/31/17, 03/25/16 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 01/31/17, 03/25/16

Based on observations and interviews with facility staff, it was determined that the facility failed to ensure that the resident's environment remained free from potential accident hazards related to storage of medications for one of 6 nursing units observed (Meadow Ridge A wing). Findings include: During an observation of the medication administration pass on Meadow Ridge floor on January 27, 2017 at approximately 9:10 a.m., a licensed nurse Employee E3, proceeded to leave five small clear packaged bags containing two to three pills each, along with an individually wrapped Tramadol (a narcotic used in the treatment of [REDACTED]. Further observation of the medication administration pass on January 27, 2017 at approximately 9:15 a.m., Employee E3 proceeded to leave the medicine cup containing sixteen pills on top of the medication cart, which she left unattended and out of site, while walking to the door of Resident D7's room which was approximately 30 to 40 feet away from the medication cart asking the resident where she was having pain. The aforementioned findings were reported to the Nursing Home Administrator and Director of Nursing on January 31, 2017 at approximately 2:35 p.m. The facility staff failed to ensure medications were safely secured and stored to prevent unauthorized persons or residents from taking items from the carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 3/25/16 28 Pa. Code: 201.18 (b)(3) Management. 28 Pa. Code: 201.18 (d)(1) Management. 28 Pa. Code: 211.12 (d)(1)(3) Nursing services. Previously cited 3/25/16

Based on clinical record review, it was determined that the facility failed to maintain accurate documentation regarding detailed documentation of a burn for one resident (Resident D10), an allegation of abuse for one resident (Resident L9) and a discrepancy in medication administration for one resident (Resident H10) for three of the 24 resident reviewed. Findings include: Review of Resident D10's clinical record revealed a nursing note on January 24, 2017 that stated new order per (physician) for burn to abdomen and right breast. There was no documentation preceding the note or thereafter describing the event of occurrence nor further descriptions of the injury. An interview was conducted with the Licensed Director of Nursing on January 20, 2017 at approximately 10:44 a.m. revealed that there was no further documentation in the progress notes about the incident. Review of Resident L9's progress notes revealed a nursing entry on August 2, 2016 at 2:35 p.m. revealed the resident accused staff of punching him when they were taking care of him. Two aides were in the room and statements were taken. Nurse Manager and Social worker notified. The facility was asked to provide the Resident Incident and Accident Report and the Electronic Event report to the state survey agency. Neither of these documents were provided for the surveyor. The Facility did provide the statements taken of the two staff members in the room at the time of the allegation and a summary that was written by the social worker. Review of the summary completed by the social worker, dated August 4, 2016, revealed Resident L9 made similar allegations on July 12, 2016 alleging that he was punched in the chest two weeks prior and also made an allegation on July 3, 2016 that a Nursing Assistant the night prior pounded on his chest. Review of resident L9's progress notes for July 12, 2016 and July 3, 2016 revealed no entry stating that the resident had made allegations of abuse against the staff. Review of Resident H10's September 1, 2015 physician's orders [REDACTED]. Review of physician's verbal order sheet dated August 9, 2016 had been faxed to physician by a licensed nurse, Employee E7 indicating that Resident H10 did not receive her dose of [MEDICATION NAME] at 6:00 a.m. The medication was not available. Review of Resident H10's Medication Administration Record [REDACTED]. Review of Resident H10's clinical record revealed two nursing progress notes, one dated August 9, 2016 at 7:40 a.m. stated [MEDICATION NAME] not given, Not available. A second note dated August 9, 2016 at 11:43 a.m. stated [MEDICATION NAME] located, given as ordered at noon. signed by a licensed nurse, Employee E8. Review of Resident H10's Medication Administration Record [REDACTED]. The aforementioned findings were reported to the Nursing Home Administrator and Director of Nursing on January 31, 2017 at approximately 2:40 p.m. The facility failed to ensure that Resident D10, H10 and L9 contained complete and accurate documentation. 28 Pa Code: 211.5(f) Clinical records Previously cited: 03/25/2016 28 Pa. Code: 211.12(d)(3)(5) Nursing services Previously cited: 03/25/2016

