Every finding on record at Wesley Enhanced Living Main Line Rehab and SKD NSG

Based on observation, facility documentation, and clinical record review, as well as staff interviews, it was determined the facility failed to ensure the hot water dispensing machine produced water at a safe temperature resulting in actual harm to Resident R1 who sustained burns on the left thigh and groin, requiring treatment in an emergency room . This resulted in an Immediate Jeopardy, when it was determined that the facility failed to monitor the temperatures of the hot water dispensing machine and facility policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety for 54 residents. Findings Include: Review of Resident R1's clinical record revealed diagnoses including but not limited to the following: Anxiety (intense, excessive and persistent worry and fear regarding everyday situations), Hydrocephalus (accumulation of cerebrospinal fluid (CSF) occurs within the brain typically causing increased pressure inside the skull. Older people may have headaches, double vision, poor balance, urinary incontinence, personality changes, or mental impairment ), and Hypertension (high blood pressure). Review of Resident R1's clinical record including nursing progress note dated July 13, 2024, at 5:20 p.m. revealed the resident spilled hot tea at dinner on her groin and inner thighs. Resident immediately transferred back to her room, placed in bed. Examined. Redness noted to inner thighs, left greater than right. Resident also complained of labial pain after initial exam. RN called on call, transfer to ED for exam. [Daughter] made aware. 911 called for transfer to ED (Emergency Department). [Local Police] Officer arrived and spoke with Resident. EMS arrived and transferred to [local hospital]. Further review of Resident R1's medical record revealed a wound consult from Doctor of Medicine (MD) dated July 16, 2024, indicating 8 Left, Medial Thigh (front) is an acute Partial Thickness Burn and has received a status of Not Healed. Initial wound encounter measurements are 1.8 centimeter (cm) length x 4.5 cm width x 0 cm depth, with an area of 8.1 sq cm. Additional review of Resident R1's clinical record revealed a progress note dated July 13, 2024, at 10:23 p.m. indicating the patient returned from the hospital with a dressing on [resident's] left thigh. Subsequent review of Resident R1's clinical record revealed a progress note dated July 14, 2024, at 11:24 a.m. indicating investigated incident recently of spillage of hot liquid onto resident lap. Resident and eyewitness report that resident was attempting to place 2 sugar packets in cup, while reaching resident struck spoon that was in vessel and subsequently spilled fluid onto lap. eyewitness (roommate) reports that table height was appropriate as both have identical w/c and require increased height to sit under table appropriately. Review of information dated July 13, 2024 submitted by the facility to Department of Health, on July 13, 2024, revealed The temperature of the hot tea was 150 degrees. The policy is that hot beverages are served no lower than 155 degrees. The machine from which the hot water was dispensed dispenses the water or coffee at 165 degrees. Interview with the Culinary and Nutritional Services Manager (Employee E1) on July 30, 2024, at 10:15 a.m. reported The only time we take temperatures of the [coffee and tea] is when the resident complains. Employee E1 reported they do not take daily temps of hot beverages. Further interview with Employee E1 on July 30, 2024, revealed the facility does not check the temperatures of hot beverages due to the State Operations Manual Appendix PP (Federal regulations for Skilled Nursing Facilities) does not specifically tell you when a drink is too hot. Review of facility policy titled Hot Beverages indicates Hot water and coffee will be dispensed at a temperature no lower than 155 degrees to ensure residents are receiving the highest quality beverages upon delivery. Director of Nursing (DON) on July 30, 2024, at 10:50 a.m. confirmed dietary staff did not take a temperature of the hot tea before giving to Resident R1; and Director of Nursing further indicated the facility had no policy in place for the use of the coffee machine for residents and no temperature logs in place prior to the resident being burned on July 13, 2024. The facility failed to have a policy and procedure in place for determining safe serving temperature of hot beverages from the dispensing machine for residents either at the time of service or periodically. An Immediate Jeopardy situation was identified on July 30, 2024, at 11:31 a.m. and the Immediate Jeopardy template was presented to the Director of Nursing (DON), regarding the facility's failure to ensure the prevention of burns sustained by one resident and placing additional residents at risk of serious burns due to lack of policy and procedure in place for the temping of hot water from the Hot Beverage dispensing machine for residents either at the time of service or periodically to ensure safe hot beverage service. The facility submitted an action plan on July 30, 2024, which included taking the hot beverage dispensing machine out of service until the dispensing machine can be serviced and dispensing temperature lowered. Developing a policy and procedure identifying a max temperature for liquids and taking the temperature of every hot beverage before serving and logging