Every finding on record at Wesley Enhanced Living - Doylestown

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department, the activities room kitchenette, and on one of three nursing units. (Nursing Unit N2) Findings include: Review of the facility policy entitled, Bare Hand Contact with Food and Use of Single-Use Gloves, last reviewed on October 29, 2025, revealed that staff were to change gloves as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and any time a contaminated surface was touched. Observation of the meal service in the satellite kitchen on N2, on March 4, 2026, between 11:30 a.m. and 12:00 p.m., revealed a dietary employee, DE 1, was handling and cutting grilled sandwiches with gloved hands, then proceeded to touch the handle of the grill/oven and then handle the grilled sandwiches again without changing gloves. DE 1 was also observed preparing two slices of bread with peanut butter with gloved hands, then walked to another station, took two packs of jelly, and returned to preparing the sandwich without changing gloves. In an interview on March 4, 2026, at 12:00 p.m., the manager of dining services confirmed that DE 1 should have changed his gloves and performed hand hygiene between tasks. Review of the facility policy entitled, Foods Brought by Family/Visitors, last reviewed on October 29, 2025, revealed that food was to be labeled and stored in a manner that distinguished it from facility-prepared food and that staff were to discard any food that was passed the package expiration date. Observation of the activities room kitchenette refrigerator on March 4, 2026, at 2:00 p.m., revealed the following: An opened bottle of salad dressing that was not labeled. The shelving had debris and a dried light-yellow substance on it. Observation of the activities room kitchenette cabinets on March 4, 2026, at 2:00 p.m., revealed the following: A bottle of cinnamon sticks with an expiration date of December 29, 2020. A bottle of ground nutmeg with an expiration date of December 27, 2024. A bottle of a thick yellow substance that was not labeled or dated. A paper bowl with a lid on it that had a powdered substance inside and that was not labeled or dated. A bottle of cream of tartar that had an expiration date of November 20, 2024. A can of pumpkin puree that had an expiration date of December 29, 2025. Three packets of thickening powder that had an expiration date of November 3, 2025. Three packets of thickening powder that had an expiration date of April 10, 2025. Two packets of thickening powder that had an expiration date of October 11, 2024. One packet of thickening powder that had an expiration date of March 9, 2023. In an interview on March 4, 2026, at 1:23 p.m., the Nursing Home Administrator confirmed that the items in the activities room kitchenette refrigerator should have been labeled and dated, the shelving should have been clean, and the expired items in the kitchenette cabinets should have been discarded. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, staff and resident interviews, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote quality of life for five of 15 sampled residents. (Residents 3, 6, 8, 21, and 32)Findings include: Clinical record review revealed that Resident 3 had diagnoses that included heart failure and debility. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. In an interview on March 4, 2026, at 11:10 a.m., Resident 3 stated that staff took a long time to answer call bells. Clinical record review revealed that Resident 6 had diagnoses that included a recent femur fracture, difficulty walking, and obesity. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. In an interview on March 3, 2026, at 1:20 p.m., Resident 6 stated that staff took a long time to answer call bells. Clinical record review revealed that Resident 8 had diagnoses that included heart failure, history of a stroke, difficulty with walking, and anxiety. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and was dependent on staff for assistance with all activities of daily living such as toileting and dressing. In an interview on March 4, 2026, at 11:15 a.m., Resident 8 stated that staff took a long time to answer call bells. Clinical record review revealed that Resident 21 had diagnoses that included a recent femur fracture, diabetes, and chronic kidney disease. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and was dependent on staff assistance for all activities of daily living such as toileting and dressing. In an interview on March 3, 2026, at 11:15 a.m., Resident 21 stated that staff took a long time to answer call bells. Clinical record review revealed that Resident 32 had diagnoses that included Parkinson's disease and hypotension. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and was dependent on staff assistance for all activities of daily living such as toileting and dressing. In an interview on March 3, 2026, at 11:48 a.m., Resident 32 stated that staff took a long time to answer call bells. Review of the facility form entitled, Status Solutions over 15 minutes Report, a report generated by the call bell system that indicates all call bell response times that exceeded 15 minutes, for Residents 3, 6, 8, 21, and 32 revealed that from February 3 through March 3, 2026, there were 65 incidents when the call bell response time exceeded 19 minutes which included: On February 28, 2026, at 8:14 p.m., Resident 3 waited 36 minutes, and on March 1, 2026, at 7:56 a.m., Resident 3 waited 30 minutes. On February 13, 2026, at 4:46 p.m., Resident 6 waited 29 minutes, and on that same day at 6:45 p.m., Resident 6 waited 31 minutes.On February 7, 2026, at 10:29 a.m., Resident 21 waited 28 minutes, and February 21, 2026, at 9:57 a.m., Resident 21 waited 27 minutes.On February 5, 2026, at 6:57 p.m., Resident 32 waited 25 minutes, and on February 12, 2026, at 8:21 a.m., Resident 32 waited 27 minutes. During an interview on March 5, 2026, at 10:35 a.m., the Nursing Home Administrator confirmed that report accurately measured the response times for call bells, and that the aforementioned residents waited more than the expected response time of 15 minutes for assistance. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for one of 15 sampled residents. (Resident 32)Findings include:Clinical record review revealed that Resident 32 had diagnoses that included hypotension (low blood pressure) and Parkinson's disease. A physician's order dated December 6, 2024, directed staff to administer 5 mg of a blood pressure medication (midodrine) three times daily. The physician ordered that staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was higher than 140 millimeters of mercury (mm/Hg). Review of Resident 32's Medication Administration Record (MAR) for December of 2025, and January of 2026, revealed that the staff administered midodrine three times in December of 2025, and twice in January of 2026, when Resident's 32's SBP was higher than 140mm/Hg.A physician's order dated January 2, 2026, reduced the dose of midodrine to 2.5 mg, three times daily. The physician ordered that staff were not to administer the medication if the resident's SBP was higher than 140 mm/Hg. Review of Resident 32's Medication Administration Record (MAR) for January and February of 2026, revealed that the staff administered 2.5 mg of midodrine twice in February 2026, when Resident's 32's SBP was higher than 140mm/Hg.In an interview on March 5, 2026, at 10:13 a.m., the Director of Nursing confirmed orders by the physician for resident 32 were not followed and medications were administered outside of the ordered parameters.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that adaptive equipment was provided to one of 15 sampled residents. (Resident 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Parkinson's Disease. Occupational therapy documentation dated August 25, 2025, indicated the resident was to use weighted utensils with meals to increase independence with self-feeding. A review of the resident's care plan indicated that the resident was to use a weighted fork and spoon at all meals. On April 8, 2025, a physician order directed staff to have adaptive equipment in place according to the resident's care plan. Observations on March 4, 2026, from 12:15 p.m. to 12:45 p.m., revealed Resident 4 was eating her lunch in the dining room. She was using regular (not weighted) utensils. On March 5, 2026, from 9:00 a.m. to 9:15 a.m., Resident 4 was observed eating breakfast in her room. The resident did not have weighted utensils. The resident was observed using regular utensils and there were scrambled eggs that had fallen onto the floor. In an interview, at that time, the resident stated that she was having difficulty using her utensils.In an interview on March 5, 2026, at 10:30 a.m., the Director of Nursing confirmed the adaptive equipment as indicated in the care plan should have been in place. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 13 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included dementia, fibromyalgia, and diabetes. On November 25, 2024, the physician ordered for the resident to receive the narcotic pain medication, oxycodone, every four hours as needed for severe, chronic pain. Review of Resident 8's care plan revealed that the resident had chronic pain and that the interventions were for staff to provide comfort measures with positioning, control noise levels, and other non-medication interventions. Review of Medication Administration Records revealed that the resident received the as needed narcotic (oxycodone) without documented evidence that non-pharmacological interventions were attempted prior to administration 62 times in January 2025 and 39 times in February 2025. In an interview on February 21, 2025, at 10:34 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a history of trauma for one of 14 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included anxiety and depression. Review of a psychological consultation dated March 15, 2023, revealed that the resident reported becoming anxious in the afternoon and had experienced childhood abuse and trauma which included physical, sexual, emotional, and verbal abuse. There was no assessment or care plan in Resident 14's clinical record that identified symptoms or triggers related to the history of trauma. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on April 20, 2023, at 12:19 p.m., the Director of Nursing confirmed there was no care plan developed to address Resident 14's trauma symptoms or triggers. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.11(e) Resident care plan.