Based on clinical record review, review of facility policy and staff interview, it was determined the facility failed to follow parameters prior to the administration of pain medication and blood pressure medication for two of 24 residents reviewed. (Residents D2 and E10). Findings include: Review of facility policy entitled Pain Assessment, revised December, 2016, revealed any time a nurse medicates a resident with a PRN (as needed) pain medication, the nurse must document in the electronic MAR (medication administration record) the date and time the medication was given, the resident's rating of his/her pain on a scale of 1-10 with 10 being the worse pain. Review of Resident D2's [DIAGNOSES REDACTED]. Review of Resident D2's January 2017 physician orders [REDACTED]. Review of Resident D2's January 2017 Medication Administration Record [REDACTED]. Further review of Resident D2's January MAR indicated [REDACTED]. Review of Resident E10's [DIAGNOSES REDACTED]. Review of Resident E10's January 2017 physician orders [REDACTED]. Review of Resident E10's January 2017 MAR indicated [REDACTED]. Further review of Resident E10's January 2017 MAR indicated [REDACTED]. The above-mentioned information was conveyed to the Director of Nursing on January 31, 2017 at approximately 10:30 a.m. The facility failed to follow parameters prior to the administration of pain medication and blood pressure medication. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 3/25/16 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/25/16 28 Pa. Code 211.12(c) Nursing Services Previously cited 3/25/16 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/25/16

Based on observations, review of clinical records and staff interview, it was determined that the nursing staff failed to administer medications in accordance with the physician's orders [REDACTED]. Findings include: During an observation of the medication pass on January 27, 2017 at 9:20 a.m., a licensed nurse Employee E3 was observed administering [MEDICATION NAME] (a medication used in [MEDICAL CONDITION]- [MEDICAL CONDITION] reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining)) 20 milligrams capsule by mouth one time a day to Resident D7. The medication was scheduled to be given at 7:30 a.m., before eating breakfast. According to the manufacturing from the Federal Drug Administration (FDA) package insert, [MEDICATION NAME] was to be given at least one hour before a meal. Resident D7 had already eaten the breakfast meal. The aforementioned observation were reported to the Nursing Home Administrator and Director of Nursing on January 31, 2017 at approximately 2:30 p.m. The facility failed to ensure that Resident D7 was adminsitered an anti- acid medication before the breakfast meal. 483.25 Quality of Care F309 Previously cited 3/25/16 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 3/25/16 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of clinical records, facility policy, documentation submitted by the facility, and staff interviews, it was determined that the facility failed to complete an investigation of possible abuse, failed to report to the State survey and certification agency a violation involving possible abuse and failed to take steps to prevent further potential abuse while the investigation was in progress and failed to promptly complete an investigation for an injury of unknown origin for two of 24 residents reviewed (Resident L9 and Resident G2) Findings include: Review of facility policy and procedure titled Abuse Investigation and Reporting, last revised November 2016, revealed all reports of resident abuse shall be promptly and thoroughly investigated and when required appropriately reported. The Nursing Supervisor will put into writing the events of the incident including the date, time and place and the individuals involved on the Resident Incident and Accident Report form and ensure completion of an appropriate Incident report Investigation Instrument. The Nursing Home Administrator or designee will notify the State Survey Agency in an appropriate time frame. Any identified team member of this facility who has been suspected of resident abuse will be immediately suspended until the results of the investigation are conclusive. The results of the investigation will be recorded on the PB-22 (Facility Abuse Report Form). Review of Resident G2's [DIAGNOSES REDACTED]. Review of Resident G2's clinical record revealed that on December 26, 2016, a bruise was discovered on Resident G2's left upper arm. Review of facility documentation revealed that three investigative statements were not obtained from staff members