Every finding on record at Titusville Nursing and Rehab

Based on review of facility policy, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure appropriate safety measures were implemented regarding the service of hot coffee to a resident that resulted in an accident and actual harm of a second degree skin burn (a burn that damages the top layer of skin and damages the second layer of skin) for one of 20 residents reviewed (Resident R28). This deficiency is cited as past non-compliance. Findings include: The Hot Liquids Policy-Food Service policy, dated 4/23/26, states, To ensure that all hot liquids served within the facility are delivered at a temperature that balances safety and palatability, while also considering the unique needs and physical capabilities of each resident.All coffee and hot liquids will be brewed in the main kitchen.The temperature of hot liquids will be recorded and will not exceed 145 degrees at the point of service.Cups must be appropriate for the resident's ability-lightweight, easy to grip, and if necessary, fitted with lids or handles to prevent spills. Resident R28's clinical record revealed an admission date of 12/7/22, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), absence epileptic syndrome not intractable without status epilepticus (seizures that cause brief sudden staring spells-that is well controlled with medications), hypertension (high blood pressure). Review of the clinical record revealed Resident R28 had a BIMS (brief interview for mental status) score of seven dated 2/20/26. The BIMS tool is used to assess cognitive function; a score of seven indicates a severe impairment. Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E3, dated 2/26/26, at 6:34 a.m. CNA (Certified Nursing Assistant) called this writer to the room, resident spilled hot coffee on her thigh. 9cm (centimeters) by 8cm redness noted to left thigh loose skin from possible blistering gave resident Tylenol for pain. Resident R28's clinical record revealed a nursing note written by the Director of Nursing (DON), dated 2/26/26, at 8:30 a.m. Medical Director in facility and assessed resident's burn area. Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E4, dated 2/26/26, at 2:35 p.m.Spilling coffee on lap.LT (left thigh) .LG (large) red area noted with scattered blistering. Resident R28's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E5, dated 2/26/26, at 10:30 p.m. LT one large blister has broke and others are starting to leak. The facility investigation revealed that LPN Employee E3 provided a written statement with an incident date of 2/26/26, and time of 5:25 a.m. which revealed, CNA called me to Resident R28's room. Stated a cup of hot coffee spilled on Resident R28's leg. The facility investigation revealed that CNA Employee E6 provided a written statement with an incident date of 2/26/26, and time of 5:25 a.m. which revealed, Got Resident R28 washed and dressed for the day. Asked [him/her] if he/she would like a cup of coffee, went and got one. [He/She] ended up spilling it on his/her leg. Documentation submitted by the facility, dated 2/26/26, revealed that .the coffee was obtained from the employee breakroom in a Styrofoam cup . [Resident R28] unable to say exactly what happened after being interviewed. The facility failed to ensure that Resident R28 was provided with a hot liquid served at a safe temperature, from the facility's main kitchen, was served in an appropriate container, and failed to properly supervise Resident R28 with a hot liquid causing second degree burns to his/her left thigh. This deficiency is cited as past non-compliance. On 2/26/26, the facility-initiated education for all staff to ensure that residents are receiving coffee at safe temperatures from the main kitchen, in an appropriate container, and are properly supervising residents. This plan includes the following: Immediate Suspension of CNA Employee E6. Immediate education regarding checking temperatures, obtaining hot liquids from the main kitchen, ensuring hot liquids are in an appropriate container, and that residents are properly supervised when drinking hot liquids was provided to all staff, which occurred from 2/26/26, through 3/15/26. Review of all residents at risk related to hot liquids completed by the DON and care plans updated as indicated. Interviews with CNA Employees E7 and E8, LPN Employees E4 and E9, RN Employee E10, Housekeeping Employee E11 ,Therapy Director, Activities Director, Dietary Manager, Laundry Supervisor, Medical Records Manager, and Business Manager, all confirmed the facility-initiated education and competencies starting 2/26/26, which included education on checking temperatures for hot liquids, obtaining hot liquids from the main kitchen, ensuring hot liquids are in an appropriate container, and that residents are properly supervised when drinking hot liquids. Audits were conducted to ensure residents receive hot liquids at appropriate temperatures, from the main kitchen, in an appropriate container, and are properly supervised, which occurred on all shifts and on all units from 2/26/26, through 3/19/26, with all performed appropriately. The facility has demonstrated compliance with hot liquids since 3/19/26. During an interview with the DON on 6/26/26, at approximately 12:00 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding hot liquids and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 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 ensure that food was stored in accordance with standards for food safety and serve food in a safe and sanitary manner during tray line in the main kitchen.Findings include: Review of facility policy entitled Food Safety Requirements dated 4/23/26, indicated Staff shall adhere to safe hygienic practices to prevent contamination of food from hands or physical objects. Review of facility policy entitled Date Marking for Food Safety dated 