Every finding on record at Upmc Magee-Womens Hospital Tcu

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for five out of five residents (Resident R6, R9, R27, R28, and R36). Findings include: Review of facility policy Infection Control - Immunizations dated 9/25/25, indicated Pneumococcal, Covid, and Influenza immunizations will be offered to residents. Other immunizations will be offered as indicated. The purpose is to prevent transmission of agents. Upon admission, establish immunization status with resident or resident representative. Review of Resident R6's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/22/25, indicated diagnoses of hypertension, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anemia (too little iron in the body causing fatigue). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a 0- resident not up to date. Review of clinical records indicated that Resident R6's last received a COVID-19 vaccination on 2/9/2022.During a review of Resident R6's clinical record on 11/24/25, at 12:35 p.m. failed to include documentation that a Covid-19 booster vaccine was offered. Review of Resident R9's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of hypertension, diabetes, and deep vein thrombosis (blood clot forms in a deep vein). Review of clinical records indicated that Resident R9's last received a COVID-19 vaccination on 12/2/21. During a review of Resident R9's clinical record on 11/24/25, at 12:37 p.m. failed to include documentation that a Covid-19 booster vaccine was offered. Review of Resident R27's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R27's MDS's dated 11/14/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), edema, and osteoporosis (condition when the bones become brittle and fragile). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a 0- resident not up to date. Review of clinical records indicated that Resident R27's last received a COVID-19 vaccination on 4/14/21. During a review of Resident R27's clinical record on 11/24/25, at 12:39 p.m. failed to include documentation that a Covid-19 booster vaccine was offered. Review of Resident R28's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R28's MDS's dated 11/19/25, indicated diagnoses of osteoporosis, chronic pain, and epilepsy (disorder of the brain characterized by repeated seizures). Review of clinical records indicated that Resident R28's last received a COVID-19 vaccination on 11/11/21. During a review of Resident R28's clinical record on 11/24/25, at 12:43 p.m. failed to include documentation that a Covid-19 booster vaccine was offered. Review of Resident R36's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R36's MDS's dated 11/24/25, indicated diagnoses of high blood pressure, cellulitis (bacterial skin infection), and gastroesophageal reflux disease (GERD- chronic digestive disorder where stomach acid flows back into throat). MDS Section O- Special treatment, Procedures, and Programs O0350 indicated COVID-19 vaccine was coded a 0- resident not up to date. Review of clinical records indicated that Resident R36's last received a COVID-19 vaccination on 7/7/22. During a review of Resident R36's clinical record on 11/24/25, at 12:47 p.m. failed to include documentation that a Covid-19 booster vaccine was offered. During an interview on 11/24/25, at 1:17 p.m. Registered Nurse Assessment Coordinator Employee E1 stated the facility does not offer Covid vaccines to residents and confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory disease) vaccine for five out of five residents (Resident R6, R9, R27, R28, and R36). 28 Pa. Code 211.5(f)(i)-(xi) Clinical records

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted catheter (a thin plastic tube inserted into a vein using a needle) in accordance with professional standards of practice for one of two residents (Resident R33). Findings include: Review of the facility policy Intravenous (IV) Therapy: Peripheral, Including Midlines last reviewed 9/25/25, indicates to maintain venous access, administer continuous/intermittent intravenous fluids, nutrition, medications, and blood products over a specific time frame. All registered Nurses and Licensed Practical Nurses that complete the IV therapy program are responsible for including but not inclusive to:. IV site inspection a minimum of every shift Maintain a clean, dry and intact dressing over insertion site Document date and time. Review of Resident R33's clinical record indicates an admission date of 11/12/25, with the diagnosis of hernia (when an organ or fatty tissue squeezes through a weak spot in muscle or connective tissue) repair, muscular deconditioning (wasting or thinning of muscle mass) and obesity. Review of Resident R33's clinical documentation indicated a size 22-gauge peripheral catheter was inserted to the left wrist on 11/23/25. During an observation on 11/24/25, at 9:32 a.m. Resident R33 was sitting in her wheelchair, a peripheral IV access site was noted to her left wrist. The IV site was noted not to have been labeled with a date or time of insertion. During an interview on 11/24/25, at 9:34 a.m. Licensed Practical Nurse Employee E3 confirmed the IV access site dressing did not contain a date or time of insertion and that the facility failed to provide adequate treatment and care for a peripherally inserted catheter in accordance with professional standards of practice for one of two residents (Resident R33). 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.28 Pa. Code: 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Resident R30).Findings include: Review of facility policy Tube Feeding via Enteral Feeding Pump last reviewed 9/25/25, indicated to deliver a liquid feeding formula directly to the stomach. Enteral feeding and tubing are changed every 24 hours or when a new bottle is hung. Label feeding bag/bottle with date and time hung. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE], with diagnosis of breast cancer, hypotension (low blood pressure) and abdominal discomfort. Review of a nutrition communication note dated 11/21/25, indicated Resident R30's recommended tube feeding formula is [NAME] Farm 1.5 calorie with goal rate of 50 milliliters (ml) per hour with water flush of 150 ml every four hours. Review of Resident R30's nursing notes dated 11/24/25, indicated tube feeding method continuous with rate of 50ml/hour tolerating without feeling of fullness. During an observation on 11/24/25, at 9:11 a.m. Resident R30's enteral feeding formula and water bag were noted in room infusing via pump. The formula and water bag failed to be labeled with a date or time hung. During an interview on 11/24/25, at 9:15 a.m. Registered Nurse Employee E2 stated I know she just hung it last night. During an interview on 11/24/25, at 9:15 a.m. RN Employee E2 confirmed that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for one of three residents (Resident R30). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for two out of three closed resident records (Residents CR25 and Resident CR26).Findings include: The facility Admission, transfer, discharge policy last reviewed on 9/25/25, indicated that the discharge of a resident from the facility is conducted in an organized manner, focusing on continuity of care. Review of Resident CR25's admission record indicated he was admitted on [DATE]. Review of Resident CR25's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 9/16/25, indicated that he had diagnoses which included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and coronary artery disease (narrowing/blockage of vessels that carry blood and oxygen to the heart). Review of Resident CR25's discharge plan documentation indicated he was discharged home with his wife and home health services. Review of Resident CR26's admission record indicated he was admitted on [DATE].Review of Resident CR26's MDS assessment dated [DATE], indicated he had diagnoses that included left clavicle fracture, hypertension and osteoporosis. Review of Resident CR26's discharge records indicated he was discharged to a nursing facility on 2/24/25.Review of facility notifications to the State Ombudsman office did not include notifications of Closed Resident Record CR25 and CR26 dischargesDuring an interview on 11/25/25, at 9:30 am. the Nursing Home Administrator (NHA) confirmed that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for Closed Resident Records R25 and R26 as required. 28 Pa. Code: 201.29 (ac.3) (2) Resident rights.