until January 15, January 19 and January 20, 2017. The above-information was conveyed to the Director of Nursing on January 31, 2017 at approximately 10:45 a.m. The facility failed to promptly complete an investigation for an injury of unknown origin. Review of Resident L9's [DIAGNOSES REDACTED]. Review of Resident L9's progress notes revealed a nursing entry on August 2, 2016 at 2:35 p.m. revealed the resident accused staff of punching him when they were taking care of him. Two aides were in the room and statements were taken. Nurse Manager and Social worker notified. The facility was asked to provide the Resident Incident and Accident Report and the Electronic Event report to the state survey agency. Neither of these documents were provided for the surveyor. The facility did provide the statements taken of the two staff members in the room at the time of the allegation and a summary that was written by the social worker. Review of the summary completed by the social worker, dated August 4, 2016, revealed Resident L9 made similar allegations on July 12, 2016 alleging that he was punched in the chest two weeks prior and also made an allegation on July 3, 2016 that a nursing assistant the night prior pounded on his chest. The facility was asked to provide the Resident Incident and Accident Report and the Electronic Event Report and PB-22s to the state agency for the allegations of abuse on July 12 and July 3, 2016. The facility provided statements for each one of these allegations and a summary written by the social worker dated July 12, 2016 summarizing the allegation of that day and there was no summary by the social worker provided for the allegation of abuse on July 3, 2016. Review of the documentation provided by the facility regarding these three allegations of abuse revealed there was no evidence that the staff members who had been alleged in the abuse allegation was suspended per the facility policy. Interview with the Nursing Home Administrator on January 30, 2017 at 12:30 p.m. confirmed that there was no Resident Incident and Accident Report completed by the facility and the allegation of abuse was not reported to the State Survey Agency and a PB-22 was not completed. NHA confirmed that the staff members who had been alleged in the abuse allegation were not suspended per the facility policy. Pa Code 201.14(a) Responsibility of licensee Pa Code 201.18(b)(1)(e)(1) Management Pa Code 211.5(f) Clinical records Previously cited: 03/25/2016 28 Pa Code 211.10(d) Resiodent care policies 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited: 03/25/2016

Based on facility policy and procedure review, clinical record review and staff interview, it was determined the facility failed to notified a resident's family and physician of an allegation of abuse for one of 24 residents reviewed. (Resident L9) Findings include: Review of facility policy and procedure titled Abuse Investigation and Reporting, last revised November 2016, revealed the resident and his/her representative shall be informed of the results of the investigation. Review of Resident L9 [DIAGNOSES REDACTED]. Review of Resident L9's progress notes revealed a nursing entry on August 2, 2016 at 2:35 p.m. revealed the resident accused staff of punching him when they were taking care of him. Two nursing assistants were in the room and statements were obtained. The nurse manager and social worker notified. Review of the summary completed by the social worker, dated August 4, 2016, revealed that Resident L9 made similar allegations on July 12, 2016 alleging that he was punched in the chest two weeks prior and also made an allegation on July 3, 2016 that a nursing assistant the night prior pounded on his chest. Review of Resident L9's clinical record and the documentation of the investigations of these allegations provided by the facility revealed there was no documented evidence that resident L9's responsible party or physician had been notified of these allegations of possible abuse. Interview with the Nursing Home Administrator on January 30, 2017 at 12:30 p.m. confirmed that Resident L9's responsible party or physician had not been notified of these allegations of abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 3/25/16 28 Pa. Code: 201.18(a)(b)(1)(3)(e)(1)(3) Management Previously cited 3/25/16 28 Pa. Code: 211.5(f)(g)Clinical records Previously cited 3/25/16 28 Pa. Code: 211.10(c) Resident care policies Previously cited 3/25/16 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 3/25/16