the temperatures. Temperature logs to be reviewed by Dining Manager or designee will audit the temperature logs daily for compliance. All dietary staff will be educated on the new policy and procedures for hot beverages prior to start of shift. The action plan was accepted on July 30, 2024, at 2:06 p.m. On July 31, 2024, a review of audits, documentation of completed employee education, and interviews with two dietary aids revealed the facility completed the interventions developed for the action plan on July 30, 2024. The Immediate Jeopardy was lifted on July 31, 2024, at 11:36 a.m. after confirmation that the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the beverage temperature policy included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage burns. Findings include: Review of the job description for the NHA revealed the essential function is to ensures compliance with all laws, rules, regulations, policies and procedures within the community for all levels of care. Assure highest quality medical care to residents. Ensure that all medical services implemented are consistent with WEL mission, vision, and values. Assures all Department Heads are in compliance with all government and agency regulatory requirements and licensing as they relate to dining, building and property, resident contracts, and residents rights and employment law. Maintains effective operations. Ensures a safe work environment for all. Ensures regulatory compliance. Review of the job description for the DON revealed the responsibility of the job position is to assumes responsibility for the development of nursing service objectives, performance standards of nursing practice for each category of nursing personnel, and nursing policies and procedures. Assumes accountability for the development, organization and implementation of approved policies and procedures and systematic approaches to providing care and services. Directs, evaluates and supervises all resident care and initiates corrective action as necessary. The findings in this report identified that the facility failed to ensure that residents were served hot beverages at a safe consumption temperature which placed residents in Immediate Jeopardy. The facility staff failed to identify hot beverage temperature parameters. The NHA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's Responsibility

Based on observations and interviews during a facility power outage, it was determined that the facility failed to ensure residents environment remained as free of accident hazards as is possible in two out of three nursing units (East and South Wings). Findings: Observations on January 10, 2024, at 9:30 a.m. revealed that the facility experienced a power outage during the night. Orange power cords (long extension cords) were in the lying, in the east and south wings of the nursing units, across the hallways into resident rooms. An interview with the Director of Nursing on January 10, 2024, revealed that the building is old and the outlets in the resident rooms were not active due to the power outage. Outlets that are in the hallways are active and for residents that are oxygen and have air mattresses need power. The extension cords provide these items power and function. Further observations at 12:00 p.m. revealed extension cords gathered in the middle of the hall in the east and south hall and staff walking over them and occasionally catching their feet in these cords. An interview with the Nursing Home Administrator on January 11, 2024, at 12:30 p.m., revealed the resident beds are powered by electricity to adjust the bed height and the head and foot of the bed. They could not secure the cords to the floor, with the tape, for this reason. The faciltiy failed to ensure the safety of residents and staff during a power outage by placing electrical cords across the hallways of the east and south halls. 28 Pa. Code 201.18(b)(1)(3) Management

Based on facility policy review, clinical record review, and staff interviews it was determined that the facility failed to provide adequate indications for use of pain medications for one of 24 residents reviewed (Resident 34). Findings include: Review of the facility policy revealed a document titled Pain Assessment and Management, dated March 2015, states the staff will document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program. Review of Resident 34's clinical record revealed an admitted [DATE], hip fracture and aftercare of joint replacement therapy. a physician order dated December 7, 2023, for Oxycodone Hcl Oral Capsule 5mg (pain medication) to be given every four hours (as needed) for severe pain (7-10). Review of the Medication Administration Record revealed that the resident received pain medication on December 7, 8, 9, 10, 11,12 (x2),13,15,16,17 (x2),18, 21,22, 24,26, 28, and 30 (x2), without indicating a pain scale and adequate documentation for administration. An interview with the Director of Nursing on January 11, 2024 at 12:00 p.m. revealed there was no further documentation. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to notify the physician about a resident's status for one of 24 residents reviewed. (Resident 59) Findings Include: Review of Resident 59's physician orders revealed an order for a PT/INR (study of the amount of time it take for blood to clot and determine the effectiveness of blood thinning medication). Further review of Resident 59's clinical record revealed the resident did not have the blood drawn as ordered. Further review of the clinical record revealed there was no documented evidence the physician was notified of the laboratory study not being completed as ordered. Interview with the Director of Nursing on January 13, 2023 at 11:00 a.m. confirmed the physician was not notified the PT/INR was not completed as ordered. 