4/23/26, indicated The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. And The marking system shall consist of, the day/date of opening, and the day/date the item must be consumed or discarded. Observations during the initial kitchen tour on 6/23/26, between 9:45 a.m. and 10:00 a.m. revealed in the walk-in refrigerator an open container of garlic with a use by date of 5/9/26. In the upright freezer there was an open bag of waffles that was not closed, four packages of hot dog buns with a best by date of 5/26/26, and four packages of English muffins which appeared freezer burnt and had no date indicating when they should be discarded. In the dry storage area, there were three open packages of pasta, one with a use by date of 6/6/26, one with no open or use by date and one with no use by date. During an interview at the time of observations the Dietary Manager confirmed the open container of garlic, hot dog buns, English muffins, and three packages of pasta were beyond their use by dates and/or lacked dates. He/she confirmed that the open bag of waffles was not properly closed to prevent contamination and that all the items should have been discarded by or before their use by date or expiration date. Observations during tray line on 6/24/26, at approximately 11:20 a.m. revealed that Dietary [NAME] Employee E2 was observed with gloved hands touching the outside of the refrigerator, countertop, oven door and the food transport cart (a cart that meal trays for residents are placed in to take out of the kitchen). He/she then picked up and placed a hamburger bun on a plate with their hands, then placed a hamburger on the bun and proceeded to pick up a slice of cheese with their hands and placed it on top of the hamburger. Dietary [NAME] Employee E2 did not remove his/her gloves and perform hand hygiene during the entire process. During an interview at the time of observations the Dietary Manager confirmed that Employee E2 touched several items then touched the resident's food with the same gloves. He/she also confirmed that Employee E2 should have removed his/her gloves, washed his/her hands and applied new gloves before touching the resident's food. 28 Pa. Code 211.6(c)(f) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to receive instructions for removal of a urinary catheter (a soft plastic tubing inserted into the bladder to drain urine into a bag) in a timely manner for one of one residents reviewed for catheters (Resident R30).Findings include: Review of facility policy entitled Appropriate Use of Indwelling Catheters dated 4/23/26, indicated Indwelling urinary catheters will be used on a short-term basis., The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter. Review of Resident R30's clinical record revealed an admission date of 4/29/26, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow). Review of Resident R30's clinical record revealed an order from urology dated 6/9/26, instructing to remove his/her urinary catheter for a trial to void (a procedure where the urinary catheter is removed to see if the person will urinate without the urinary catheter) attempt. Monitor patient for six hours following the catheter being discontinued - if no void- straight catheter (a urinary catheter that does not remain in the patient's body) the patient. If greater that 350 ml (milliliters) of urine retained leave indwelling catheter and reach out to the urology team for the next steps. Review of Resident R30's progress notes revealed the following notes:note dated 6/9/26, at 2:37 p.m. indicating urology wanted to do a trial void noted dated 6/9/26, at 7:18 p.m. catheter was reinserted per resident's request.note on 6/10/26, at 10:50 a.m. revealed urology updated on urinary catheter and will call back with further instructions.Progress notes lacked evidence that the facility followed up with urology for further instructions for the potential removal of Resident R30's urinary catheter in a timely manner. During an interview on 6/25/26, at 12:10 p.m. Registered Nurse (RN) Employee E1 confirmed there was no evidence that the facility followed up with urology for further instructions for Resident R30's urinary catheter and on 6/26/26, at 9:30 a.m. RN Employee E1confirmed that the facility failed to follow-up with urology for further instructions regarding Resident R30's urinary catheter in a timely manner, and that the facility should have reached out to urology in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of two medication rooms reviewed (first floor and ground floor medication rooms) and failed to prevent the opportunity for potential unauthorized access of medications on one of three medication carts observed (B wing medication cart). Findings include: Review of a facility policy entitled Labeling of Medications and Biologicals dated 12/11/24, revealed that labels for multi-use vials must include the date the vial was initially opened . and all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different . date for that opened vial. Review of a facility policy entitled Security of Medication Cart dated 12/11/24, revealed that medication carts must be securely locked at all times when out of the nurse's view. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. Observation of drug storage on 6/3/25, at 12:33 p.m. of the first floor medication room revealed an open vial of Tubersol with no date indicating when the vial was open. During an interview with Licensed Practical Nurse (LPN) Employee E3 on 6/3/25, at the time of observation he/she confirmed that the open vial of Tubersol lacked an open date, and staff were unable to determine the discard date. LPN Employee E3 also confirmed that the vial of Tubersol should have been discarded. Observation on 6/3/25, at 1:17 p.m. of the ground floor medication room revealed an open vial of Tubersol with an open date of 4/25/25. During an interview with LPN Employee E4 on 6/3/25, at the time of observation, he/she confirmed that the open vial of Tubersol had an open date of 4/25/25 and also confirmed that the vial of Tubersol should have been discarded. Observation of medication administration on 6/4/25, at 8:45 a.m. revealed that LPN Employee E3 prepared medications for a resident from the B wing medication cart that was parked in the hall in front of the nurse's station. LPN Employee E3 then proceeded into the pantry to obtain a glass of milk for the resident. LPN Employee E3 left medications on top of the medication cart and did not securely lock the medication cart. LPN Employee E3 was unable to view medication cart while he/she was in the pantry. During an interview on 6/4/25, at the time of observation, LPN Employee E3 confirmed that the medication cart was left unlocked and with medications on top of the medication cart while it was parked at the nurse's station, which was out of view when going into the pantry. LPN employee E3 also confirmed that the medication cart was to be locked, and medications should not be left on top of the medication cart when out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to promote resident choices about aspects of his or her life in the facility that are significant to the resident regarding medication administration for two of 16 residents reviewed (Residents R11 and R51). Findings include: The facility policy entitled Medication Administration-General Guidelines, dated 12/11/24, indicated that medications are administered within 60 minutes of scheduled time. Resident R11's clinical record revealed an admission date of 3/27/23, with diagnoses that included diabetes (condition of improper blood sugar control), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and chronic obstructive pulmonary disease (a progressive lung disease with chronic respiratory symptoms). During an interview with Resident R11 on 6/4/25, at 10:30 a.m. the resident shared that he/she had received medications late on 5/28/25, and had filed a grievance against Licensed Practical Nurse (LPN) Employee E5. Resident R11 indicated that receiving medications at 9:30 p.m. is too late and prefers to have the medications administered closer to 8:00 p.m. Review of Resident R11's May Medication Administration Record (MAR) revealed that on 5/28/25, seven medications that were ordered for 8:00 p.m. were administered at 9:25 p.m. Resident R51's clinical record revealed an admission date of 5/23/24, with diagnoses that included protein-calorie malnutrition, anxiety, and bipolar disorder( a mental disorder with periods of depression and abnormally elevated moods). During an interview with Resident R51 on 6/3/25, at 11:00 a.m. the resident shared that he/she had received medications late on a few days from LPN Employee E5 and prefers to have the medications administered closer to 8:00 p.m. Review of Resident R51's May MAR revealed that on 5/28/25, five medications that were ordered for 8:00 p.m. were administered at 9:06 p.m. and on 5/30/25, five medications that were ordered for 8:00 p.m. were administered at 9:24 p.m. During an interview on 6/04/25, at 1:00 p.m. the Infection Control Preventionist confirmed that Residents R11 and R51 medications were not administered timely for the above dates and in accordance with resident preferences and choices. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R209). Findings include: Review of facility policy entitled Oxygen Administration dated 12/11/24, revealed Review the physician's order . for oxygen administration. Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at . and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident R209's clinical record revealed an admission date of 5/23/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes (a health condition that caused by the body's inability to produce enough insulin), and acute respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R209's physician's orders dated 5/23/25, revealed an order for oxygen at 6 liters/minute via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen). Observations on 6/3/25, at 11:24 a.m., 12:50 p.m., 2:06 p.m., and again at 2:14 p.m. revealed Resident R209 sitting on their bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 8 1/2 liters/minute. During an interview on 6/3/25, at 2:14 p.m. the Director of Nursing confirmed that Resident R209's oxygen concentrator was on and set at 8 1/2 liters/minute and was not in accordance with the physician's order dated 5/23/25, for oxygen delivery at 6 liters/minute. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of three residents with pressure ulcers requiring wound care reviewed and also failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) (Resident R109). Findings include: Review of the facility policy entitled, Wound Care, dated 12/11/24, indicated to remove the soiled dressing, remove soiled gloves and then wash hands. Review of the facility policy entitled, Enhanced Barrier Precautions, dated 12/11/24, are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO). It also indicated that gloves and gown are to be applied prior to performing the high contact resident care activities, which includes wound care. Review of Resident R109's clinical record revealed an admission date of 10/11/24, with diagnoses that included paraplegia ( loss of feeling in legs and lower body), pressure ulcers of sacral region, right buttock and left hip all at stage four (full thickness tissue loss with exposed muscle, tendon, ligament, cartilage or bone). Review of Resident R109's physician's orders dated 5/30/25, included an order to cleanse the stage four sacrum, right trochanter (hip area), left trochanter and right ischium (lower back area of the hip) pressure ulcers and apply collagen particles to the wound and cover with island dressing. Resident R109's physician's orders dated 1/06/25, revealed EBP related to a urinary catheter (tubing entering the bladder to drain urine) / MDRO. Gown and gloves for resident care. Observation of wound care on 6/04/25, at 10:00 a.m. revealed that Licensed Practical Nurse (LPN) Employee E1 entered Resident R109's room without donning (putting on) a gown. LPN Employee E1 removed the soiled dressing without washing hands afterwards and then continued to cleanse the wound without washing hands. During an interview on 6/04/25, at 10:15 a.m. LPN Employee E1 confirmed he/she did not don a gown prior to entering Resident R109's room and did not complete hand hygiene when indicated. During an interview on 6/04/25, at 10:45 a.m. the Infection Control Preventionist confirmed that LPN Employee E1 should have donned a gown prior to entering Resident R109's room and adhered to EBP related to wound care and catheter care and should have completed hand hygiene when indicated. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observations, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to notify the physician and begin treatment timely related to a change in a resident's condition, and obtain a physician's order/clarification for the use of an assistive device for two of 17 residents reviewed (Residents R4 and R25). Findings include: Review of facility policy entitled, Change in a Resident's Condition or Status dated 3/28/24, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. Resident R4's admission record revealed an admitted [DATE], with diagnoses that included dementia (condition with symptoms that affect memory and thinking), atrial fibrillation (irregular heart rate), and type II diabetes (condition of insufficient production of insulin). Review of a nursing note dated 7/20/24, at 6:01 p.m. indicated that the physician was faxed information regarding white patches in Resident R4's mouth. Continued review of Resident R4's clinical record revealed a nursing note dated 7/22/24, at 11:40 a.m. indicating that the physician's office was contacted regarding white patches on Resident R4's tongue and mouth. A nursing note dated 7/23/24, at 12:03 p.m. indicated an order was received for Nystatin Mouth/Throat Suspension (a medication used to treat a fungal infection in the mouth) Give 5 milliliters by mouth three times a day (8:00 a.m., 1:00 p.m., and 5:00 p.m.) for thrush swish and spit. Nursing notes dated 7/23/24, at 1:31 p.m. and 7/23/24, at 4:18 p.m. revealed that Resident R4 did not receive the Nystatin Mouth/Throat Suspension as ordered due to it not being delivered to the facility. Review of Resident R4's July 2024 Medication Administration Record revealed Resident R4 received his/her first dose of Nystatin Mouth/Throat Suspension on 7/24/24, during the 8:00 a.m. medication pass, this was approximately 86 hours after the white patches on his/her mouth and tongue were observed. During an interview with the Director of Nursing (DON) on 7/24/24, at 12:20 p.m. it was confirmed that there was a delay in treatment regarding Resident R4's change in condition and that nursing staff should have called the physician on Saturday 7/20/24, rather than faxing the physician with the resident condition concerns. Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included status post right hip fracture and repair, heart failure, and right leg blood clots. The clinical record lacked of evidence of physician's orders, care plan interventions, nurse aide tasks, or progress notes regarding application of an abductor pillow (soft but firm foam pillow that is placed between the thighs and strapped onto the patient's legs while they are in a resting position to aid in keeping the body stable and prevents an abducting motion that could cause pain or further injury post-surgery). During an interview on 7/24/24, at 11:45 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R25 came back from an orthopedic appointment with the pillow and that there was no physician's order for it in the clinical record. During an interview on 7/24/24, at 11:57 a.m. Nurse Aide (NA) Employee E2 confirmed that he/she has inconsistently discovered the abductor pillow between Resident R25's legs upon entering the room and removed the pillow and placed at the top of his/her closet in an effort to prevent others from using it because there was no physician's order for it. During an interview on 7/24/24, at 1:21 p.m. the DON confirmed Resident R25 did not have a physician's order for the use of an abductor pillow and the Therapy Director confirmed that the abductor pillow present in Resident R25's room was not an the appropriate size for he/she to use. During an interview on 7/24/24, at 1:35 p.m. Registered Nurse (RN) Employee E3 confirmed he/she had only seen the pillow once prior on 7/19/24. During an interview on 7/24/24, at 2:20 p.m. LPN Employee E4 confirmed he/she had only seen the pillow once prior on 7/19/24, and did not know where it came from. During an interview on 7/24/24, at 2:28 p.m. NA Employee E5 confirmed he/she was not sure how often the pillow was placed between Resident R25's legs and that if used, it was painful for the resident. During an interview on 7/24/24, at 2:35 p.m. NA Employee E6 confirmed that when he/she comes over to that hall to help the pillow is already in there, it is removed to provide care and Resident R25 doesn't like it in there. During an interview on 7/25/24, at 10:00 a.m. the Corporate Nurse Consultant confirmed there was no care plan or nurse aide tasks for the use of the abductor pillow. Observation on 7/25/24, at 10:26 a.m. revealed a pink, foam abductor pillow remained laying in Resident R25's closet. During an interview at that time, LPN Employee E1 confirmed the abductor pillow was laying in Resident R25's closet and that there was no physician's order for the pillow. During an interview on 7/25/24, at 1:00 p.m. NA Employee E7 confirmed that he/she has discovered the pillow already in place between Resident R25's legs upon entering the room. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12 (d)(2)(3) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one resident reviewed for respiratory care (Resident R210). Findings include: Facility policy entitled Departmental (Respiratory Therapy) - Prevention of Infection dated 3/28/24, indicated Infection Control Considerations Related to Oxygen Administration . Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Resident R210's clinical record revealed an admitted [DATE], with diagnoses that included fracture of right femur (broken bone of the upper leg), hypertension (high blood pressure), and diabetes (a health condition that causes by the body's inability to produce enough insulin). Resident R210's physician orders dated 7/12/24, revealed an order indicating to provide oxygen at 2 liters per minute via nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery). Observation on 7/22/24, at 11:45 a.m. revealed Resident R210's nasal cannula had a piece of tape wrapped around the oxygen tubing dated 7/17/24. The oxygen tubing was connected to the oxygen concentrator and the prongs that go into the nostrils was laying on the floor. Observation on 7/22/24, at 4:10 p.m. revealed that the oxygen tubing remained with the prongs that go into the nostrils laying on the floor. Observation on 7/23/24, at 8:28 a.m. revealed Resident R210's nasal cannula had a piece of tape wrapped around the oxygen tubing dated 7/17/24, the oxygen tubing was connected to the oxygen concentrator and the prongs that go into the nostrils was laying on the floor. During an interview on 7/23/24, at 8:41 a.m. the Director of Nursing confirmed that the nasal cannula was laying on the floor. He/she also confirmed that the nasal cannula should not be on the floor and the nasal cannula should be placed in a bag when the resident is not using it. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of five residents reviewed for psychotropic medications (Resident R6). Findings include: A facility policy entitled Antipsychotic Medication Use dated 3/28/2024, indicated that PRN orders for psychotropic medications are limited to 14 days and If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and heart failure (a condition where the heart cannot supply the body with enough blood). Review of Resident R6's Medication Administration Record (MAR) revealed a physician's order dated 7/9/24, to administer Vistaril (anti-anxiety medication) 25 milligrams (mg) every eight hours as needed (PRN) for 14 days. Further review of Resident R6's MAR revealed PRN Vistaril order was revised on 7/16/24, 7/17/24, and 7/18/24. After the revision on 7/18/24, the PRN Vistaril order lacked evidence of a specified duration. Resident R6 received PRN Vistaril on 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/23/24 and 7/24/24, which was beyond 14 days from the original order date. Resident R6's Vistaril order lacked the required stop date within 14 days and a clinical rationale for continued use beyond 14 days. During interview on 7/25/24, at 9:25 a.m. the Director of Nursing revealed he/she was provided information that the PRN Vistaril did not need a duration to continue use, he/she confirmed that the information was incorrect. He/she also confirmed that the PRN Vistaril lacked the required stop date within 14 days and a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that keys to the medication cart and medication room were secured on one of five units reviewed (Unit B). Findings include: Facility policy entitled, Security of Medication Cart dated 3/28/24, indicated, The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Facility policy entitled, Medication Storage in The Facility dated 3/28/24, indicated, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observations on 7/22/24, at 1:30 p.m. in room [ROOM NUMBER] on Unit B revealed the nurse's medication cart and medication room keys were on the resident's bed and were unsecured. At that time, the Director of Nursing (DON) was called to room [ROOM NUMBER] on Unit B. The DON confirmed that the unsecured keys were for the medication cart on Unit B and the medication room. The DON confirmed that medication cart keys and medication room keys should be secured at all times and should never be left in a resident's room. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(2) Nursing services

Based on review of facility records and staff interview, it was determined that the facility failed to assure required attendance of the Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for two of four quarterly QAPI Committee meetings (July 2023 through December 2023). Findings include: A facility policy entitled Guardian Elder Care Quality Assurance and Process Improvement Committee dated 3/28/24, indicated the following individuals will serve on the committee . j. Infection Control Representative . and The committee will meet monthly at an appointed time. Review of the QAPI Committee Attendance Records from July 2023 through December 2023 revealed no evidence on the attendance sign-in sheets for the required QAPI meetings that the Infection Preventionist was in attendance. During an interview on 7/25/24, at 11:00 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that an Infection Preventionist attended the quarterly QAPI Committee meetings as required in the quarters between July 2023 through December 2023. He/she also confirmed that the Infection Preventionist should be in attendance for the QAPI meetings as required. 