Based on clinical record review and observations, it was determined that the facility failed to ensure that special eating equipment was provided for one of 24 residents reviewed (Resident H10). Findings include: Review of Resident H10's [DIAGNOSES REDACTED]. Arteries supplying oxygen to the brain are affected), Dementia (Irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability), [MEDICAL CONDITION] (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and [MEDICAL CONDITION] (increased eye pressure resulting in the inability of fluid to drain from the inner eye). Review of Resident H10's January 2017, physician's orders [REDACTED]. Observation of Resident H10 eating breakfast in the main dining room on January 31, 2017 at approximately 9:30 a.m. revealed that the resident had a blue insulated mug with handle and no lid, containing a brown liquid, which resident had sipped. Resident also had a juice glass containing orange juice and a glass of water which were placed to the left of the resident's bowl of oatmeal. Further observation of Resident H10 during the lunch meal in the main dining room on January 31, 2017 at approximately 12:30 p.m. revealed the resident had a glass of water to the left of her lipped plate. Resident H10 was not provided a travel mug during the lunch meal according to the physician's orders [REDACTED]. Interview with the Director of Dining Services and the Clinical Dietician on January 31, 2017 at 2:55 p.m. confirmed that Resident H10 should have used a travel mug during meals. Resident H10's meal tickets provided during the interview, confirmed the use of a travel mug and lipped plate for breakfast, lunch and dinner. The facility failed to ensure that Resident H10 was provided with the special eating utensils at ordered by the physician. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Previously cited 3/25/16

Based on clinical record review and staff interview it was determined that the facility failed to timely act upon pharmacy recommendations for two of 24 residents reviewed (Resident E9 and Resident N1). Findings include: Review of Resident E9's clinical record revealed a recommendation from the facility pharmacist dated October 13, 2016 to add a routine order for Zyrtec (anti-histamine medication) to Resident E9's medication regimen to help with the resident's chronic rash and itching condition. Further review of Resident E9's clinical record revealed that the recommendation from the facility pharmacist was not reviewed and signed by Resident E9's physician until January 12, 2017. Interview with the Director of Nursing on January 31, 2017 at approximately 10:45 a.m. confirmed that the above-mentioned pharmacy recommendation should have been addressed and signed prior to January 12, 2017. Review of Resident N1's clinical record revealed a recommendation from the facility pharmacist dated December 8, 2016 to review and assess the resident's anxiety and history of falls (Falls on November 23, 2016 and December 1, 2016) recommending a trial to decrease the Ativan (medication for anxiety) 0.5 milligrams to Ativan 0.25 milligrams twice a day was not addressed until January 31, 2017. The aforementioned findings were reported to the Nursing Home Administration and Director of Nursing on January 31, 2016 at approximately 2:35 p.m. The facility failed to ensure that Resident E9's pharmacy recommendations were acted timely. 28 Pa. Code 211.9(f)(3) Pharmacy Services Previously cited 3/25/16

Based on observation of a medication administration pass, it was determined that the facility failed to implement proper hand hygiene for three of three residents who received medications (Residents D2, G7 and J1). Findings include: The medication pass was observed on the Meadowbrook Nursing Unit on January 27, 2017 beginning approximately 8:20 a.m. After administering medication to Resident J1 at 8:20 a.m., Licensed Employee E4 performed hand hygiene for approximately 3 to 5 seconds in Resident J1's bathroom. Employee E4 then returned to the medication cart to prepare medications for administration to Resident G7. Further observation of the medication pass on January 27, 2017 at approximately 8:30 a.m., revealed Licensed Employee E4 administer medication to Resident G7. After completion of the medication administration to Resident G7, Licensed Employee E4 performed hand hygiene for approximately 3 to 5 seconds in Resident G7's bathroom and returned to the medication cart and prepared medications for administration to Resident D2. The above information was conveyed to the Director of Nursing and Nursing Home Administrator on January 31, 2017 at approximately 2:00 p.m. The facility failed to implement proper hand hygiene between the administration of medications for Resident D2, G7 and J1. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/25/16