Based on a review of policy, observation and staff interview, it was determined that the facility failed to maintain the cleanliness and sanitation of equipment to prevent the potential for cross-contamination or foodborne illness in the Transition Care Unit (TCU) Dining Room (3rd floor, 3100 unit).Findings include: Review of facility policy SRC-Food and Nutrition - Sanitation-AB dated 9/30/25, indicated all employees are responsible for keeping equipment and the department clean. All kitchen equipment will be cleaned and sanitized following each use. During an observation on 11/24/25, at 10:45 a.m., of the dining room on the TCU, which included the Resident Pantry area, revealed the microwave oven's (kitchen appliance used to reheat foods) interior cooking surfaces were covered with dried food particles and splatters of dried food debris. During an interview on 11/24/25, at 11:02 a.m., the Nursing Home Administrator (NHA) confirmed the unit's microwave oven needed cleaned and sanitized and that the facility failed to maintain the cleanliness and sanitation of equipment to prevent the potential for cross-contamination or foodborne illness in the Transition Care Unit (TCU) Dining Room (3rd floor, 3100 unit). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) for four of eleven residents (Resident R65, R115, R118 and R123), and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R65). Findings include: The Centers for Disease Control defines Enhanced Barrier Precautions (EBP) as: an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and gloves during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of the facility policy Transmission-Based Isolation and Standard Precaution Policy dated 10/4/24, Types of transmission based precautions did not include Enhanced Barrier Precautions. Review of the facility policy Wound Care last reviewed 8/1/23, indicates dressings are changed daily and as needed. Maintain aseptic technique during dressing change. Procedure includes but not inclusive to: . Remove dressing, discard the dressing and gloves. . Wash hands. . Apply gloves. Review of Resident R65's clinical record indicates an admitted [DATE], with the diagnosis of right humerus fracture (long bone of upper arm), anxiety and panic disorder. Review of a physician order dated 12/13/24, indicated Resident R65 had a surgical wound to her right arm. Review of Resident R65's clinical record on 12/18/24, failed to reveal an order or care plan for Enhanced Barrier Precautions in relation to Resident R65's surgical wound. Review of Resident R115's clinical record indicates an admitted [DATE], with the diagnosis of coronary artery disease (CAD- a buildup of plaque in the arteries that reduces blood flow to the heart) hypertension (high blood pressure) cholecystitis (inflammation of the gallbladder). During an observation on 12/18/24, at 08:55 a.m. a bulb shaped device connected to a tube was noted to be inserted into Resident R115' s right lower abdomen. Review of Resident R115's physician orders dated 12/16/24, indicated pigtail catheter, empty and record daily, flush with 10cc (cubic centimeter) of normal saline every 12 hours. Review of Resident R115's clinical record on 12/18/24, failed to reveal an order or care plan for Enhanced Barrier Precautions in relation to Resident R115's pigtail catheter. Review of Resident R118's clinical record indicates an admitted [DATE], with the diagnosis of congestive heart failure (CHF- the heart doesn't pump blood as well as it should), atrial fibrillation (irregular and often rapid heartbeat), and chronic obstructive pulmonary disease (COPD-causes breathing problems and restricted airflow). Review of a physician order dated 12/17/24, indicated foley catheter. Review of Resident R118's clinical record on 12/18/24, failed to reveal an order or care plan for Enhanced Barrier Precautions in relation to Resident R115's foley catheter. Review of Resident R123's clinical record indicates an admitted [DATE], with the diagnosis of left hip arthroplasty, atrial fibrillation, and hyperlipidemia (high fat in the blood). During an interview completed on 12/18/24, at 8:24 a.m. Resident R123 stated she was new to the facility and had recent left hip surgery. Review of Resident R123's care plan on 12/18/24, indicated potential for wound/incisional infection. Review of Resident R123's clinical record on 12/18/24, failed to reveal an order or care plan for Enhanced Barrier Precautions in relation to Resident R123's surgical incision. During an interview completed on 12/18/24, at 12:34 p.m. the Director of Nursing stated all the doors have bins and a stop see nurse sign, the stop sign is meant for dietary, we have separate signs for the other precautions in a clear sleeve next to the door, there are no enhanced barrier signs, no enhanced barrier precautions are being used and enhanced barrier precautions are not in any care plans, I am going to put all the care plans in, that ' s what being a nurse is. During an interview completed on 12/19/24, at 10:52 a.m. the Infection Preventionist Employee E1 stated I have never heard of enhanced precautions, were not aware that was a new piece added to infection control, I am going to make a recommended to the hospital system to add it to the policy. I am going to add it to the infection control plan/policy for this unit as well. During an observation on 12/19/24 at 11:44 a.m. of a dressing change for Resident R65 the following cross contamination opportunities were observed. Licensed Practical Nurse (LPN) Employee E4 removed Resident R65's soiled dressings, removed gloves, did not complete hand hygiene and applied new gloves. Employee E4 continued to cleanse wounds, patted wounds dry, applied adaptic (non adherent dressing) , removed gloves, did not complete hand hygiene and applied new gloves. LPN Employee E4 continued to apply the adaptic to second and third areas removing gloves in between and not completing hand hygiene prior to donning new gloves. LPN Employee E4 applied the ABD pads (highly absorbent dressings that provide padding and protection) removed gloves, did not complete hand hygiene, applied new gloves, applied the kerlix wrap and secured with tape. During an interview completed on 12/19/24, at 12:15 p.m. LPN Employee E4 confirmed she failed to implement infection control practices to prevent cross contamination during a dressing change for Resident R65 by not completing hand hygiene after removal of gloves and donning of new gloves for one of three residents (Resident R65). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing Services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to store medications and treatments for residents properly to prevent cross contamination for two of three medication carts (front hall medication cart and back hall medication cart) and failed to label medications upon opening for two of three medication carts (front Hall medication cart and back hall medication cart). Findings include: During an observation on 12/18/24, at 6:59 a.m. the front hall medication cart contained: . Two dispensing bottles of nystatin powder. . One tube of hydrocortisone cream. . One vial of brimonidine eye drops with no date opened. . One bottle of calcitonin nasal spray with no date opened. During an interview completed on 12/18/24, at 7:00 a.m. Registered Nurse (RN) Employee E5 confirmed the above observations and stated, we have a treatment cart. During an observation on 12/18/24, at 7:03 a.m. the back hall medication cart contained: . One tube of lidocaine and prilocaine (EMLA cream). . One tube of lidocaine gel. . One vial polyvinyl eye drops with no date opened. . One vial of Lantus insulin with no date open. During an interview on 12/18/24, at 7:06 a.m. RN Employee E5 confirmed the above observations and that the facility failed to store medications and treatments for residents properly to prevent cross contamination for two of three medication carts (front hall medication cart and back hall medication cart) and failed to label medications upon opening for two of three medication carts (front hall medication cart and back hall medication cart). 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of four residents reviewed (Resident R118). Findings include: Review of the facility policy Respiratory Equipment Maintenance dated 8/1/24, indicates to prevent the spread of nosocomial infections. BIPAP/CPAP (positive airway pressure ventilation system that helps a person breathe. Using a tightly fitted face mask to deliver the ventilation) should be changed as needed for soiling or equipment integrity. Remove old equipment and treatment bag. Label new patient belonging bag with patient's last name, room number, and date. Review of Resident R118's clinical record indicates an admitted [DATE], with the diagnosis of congestive heart failure (CHF- the heart doesn't pump blood as well as it should), atrial fibrillation (irregular and often rapid heartbeat), and chronic obstructive pulmonary disease (COPD-causes breathing problems and restricted airflow). Review of Resident R118's physician orders dated 12/11/24, indicated BiPAP/non -invasive therapy at bedtime. During an observation on 12/18/24, at 9:52 a.m. Resident R118's fitted face mask was noted in a basket on a cart, the mask failed to be labeled and in a bag. During an interview completed on 12/18/24, at 10:02 a.m. Registered Nurse (RN) Employee E3 stated respiratory therapy does a lot with the BIPAP, normally I would have it in its own bag and dated and confirmed that the facility failed to maintain sanitary conditions of respiratory equipment for one of four residents reviewed (Resident R118). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted catheter (a thin plastic tube inserted into a vein using a needle) in accordance with professional standards of practice for one of two residents (Resident R118). Findings include: Review of the facility policy Intravenous (IV) Therapy: Peripheral, Including Midlines last reviewed 8/1/24, indicates to maintain venous access, administer continuous/intermittent intravenous fluids, nutrition, medications, and blood products over a specific time frame. All registered Nurses and Licensed Practical Nurses that complete the IV therapy program are responsible for including but not inclusive to: . IV site inspection a minimum of every shift. . Dressing changes for peripheral IV catheters. Site change is required for a contaminated IV or an IV showing signs and symptoms of complications. Peripheral IV site maintenance including but not inclusive to: . Maintain a clean, dry, and intact dressing over the insertion site. Review of Resident R118's clinical record indicates an admitted [DATE], with the diagnosis of congestive heart failure (CHF- the heart doesn't pump blood as well as it should), atrial fibrillation (irregular and often rapid heartbeat), and chronic obstructive pulmonary disease (COPD-causes breathing problems and restricted airflow). Review of physician orders dated 12/17/24, indicated cefepime 1 gram intravenously every eight hours for seven days. During an observation on 12/18/24, at 8:49 a.m. Resident R118's right wrist peripheral intravenous (IV) access site was noted not to have been labeled with a date or time, the area of dressing under his wrist was observed lifting off and the center around the insertion site had noticeable dried blood. During an interview on 12/18/24, at 9:59 a.m. Registered Nurse (RN) Employee E3 confirmed the dressing did not contain a date or time of insertion, the dressing was lifting, and the center of dressing was noted to have dried blood. RN Employee stated I will do a dressing change today and confirmed that the facility failed to provide adequate treatment and care for a peripherally inserted catheter in accordance with professional standards of practice for one of two resident s (Resident R118). 