Based on clinical record review, review of incident documentation and staff interview, it was determined that the facility failed to report an allegation of abuse and results of the investigation to the administrator of the facility and to other required officials, including the State Survey Agency for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required staff assistance for activities of daily living; such as, transferring between surfaces and walking. Nursing documentation on January 16, 2020, at 7:20 a.m. and 7:32 a.m., noted that the resident had reported being hit with a cane by her roommate at approximately 2:00 a.m. Review of the facility's investigation of the abuse allegation revealed a lack of evidence to support that the facility had notified the nursing home administrator and other officials, including the State Survey Agency, of the allegation and results of the investigation. In an interview on January 16, 2020, at 2:00 p.m., the Director of Nursing confirmed that the administrator and State Survey Agency had not been notified as required. 201.14(c) Responsibility of licensee.

Based on policy review and clinical record review, it was determined that the facility failed to accurately monitor weight changes and follow dietitian recommendations for one of four sampled residents with nutrition concerns. (Resident 23) Findings include: According to the facility policy entitled, Weight Management, last reviewed (MONTH) 1, 2019, facility staff was to notify the dietitian and physician of any weight changes five pounds or more, and confirm any significant weight changes with a reweigh within 72 hours. Clinical record review revealed that Resident 23 was admitted to the facility on (MONTH) 17, 2019, with [DIAGNOSES REDACTED]. According to the comprehensive plan of care upon admission, the facility identified that the resident was at risk for nutrition problems. On (MONTH) 9, 2019, the resident weighed 156 pounds. On (MONTH) 4, 2019, the resident weighed 141.6 pounds, a significant 9.6 percent loss in one month. On (MONTH) 11, 2019, the dietitian noted the resident's weight loss, and requested that nursing staff reweigh the resident to confirm the loss. As of (MONTH) 31, 2019, the reweigh was not done in accordance with the dietitian's recommendations and facility policy. On (MONTH) 1, 2019, the resident weighed 135.8 pounds, an additional loss of 5.8 pounds or 4 percent. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review and observation, it was determined that the facility failed to ensure that resident respiratory equipment was handled in a safe and sanitary manner to prevent the spread of infection for three of 15 sampled residents. (Residents 8, 19, 43) Findings include: Review of the facility policy entitled Infection Control: Respiratory equipment tracking, dated (MONTH) 11, (YEAR), revealed that respiratory equipment and storage bags were to be checked daily. Resident tubing and nasal cannulas of nebulizer machines and concentrators were to be stored in the plastic bag when not in use. All certified nursing assistants, on all shifts were to report missing plastic bags from a nebulizer machine or concentrator to their team nurse. During observations on (MONTH) 24, (YEAR), at 11:14 a.m., and (MONTH) 25, (YEAR) at 11:00 a.m., Resident 8's nebulizer mask and tubing was unbagged at the nebulizer machine. During multiple observations on (MONTH) 23, (YEAR), at 1:18 p.m., and (MONTH) 24, (YEAR), from 10:13 a.m., until 1:40 p.m., Resident 19's oxygen tubing and nasal cannula was not bagged and were slung over a stuffed bear in a corner. The nebulizer mask and tubing were not bagged. During multiple observations on (MONTH) 23, (YEAR), at 11:30 a.m., 12:40 p.m., and (MONTH) 24, (YEAR), at 11:21 a.m., and (MONTH) 25, (YEAR) at 9:12 a.m. Resident 43's oxygen tubing and nasal cannula was not bagged. During an interview (MONTH) 25, (YEAR), at 1:30 p.m., the Director of Nursing stated that the nasal cannulas, nebulizer masks, and tubing should have been placed in the storage bag when not in use.