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that care plans were developed and updated to reflect the needs and interventions related to history of suicidal ideation, [MEDICAL CONDITION], mood disorders and deep tissue injury for three of 24 residents reviewed (Resident D8, G8 and J9). Findings include: Review of Resident D8's clinical record revealed the following (but not limited to) Diagnoses: [REDACTED]. Further review of Resident D8's clinical record revealed a physician's orders [REDACTED]. Review of Resident D8's active care plan revealed no interventions or goals for depressive episodes or anxiety. Further review of Resident D8's clinical record revealed a physician's orders [REDACTED]. The active care plan revealed no interventions or goals for [MEDICAL CONDITION]. An interview was conducted with the Nursing Home Administrator on January 31, 2017 at approximately 11:06 a.m. concurred with the findings. Review of Resident G8's clinical record revealed a [DIAGNOSES REDACTED]. Further review revealed a skin assessment on January 19, 2017 that revealed a deep tissue injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) of the foot. Review of Resident G8's active care plan revealed no interventions or goals for deep tissue injury of the resident's foot. An interview was conducted with the Director of Nursing on January 31, 2017 at approximately 1:06 p.m., confirmed that the resident's active care plan did not address the deep tissue injury. Review of Resident J9's clinical record revealed an admitted [DATE] with the following but not limited to, diagnoses; [MEDICAL CONDITION] disorder and anxiety. Further review of the resident's clinical record revealed a Pennsylvania Preadmission Screening Resident Review Identification (PASRR-ID) (identifies individuals with neurocognitive disorders or mental illness) stating that the resident does have major [MEDICAL CONDITION], anxiety disorder with a recent psychiatric hospitalization in May, 2016. Further review of the clinical record revealed a psychiatric consultation dated on August 29, 2016 identified the resident with depression and chronic pain and has had [MEDICAL CONDITION] in the past but denies any thoughts to harm self currently. Review of Resident J9's active care plan revealed no interventions or goals for depression or a history of suicidal ideation. An interview was conducted with the Nursing Home Administrator on January 31, 2017 at approximately 11:06 a.m. concurred with the findings. The facility failed to ensure that plans of care were developed and updated in relation to history of suicidal ideation, depression and a deep tissue injury. 28 Pa. Code 211.5(f) Clinical records Previously cited: 03/25/2016 28 Pa Code 211.10(d) Resident Care Policies Previously cited: 03/25/2016

Based on review Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, the professional nurse practical act, clinical record review, observation and staff interview, it was determined that the facility failed to meet the standards of quality nursing during provisions of care and the administration of medications and treatments, as ordered by the physician and in accordance with professional standards for one of 8 residents reviewed.(Resident I1, K8) Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, dated April 6, 2013, in Subchapter B.Vocational Practical Nurses, Section 21.145(a)(b) Functions of a Licensed Practical Nurse (LPN), reads that a LPN is prepared to function as a member of the health care team based on preparation, knowledge, and experience in nursing competency; administers medications and carries out therapeutic treatment orders for the individual. Review of resident K8 ' s physician orders [REDACTED].) when flushing Port-A-Cath (a small medical appliance with a catheter that connects the port to the vein and is installed beneath the skin on the chest wall in which drugs can be injected; it is classified as a central venous catheter as the tip ends in the superior vena cava of the heart. Flushing a port is by using a syringe to push a small amount of liquid into the port and catheter. Air bubbles in the IV tubing can block blood flow if they are large, and can also prevent the heart from effectively pumping blood or stop.) 1 time a day at 10:00 am. During the observation of an intravenous medication pass on March 23, 2015 at approximately 10:05 a.m. with licensed nurse, Employee E5, it was observed that the nurse connected a prefilled saline syringe to the Port-A-Cath with an air bubble moving inside of the syringe. The nurse was about to push the air bubble into the catheter before the surveyor intervened. Upon observation of the air bubble, the nurse aborted the administration of the Intravenous flush. Employee E5 confirmed by saying, I forgot about the air and proceeded to expel