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that the physician order for a urinary catheter (insertion of a tube into the bladder to remove urine) included the size of the foley catheter and the amount of fluid needed to insert for balloon inflation/securement (the balloon keeps catheter in the bladder) for two out of three sampled residents (Resident R66 and Resident R118) and failed develop a baseline care plan for the use of the foley catheter for one out of three residents (Resident R118). Findings include: The facility Management of indwelling, intermittent, and external urinary catheters insertion care policy last reviewed 8/1/24, indicated to provide the appropriate indications for inserting urinary catheters. Review of Resident R66's admission record indicated he was admitted [DATE]. Review of Resident R66's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/28/24, indicated he had diagnoses that included thyroid disorder (decrease in production of thyroid hormone), Parkinson's disease (a disorder of the central nervous system which affects movement and includes tremors), and coronary artery disease (narrowing/blockage of vessels that carry blood and oxygen to the heart). The diagnoses were the most recent upon review. Section H (Bladder and Bowel) H0100A indicated an X for the use of an indwelling catheter. Review of Resident R66's care plans dated 11/21/24, indicated to provide elimination intervention and monitor output. Review of Resident R66's physician orders dated 12/16/24, indicated to insert foley catheter. Review of Resident R66's physician progress notes, other physician orders, nurse clinical notes, and certified nurse practitioner notes did not include the size of catheter in use. During observations on 12/18/24, at 7:37 a.m. observations of Resident R66 found him in bed resting, his foley catheter in place, and urinary catheter bag hanging on his bed. During observations on 12/20/24, at 8:57 a.m. observations of Resident R66 found him in bed resting, his foley catheter in place, and urinary catheter bag hanging on his bed. During an interview on 12/20/24, at 9:00 a.m. Registered Nurse (RN) Employee E2 confirmed that the facility failed to ensure that the physician order for a urinary catheter indicated the catheter size for Resident R66 as required. Review of Resident R118's clinical record indicates an admitted [DATE], with the diagnosis of congestive heart failure (CHF- the heart doesn't pump blood as well as it should), atrial fibrillation (irregular and often rapid heartbeat), and chronic obstructive pulmonary disease (COPD-causes breathing problems and restricted airflow). Review of R118's physician order dated 12/17/24, indicated the resident has a foley catheter the order failed to include the size of the foley catheter or the amount of fluid needed to insert for balloon inflation/securement. Review of Resident R118's baseline care plan dated 12/11/24, failed to include care for the foley catheter. During an interview completed on 12/20/24, at 9:12 a.m. RN Employee E2 confirmed that the facility failed to ensure that the physician order for Resident R118's foley catheter included the size of the foley catheter and the amount of fluid needed to insert for balloon inflation/securement and the facility failed to ensure a care plan for the foley catheter was in place. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide comprehensive documentation of pressure ulcer characteristics (measurements) consistent with professional standards of practice for one of two sampled residents (Resident R119). Findings include: The facility Wound care assessment policy dated 8/22, and last reviewed on 1/11/23, indicated that the facility will have skin assessments done on all residents admitted to the unit. If a resident has a pressure area, it will be documented in the skin assessment. The wound nurse will stage pressure injuries and monitor on a weekly basis. Pressure ulcer and stasis ulcer assessments will include location, description, drainage, stage and size. Review of Resident R119's admission record indicated she was originally admitted on [DATE]. Review of Resident R119's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs), dated 1/27/23, indicated that she had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), Hyperlipidemia (elevated lipid levels within the blood), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and morbid obesity. Review of Resident R119's care plans dated 1/28/23, indicated a left thigh area, opened blister and Resident R119 was at risk of skin breakdown. Review of Resident R119's Registered Nurse assessment dated [DATE], indicated an area found behind the left knee. Review of Resident R119's physician orders indicated an order for ostomy/therapy consult, initial pressure ulcer assessment. Review of Resident R119's ostomy/therapy consult, initial pressure ulcer assessment completed on 1/30/23, indicated that Resident R119 had a Stage two blister with red wound base to her left popliteal fossa (behind the knee). Review of Resident R119's ostomy/therapy pressure ulcer consultation assessments and clinical nurse notes dated 1/28/23, 1/30/23, 1/31/23, 2/1/23, and 2/2/23 did not indicate measurements of the wound. During an interview on 2/7/23, at 11:39 a.m. Registered Nurse (RN)/wound specialist Employee E1 stated: Resident R119's wound was found as a medical device related pressure injury. Resident R119's told me it was uncomfortable. I took the brace off to look at it. Brace and skin should be checked daily. If the brace was rubbing, it would cause the area. A new brace was ordered. The brace from in-patient for her left leg was solid thru-back. Resident R119's current brace is strapped. Skin checks are on record. During an interview on 2/7/23, at 12:57 p.m. Registered Nurse Employee E2 stated that Resident R119 has her skin assessed once a shift. During an interview on 2/8/23, at 8:59 am. the Director of Nursing (DON) confirmed that the facility failed to provide comprehensive documentation of