28 Pa. Code 201.18(b)(1) Management 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 staff interview, it was determined that the facility failed to develop a care plan for anticoagulants for one of two residents reviewed (Resident 16) Findings include: Review of Resident 16's clinical record revealed an active diagnosis of Paroxysmal Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident 16 has a cardiac Pacemaker (a device implanted in the chest to help control the heartbeat). Review of Resident 16's clinical record revealed an active order for Apixaban, Tablet 5mg, twice daily (used to treat and prevent blood clots and to prevent strokes). Review of Resident 16's Admission Minimal Date Set assessment (MDS- an assessment of care needs) dated December 28, 2022, revealed Resident 16 takes anticoagulant medication daily. Review of Resident 16's electronic medication administration record (eMAR) revealed Resident 16 was receiving Apixaban twice daily since his admission on December 16, 2022. Review of Resident 16's current care plan goals and interventions failed to reveal a care plan developed to address the resident's anticoagulant usage. Interview conducted with the Director of Nursing at approximately 10:56 A.M. confirmed that the resident did not have a care plan developed for anticoagulants. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure adequate supervision during a transfer and an elopement for two of 20 residents reviewed (Residents 4 and 110). Findings include: Review of Resident 4's clinical record revealed a care plan identifying the resident as having an ADL (activities of daily living) deficient due to the resident's diagnosis of dementia. The care plan had an intervention added on April 22, 2018 for the resident indicated a two person assist for transfers using a sit-to-stand lift. Review of Resident 4's progress notes revealed a nursing note dated October 15, 2022, which stated: skin tear to resident's left posterior leg. Nurse called to resident's room by resident's [nurse aide] having been informed that resident had some bleeding to a lower extremity. Nursing assessed resident to find skin tear to left posterior leg. Resident unable to narrate how he sustained the injury. Skin tear noted with moderate bleeding at the time of assessment. Pressure applied to site. Steri strips and absorbent dressing applied, area wrapped with kerlix. Review of facility documentation revealed the investigation concluded that the nurse aide Employee E3 was transferring Resident 4 using the sit-to-stand lift without a second staff person present to assist. Interview with the Director of Nursing on January 13, 2023, at 10:49 a.m. confirmed the nurse aide Employee E3 did not follow Resident 4's plan of care and transferred the resident without the assistance of a second staff person. Review of facility policy and procedure titled Wandering and Elopements, Revised March 2019, revealed if an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. Review of facility assessments revealed an elopement assessment for resident 11 completed on July 27, 2022 indicating the resident was not a risk for elopement. Review of Resident 110's admission minimum data set (MDS- periodic assessment of resident needs) assessment completed August 3, 2022 revealed the resident had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Review of Resident 110's progress notes revealed a nursing entry dated August 3, 2022 stating This morning resident packed some bags and said he was going back home. He took his bags into the dining room and the staff informed him that those doors were locked. He sat there for awhile but then got up and headed toward the exit to the rest of the community. The staff made multiple attempts to redirect him while still in skilled but he argued and would not accept redirection. The CNA (Certified Nurse Aide) followed him to the front door of the community where she was still attempting to redirect him and was joined by some nursing students and security. He could not be coaxed to return to the skilled unit. The CNA continued to follow him out of the building where he continued walking and entered a door near his IL apartment. He had thrown his belongings onto the ground which the CNA picked up. When they got to the apartment he unlocked the door then immediately slammed the door and locked it. The CNA stayed outside for a few minutes but then returned to the unit to inform the nurse what had happened. By the time she returned to the unit on-coming nurse, OT (Occupational Therapy) and the Director of Wellness had started over to the apartment with a key. When they arrived at the apartment he was not longer there. They called his cell phone to determine his location. He had taken his car and was driving. He was instructed to pull over which he did and he was able to tell them where he was. They drove and found him to bring him back to the facility along with his car. He returned stating that he had made a big mistake. Review of Investigation completed by the facility revealed a written statement from the CNA who followed the resident to his apartment revealing she thought he was safe in his apartment and was not aware the resident had a car or had any intention to leave the campus. Further review of the clinical record revealed the resident was discharged back to his Independent Living Apartment on August 30, 2022. Interview with the Director of Nursing and the Nursing Home Administrator revealed the resident was found approximately one mile from the facility. Further interview confirmed the resident was not provided proper supervision when the CNA left the apartment to come back to the facility. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on clinical record review, it was determined that the facility failed to ensure the physician provided clinical rationales for declining consultant pharmacist recommendations for one of five residents reviewed for unnecessary medications (Resident 55). Findings include: Review of Resident 55's Physician Recommendation from the consultant pharmacist dated November 18, 2022, revealed the pharmacist recommended: The order for Bupropion SR [(antidepressant)] 150 mg, which is the sustained release 12 hour formulation and the directions read: 'Give 2 tablet by mouth in the morning for depression.' Will you consider reviewing this order, to verify if the 12 hour sustained release formulation should continue or if it should be changed to Bupropion XL 150 mg, which is the Extended release 24 hour formulation; but if no changes are to be made, please document your reason why below. Further review of Resident 55's Physician Recommendation from November 18, 2022, revealed the physician signed the recommendation on November 21, 2022, and wrote disagree under the response. The physician's failure to provide clinical rationale for declining the consultant pharmacist's recommendation for Resident 55 was discussed and confirmed with the Director of Nursing on January 13, 2023, at 10:50 a.m. 28 Pa. Code 201.18(b)(1)(2) Management

Based on clinical record review and staff interview it was determined the facility failed to complete laboratory studies as ordered by the physician for two of 24 residents reviewed. (Resident 48 and 59) Findings Include: Review of Resident 48's Progress Notes revealed a nursing entry dated January 3, 2023 at 3:55 p.m. stating, resident noted with hematuria (blood in the urine). Resident denies having lower abdominal pain, burning or painful urination, no odor. MD made aware and ordered CBC (Complete Blood Count- counts the number of different cells in the blood) and UA C+S (urine tested for infection). Review of Resident 48's physician orders revealed an order dated January 3, 2023 for a CBC. Review of Resident 48's lab results revealed there were no results for a CBC on January 4, 2023. Further review of Progress notes revealed a physician entry dated January 10, 2023 at 10:50 a.m. stating CBC not done as ordered Interview with the Director of Nursing on January 13, 2023 at 10:48 a.m. confirmed the CBC was not drawn as ordered by the physician. Review of Resident 59's physician orders revealed an order for a PT/INR (study of the amount of time it take for blood to clot and determine the effectiveness of blood thinning medication). Further review of Resident 59's clinical record revealed the resident did not have the blood drawn as ordered. Interview with the Director of Nursing on January 13, 2023 at 11:00 a.m. PT/INR was not completed as ordered. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to follow a doctor's order regarding an intervention to prevent urinary tract infection [MEDICAL CONDITION] for one of three residents reviewed (Resident R35). Findings include: A review of the facility's policy and procedure titled Catheter Care, Urinary (a hollow partially flexible tube that collects urine from the bladder and leads to a drainage bag), with a revision date of September 2014, revealed that the urinary catheter procedure is to prevent catheter-associated urinary tract infection. Further review of the same policy revealed that information which includes date and time that catheter care was given, and assessment data obtained when giving catheter care should be recorded in the resident's medical record. Review of a progress note dated August 24, 2020, at 4:14 p.m. revealed that the resident was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the same note revealed that the resident had a urinary catheter 14 FR(indicates size), in place. Resident R35 had a care plan initiated on August 24, 2020, for at risk for infection due to urinary catheter use. Interventions included that the resident will be provided with catheter care daily. Review of progress notes dated September 2, 2020, at 7:56 a.m., revealed that Resident R35's urinary catheter was discontinued on September 1, 2020, but the resident did not have urine output on the evening shift; a urinary catheter was reinserted, with return of 400 ml clear yellow urine noted flowing to a connected urine bag. Review of the Nurse practitioner's progress note dated September 2, 2020, at 9:47 a.m. revealed that the resident's voiding trial was not successful, and the urinary catheter was re-inserted. A review of the physician's orders [REDACTED]. Review of Resident R35's September 2020, Treatment Administration Record (TAR), revealed that Resident R35's urinary catheter care, every shift, was not done from September 2, 2020, until September 29, 2020. The