Every finding on record at Upmc Northwest Transitional Care Unit

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of one medication carts reviewed.Review of facility policy entitled Multi Dose Medication-A dated 4/21/25, indicated all multiple use (multi-dose) medications should be labeled by the facility with the date first use so that expiration dates or date for last use can be determined, and discard any vial found opened without being dated. Review of facility policy entitled Expiration Dates dated 4/21/25, indicated injectable diabetes product storage recommendations, Humalog insulin pen opened expires in 28 days. Review of manufacturer's guidelines revealed that an open pen of Humalog Insulin must be used within 28 days after opening or be discarded, even if the vial still contained insulin. Observation of drug storage on 8/11/25, at 3:55 p.m. of the medication cart revealed an open Humalog Insulin pen with no resident name or date indicating when the insulin pen was opened. During an interview on 8/11/25, at the time of observation Licensed Practical Nurse (LPN) Employee E2 confirmed that the open Humalog insulin pen lacked a resident name and an open date, and staff were unable to determine the discard date. LPN Employee E2 also confirmed that the insulin pen should have been discarded. 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, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of an as needed (PRN) psychotropic (mind altering) medication beyond 14 days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for two of six residents reviewed (Residents R17 and R29).Findings include: A facility policy entitled Psychotropic Drug Management dated 4/21/25, revealed PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Identify non-pharmacological interventions that can be utilized to use the lowest possible dose and to work in conjunction with the goal of reduction or discontinuation. Documentation will reflect attempts to implement care-planned, non-pharmacological approaches and ongoing effectiveness of these interventions. Resident R17's clinical record revealed an admission date of 7/25/25, with diagnoses that included hypertension (high blood pressure), congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). A physician's order dated 7/25/25, identified to administer clonazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth two times a day PRN for anxiety, this order was discontinued on 8/6/25. A new physician's order dated 8/6/25, identified to administer clonazepam 0.5 mg by mouth two times a day PRN for anxiety and lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R17's July 2025 and August 2025 Medication Administration Records (MAR) revealed that the PRN clonazepam was used on 7/30/25, 7/31/25, 8/3/25, 8/4/25, 8/7/25, 8/8/25, 8/9/25, 8/10/25, and 8/11/25. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN clonazepam for two administrations in July 2025 and for eight administrations in August 2025. Resident R29's clinical record revealed an admission date of 8/7/25, with diagnoses that included respiratory failure, heart failure, and chronic kidney disease. A physician's order dated 8/7/25, identified to administer clonazepam 3 mg by mouth PRN for restlessness at bedtime. Review of the August 2025 MAR for Resident R29 revealed that the PRN clonazepam was used on 8/7/25, 8/9/25, 8/10/25, and 8/11/25. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN clonazepam for four administrations in August 2025. During an interview on 8/12/25, at 2:10 p.m. Registered Nurse Employee E1 confirmed that Resident R17's clonazepam lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and that Resident R17's and Resident R29's clinical records lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN clonazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator. Findings include: A facility policy entitled, Management of Controlled Drugs dated 8/2024, revealed, Storage and maintenance of Controlled drugs: Store and maintain controlled drugs properly according to federal, state, or local regulations. Observation on 9/4/24, at 1:05 p.m. of the medication room refrigerator revealed several vials of controlled scheduled II-V medications in a separately locked container that was attached to a removable shelf, therefore it was not permanently affixed to the refrigerator, this was witnessed and confirmed by the Licensed Practical Nurse Employee E1. Interview with the Director of Nursing on 9/4/24, at approximately 1:30 p.m. confirmed that the controlled scheduled II-V medications should be stored in a separately locked permanently affixed compartment, and not attached to a removable shelf. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management