pressure ulcer characteristics and measurements consistent with professional standards of practice for Resident R119 as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records and resident and staff interviews it was determined that the facility failed to notify the physician of changes in condition for one of eight residents (Resident R65). Findings include: A review of Resident R65's clinical record revealed the resident was admitted on [DATE], and current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R65's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of Resident R65's medication pass on 3/3/22, at 8:30 a.m. he indicated he did not want the [MEDICATION(S)] due to the medication making them sleepy and he wanted to be able to participate in therapy. Review of Resident R65's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents R65's clinical record failed to indicate that the physician was notified of Resident R65's refusal of medication. During an interview on 3/4/22, at 10:21 a.m. the Director of Nursing confirmed that the physician was not notified of Resident R65 refusal of medication, and the residents reason why they did not want the medication and the change of condition. 28. Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility documentation and staff interview, it was determined that the facility failed to include contact information for the Quality Improvement Organization on the Notice of Medicare Non-Coverage forms for three of three residents, as required (R6, R112 and R165). Findings include: The form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- informs the recipient when care received from a skilled nursing facility is ending and contains contact information for the Quality Improvement Organization (QIO) to appeal the termination of services. Closed clinical record review for Resident R6, indicated she was admitted on [DATE], and her current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Closed clinical record review for Resident 165 indicated he was admitted on [DATE], and his current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Closed clinical record review for Resident R112 indicated she was admitted on [DATE], and her current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R6's NOMNC dated 2/16/22, revealed it failed to contain contact information for the QIO. Review of Resident R165's NOMNC dated 1/24/22, revealed it failed to contain contact information for the QIO. Review of Resident R112's NOMNC dated 12/28/21, revealed it failed to contain contact information for the QIO. During an interview on 3/3/22, at 1:30 p.m. Social Worker Employee E1 confirmed that the facility failed to provide contact information for the QIO for Resident's R6, R165 and R112, as required. 28 Pa. Code: 201.29(e) Resident rights.

Based on a review of facility policies and documents, observations, and staff interviews, it was determined that the facility failed to purchase food products for the safe consumption of medically compromised residents in the Main Kitchen. (Main Kitchen). Findings include: A review of facility Food, Supplies, and Equipment Procurement policy last reviewed on 3/1/18, indicated that the facility purchases foods containing meat, fish, poultry, eggs, milk or other dairy products that are government inspected and certified as safe and wholesome. A review of the facility menu revealed that the residents may order an Egg and Cheese Sandwich or a Bacon, Egg and Cheese Sandwich for the breakfast meal. During an interview on 2/24/2020, at 9:00 a.m. Food Service Manager Employee E6 confirmed that the facility utilizes shell eggs to produce these menu items. During an observation of the Main Kitchen on 2/24/2020, at 9:00 a.m. it was revealed that the facility had in storage unpasteurized raw shell eggs for the production and consumption of a fried egg product. A review of the facility vendor order detail reports revealed that the facility purchased Eggs, Shell, Medium Grade A, Refrigerated as follows: - delivered on 2/10/2020, 2/12/2020, 2/17/2020, 2/19/2020, 2/21/2020,2/24/2020, and 2/26/2020. The order detail reports failed to provide documentation that the eggs purchased by the facility were pasteurized as required. During an interview on 2/24/2020, at 9:14 a.m. Food Service Manager Employee E6 confirmed that the facility's raw shell eggs were unpasteurized and that the facility did not purchase pasteurized raw shell eggs for consumption by the residents which created the potential for food borne illness. 28 Pa Code: 211.6(b)(c) Dietary services.

Based on a review of facility policies, staff performance evaluations, and staff interviews, it was determined that the facility failed to conduct timely annual performance evaluations for two of two employees (Nursing Assistant (NA) Employees E3 and E4). Findings include: A review of facility Performance Management policy dated 1/24/2020, indicated that the policy of the facility to measure and reward employee performances. The purpose of the performance management is to provide an ongoing consistent process and tool to link job responsibilities with values, goals, and performance standards to support the vision of the facility. During a review of facility Performnce evaluations on 2/26/2020, it was revealed that no annual performance evaluations were completed in 2019, for NA Employees E3 and E4. -NA Employee E3's most recent performance evaluation was for the review period of 3/11/17, through 3/10/18, and was electronically signed by the employee on 3/10/18. -NA Employee E4's most recent performance evaluation was for the review period of 6/2/17, through 6/1/18, and was electronically signed by the employee on 6/1/18. During an interview on 2/26/2020, at 9:50 a.m. Human Resources Director Employee E5 confirmed that the facility had not completed annual Employee Performance Evaluations for the year 2019 for NA Employee E3 and E4 as required. 28 Pa Code 201.20(a)(d) Staff development.