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility records and staff interviews, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) attended the Infection Control Committee meetings and works at the facility focusing only on infection control at least part-time as required. Findings include: Review of facility documentation identified that the Director of Nursing (DON) fulfilled the job of the IP from November 2023 through May 2024. The DON works full-time and was unable to provide proof that additional part-time hours focusing only on infection control were completed in addition to his/her full-time DON duties. Review of Infection Control committee meetings from July 2023 through December 2023 revealed there was not anyone who attended the meetings and signed in as the IP. During an interview on 7/25/24, at 11:00 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that an IP attended the meetings from July 2023-December 2023, and the DON confirmed that he/she could not provide proof that he/she completed additional part-time hours focusing only on infection control in addition to his/her full-time DON duties. 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to invite residents and/or representatives to care plan meetings and failed to review and revise comprehensive care plans to reflect the current necessary care and services for four of 17 residents reviewed (Residents R18, R28, R32, and R59). Findings include: Review of a facility policy entitled, Goals and Objectives, Care Plans dated 5/25/2023, indicated that goals and objectives are reviewed and/or revised when the desired outcome has not been achieved. Review of a facility policy entitled Resident Participation Assessment/Care plans policy dated 5/23/2023, revealed that The resident/representative's right to participate in the development and implementation of his/her plan of care includes the right to: (3) a. Participate in the planning process., (7) A seven day advance notice of the care planning conference is provided to the resident and his or her representative. Review of Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 Diabetes (chronic condition that affects the way the body processes blood glucose [sugar]), heart failure, heart disease, high blood pressure and a history of a stroke. Resident R18's clinical record lacked any evidence of resident/resident representative being invited or attending a care plan meeting. Review of Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included major depressive disorder, hypokalemia (a condition when your blood level of potassium is low), schizophrenia (impaired thinking process), and localized edema (swelling in one area of the body) Review of Resident R32's clinical record revealed a care plan conference meeting invitation on 3/31/23. Review of Resident R32's clinical record lacked evidence that he /she and/or resident representative had attended the care plan conference meeting. During an interview on 8/1/23, at 2:34 p.m. Resident R32 disclosed that he/she had not attended care plan meeting. During an interview on 8/3/23, at 9:50 a.m. the Social Services Director indicated that the care plan invitation and care plan meeting would be documented in the resident's clinical record. Review of Resident R59's clinical record Resident R59 clinical record revealed an admitted [DATE], with diagnoses that included congestive heart failure (a condition where the heart becomes weak that leads to a build up of fluid in the lungs and surrounding body tissue), hyperlipidemia (high cholesterol), and cerebral infarction (a blockage of blood flow to the brain) Review of Resident R59's clinical record lacked evidence that he/she and/or the resident representative was invited/attended the care plan conference meetings. During an interview on 8/1/23, at 11:00 a.m. Resident R59 disclosed that he/she had not attended and/or been invited to a care plan meeting. During an interview on 8/3/23, at 9:50 a.m. the Social Service Director indicated that the care plan invitation and care plan meeting would be documented in the resident's clinical record. Resident R59's clinical record lacked evidence that Resident R59 or R59's representative was invited to and/or attended a care plan meeting. During an interview on 8/3/23, at 11:50 a.m. the Social Services Director confirmed there was no evidence that Residents R18 and R59 had attended care plan meetings or been invited to care plan meetings and no evidence of Resident R32 attending the care plan meeting. Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 Diabetes, long-term irregular heartbeat, need help with personal care, and artificial left knee, a care plan entitled, Shows potential for discharge and patient, relative or representative expresses wish for discharge date d 12/06/22, included the goal will be discharged to home when clinical and rehabilitation goals are met. Further review of Resident R28's clinical record revealed a departmental progress note dated 5/18/23, indicating that Resident R28 lived alone in an apartment and planned to return there, however he/she requires 24-hour care which is not available, and he/she must be able to transfer without the use of a lift. Review of a Physical Therapy Discharge Summary dated 5/18/23, indicated that Resident R28 had attained his/her highest practical level and was to be discharged to the long-term care setting. During an interview on 8/03/23, at 9:04 a.m. the Social Services Director confirmed that Resident R28 was not able to go home due to requiring the use of a mechanical lift and lack of caregivers in the home, and that Resident R28's discharge care plan should have been updated to reflect that status. During an interview on 8/03/23, at 9:40 a.m. Physical Therapy Employee E1 confirmed that Resident R28 was discharged from therapy services on 5/18/23, and did not achieve the necessary physical requirements to safely discharge home with home health services. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 17 residents (Resident R10). Findings include: Review of Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, irregular heartbeat, broken right leg, Type 2 Diabetes (chronic condition that affects the way the body processes glucose [sugar]), and high blood pressure. Resident R10's clinical record also revealed that Resident R10 was his/her own responsible party. There was no documentation of an assigned Power of Attorney (individual designated by the resident to make decisions when/if the resident becomes unable to). Review of the most recent Quarterly Minimum Data Set (periodic assessment to determine the resident's current health status and functioning) dated 6/20/23, Section C-Cognitive Pattens Section C0500 indicated that Resident R10's Brief Interview of Mental Status (BIMS-assessment of resident's current cognitive [level of understanding] status) had a score of 15 (cognitively intact). Review of departmental progress notes revealed: 7/26/23: hard to awaken, doesn't make sense. Facility phoned son and he didn't want anything invasive. There was no evidence of asking Resident R10 of wanting to go to the hospital. 7/27/23: very fatigued for a few days, blood sugar dropped. Facility phoned son and he didn't' want anything invasive done. There was no evidence of asking Resident R10 of wanting to go to the hospital. 8/01/23: spoke to son about changing resident's room. There was no evidence the facility spoke to resident about changing rooms. 8/01/23: required assistance with eating, unable to use hands, spilled food all floor and self. There was no evidence of asking Resident R10 of wanting to go to the hospital due to these changes. During an interview on 8/03/23, at 3:09 p.m. Resident R10 confirmed he/she wants to go to the hospital if he/she is sick. During an interview on 8/04/23, at 10:47 a.m. the Director of Nursing confirmed that there was no evidence that the facility asked Resident R10 about going to the hospital, changing rooms, and no evidence of a Power of Attorney document in the clinical record. 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, and resident and staff interview, it was determined that the facility failed to update the resident's discharge plan to reflect changes in determining the resident's potential for discharge, involve the interdisciplinary team, involve the resident and representative, and update the comprehensive care plan and discharge plan in response to information received from referrals for one of 17 residents (Resident R28). Findings include: Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 Diabetes (chronic condition that affects the way the body processes blood glucose [sugar]), long-term irregular heartbeat, needs help with personal care, and artificial left knee. Resident R28's care plan entitled, Shows potential for discharge and patient, relative or representative expresses wish for discharge date d 12/06/22, included the goal will be discharged to home when clinical and rehabilitation goals are met. Review of Resident R28's clinical record revealed a departmental progress note dated 5/18/23, that indicated Resident R28 lived alone in an apartment and planned to return there, however he/she requires 24-hour care which is not available and he/she must be able to transfer without the use of a lift, and a Physical Therapy Discharge Summary dated 5/18/23, indicated that Resident R28 had attained his/her highest practical level and was to be discharged to the long-term care setting. Resident R28's clinical record lacked documentation regarding changing and/or updating Resident R28's discharge plan, and lacked evidence of including the interdisciplinary team and resident/representative in updating the discharge plan. During an interview on 8/01/23, at 2:32 p.m. Resident R28 confirmed that he/she had caregivers at home before coming into the facility and was trying to find home health caregivers so he/she can go back home. During an interview on 8/03/23, at 9:04 a.m. the Social Services Director confirmed that Resident R28 was not able to go home due to requiring the use of a mechanical lift and lack of caregivers in the home, and that Resident R28's discharge plan should have been updated. During an interview on 8/03/23, at 9:40 a.m. Physical Therapy Employee E1 confirmed that Resident R28 was discharged from therapy services on 5/18/23, and did not achieve the necessary physical requirements to safely discharge home with home health services, did not qualify for 24-hour care at home, and that Resident R28 was not safe to discharge home with services. During an interview on 8/04/23, at 9:47 a.m. Social Services Director confirmed that there was no evidence that the change in the discharge plan was discussed with the interdisciplinary team, Resident R28, and his/her representative. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(e) Resident care plan

Based on review of facility policy and facility grievances, and staff interviews it was determined that the facility failed to properly and safely administer resident medications on two separate incidents for one of 17 residents (Resident R3) Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of facility policy dated 5/25/23, entitled Documentation of Medication Administration, indicated that a nurse documents all medication administered to each resident on the resident's Medication Administration Record (MAR), it further indicated that the reason why a medication or medications not administered should be documented. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when the family member came to visit on 5/29/23, at 3:30 p.m. Review of a facility grievance dated 6/22/23, revealed that on 6/22/23, Resident R3 had received their morning medications twice by two different nurses. Review of Resident R3's admission record revealed an admitted [DATE], with diagnoses that included dementia, heart disease, high blood pressure, atrial fibrillation and diabetes. Review of a quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment for Resident R3, dated 5/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) that identified she had severely impaired cognition. Review of Resident R3's MAR for May 2023, identified that Resident R3 was administered all of their medications on 5/28/23 and 5/29/23, even though a medication cup full of medications was found at Resident R3's bedside stand on 5/29/23, at 3:30 p.m. by a family member. A nurse's note dated 6/22/23 at 9:42 a.m. revealed that Resident R3 was given a double dose of her morning medications and a nurse's note dated 6/23/23 at 10:46 p.m. revealed that Resident R3 was doing well post medication overdose; No ill effects. During an interview on 8/03/23, at 10:20 a.m. the Director of Nursing (DON) confirmed that Resident R3's medications should not have been left alone in the room for the resident and should not have been documented as administered. The DON also confirmed that on 6/22/23, Resident R3 did receive two doses of their morning medications in error. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1)(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and grievances and staff interviews, it was determined that the facility failed to properly administer resident medications for one of 17 residents (Resident R3) Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included dementia, heart disease, high blood pressure, atrial fibrillation and diabetes. Review of a quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment for Resident R3, dated 5/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) and had severely impaired cognition. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when the family member came to visit on 5/29/23, at 3:30 p.m During an interview on 8/03/23, at 10:20 a.m. the Director of Nursing confirmed that Resident R3's medications should not have been left alone in the room for the resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to offer and comprehensively address the formulation of advance directives (oral and/or written instructions about future medical care in the event of becoming unable to express medical wishes) for one of 16 residents (Resident R32). Findings include: The facility policy entitled Advanced Directives, dated [DATE], revealed that residents have a right to execute or refuse to execute an advance directive (defined in the policy as a written instruction regarding care and treatment such as a living will (a document that specifies a resident's preferences about measures used to sustain life), or a durable power of attorney (a person designated to make decisions) for healthcare, recognized under state law in relating to the provision of such care when her resident is incapacitated) that stipulates how decisions regarding his/her medical care will be made. The policy further indicated that upon admission the facility would notify the resident/family/legal representative that the resident may execute an advance directive that the facility would honor; provide a copy of the facility policy related to advance directives to the resident/family/legal representative; obtain a documented acknowledgement from the resident/family/legal representative that advance directive information was given and discussed; and all executed advance directives placed in the resident's current medical chart. Resident R32's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R32's admission physician orders, dated [DATE], lacked any orders regarding the resident's code status for either DNR (do not resuscitate) or cardiopulmonary resuscitation (CPR-artificial support for heart and lung function) until [DATE], a period of 79 days since admission. The clinical record lacked evidence that information was provided to Resident R32's/family/legal representative regarding their right to formulate full advance directives or documentation related to the code status. During an interview on [DATE], at 2:30 p.m. the Director of Nursing confirmed that the facility failed to comprehensively address advance directives for Resident R32. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.5(f) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE]

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to revise resident care plans with changes in care and condition for two of 33 residents (Residents R14 and R29). Findings include: The facility policy entitled Care Plans, Comprehensive Person-Centered, dated 1/18/19, indicated that residents' care plans would be revised as information about the resident and the resident's conditions change. Resident R29's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A Report of Consultation dated 1/24/19, included a recommendation from a urologist for Resident R29 to drink cranberry juice daily. A Progress Note, dated 1/24/19, indicated a request was sent to the dietary department for cranberry juice to be provided with Resident R24's meals and snacks. Resident R29's urinary incontinence/UTI care plan, initiated on 10/06/17, and last revised on 8/29/18, and the nutritional status care plan, initiated on 11/29/17, and last revised on 8/29/18, lacked reference to the recommendation for cranberry juice from Resident R29's urologist. During an interview on 2/13/19, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R29's care plan was not revised to include the urology recommendation for cranberry juice. Resident R14's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Wound Evaluation Flow Sheets, dated 2/14/19, revealed that Resident R14 had a current vascular wound of the right third toe and a vascular wound of the right second toe that was assessed as healed on 1/10/19. Resident R14's care plan related to alteration in skin integrity, initiated on 8/17/18, and last revised on 9/11/18, indicated that Resident R14 had a scab to the left foot, third digit and a scab to the right foot, second digit. During an interview on 2/14/19, at 11:52 a.m. LPN Employee E1 confirmed that Resident R14's current care plan was not revised to reflect the current status of his/her vascular wounds. 28 Pa. Code 211.11(d) Resident care plans 28 Pa. Code 211.12(1)(3)(5) Nursing services Previously cited 3/23/18