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 R1). Findings include: Review of facility policy dated 8/2024, entitled Oxygen Administration indicated that Verify physician order for desired oxygen saturation and oxygen flow rate. And do not change the oxygen flow rate on fixed flow orders or titrate outside ordered parameters without contacting the physician and obtaining appropriate orders. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R1's clinical record revealed a physician's order dated 8/16/24, for Oxygen via Nasal Cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) 3 lpm (liters per minute) at all times. Observation on 9/4/24, at 10:30 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm. Observation on 9/4/24, at 12:25 p.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and liter flow rate set at 2 lpm. Observation on 9/5/24, at 8:50 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm. During an interview on 9/5/24, at 12:50 p.m. Registered Nurse Employee E2 confirmed that Resident R1's supplemental oxygen was on and set at 2 lpm and the provision of their respiratory services was not consistent with the physician's order dated 8/16/24, for oxygen at 3 lpm. 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 records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R63). Findings include: Review of facility policy entitled, Psychotropic Drug Management dated 6/2023, states If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. Review of Resident R63's clinical record revealed an admitted [DATE], with diagnoses that included physical deconditioning, Diabetes type II, hypertension (high blood pressure), and anxiety. The clinical record revealed that on 9/16/2023, Resident R63's physician ordered Lorazepam (medication ordered to treat anxiety) one milligram (mg) three times a day PRN for anxiety. Review of the September 2023 and October 2023 Medication Administration Record (MAR) for Resident R63 revealed that the PRN Lorazepam was used on 9/16/23, 9/17/23, 9/22/23, 9/23/23, 9/24/23, 9/25/23, 9/27/23, 9/29/23, 9/30/23, 10/1/23, 10/2/23, and 10/3/23. Review of September 2023 and October 2023 MAR, clinical records, and progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the nine administrations in September 2023 and the three administrations in October 2023. During an interview on 10/04/2023, at 10:25 a.m. Registered Nurse Employee E1 confirmed that R63's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility records and staff interviews, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was qualified with specialized training in infection prevention and control. Findings include: Review of facility key personnel identified that Registered Nurse Employee E1, was serving as the designated IP. There was no evidence that the designated IP had completed specialized training and education in infection prevention and control. During a review of the facility's infection control program and staff interview on 12/1/21, at 1:36 p.m. the IP and the Director of Nursing confirmed that the facility's designated IP had not completed the required specialized training and education. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records and facility policies and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination for one of eight residents reviewed (Resident R60). Findings include: Review of facility policy related to catheter (tubing to collect urine inserted into the bladder) bags (device used to collect the urine from the catheter), dated 5/01/21, revealed that catheter drainage bags will be below the level of the resident's bladder and off the floor. Review of Resident R60's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident R60 on 11/30/21, at 8:15 a.m. revealed his/her urinary catheter bag not attached to the bed and was resting directly on the floor which presented a source of contamination and possible infection. During an interview on 11/30/21, at 8:20 a.m. the Director of Nursing confirmed that the urinary catheter bag should not be directly on the floor. 483.80 Previously cited state deficiency 1/6/21 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 and clinical records and staff interviews, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving [CONDITION(S)] (method of mechanically cleaning the blood) for two of eight residents reviewed (Residents R62 and Closed Record Resident CR9). Findings include: Review of the facility policy Medication Administration, dated 5/01/21, indicated that medications not given for reasons other than refusal, physician notification should be documented. Review of Resident R62's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders dated 11/20/21, indicated that Resident R62 was to have [MEDICATION(S)] opthalmic (eye drop that treats high eye pressures) 0.15 % solution one drop into each eye three times a day and [MEDICATION(S)] (a high blood pressure medication) 10 milligrams (mg) four times a day. Review of the November 2021, Medication Administration Records (MARs) revealed that Resident R62 did not receive the [MEDICATION(S)] as ordered on 11/23/21, 12:00 noon dose, Friday 11/26/21 and Monday 11/29/21, 8:00 a.m. dose. Resident R62's [MEDICATION(S)] eye drops were not given as ordered on 11/23/21, 12:00 noon dose and Monday 11/29/21, 8:00 a.m. dose. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the [MEDICATION(S)] and [MEDICATION(S)] for Resident R62 on [CONDITION(S)] days. Review of Resident CR9's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders dated 10/25/21, indicated that Resident CR9 was ordered Sevelamer ([MEDICATION(S)] binding medication) 1,600 mg three times a day with meals at 8:00 a.m., 12:00 p.m. and 5:00 p.m. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation that the physician was notified of a need to hold or alter the time of administration for the Sevelamer for Resident CR9 on [CONDITION(S)] days. During an interview on 12/02/21, at 10:15 a.m. the Director of Nursing confirmed that the above medications for Residents R62 and CR9 were not administered on [CONDITION(S)] days as ordered by the physician. 483.25(l) Previously cited state deficiency 1/6/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interviews it was determined that the facility failed to utilize proper hand hygiene to prevent potential contamination of food in the main kitchen. Findings include: Review of Facility Policy entitled Infection Control Program- Nutrition Services dated 3/2020, indicated that kitchen staff are expected to wash their hands after breaks and after touching their nose, mouth, or hair, after donning (put on) their mask, and after touching or removing their mask. Observations on 1/04/21, between 11:45 a.m. and 12:15 p.m. of meal tray assembly, revealed the following: Dietary Employee E4 halted serving food from the steam table with utensils, and stepped over to a cupboard and with bare hands touched the outside of his/her mask to pull it down over his/her chin, then took a drink from a personal beverage, then replaced his/her mask using bare hands to touch the outside. Dietary Employee E4 returned to the steam table and resumed serving food with utensils and did not wash his/her hands. Dietary Employee E5 entered the kitchen through a doorway from the main hospital, proceeded through the kitchen to retrieve a food cart without washing his/her hands. Dietary Employee E5 then proceeded toward the exit with the food cart, he/she stopped, and with bare hands touched the outside of his/her mask to pull it down over his/her chin, then took a drink from a personal beverage, then replaced his/her mask using bare hands to touch the outside. He/she then resumed toward the exit with the food cart. Dietary Employee E6 stepped over to a counter and with bare hands touched the outside of his/her mask to pull it down over his/her chin, then took a drink from a personal beverage, then replaced his/her mask using bare hands to touch the outside. He/she then resumed to handle clean pans without washing his/her hands. During an interview on 1/04/21, at 11:57 a.m. the Dietary Manager confirmed that staff are required to wash their hands with soap and water after touching their hair, face, mask, etc., and before returning to the tray line or touching 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 observation, review of clinical records and facility policy and staff interview it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of eight residents reviewed (Resident R9). The facility also failed to ensure COVID-19 infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on the unit. Findings include: The facility policy entitled, Wound Dressing Change, dated 3/2020, indicated that staff are to change gloves and complete hand hygiene; before and after arranging resident supplies on a protective barrier, before and after removing the soiled dressing, before and after cleaning the wound, and before and after applying the treatment to the wound. Resident R9's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record also included a physician's orders [REDACTED]. Observation of wound care on 1/05/21, at 9:08 a.m. revealed that Licensed Practical Nurse (LPN) Employee E1 applied a clean gown and gloves, placed the basin of resident supplies on the over-bed table, prepared dressing materials, removed the soiled dressing, measured the wound on the anterior left ankle, cleansed the wound with normal saline and patted it dry, applied the Santyl ointment to a clean 2 inch x 2 inch gauze and placed it on the wound, then cleansed the foot with normal saline. While retrieving the tube of [MEDICATION NAME] from the bag LPN Employee E1 dropped the tube of ointment on the floor. He/she then bent and picked up the tube with his/her gloved hands and proceeded to apply dabs of ointment to his/her gloved fingertip and transfer the ointment to one open wound on the left heel, and two open wounds on the top of the left foot. LPN Employee E1 wrapped the left foot and ankle with Kling wrap gauze and taped the edge. During the procedure LPN Employee E1 did not change his/her gloves and complete hand hygiene when indicated, did not place resident supplies on a protective barrier, did not discard the dropped tube of [MEDICATION NAME], and inappropriately applied the [MEDICATION NAME] to open wounds with his/her contaminated gloves. During an interview on 1/05/21, at 9:17 a.m. LPN Employee E1 confirmed he/she did not change gloves and complete hand hygiene when indicated, did not discard the contaminated tube of ointment, and inappropriately applied the [MEDICATION NAME] ointment to open wounds using contaminated gloves. Observations on 1/04/21, at 3:40 p.m. revealed two hospital staff wearing surgical masks entering the unit without seeking unit staff assistance prior to assisting a new admission resident via a wheelchair to room [ROOM NUMBER]. Observations also revealed that at 3:45 p.m. Nurse Aide (NA) Employee E7 entered room [ROOM NUMBER] wearing only a N95 face mask. Interview with the Nursing Home Administrator during the observations verified that hospital staff are not to enter the unit without ringing for assistance for unit staff to come and accept the new admissions and that NA Employee E7 should have donned (put on) a face shield and gown before entering the room and providing assistance to the resident. During an interview on 1/05/21, at 11:45 a.m. the Infection Preventionist confirmed that LPN Employee E1 did not follow all proper procedures for wound care as above and that hospital staff should not have entered the unit with the new admission resident and that NA Employee E7 did not follow proper procedures regarding wearing personal protective equipment. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to [MEDICAL TREATMENT] communication for one of 10 residents (Resident R13). Findings include: Resident R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R13's physician orders [REDACTED]. During an interview on 1/05/21, at 11:00 a.m. the Director of Nursing confirmed that Resident R13 did not have any documented daily communication between the facility and the [MEDICAL TREATMENT] clinic. 28 Pa. Code 211.5(f)Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to accurately and consistently measure a pressure ulcer on admission for one of two residents (Resident R109). Findings include: Resident R109's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical record documentation located under the Skin section of the Physical Assessment Summary and on the Treatment Record for 5/4/19, revealed a pressure ulcer to the right heel as measuring 3.5 centimeters (cm) in length x 4.5 cm in width with the description of the area as being pink with a smaller area in the center that is yellow/brown slough. Wound nurse documentation dated 5/7/19, indicated that the right heel pressure ulcer Stage 3 (full-thickness skin loss) measured 0.6 cm in length x 1.0 cm in width, x 0.05 cm in depth. Wound nurse documentation dated 5/14/19, indicated that the right heel pressure ulcer Stage 3 measured 0.7 cm in length x 1.0 cm in width x 0.05 cm in depth. During an interview on 5/23/19, at 11:00 a.m. Director of Nursing confirmed the initial assessment measurements were not accurate. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for one of 10 residents reviewed (Resident R109) Findings include: Resident R109's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R109's MDS with an Assessment Reference Date (ARD) of 5/11/19, was coded as having one Unstageable (obscured full-thickness skin and tissue loss)-deep tissue injury. Clinical record documentation located under the Skin section of the Physical Assessment Summary for 5/7/19, 5/8/19, 5/9/19, and 5/11/19, all revealed the presence of a Stage 3 (full-thickness skin loss) pressure ulcer. Clinical record documentation located on Treatment Record for 5/11/19, revealed the presence of a Stage 3 pressure ulcer. Clinical record documentation by the [MEDICATION NAME][MEDICATION NAME] Nurse (Registered Nurse who specializes in ostomies and wound care) from an assessment completed on 5/7/19, revealed the presence of a Stage 3 pressure ulcer. During an interview on 5/23/19, at 1:00 p.m. the Director of Nursing confirmed that the 5/11/19, MDS was coded incorrectly as Unstageable regarding the current stage of a pressure ulcer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on a review of facility documentation and staff interview, it was determined that the facility's Quality Assurance (QA) Committee failed to ensure that all required members attended the meetings throughout the past year. Findings include: Review of the facility's quarterly attendance records dated 10/25/16, 1/24/17 and 4/10/17, lacked any attendance from the medical director or their designee, a board member, an infection control/prevention officer, and another individual in a leadership role. During an interview on 5/11/17, at 9:15 a.m., the Nursing Home Administrator confirmed that the facility's QA committee lacked all the required members in attendance at the meetings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on staff interviews, it was determined that the facility failed to ensure a three day supply of water was available onsite in the event of an emergency. Findings include: Upon request to see the onsite emergency water supply on 5/10/17, at 10:41 a.m., the Director of Nutrition Services indicated that the emergency water supply was offsite down the road in another building that's associated with the facility. During an interview on 5/10/17, at 11:15 a.m., the Nursing Home Administrator verified that the emergency water supply was not onsite. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to contain garbage and refuse in the outside storage receptacle, covered and in a manner to help prevent pest infestation. Findings include: Observation of the trash compactor on 5/10/17, at 10:38 a.m. revealed the lids up which exposed the interior of the compactor to visibly see bags of garbage inside. Additionally, there was some trash on the ground beside the compactor. During an interview on 5/10/17, at 10:41 a.m. the Director of Nutrition Services confirmed the above observation. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and staff interview, it was determined that the facility failed to maintain kitchen sanitation regarding adequate hair restraints to prevent contamination of the food for one of one kitchens (Main Kitchen). Findings include: Observations on 5/09/17, from 11:10 a.m. through 11:30 a.m. revealed two male dietary employees with visible facial hair conducting kitchen operations without a facial hair covering. An additional observation of one female dietary employee revealed a large amount of uncovered hair protruding from underneath her hair restraint. Observations on 5/10/17, at 11:10 a.m. revealed a third male dietary employee, a cook, with visible facial hair without a facial hair covering. Another female dietary employee was observed with a large amount of uncovered hair protruding from underneath her hair restraint. During an interview on 5/11/17, at 11:05 a.m. the Director of Nutrition Services confirmed that not all dietary employees wore hair restraints in a manner to help prevent contamination during food service and that the male dietary employees were not wearing coverings for their facial hair. 28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to implement non-pharmacological interventions (methods that do not include medication) prior to the use of pain medication for two of five residents (Residents R3 and R2) and failed to follow physician's orders [REDACTED]. Findings include: The facility policy Pain Assessment and Management dated 4/ 13/17, identified non-pharmacological approaches that would be used instead of or in conjunction with pain medications. Resident R3's Admission Record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. [REDACTED]. During an interview on 5/10/17, at 8:45 a.m. Registered Nurse Employee E1 confirmed that documentation to identify non-pharmacological interventions used prior to the [MEDICATION NAME] administration was lacking. Resident R2's Admission Record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The physician order, dated 4/21/17, revealed that Resident R2 was ordered [MEDICATION NAME] 650 milligrams (mg) every six hours as needed for mild pain and [MEDICATION NAME] and [MEDICATION NAME] 5/325 mg every six hours as needed for moderate pain. Resident R2's April and May 2017 MARs from 4/22/17 through 5/10/17, revealed 24 of 29 times that a pain medication ordered was administered, but had not identified what non-pharmacological interventions were utilized prior to the administration of the medication. During an interview on 5/11/17, at 1:50 p.m., the Director of Nursing confirmed that non-pharmacological interventions were not consistently documented for Resident R2. Resident R1's Admission Record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The physician order, dated 4/27/17, revealed that Resident R1 was ordered daily weights. The clinical record lacked a weight recorded for one of 13 days (May 6, 2017). During an interview on 5/11/17, at 2:30 p.m., Registered Nurse Employee E2 confirmed that the daily weight was not done as ordered. 28 Pa. Code 211.12(d)(2)(5) Nursing services Previously cited 7/8/16

Based on review of clinical records and staff interview, it was determined that the facility failed to have the initial physician visit performed by the required staff person for one of 5 residents (Resident R3). Findings include: The admission face sheet revealed that Resident R3 was admitted on [DATE]. Resident R3's initial physician visit was performed by a certified registered nurse practitioner on 5/04/17. During an interview on 5/11/17, at 1:30 p.m., the Director of Nursing confirmed that the initial physician visit was not performed by the physician as required. 28 Pa. Code 211.2(a)(d)(2) Physician services

Based on review of clinical records and the Resident Assessment Instrument (RAI) User's Manual (provides direction for the completion of the Minimum Data Set (MDS - periodic assessment of resident care needs)) and staff interviews, it was determined that the facility failed to document the required supporting date and location of clinical information related to the Care Area Assessment (CAA - potential areas of resident problems) for one of five residents (Residents R2). Findings include: The RAI User's Manual provides the instruction that the documentation related to the Care Area Assessments (CAAs) should indicate the basis for the care plan decision, why the finding requires an intervention, and the rationale for selecting specific interventions. For each triggered care area, the facility must indicate the date and location of where the information related to the CAAs can be found in the resident's clinical record. Review of Resident R2's Initial MDS assessment, dated 4/28/17, revealed that the CAA summary did not indicate the date or location of where the supporting information related to the CAA could be found. During a interview on 5/10/17, at at 9:40 a.m. Registered Nurse Employee E1 confirmed that the areas of concern triggered on the MDS CAA sheet did not include the date and location of the information reviewed to determine the outcome for the CAA. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(5) Nursing Services Previously cited 7/08/16