facility failed to provide documented evidence that the urinary catheter care, every shift, was provided to Resident R35. A progress note dated September 15, 2020, at 5:20 a.m., revealed that Resident R35 was sent to the hospital (September 14, 2020) and returned to the facility with a [DIAGNOSES REDACTED]. The urinary catheter was replaced and a new order for [MEDICATION NAME] (antibiotic) 500 milligrams one tablet by mouth two times a day for seven days was ordered. A review of POS dated September 24, 2020, revealed another order for [MEDICATION NAME] (antibiotic) 500 milligrams one tablet by mouth two times a day for seven days for urinary tract infection. The above was discussed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 1, 2020 at 1:00 p.m. The facility failed to follow a physician's orders [REDACTED]. 28 Pa Code 211.5(f) Clinical records Previously cited 3/11/2019 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 3/11/2019

Based on clinical record review and staff interview, it is determined the facility failed to provided follow-up psychological consults for three of 5 residents reviewed (Resident 23, 24, and 26) Findings include: Review of Resident 23's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 23's clinical record revealed a consult dated (MONTH) 25, (YEAR) revealed resident was being treated for [REDACTED]. Further review of neurology consult revealed resident was requested to have a follow up visit in one month. Review of Resident 23's entire clinical record revealed no documented evidence that the resident return for a follow up appointment. Review of Resident 24's neurology consult report, dated (MONTH) 29, (YEAR) revealed Resident 24 was being treated for [REDACTED]. to perform everyday activities), and depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Further review of the neurology consult report revealed the resident was requested to have a follow-up consult in three months. Review of the clinical record revealed the resident had not returned for a follow-up appointment. Review of Resident 26's neurology consult report, dated (MONTH) 14, (YEAR) revealed Resident 26 was being treated for [REDACTED]. Further review of the neurology consult report revealed the resident was requested to have a follow-up consult in two to four weeks. Review of Resident 26's entire clinical record revealed no documented evidence that the resident returned for a follow-up appointment. Further review of Resident 26's clinical record revealed the resident was again seen for a neurology consult on (MONTH) 27, (YEAR) and was requested to have a follow-up in three months. Review of the clinical record revealed the resident had not returned for a follow-up appointment. Interview with the Nursing Home Administrator on (MONTH) 8, 2019 at 2:30 p.m. confirmed Residents 24 and 26 had not had follow-up appointments with the neurologist for treatment of [REDACTED]. 28 Pa Code 201.18 (b)(1) Management Previously cited 4/20/18 28 Pa Code: 201.29(j) Resident rights Previously cited 4/20/18 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/18

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident's physician of a significant weight gain for one of 15 residents reviewed (Resident 16). Findings include: Review of Resident 16's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident 16's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident 16's weights revealed that the resident weighed 169 pounds on (MONTH) 29, (YEAR) and 174.5 pounds on (MONTH) 30, (YEAR), indicating a 5.5 pounds weight gain in 24 hours. Review of Resident 16's clinical record failed to reveal evidence that the physician was notified of the 5.5 pounds weight gain on (MONTH) 30, (YEAR). Interview with the Director of Nursing on (MONTH) 11, 2019 at approximately 10:20 a.m. confirmed that there was no evidence that Resident 16's physician was notified of the 5.5 pounds weight gain on (MONTH) 30, (YEAR). 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/18

Based on clinical record review and staff interview, it was determined that the facility failed to clarify a physician's order regarding weights for one of 15 residents reviewed (Resident 16). Findings include: Review of Resident 16's clinical record revealed a [DIAGNOSES REDACTED]. Review of Resident 16's physician's orders revealed an order dated (MONTH) 22, (YEAR) for weekly weights on Mondays and to notify the physician or nurse practitioner of a weight gain greater than 2 pounds in 24 hours or weight gain greater than 5 pounds in 3 days. Review of Resident 16's weights revealed the resident received weekly weights from (MONTH) 29, (YEAR) to (MONTH) 4, 2019. Interview with the Director of Nursing on (MONTH) 11, 2019 at 10:20 a.m. confirmed that weekly weights would not indicate if Resident 16 had a 2 poumds weight gain in 24 hours or 5 pounds weight gain in 3 days, and that the facility should have clarified the weight order with Resident 16's physician. 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/18