the air from the syringe. Review of facility Policy and Procedure titled Medication Incident Report, last revised on June 2011, revealed the nurse discovering a medication incident will report the incident to the appropriate nurse supervisor. The nurse supervisor shall initiate the Medication Incident Report by completing the top section only and photo copy all pertinent information. The nurse supervisor will notify the nurse who initially made the error and forward the medication incident report for that nurse to complete. Review of Resident I1 clinical record revealed a [DIAGNOSES REDACTED]. Review of resident I1 physician orders [REDACTED]. Review of residents Medication Administration Record [REDACTED]. The facility was asked to provide a copy of the Medication Incident Report for this incident. Interview with the Director of Nursing on March 24, 2015 at 2:20 p.m. revealed there was no incident report completed for this medication error. 28 Pa Code: 211.10(c) Resident care policies Previously cited 1/23/2015,10/21/2015 28 Pa Code: 211.10(d) Resident care policies Previously cited 10/21/2015 28 Pa Code: 211.12(d)(1)(5) Nursing services Previously cited 1/23/2015, 10/12/2015 28 Pa Code: 211.12(d)(3) Nursing services Previously cited 1/23/2015, 10/21/15

Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for bowel protocol, insulin sliding scale, administration of medications and [DIAGNOSES REDACTED] protocol for three of 24 residents reviewed (Residents E5, E18, and I1). Findings include: Review of the facility policy for Bowel Elimination, revised October 2014, revealed that each shift's nurses shall review the bowel movement record and determine the intervention required as follows: if no bowel movement for six shifts, staff shall offer prunes or other interventions as appropriate and if no bowel movement for nine shifts,shall follow the appropriate physician's laxative order. Review of Resident E18's February 2016 physician orders revealed [DIAGNOSES REDACTED]. Further review of physician orders revealed an order for [REDACTED]. Review of the resident's bowel detail report for February 2016 revealed that the resident did not have a bowel movement for nine shifts from February 1, 2016 through February 3, 2015 and the electronic medication report revealed no documented evidence that the bowel protocol was put into place. Further review of the bowel detail report revealed that the resident did not have a bowel movement for ten shifts from February 10, 2016 through February 13, 2016 and the electronic medication report revealed no documented evidence that the bowel protocol was put into place. Interview with the director of nursing on March 24, 2016 at approximately 2:00 p.m. confirmed that there was no docuemnted evidence in either the electronic medication report or in nursing notes that the bowel protocol was followed. Review of facility policy and procedure entitled, Medication Incident Report, revised date June 2011, revealed the nurse shall notify the Power of Attorney of a medication or treatment errors which included medication omissions; treatment omissions, wrong medication, wrong dosage, wrong route, etc. Review of resident I1 clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident I1 physician orders revealed an order on December 21, 2015 for [MEDICATION NAME] (antidepressant) 10 milligrams orally at hour of sleep for depression. Review of residents Medication Administration Record [REDACTED]. Interview with the Director of Nursing on March 24, 2016 at 2:20 p.m. confirmed that the resident did not receive this medication as ordered. Review of Resident E5's February 2016 physician orders revealed [DIAGNOSES REDACTED]. Review of February 2016 physician's orders revealed an order for [REDACTED]. Review of the electronic Medication Administration Record [REDACTED]. Interview on March 25, 2016 with the director of nursing at approximately 9:30 a.m. confirmed that there was no evidence that the physician orders for the sliding scale were followed for the aforementioned dates. F309 483.25 QUALITY OF CARE Previously cited 10/21/2015; 1/23/2015 28 Pa. Code: 211.5(f) Clinical records 28 pa. Code: 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/21/2015; 1/23/2015