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to review the risks and benefits related to the use of bed rails with residents or their representatives and obtain informed consent for utilization of bed rails for five of 15 sampled residents (Resident 2, 3, 19, 42, 43) Findings include: Clinical record review revealed that Resident 2 was admitted to the facility on (MONTH) 2, 2010, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed (MONTH) 25, (YEAR), revealed that the resident had no memory impairment and required limited assistance of one staff member for transfers. On (MONTH) 23, (YEAR), at 1:20 p.m. and (MONTH) 24, (YEAR), at 1:10 p.m., Resident 2 was observed in bed with two bed rails in the upright position at the top of the bed. Clinical record review revealed that Resident 3 was admitted to the facility on (MONTH) 7, 2005, with [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 27, (YEAR), revealed that the resident had no memory impairment and required limited assistance of one staff member for transfers. On (MONTH) 23, (YEAR), at 11:40 a.m and (MONTH) 24, (YEAR), at 10:08 a.m., Resident 3 was observed in bed with two bed rails in the upright position at the top of the bed. Clinical record review revealed that Resident 19 was admitted to the facility on (MONTH) 27, 2009, with [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 9, (YEAR), revealed that the resident had memory impairment and received extensive assistance of one staff member for bed mobility and transfers. On (MONTH) 23, (YEAR), at 1:18 p.m., (MONTH) 24, (YEAR), from 10:13 a.m., until 1:40 p.m., and on (MONTH) 25, (YEAR) at 9:10 a.m., Resident 19 was observed in bed with two bed rails in the upright position at the top of the bed. Clinical record review revealed that Resident 42 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 1, (YEAR), revealed that the resident had memory impairment and total dependence on one staff member for bed mobility and transfers. On (MONTH) 23, (YEAR), at 11:20 a.m. and 1:15 p.m., and (MONTH) 24, (YEAR), at 10:05 a.m. and 1:00 pm., Resident 42 was observed in bed with two bed rails in the upright position at the top of the bed. Clinical record review revealed that Resident 43 was admitted to the facility on (MONTH) 28, 2013. Resident had [DIAGNOSES REDACTED]. A MDS assessment completed (MONTH) 17, (YEAR), revealed that the resident had memory impairment and received extensive assistance from one staff member for bed mobility and transfers. On (MONTH) 24, (YEAR), at 1:49 p.m., Resident 43 was observed in bed with two bed rails in the upright position at the top of the bed. There was no evidence to support that a resident assessment was completed, that the facility attempted to use alternatives, or that the risk versus benefits of bed rail use was discussed or that informed consent was obtained from any of the residents or representatives prior to the use of the bed rails. In an interview on (MONTH) 26, (YEAR), at 10:00 a.m., the Director of Nursing stated that the facility had not assessed the residents for bed rails or educated residents or resident's representatives on bed rail usage or had obtained consent for their use.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, family member or legal representative at the time of transfer out of the facility for five of 15 sampled residents. (Residents 13, 42, 43, 47, 54) Findings include: Clinical record review revealed that Resident 13 was transferred and admitted to the hospital on (MONTH) 8, (YEAR), after a change in condition. There was no documented evidence that the resident's legal representative was provided written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) at the time of transfer. Clinical record review revealed that Resident 42 was transferred and admitted to the hospital on (MONTH) 13, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 43 was transferred and admitted to the hospital on (MONTH) 13, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 47 was transferred and admitted to the hospital on (MONTH) 26, (YEAR), after a change in condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed-hold policy at the time of transfer. Clinical record review revealed that Resident 54 was transferred and admitted to the hospital on (MONTH) 28, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information about the facility's bed-hold policy at the time of transfer. In an interview conducted on (MONTH) 26, (YEAR), at 9:30 a.m., the Director of Nursing confirmed that no written notice of the bed hold policy was given to the residents or the residents' representatives on transfer out of the facility.