Based on review of faciltiy policy, observation, and staff interviews it was determined that the facility failed to follow proper infection control technique during a dressing change (Resident R119). Findings include: A review of facility policy Dressing Change updated 10/15/19, indicated all dressing changes will utilize a clean technique, unless the physician orders [REDACTED]. A review of the admission Minimum Data Set (periodic review of care needs) dated 2/20/20, indicated Resident R119 was admitted to the facility on [DATE], with current [DIAGNOSES REDACTED]. A skin ulcer assessment form indicated the resident had an unstageable (wound base with necrotic tissue) ulcer to their right hip covered with eschar (necrotic tissue). A review of Resident R119's physician order [REDACTED]. During an observation of Resident R119's dressing change on 2/24/20, at 2:22 p.m. Registered Nurse (RN) Employee E1 washed the wound with soap and water and without changing gloves and performing handwashing, applied santyl ointment to the finger tip of their gloved hands then applied it to the residents hip wound. The nurse then applied the gauze and [MEDICATION NAME] over the wound. RN Employee E1 then removed the drape under the wound that had small drops of blood on it and placed the drape into a garbage bag, repositioned Resident R119 touching their pillows and bed wedge (large sponge to aid in positioning), moved the bedside table back into reach, and opened the door of the bedside cabinet to retrieve and item, without removing the gloves or performing handwashing. During an interview on 2/25/20, at 11:55 a.m. the Infection Preventionist and Nursing Home Adminstrator confirmed that the faciity failed follow proper infection control techniques during a dressing change. 28 Pa. Code: 211.10(d) Resident Care Policies. Previously cited 3/11/19. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services. Previously cited 3/11/19.

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to timely identify and address declines in skin integrity to prevent worsening of a pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over bony prominence's as a result of usually long term pressure in combination with shear friction) for three of six residents reviewed (Residents R67, R200, R204) resulting in harm. Findings include: Review of the facility's wound care assessment policy last reviewed on 10/9/18, indicated that residents will have a complete skin assessment upon admission and if a pressure area is found it will be put on a skin assessment sheet. The Registered Nurse Assessment Coordinator will measure and monitor wounds weekly. The [MEDICATION NAME][MEDICATION NAME] Nurse (ET-nurse specialized in draining wound care) will be consulted for any wound that doesn't appear to be healing. Review of the clinical record indicated that Resident R67 had been admitted from the hospital to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record failed to reveal any evidence that an admission skin assessment was completed. An [MEDICATION NAME][MEDICATION NAME] note dated 4/24/18, indicated Resident R67 had a deep tissue injury of the right heel which was identified inside the CAM boot and had evolved into an unstageable pressure ulcer. Review of a progress note signed by the physician on 4/21/18, indicated that Resident R67 was non-weight bearing for 8 weeks and the CAM boot could be removed for bathing (residents are assisted with ADL's/bathing daily). The clinical record did not include any evidence that the boot was removed for bathing or that any assessment was completed. Review of an [MEDICATION NAME][MEDICATION NAME] note dated 4/24/18, indicated that Resident R67 developed an open area on her coccyx, her right heel had a deep tissue injury, and her right calf had faded ecchymotic (bruised) areas. Areas were not measured or staged. The [MEDICATION NAME][MEDICATION NAME] plan of care which is part of the ET Nurse's note indicated that Resident R67 was to receive [MEDICATION NAME] cream to her coccyx twice a day and to monitor her right heel daily. There was no documentation indicating that the Resident R67's right heel was monitored daily per the ET Nurse's recommendation. Review of a nurse's note entitled, Interventions for pressure ulcer dated 4/25/18, did not include an observation of Resident R67's right heel. Review of an ET Nurse's note dated 4/26/18, indicated that Resident R67 was seen for reassessment of her coccyx, there was no documentation of an observation of the right heel. Review of an ET Nurse's note dated 5/7/18, 13 days after the area was identified, indicated that Resident R67's right heel was open with brown/black tissue, documented as unstageable (unable to determine depth of the wound), and the surrounding skin was macerated (moist). treatment of [REDACTED]. Use of the CAM boot was continued. This was clinically worse as the right heel had been a closed bruised area only requiring monitoring, developing into an open area with black eschar with slough tissue requiring a treatment change to [MEDICATION NAME] (a [MEDICATION NAME] agent) to remove the sloughing tissue. The left heel was in a multipodis boot (a boot to correct foot misalignments and minimize chance of skin breakdown) which when removed, and showed discolored tissue of the heel, foot, and calf. The boot was put back on without treatment of [REDACTED]. There was no evidence that the facility assessed the resident's skin and monitored for breakdown even after a deep tissue injury was noted, resulting in Resident R67 developing an unstageable pressure ulcer on the right heel. Review of the clinical record indicated that Resident R200 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R200's orders included an air mattress, float heels off bed, head of bed elevated 30 degrees, and turn and position every two hours. Review of a nutritional assessment dated [DATE], indicated that the resident had been assessed by the Dietician which indicated that Resident R200 was above her ideal body weight; however, she was receiving Total [MEDICATION NAME] Nutrition (TPN) due to [DIAGNOSES REDACTED] after having part of her large intestine removed which causes loss of nutrients. Review of a progress note dated 5/22/18, indicated Resident R200 was admitted from the hospital with an open area on her coccyx that was being treated with [MEDICATION NAME] A (antimicrobial treatment for [REDACTED]. On 5/22/18, the ET Nurse was unable to assess the coccyx wound as Resident R200 was sitting in her wheelchair eating breakfast. Documentation indicated Resident 200 was not seen until 5/23/18. Review of an incident report (a report that the facility uses for any unusual occurrence or change in the condition of the resident including falls, med errors, incidents, etc.) dated 5/23/18, indicated staff found three deep tissue injury areas to Resident R200's sacrum and a Stage