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 15 residents reviewed (Resident 10). Findings include: Review of facility policy Catheter Care (Indwelling Catheter), effective date (MONTH) 1, 2009, revealed that the purpose of catheter care was to prevent infection. Under General Documentation Guidelines, it states that the date, time (or shift), procedure, and condition of the perineum and catheter insertion site should be documented. Review of Resident 10's clinical record revealed the resident was readmitted to the facility from the hospital on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Resident 10 returned to the facility with a Foley catheter (tube inserted into the bladder through the urethra that drains urine from the bladder). Review of Resident 10's progress notes revealed the resident was diagnosed with [REDACTED]. Further review of Resident 10's progress notes revealed that the resident's Foley catheter was removed at a urology appointment on (MONTH) 21, (YEAR). Review of Resident 10's (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARs) revealed that there was no documented evidence that catheter care was being done during the time in which the resident had a Foley catheter (November 23, (YEAR) to (MONTH) 21, (YEAR).) Interview with the Director of Nursing on (MONTH) 11, 2019 at 11:35 a.m. confirmed that there was no documented evidence that Resident 10 received catheter care to prevent further UTIs. 28 Pa Code 211.5(f) Clinical records Previously cited 4/20/18 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/18

Based on observation and staff interviews and review of manufacturer's guidelines, it was determined that the facility failed to date medications after being opened in the one of one medication rooms and two of three medication carts observed (Medication room, East Hall and West Hall Medication Carts). Findings include: Review of manufacturer's guidelines for [MEDICATION NAME] Insulin (medication used to treat high blood sugar levels) revealed that [MEDICATION NAME] Insulin is to be discarded 28 days after opening. Review of manufacturer's guidelines for Humalog Insulin revealed that Humalog Insulin is to be discarded 28 days after opening. Review of manufacturer's guidelines for [MEDICATION NAME] revealed that unopened [MEDICATION NAME] should be stored in a refrigerator. Un-refrigerated [MEDICATION NAME] must be used within the 28-day period or it must be discarded. Observation on (MONTH) 17, (YEAR), at approximately 7:20 p.m. revealed two open and undated [MEDICATION NAME] Insulin Flex Pens; one open and undated Humalog Insulin Kwik Pen and one unopened and un-refrigerated [MEDICATION NAME] Pen. During an observation of the medication refrigerator in the Medication Room accompanied by a licensed nurse, Employee E 3 on (MONTH) 17, (YEAR), at 7:35 p.m. revealed two bottles of Latanoprost solution (medication used in the treatment of [REDACTED]. The manufacture's package insert indicated that once the bottle has been opened it must be used within six weeks after opening the bottle. A multidose vial of [MEDICATION NAME] (indicated to aid [DIAGNOSES REDACTED]. Manufacturer's package insert indicated that a vial of [MEDICATION NAME] which has been in use for 30 days should be discarded. Interview with licensed nurse, Employee E3 on (MONTH) 17, (YEAR), at 7:45 p.m. during the observation confirmed the three bottles of eye drops and the vial of [MEDICATION NAME] were opened and undated. The facility failed to indicate the open bottles of eyedrops and vial of [MEDICATION NAME] solution were not dated. Interview with the Director of Nursing on (MONTH) 20, (YEAR), at approximately 12:30 p.m. confirmed that the insulin located in the medication carts should be labeled with the open date. CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals Previously cited 03/20/17 28 Pa. Code 211.12(c) Nursing Services Previously cited 09/18/17, 04/15/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16

Based on review of facility policy, observations, clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from restraints for one of 12 residents reviewed (Resident R25). Findings include: Review of facility policy, Restraint Use, revised (MONTH) 15, 2011, revealed that the facility prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The policy also defined a physical restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts the freedom of movement or normal access to one's body. Review of Resident R25's initial MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 13, (YEAR), revealed that the resident had severe cognitive impairment and [DIAGNOSES REDACTED]. Review of the current care plan revealed that the resident was identified at risk for falls due to history of falls, impaired cognition, impaired communication and physical mobility. An intervention initiated (MONTH) 14, (YEAR), revealed that a self releasing seat belt was added to the resident's wheel chair which relieved the resident's anxiety. Observation on (MONTH) 19, (YEAR), at 11:25 a.m. accompanied by licensed staff, Employee E4, revealed Resident 25 was sitting at the nurse's station in a wheelchair with a velcro seatbelt in place. When Resident 25 was asked to release the velcro seatbelt by Employee E4, resident was unable to do so. Observation on (MONTH) 19, (YEAR), at 2:26 p.m. accompanied by licensed staff, Employee E5, revealed that the Resident 25 was unable to release the seatbelt when requested by Employee E5. Observation on (MONTH) 20, (YEAR), at 11:23 a.m. revealed Resident R25 again sitting in the wheelchair with a velcro seatbelt. Resident was asked to release the seatbelt by licensed staff, Employee E6, in the presence of the Director of Nursing. Resident stated I can't and was unable to release the seatbelt. Review of Resident R25's (MONTH) (YEAR), physcian's orders revealed