Based on clinical record review and staff interview it was determined that the facility failed to notify the residents and the residents' representative(s) of the transfers and the reasons for the moves in writing upon transfer from the facility for five of 15 sampled residents. (Residents 13, 42, 43, 47, 54) Findings include: Clinical record review revealed that Resident 13 was transferred and admitted to the hospital on (MONTH) 8, (YEAR), after a change in condition. There was no documented evidence that the resident's legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 42 was transferred and admitted to the hospital on (MONTH) 13, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 43 was transferred and admitted to the hospital on (MONTH) 13, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 47 was transferred and admitted to the hospital on (MONTH) 26, (YEAR), after a change in condition. There was no documented evidence that the resident or the resident's responsible party was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 54 was transferred and admitted to the hospital on (MONTH) 28, (YEAR), after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital. In an interview conducted on (MONTH) 26, (YEAR), at 10:00 a.m., the Director of Nursing confirmed that no written transfer notices were given to the residents or the residents' representatives on transfer out of the facility.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medical justification was met for the administration of an antianxiety medication and that nonpharmacological interventions were attempted prior to the use of an as needed antianxiety medication for one of four residents sampled. (Resident R22) Findings include: Clinical record review revealed that Resident R22 was admitted to the facility with [DIAGNOSES REDACTED]. On September 1, 2017, a physician directed staff to administer a medication to treat anxiety ([MEDICATION NAME]) every six hours as needed orally. A note by a nurse on September 19, 2017, at 12:46 a.m. revealed that the resident requested a medication for sleep. There was a lack of documentation that non pharmaceutical interventions were attempted prior to the administration of the [MEDICATION NAME]. A note by a nurse on September 26, 2017, at 12:30 a.m. revealed that the resident requested a medication for sleep. There was a lack of documentation that nonpharmacological interventions were attempted prior to the administration of [MEDICATION NAME]. In an interview on September 28, 2017, at 1:05 p.m. the Director of Nursing stated that the [MEDICATION NAME] was not to be adminstered for sleep, and that nonpharmacological interventions should have been attempted prior to medication administration. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure ongoing skin assessment in accordance with physician's orders [REDACTED]. (Resident R55) Findings include: Clinical record review revealed that Resident R55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) assessment dated [DATE], identified that the resident was dependent on staff for all activities of living including personal hygiene, dressing and bed mobility. The MDS indicated that the resident was at risk for pressure sore development. A physician's orders [REDACTED]. Review of Treatment Administration Record (TAR) revealed that skin assessments were completed on March 6, 13, 20 and 27, 2017. The nurse completing the skin assessment failed to document the findings of the skin assessment in the clinical record in accordance with the physician's orders [REDACTED].>In an interview on September 28, 2017, at 11:35 a.m. the Director of Nursing stated that nursing staff was to document an assessment of each resident's skin condition in the clinical record after each skin check. He also stated that their was no documentation of the Resident R55's skin condition during skin checks during the aforementioned March 2017, checks. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of quality improvement meeting attendance records and staff interview, it was determined that the facility failed to ensure that required staff attended the quarterly quality improvement meetings . Findings include: Based on a review of the quality improvement meeting attendance records, there was no documented evidence that the Medical Director or designee attended the July 26, 2017, quarterly quality improvement meeting . In an interview on September 28, 2017, at 12:00 p.m. the Administrator confirmed that there was no documented evidence that the Medical Director or designee attended the quarterly quality improvement meetings on July 21, 2017 . 28 Pa. Code 201.18(3) Management

Based on observation and review of facility staffing data, it was determined that the facility failed to post actual hours worked of licensed and unlicensed staff directly responsible for the nursing care on two of three days during the survey. Findings include: Observation of the posted staffing data during the initial tour on October 12, 2016, at 10:00 a.m. revealed that the required nursing hours for that day were not posted. An observation on October 13, 2016 at 1:20 p.m. indicated that the required nursing hour posting was not done. In an interview with the Director of Nursing on October 13, 2016 at 1:30 pm., the Director of Nursing confirmed that the postings were not done. 28 Pa Code 201.19(a)(3) Management.

