Every finding on record at Transitional Sub-Acute Unit

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to administer medications in accordance with physician's orders for one of four sampled residents. (Resident CL1) Findings include: Review of the facility policy entitled, Patient's Own Medications, dated January 2023, revealed that patient's own medications would be administered by facility staff to assure that the appropriate medication and dose were taken at the the appropriate time. Clinical record review revealed Resident CL1 was admitted to the facility on [DATE], with diagnoses that included prostate cancer, arthritis, and hypertension (high blood pressure). On March 31, 2023, the physician ordered Xtandi (a medication used to treat prostate cancer) 120 milligrams (mg) each day. Review of the Medication Administration Record revealed that the resident was to receive three 40 mg capsules of the resident's own supplied medication of Xtandi to total 120 mg. Review of a facility statement, dated April 11, 2023, revealed that Registered Nurse 1 stated she only administered one 40 mg capsule of Xtandi to Resident CL1 on four occassions. In at interview on April 17, 2023 at 10:08 a.m., the Administrator confirmed the medication was not administered in accordance with the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of quality assurance meeting attendance records and staff interview, it was determined that the facility failed to ensure that appropriate and required staff attended the facility's quality assurance meetings at least quarterly. Findings include: Based on review of the quality assurance meeting attendance records, there was no documented evidence that the Director of Nursing attended the September 20, 2016 quarterly quality assurance meeting. In an interview on May 17, 2017, at 12:00 p.m., the Administrator confirmed that the Director of Nursing had not attended the September 20, 2016, quarterly quality assurance meeting. 28 Pa. Code 201.18(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records for five of 12 sampled residents. (Resident R3, R9, R21, R35, R37) Findings include: Clinical record review revealed that Resident R3 had [DIAGNOSES REDACTED]. Clinical record review revealed that Resident R9 had [DIAGNOSES REDACTED]. Clinical record review revealed that Resident R21 had [DIAGNOSES REDACTED]. Clinical record review revealed that Resident R35 had [DIAGNOSES REDACTED]. Clinical record review revealed that Resident R37 had a [DIAGNOSES REDACTED]. A review of the fluid intake and urine output records revealed omissions on three days from April 28, 2015 through April 30, 2015, and on 12 days from May 1, 2015 through May 12, 2015. In an interview on May 13, 2015, at 2:20 p.m., the Director of Nursing confirmed that documentation for physician ordered fluid intakes and urine outputs was to be completed on each shift. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/26/14

Based on clinical record review and staff interview it was determined that the facility failed to attempt non-pharmacological interventions prior to administering an anti-anxiety medication for one of three sampled residents who used these medications. (Resident R8) Findings include: Clinical record review revealed that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. At the time of admission, the physician ordered an anti-anxiety medication ([MEDICATION NAME]) to be administered as needed for anxiety. Review of the Medication Administration Records for June 2014 revealed that staff had administered the anti-anxiety medication 17 times between June 4, and June 24, 2014. There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the medication. In an interview on June 26, 2014, at 9:28 a.m., the Administrator confirmed that there was no documented evidence that non-pharmacological interventions had been attempted prior to the administration of the as needed medication. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/30/13

Based on observation, clinical record review and policy review, it was determined that the facility failed to ensure sanitary measures were maintained for two of three residents observed during the medication pass observation. (Residents R41,R42) Findings include: Review of the facility's "Infection Control Program Guidelines" and "Hand Hygiene" policy dated May 2014 revealed that staff was to wash their hands "after contacting a contaminated or potentially contaminated source including inanimate objects" and "after contacting the patient's skin." During the observation of the medication pass conducted on the East nursing unit, on June 25, 2014, between 7:50 a.m., and 8:15 a.m., LPN1 logged onto the computer and then placed Resident 41's medications into a medication cup. The nurse then went into the resident's room, and without washing or gloving her hands, placed the medications one by one into the resident's hand. This same nurse then washed her hands and exited the room. She then prepared Resident R42's medications which included a subcutaneous injection and pills. She donned gloves and administered the injection into the resident's abdomen with her gloved hands making direct contact with the resident's gown and skin. Without changing her gloves or washing her hands she then proceeded to administer the resident's pills by placing them one by one into the resident's hand. The nurse failed to administer medications in a manner that would prevent the spread of infection. In an interview on June 25, 2014, at 10:45 a.m., the Director of Nursing confirmed that staff was not to touch medications with their hands. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/30/13

Based on observation, review of manufacturer's product specifications and staff interview, it was determined that the facility failed to ensure that nutritional supplements were stored according to acceptable standards on one of two nursing units. Findings include: Observation during the initial tour on May 28, 2013, at 10:00 a.m., revealed that the refrigerator in the West Wing dining room contained four nutritional supplements ("Mighty Shakes") that were not labeled with expiration dates. Further observation revealed that the refrigerator in the kitchenette located across the hall from room 105 contained five Mighty Shakes without an expiration date. There were two of the supplements dated May 2, 2013, and one dated May 9, 2013. Review of the manufacturer's specifications revealed that staff was to discard the Mighty Shakes if not used within 14 days of being thawed. In an interview on May 30, 2013, at 1:20 p.m., the Nutrition Manager confirmed that the "Mighty Shakes" were to be discarded if not used within 14 days of being thawed. He also stated that dietary staff was to label each carton of "Mighty Shake" with an expiration date at the time the product is thawed.

Based on observation during the medication pass it was determined that the facility failed to ensure that all drugs were securely stored at all times on one of three medication carts on the West Wing nursing unit. Findings include: During observation of the medication pass on May 29, 2013, at 9:15 a.m., LPN1 entered room [ROOM NUMBER] to administer medications and pulled the privacy curtain. At that time she left the medication cart outside the room unsupervised. The cart was unlocked with and a drawer was partially opened. There were two staff members (maintenance workers) in the immediate vicinity of the unsecured medication cart that had access to the medications. 28 Pa. Code 211.12(d)(1) Nursing services.