I (intact skin with non-blanchable redness) area noted on the left outer buttock which had not been identified previously. Review of an ET therapy form dated 5/23/18, indicated that deep tissue injuries to Resident R200's deep tissue injuries to the right buttock, left lower buttock, and left upper buttock. Resident R200's left hip had two linear areas of intact red skin, Stage I. Resident R200 required assistance with turning and positioning. Resident R200 had a healing right [MEDICAL CONDITION] requiring assistance to prevent displacement of prosthesis. Review of the ET Nurse's note dated 6/1/18, seven days later, indicated Resident R200's coccyx wound had worsened with black tissue and the two areas on the left buttocks had worsened to become one large unstageable area with black tissue. The sacral wound treatment was then changed to 1/4 strength Dakins solution (treatment containing bleach and [MEDICATION NAME]) to be placed on coccyx wound. Review of an incident report dated 6/1/18, indicated that Resident R200 had a newly developed unstageable area to the right heel, a Stage I to right anterior ankle, and two Stage II (partial thickness loss of dermis presenting as a shallow open area with a red or pink wound bed) areas of left heel. Review of an incident report dated 6/12/18, 11 days later, indicated that Resident R200 developed an unstageable area of the superior aspect of her right great toe. An ET Nurse's note dated 6/12/18, measured the unstageable area as a 0.9 centimeters (cm) by 1.3 cm., and the area was possibly from the slipper sock which was then left off. Her right second toe had a scab measuring 0.4 cm by 0.3 cm. Her left dorsal foot has a blanchable reddened area 2.0 cm by 1.2 cm. The wound nurse removed an Allevyn foam dressing from Resident R200's right lateral calf revealing bruising. Bruising was documented of the left great toe extending to the dorsal foot at the base of the toes. A foam dressing dated 6/6/18, was removed from Resident R200's right medial knee. Resident R200's right anterior ankle was purple with a yellow fluid filled blister with no measurements. The right and left heels had unstageable, unmeasured areas of black and red tissue. The left heel also had a deep tissue injury (exact site not documented) not measured. Review of an ET Nurse's note dated 6/20/18, indicated that, the foam dressing was removed from the right ischium to reveal a newly developed deep tissue injury (DTI) of purple and red tissue without any drainage for Resident R200. Review of clinical documentation failed to reveal any evidence of care plans specific to pressure ulcers, or entries to identify skin integrity decline concerns. Review of the clinical record indicated that Resident R204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation indicated that Resident R204 was at risk for skin breakdown and impaired skin integrity. Documentation did not include any preventative measures were in place. Resident R204 required assistance for toileting and ambulation was to be encouraged. Documentation did not include if Resident R204 required assistance to turn and reposition self. Review of a P[NAME] -Plan of Care note dated 6/4/18, indicated [MEDICATION NAME][MEDICATION NAME] therapy was to be consulted for preventive skin measures. Review of the ET Nurse's consult dated 6/12/18, eight days later, indicated that Resident R204 had developed a Stage III pressure ulcer (full thickness tissue loss with exposed, subcutaneous fat may be visible) to her coccyx and her right buttock was reddened. The areas were cleansed, and Triad cream applied (paste cream that helps wounds heal with natural debridement used in difficult to dress areas). Recommendation of a low air loss mattress and a cushion for her wheelchair. Review of an incident report dated 6/13/18, indicated that Resident R204 developed a Stage III pressure ulcer to her right buttock. Review of Resident R204's clinical record did not include care plans specific to coccyx and buttocks ulcers, documentation of a skin assessment being performed, or documented clinical entries to address or to identify skin integrity concerns prior to developing a Stage III pressure ulcer. During an interview on 3/8/19, at 10:00 a.m. the Nursing Home Administrator confirmed that that the facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure ulcer, thus resulting in harm. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, observation, and staff interviews, it was determined that the facility failed to notify residents of the procedures for filing a grievance for one of one nursing units (Transitional Care Unit - TCU). Findings include: The facility's Resident Problem Resolution policy last reviewed on 10/9/18, indicated that residents and/or families are encouraged to immediately express concerns. Information on the resolution process is included in the information provided to the residents upon admission. During an observation on 3/05/19, at 10:00 a.m. postings on the nursing unit did not include information regarding the grievance/complaint process or who the grievance officer was. During an interview on 3/6/19, at 12:48 p.m. the Nursing Home Administrator indicated that calls can be placed to the risk management office and reviewed and if there is a problem, they'll handle it. There was no procedure for making an anonymous grievance, time frames for getting a response, or the right to obtain a written decision about the grievance. The facility had no grievance/concern log for tracking. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(i) Resident rights.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to develop and/or implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical well-being for 10 of 10 residents reviewed (Resident R13, R67, R116, R117, R118, R120, R121, R123, R200, R204). Findings include: A review of the facility's policy, Assessments/Care Planning dated 10/9/18, indicates that the facility will ensure each resident's physical, functional, psychosocial, and nutritional status is assessed upon admission, to determine the need for care, the type of care to be provided, and the need for further assessment. Review of the clinical record indicated that Resident R67 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R67 had also been treated for [REDACTED]. On 4/24/18, Resident R67 had a deep tissue injury of the right heel inside the CAM boot that had evolved into an unstageable pressure area. Review of the facility's IP Progress note dated 4/21/18, indicated that Resident R67 was non-weight bearing for 8 weeks and the CAM boot could be removed for bathing. Clinical documentation did not include an assessment of the right foot when the CAM boot had been removed until 4/24/18, after the [MEDICATION NAME][MEDICATION NAME] (ET) Nurse (nurse that specializes in management of patients with draining wounds) had been consulted for Resident