Based on observation, it was determined that the facility failed to provide a home like setting and quality dining experience during meals in the dining room. (Fountainville and Buckingham) Additionally, the facility failed to ensure that staff knocked on a resident's door prior to entering the room for one of 13 residents observed. (Residents R12, R13, R36) Finding include: Observation of the Fountainville dining room on November 23, 2015, at 12:05 p.m., through 1:15 p.m., revealed that there were 11 residents seated at lunch. At 12:05 p.m., Resident R16 was served lunch. It was not until 1:15 p.m., one hour and ten minutes later, that the last resident, Resident R32 was served lunch. At that time the other residents had been served and were eating dessert. On November 23, 2015, Residents R51, R53, R57 were seated at a table. Residents R51 and R53 were served and eating their meal at 12:55 p.m. It was not until 1:12 p.m., (almost 20 minutes later) that Resident R57 was served his meal. On November 24, 2015, at 12:00 p.m., Resident R22 was served soup and then the meal at 12:08 p.m. Residents R10 and R56 were not served their soup until 12:15 p.m., when Resident R22 was finishing her sandwich. On November 24, 2015, at 8:55 a.m., NA1 was observed entering Resident R36 room without knocking and announcing herself. The resident's door was closed. At 12:52 p.m., NA1 was observed entering Residents' R12 and R13 room without knocking and announcing herself. 483.15(a) Dignity and Respect of Individuality Previously cited 10/22/14 28 Pa. Code 201.29(j) Resident rights Previously cited 10/22/14

Based on observation, it was determined that the facility failed to ensure that sanitary conditions were provided when food was served to residents during meals. (Buckingham and Fountainville dining rooms) Findings include: The facility had two dining rooms that served residents from a steam table that was located in the Buckingham dining room. During observation of lunch on November 23, 2015, at 12:10 p.m., through 12:30 p.m., Dietary Employee 1 (DE1) applied gloves and was plating food for residents. Throughout the process, DE1 was touching various environmental surface (serving utensils, refrigerator handle, cabinet handles, soup cups) while plating the food from the steam table. On eight ocassions without washing his hands and applying clean gloves DE1 picked up pre-made sandwiches from a tray on a side counter and placed the sandwich on the plate that was then served to the resident. On November 24, 2015, at 12:05 p.m., through 12:25 p.m., Dietary Employee 2 (DE2)applied gloves and was plating food for residents. Throughout this time, the employee was touching various environmental surfaces (serving utensils, refrigerator handles, condiment bottles, ice cream cups from the freezer) while plating the food from the steam table. On four occasions, without washing his hands and changing gloves, DE2 was observed removing bread from the bag and making a sandwich. On two occasions DE2 was observed picking up a grilled cheese sandwich from the steam table without changing his gloves. On two occasions DE2 was observed picking up pieces of meat that came out of the roll and was putting the meat back into the roll, without changing his gloves. 483.35(i) Food Procure4, Store/Prepare/Serve-Sanitary Previously cited 10/22/14

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for two of 16 sampled residents. (Residents R7, R37) Findings include: Review of the facility's policy entitled Weight Measurement dated January 2015 revealed that staff was to reweigh a resident when there was a three to five pound weight change from the previous weight. The reweigh was to be done within 72 hours. Clinical records revealed that Resident R7 had [DIAGNOSES REDACTED]. On November 7, 2015, the resident's weight was documented at 86 pounds. There was no documentation that staff reweighed the resident to ensure accuracy. Clinical record review revealed that Resident R37 had [DIAGNOSES REDACTED]. On September 10, 2015, the resident's weight was documented at 158.4 pounds. On October 16, 2015, the resident's weight was documented at 142 pounds. There was no documentation that staff reweighed the resident to ensure accuracy. In an interview on November 25, 2015, at 8:55 a.m., the Director of Nursing confirmed that staff had not reweighed Residents R37 and R7. 483.75(l)(1)Res Records-Complete/Accurate/Accessible Previously cited 10/22/14 28 Pa. Code 211.5(f) Clinical records Previously cited 10/22/14 28 Pa. Code 211.12(d)(5)Nursing service Previously cited 10/22/14