no order for the use on a self releasing seat belt of the resident's wheel chair. Further review of the resident's clinical record revealed no evaluation for the use of the velcro seatbelt, no documented evidence that the facility had obtained a consent from the resident's Power of Attorney for the use of a restraint, and no evidence that Resident R25 was being release from the velcro seatbelt periodically to allow for movement. Interview with the Director of Nursing on (MONTH) 20, (YEAR), at 11:30 a.m. confirmed that the resident was unable to release the seatbelt. Right to be Free from Physical Restraints CFR 483.10(e)(1), CFR 483.12(a)(2) Previously cited 04/15/16 28 Pa. Code 201.29(j) Resident rights Previously cited 03/20/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/15/16 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for a resident suicidal ideation for one of 24 resident reviewed (Resident R43). Findings include: Review of Resident R43's [DIAGNOSES REDACTED]. Review of Resident R43's psychiatry consult dated (MONTH) 22, (YEAR), revealed recommendations for a psychology consult and to provide every hour safety checks. Review of the facility, Medical Communication Sheet, dated (MONTH) 22, (YEAR), revealed behavior changes and suicidal thoughts - q (every) 1 hour checks - psych (psychiatrist) aware. Review of Resident R43's nursing notes dated (MONTH) 23, (YEAR), at 2:00 p.m. revealed very angry, suicidal thoughts, even when talking with son on phone, belligerent, wants to leave facility. Resident is on q 1 hr (hour) checks, son would like a call from psyche CRNP (Certified Registered Nurse Practitioner) when she comes in again, noted in consult book. Review of Resident R43's comprehensive care plan failed to reveal that Resident R43 had suicidal thoughts and failed to reveal any interventions and/or safety plans regarding the resident's suicidal thoughts. Interview with the Director of Nursing on (MONTH) 20, (YEAR), at approximately 11:00 a.m. revealed that the facility maintained every 1-hour safety checks on Resident R43, however, this interview confirmed that a comprehensive care plan regarding suicidal ideation with interventions was not developed for this resident. Develop/Implement Comprehensive Care Plan CFR 483.21(b)(1) Previously cited 03/20/17, 04/15/16 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/15/16 28 Pa. Code 211.5(f) Clinical records Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.11(c) Resident care plan Previously cited 03/20/17 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited 09/18/17, 04/15/16 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16

Based on review of clinical records, facility documentation and staff interview, it was determined that the facility failed to timely examine a resident's bed for potential accident hazards for one of 12 residents reviewed. (Resident R29) Findings include: Review of Resident 29's [DIAGNOSES REDACTED].). Review of nursing documentation Skin/Wound note dated (MONTH) 20, (YEAR), at 7:16 p.m. revealed that the licensed nurse was called to residents room by the nursing assistant. The licensed nurse noticed a large laceration to left lower extremity exposing adipose (connective tissue consisting mainly of fat cells). The nursing assistant applied pressure and stated that when she was transferring resident from shower chair to the resident's bed using the resident's walker the resident's leg hit a metal piece that was connected to the bed and side rail and gave the resident a laceration. The laceration appears to be 2 x 3 inches. The resident was immediately transported to the hospital for stitches. Review of nursing documentation Skin/Wound note dated (MONTH) 20, (YEAR), at 10:16 p.m. revealed the the resident returned from the hospital with eight sutures to the left lower extremity. Review of a Maintenance Work Order dated (MONTH) 30, (YEAR), at 3:36 p.m. ten days after the (MONTH) 20, (YEAR), accident with a laceration, revealed that Resident R29's bed was examined on that date and the work order further stated, checked bed soft rubber side rail didn't see any sharp metal or edges. Interview with the Director of Nursing on (MONTH) 20, (YEAR), at approximately 11:00 a.m. failed to reveal information regarding the condition of Resident R29's bed prior to the accident and failed to reveal any information regarding the delay in examining Resident R29's bed and bed rails for safety until 10 days after the occurrence. The facility failed to timely examine Resident 29's bed and bed rails for potential accident hazards. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 04/15/16 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 09/18/17, 03/20/17 28 Pa. Code 201.18(b)(1) Management Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16 28 Pa. code 201.18(b)(3) Management Previously cited 09/18/17, 03/20/17 28 Pa. Code 201.18(e)(1) Management Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to follow infection control standards in providing wound care to one of 24 residents reviewed (Resident R4). Findings include: Review of facility policy titled, Handwashing, effective date (MONTH) 1, 2009, indicated to thoroughly cleanse hands with friction, soap and water. Hands should be thoroughly washed before and after providing resident care. Proper hand-washing techniques must be followed at all times. Observe (standard) universal precautions or other infection control