Based on review of clinical record, facility documentation review, staff interviews and review of facility policy and procedure, it was determined that the facility failed to notify the physician and the family or legal resident representative of an accidental clinical complication requiring physician intervention for two of 24 residents reviewed (Residents H5 and I1). Findings include: Review of facility policy and procedure entitled, Medication Incident Report, revised date June 2011, revealed the nurse shall notify the Power of Attorney of a medication or treatment errors which included medication omissions; treatment omissions, wrong medication, wrong dosage, wrong route, etc. Review of facility policy and procedure, entitled [DIAGNOSES REDACTED], revised date January 2008, defined [DIAGNOSES REDACTED] as Insulin Shock, a condition that occurs in diabetic residents when their blood sugar is too low, the onset is sudden. General guidelines for the signs and symptoms which indicated [DIAGNOSES REDACTED] included a blood glucose value less than 60. If signs and symptoms indicated [DIAGNOSES REDACTED], blood sugar was to be tested immediately, and results reported to the supervisor. If resident had [DIAGNOSES REDACTED], staff to follow the Hypoglycemic Protocol and if resident did not have order for the protocol, staff to follow the protocol for Patients Able to Take by Mouth but obtain a physician order [REDACTED]. Guideline Step 5 proceeded for the supervisor to notify the physician if signs and symptoms persist or worsen, or if the blood sugar did not return to normal range. Finally, Step 6 proceeded with documentation in the nurses' notes the date and time of assessments, treatment provided, resident's response, the resident's blood sugar, if the physician was notified and staff signature. Review of Resident H5's clinical record revealed a [DIAGNOSES REDACTED]. Review of current physician orders, revealed order for the insulin Humalog Solution 100 units four times a day before meals and bedtime per sliding scale coverage per bedside glucose testing. Physician orders [REDACTED]. Check blood glucose testing 15 minutes later and call results to physician for further instructions. Review of Resident H5's vital signs documentation for month February 2016, documented resident with a blood glucose value of 47 on February 9, 2016 at 5:54 p.m. Review of H5's clinical record documentation for nursing progress notes, failed to document that the resident's attending physician or the resident's responsible family were notified of a clinical incident warranting physician notification on this date. Review of Resident H5's nursing note, dated February 16, 2016 at 6:00 p.m., documented resident blood sugar taken at 4:00 p.m. blood sugar 25. Review of facsimile notification to oncall certified registered nurse practitioner, dated February 16, 2016 at 9:30 p.m., revealed an order to hold Humalog sliding scale x 1 at 9:00 p.m. Further review of clinical record, confirmed that licensed staff failed to document notification of this incident, on February 16, 2016, to the supervisor for notification to the physician when the hypoglycemic condition persisted and did not return to the resident's normal range; or subsequent notification to resident's attending physician. In addition, the facility failed to provide documented evidence that the resident's responsible family were notified of a clinical incident warranting physician notification. Review of Resident H5's nursing note, dated February 19, 2016 at 8:00 p.m., documented resident blood sugar checked before with result of 55, orange juice with sugar given rechecked with result of 56. Sugar packets opened; put in resident's mouth. Blood sugar taken then was 61. Dinner tray came, sandwich and hot chocolate given and accepted. Blood sugar rechecked with result of 71. Resident then ate dinner, rechecked with blood sugar of 89. Interview with Director of Nursing, on March 24, 2016 at 10:30 a.m. and at 1:00 p.m., confirmed that licensed staff failed to include notification to Resident H5's responsible family representative and to resident's attending physician regarding those incidents and conditions of [DIAGNOSES REDACTED] for dates February 9, 2016; February 16, 2016 and February 19, 2016. Review of Resident I1's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident I1's December 2015 physician's orders [REDACTED]. Review of resident's Medication Administration Record [REDACTED]. Further review of Resident I1's clinical record revealed no documentation that the facility notified the responsible family member/power of attorney of this medication omission and further there was no Medication Incident Report completed for this incident as indicated in the facility's policy. Interview with the Director of Nursing, on March 24, 2016 at 2:45 p.m., confirmed that facility had no documented evidence that the resident's power of attorney was notified of the medication error and was not aware that a medication error had occurred. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(a)(e)(1)(3) Management 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.5(g) Clinical records 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 10/21/2015; 1/23/2015