Based on clinical record review, it was determined that the facility failed to ensure that a medication dose was evaluated for one of 16 sampled residents. (Resident R37) Also, the facility failed to ensure that non-pharmacological interventions were offered prior to the administration of an antianxiety medication for one of four residents sampled that received anti-anxiety medication. (Resident R7) Findings include: Clinical record review revealed that Resident R37 had [DIAGNOSES REDACTED]. The resident received Vitamin B12, 2000 milligrams daily. A laboratory report completed on October 2, 2015, indicated that the results of a Vitamin B12 blood level was high. The result was greater than 1500 pg/mL (picograms/milliliter). The normal reference range was 180-914 pg/mL. The laboratory result was initialed by the Nurse Practitioner (meaning that the report had been reviewed) but there was a lack of evidence to support that the dose of the Vitamin B12 was evaluated as necessary. Clinical record review revealed that Resident R7 had [DIAGNOSES REDACTED]. On October 5, 2015 and November 21, 22, 2015, staff adminstered the as needed [MEDICATION NAME] to the resident for agitation during care. There was no documentation that staff offered non-pharmacological interventions prior to administration of the anti-anxiety medication. 483.25(1) Drug Regimen is Free from Unnecessary Drugs Previously cited 10/22/14 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/2214

Based on clinical record review, review of facility policy, observation and staff interview, it was determined that the facility failed to provide timely care for one of two sampled residents with a newly developed pressure sore. (Resident R23) Findings include: Review of the facility's policy entitled "Pressure Ulcer Prevention", dated January 2014 revealed that nursing staff was to carry out wound treatment as ordered by the attending physician and document wound measurements on a weekly basis. Clinical record review revealed that Resident R23 had [DIAGNOSES REDACTED]. The care plan from February 2013 identified the resident at risk for the development of pressure sores. The most recent Minimum Data Set assessment dated [DATE], revealed that Resident R23 required the assistance of staff for mobility in bed and activities of daily living. Nursing documentation revealed that on October 10, 2014, the resident developed a Stage II pressure sore on her lower sacrum that measured 0.8 centimeters in length by 0.3 centimeters in width and no depth. Although nursing contacted the physician regarding the new pressure sore, there was no documentation to indicate that an order was obtained to treat the wound. In addition, there was no documentation that a weekly wound assessment was done on October 17, 2014, as per policy. On October 21, 2014, eleven days after the wound was first identified, at approximately 1:50 p.m. the wound care physician examined the resident and documented that the wound was now a Stage III pressure sore, 1.5 centimeters in length by 1.0 centimeters in width and 0.1 centimeters in depth. In an interview on October 21, 2014, at 11:30 a.m., the Director of Nursing confirmed that staff failed to obtain a treatment order on October 10, 2014, when the pressure sore was first identified and that staff did not assess nor document wound measurements weekly as per facility policy. 28 Pa. Code 211.12(d)(5) Nursing services.