R67 developing an open area on her coccyx, contact [MEDICAL CONDITION] (inflammation of the skin caused by direct contact with an irritant or allergen) around her spinal surgical incision, and her right heel having a possible deep tissue injury and right calf having fading ecchymotic (bruised) areas. Resident R67 was to receive [MEDICATION NAME] cream (protects skin from wetness, urine, or stool. Used to treat minor cuts, scrapes, or burns) to her coccyx twice a day and to have her right heel monitored daily. Review of an [MEDICATION NAME][MEDICATION NAME] Nurse's note dated 4/26/18, indicated that Resident R67 was seen for reassessment of her coccyx. Documentation did not include observation of the right heel. Review of the clinical record indicated that Resident R200 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an IP-Progress note dated 5/22/18, indicated Resident R200 had an open area of her coccyx with a treatment of [REDACTED]. During an interview on 3/7/19, at 9:30 a.m. the RNAC Employee E3, confirmed that the facility failed to develop and implement a comprehensive resident-centered care plan for Resident R67 and R200 to attain or maintain the highest practicable physical well-being with input from the residents and goals that are attainable. Review of the clinical record indicated that Resident R204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R204's clinical record did not include documentation of a comprehensive person-centered care plan for Resident R204 to attain or maintain the resident's highest practicable physical well-being related to pressure ulcer prevention/healing/treatment and other care areas in a resident-centered care plan to address Resident R204's care needs. During an interview on 3/8/19, at 10:00 a.m. the Nursing Home Administrator confirmed that documentation provided did not include a resident-center care plan to ensure Resident R204's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, the type of care to be provided, and the need for further assessment. Review of Resident R13's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R13's clinical record did not include a resident-centered care plan to ensure Resident R13's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment. A review of Resident R116's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R116's clinical record did not include a resident-centered care plan to ensure Resident R116's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment A review of Resident R117's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R117's clinical record did not include a resident-centered care plan to ensure Resident R117's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment A review of Resident R118's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident R118's physician orders [REDACTED]. A review of Resident R118's clinical record did not include a resident-centered care plan to ensure Resident R118's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment. A review of Resident R120's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R120's clinical record did not include a resident-centered care plan to ensure Resident R120's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment. A review of Resident R121's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R121's clinical record did not include a resident-centered care plan to ensure Resident R121's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment. A review of Resident R123's clinical record revealed that resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R123's physician orders [REDACTED]. Review of Resident R123's clinical record did not include a resident-centered care plan to ensure Resident R123's physical, functional, psychosocial, and nutritional status were assessed upon admission to determine the need for care, type of care provided, and the need for further assessment. During an interview on 3/8/19, at 12:54 p.m. the Registered Nurse Assessment Coordinator Employee E3, confirmed that the facility failed to develop and implement a comprehensive resident-centered care plan for Residents R13, R116, R117, R118, R120, R121, and R123, to attain or maintain the highest practicable physical well-being, with input from the residents, and goals that are attainable. 28 Pa. Code 211.11(a)(b)(c)(d)(e) Resident care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, observations, and staff interviews it was determined that the facility failed to conduct an interdisciplinary assessment to evaluate a resident's ability to safely administer medications for one of six residents reviewed (Resident R13). Findings include: A review of the facility's policy Self-Administration of Medication dated 10/9/18, indicated that the facility will assure that residents who desire to self-administer medication may be permitted to do so if the facility interdisciplinary team has determined that the practice would be safe for the resident. Self-administration should be written in the care plan, once safety is established. The interdisciplinary team's assessment will include a review of the resident's cognitive, physical, and visual ability to carry out safe self-administration. The medical record will contain an order by the attending physician for self-administration. Nursing will document in the care plan that the resident is self-administering medications. A review of the facility's policy Opth. Administration dated 10/9/18, indicated that proper administration of eye medication includes not to touch the eye with the tip of the medication tube. A review of Resident R13's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident R13's recapitulation orders for (MONTH) 2019, indicated that the resident is to receive [MEDICATION NAME] ophthalmic (an eye drop that reduces the pressure inside the eyes), one drop in both eyes, two times a day. During an observation on 3/7/19, at 8:27 a.m., during a medication observation, Licensed Practical Nurse, (LPN) Employee E5, entered Resident R13's room. Resident R13 asked to give their own eye drops. LPN, Employee E5, handed Resident R13 the bottle of eye drops. Without any instruction from LPN, Employee E5, Resident R13 attempted to administered one drop in each eye. Resident R13 touched both eyes with the tip of the medication tube as the resident had difficulty leaning their head back and squeezing the bottle. LPN, Employee E5, had to assist Resident R13 with the drop in the left eye. During an interview on 3/7/19, at 8:47 a.m. LPN, Employee E5, confirmed that the resident did not properly administer the eye drops and the facility failed to have Resident R13 properly assessed by an interdisciplinary team, failed to include the self-administration of the eye drops in the resident's care plan, and failed to obtain a physician order [REDACTED].>28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.