Based on observations, clinical record review, facility documentation, reportable event review, facility policy review, and staff interviews it was determined the facility failed to ensure the residents were free from accidents and hazards for 10 of 34 residents reviewed resulting in harm to two resident. (Residents: D3 and I5). Findings include: Review of resident D3s [DIAGNOSES REDACTED]. Review of resident D3s significant change minimum data set (MDS- assessment of resident needs and status) revealed the resident had a Brief interview for mental status (BIMS) score of 15/15 which indicated he was cognitively intact. Occupational therapy assessed the resident on August 26, 2013 was that the resident only need adaptive utensils and no need for adaptive drinking devices and needed supervision with meals. On September 13, 2013 the occupational therapy assessment indicated set up only for meals and was able to independently eat and drink. Review of the care plan indicated there was no direction for meal tray set up regarding hot liquids due to his paralysis on the right side. Nursing note dated September 17, 2013 at 11:00 a.m. revealed that the resident knocked his coffee off of his breakfast tray into his lap. A nursing note on September 17, 2013 at 2:20 p.m. revealed that therapy reported two blisters had developed on the right thigh measuring 4.0 x 1.4 centimeters (cm) and 1.3 x 1.0 cm with a reddened area of 42 x 15 cm. on the posterior (back) right thigh measuring 3.0 x 1.1 cm and the others clustered at 0.2 x 0.2 each. All blisters were intact. Resident D3 spilled coffee which caused burns resulting in harm to the resident. Review of facility documentation dated January 24, 2014 revealed that at approximately 12:30 p.m., Resident I5 and a family member reported to the staff that the resident burned her upper lip on coffee. The resident refused cool compresses but the burn did result in swelling and a scabbed blister on the lip resulting in harm to the resident. Review of facility documentation revealed that between burn to Resident D3 on September 17, 2013 from spilled coffee and the injury to Resident I5 on January 24, 2014, there were eight other resident incidents when hot liquids were spilled requiring staff assessment and monitoring. The Nursing Home Administrator confirmed that a policy that would provide direction for staff but the policy has not been developed relating to hot beverages and the changes related to repeat incidents. Review of the resident B3's clinical record revealed a nurse's note dated January 29, 2014 that stated the resident received an abrasion to the right great toe during transport, 2.3 x 1.5 cm. Review of facility incident report dated January 29, 2014 revealed a nurse stopped a nursing assistant who was pushing the resident in the shower chair down the hall and observed the resident foot dragging on the floor. The nurse noted the abrasion while assisting the resident back to his room. The aide who was assigned to him that day stated that the abrasion was not there when she washed him and must have happened when pushing him down the hall. Interview with licensed nurse Employee E5 on February 12, 2013 at 11:00 a.m. confirmed that the resident was being moved in the shower chair to his room, and his feet were dragged along the floor causing actual harm to the resident. Observation made during the initial tour of the facility on February 6, 2014 at 12:30 p.m. revealed on the Heather Gardens locked dementia nursing unit in residents E6, E7, E8, E9, and E10 rooms, it was observed that the bathroom cabinets were unlocked and contained mouthwash, toothpaste, shaving cream, and Aloe Vera. Further observations of Residents E7 and E8 room revealed a tube of Aloe Vera lotion was found, lying unattended on the top of a cabinet in the room. Observation of the Heather Gardens soiled utility closet revealed it was unlocked and an unlocked cabinet inside contained a bottle of liquid air freshener and a bottle of disinfectant cleanser which both had labels that warned to keep out of the reach of children. Interview with licensed nurse Employee E5 at the time of the observations confirmed that this was a unit specific for cognitively impaired residents and these items should be secured so that the residents would not have access to them. F 323 Previously cited 2/13/13 28 PA Code: 201.14(a) Responsibility of licensee Previously cited 2/13/12 28 PA Code: 201.18(b)(1) Management Previouly cited 2/13/12 28 PA Code: 201.18(b)(3)(e)(1) Management Previouly cited 1/15/13, 2/12/12 28 PA Code: 211.10 (d) Resident care policies 28 PA Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 1/15/13, 2/13/12