standards as approved by the appropriate facility committee. Follow the Center for Disease Control (CDC) Guidelines for hand washing. (CDC Hand washing guidelines dated (MONTH) 7, (YEAR), indicated to wet your hands with clean, running water (warm or cold), turn off the tap and apply soap. Lather your hands by rubbing them together with soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Rinse your hands well under clean, running water. Dry your hands using a clean towel. Wash hands before and after treating a cut or wound.) Wash your hands before and after all procedures. Clean and dry hands well. Wear gloves when coming in contact with blood or body fluids. Observation of Resident R4's wound treatment and observation of licensed nurse, Employee E6 on (MONTH) 20, (YEAR), at 10:15 a.m. revealed during wound treatment of [REDACTED]. heel. Employee E6 washed her hands for 5 seconds, put on a pair of gloves and removed the soiled dressing from the shin area and placed it into a plastic trash bag inside the trash can. Employee E6 then removed the pair of gloves, and put on a clean pair of gloves without washing her hands. Employee E6 proceeded to pour normal saline solution on the two opened areas on the left shin, applied the wound treatment [MEDICATION NAME] ointment (topical ointments for wound care) and covered the wound with [MEDICATION NAME] dressing (non-adherent). At 10:21 a.m., Employee E6 removed the soiled pair of gloves and proceeded to the bathroom where she washed her hands for a total of 10 seconds. Employee E6 put on a clean pair of gloves and proceed to pour normal saline solution onto the left heel wound, applied the wound treatment Santyl, covered wound with a clean dry dressing and used gauze to hold dressing in place. Employee E6 then removed the soiled gloves placing them into the trash bag in the trash can. Employee E6 then went into the bathroom and proceeded to wash hands for 13 seconds. Employee E6 then closed and tied the plastic trash bag containing the soiled dressings and gloves secure and disposed of the bag in the soiled utility room. Interview with the Director of Nursing on (MONTH) 20, (YEAR), at 3:00 p.m. confirmed that the licensed nurse did not maintain the facility's infection control practices. 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/15/16 28 Pa. Code 211.12(c) Nursing services Previously cited 09/18/17, 04/15/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 09/18/17, 03/20/17, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/18/17, 03/20/17, 06/14/16, 04/15/16

Based on observations, resident, and staff interviews, it was determined that the facility failed to provide contact information including the name, address, and telephone number of the State Survey Agency to eight of eight residents. (Resident R5, Resident R7, Resident R11, Resident R15, Resident R18, Resident R31, Resident R33, Resident R38) Findings include: During the group interview conducted on (MONTH) 18, (YEAR), at 2:15 p.m. with Resident R5, Resident R7, Resident R11, Resident R15, Resident R18, Resident R31, Resident R33, and Resident 38 were asked by the surveyor if they knew how to contact the State Survey Agency. Resident R5, Resident R7, Resident R11, Resident R15, Resident R18, Resident R31, Resident R33, Resident R38 indicated that they were unaware of how to contact the State Survey Agency. Observations on (MONTH) 19, (YEAR), at 12:00 p.m. revealed no posting in the facility of contact information for the State Survey Agency. Interview with the Director of Nursing on (MONTH) 19, (YEAR), at 1:39 p.m. confirmed that there was no posting of the required information. 28 Pa. Code 201.18(b)(3) Management Previously cited 09/18/17, 03/20/17

Based on clinical record review and staff interview it was determined the facility failed to assess and monitor a resident with a change in condition causing actual harm to one of three residents reviewed (Resident R2) Findings Include: Resident R2 was admitted to the facility with a [DIAGNOSES REDACTED]., behavior, feelings, and sense of well-being). Review of the progress notes revealed a nursing entry on [DATE] at 4:17 p.m. stating Resident R2 had vomited once this morning and had a large amount of loose stools twice and there were no new orders at that time. Further review of the progress notes revealed a nursing entry on [DATE] at 1:49 p.m. stating that the resident vomited once in the AM and the physician was notified and there was a new order for a CBC and a CMP, lab draw pending at this time. Review of the physician progress notes [REDACTED]. Further review of the physician progress notes [REDACTED]. Under the [DIAGNOSES REDACTED].). Review of the physician orders [REDACTED]. Review of the laboratory results revealed a CBC was drawn on [DATE] and had a result of 14.30 for the white blood cell count (indicative of infection, normal is 3XXX,[DATE].5). The lab results were singed by a nurse indicating they were communicated to the physician on [DATE] and singed by the physician on [DATE]. Further review of the progress notes revealed there was no progress note entered on [DATE]. A nursing entry on [DATE] at 4:17 p.m. revealed nurse was checking on resident after lunch secondary to 2 days of NVD (nausea, vomiting, diarrhea). When nurse started V.S (Vital Signs) and reached for the resident, hand was cold and clammy, resident V.S. were as follows T (temp) 100.5 HR (Heart rate) 160 B/P (Blood Pressure) ,[DATE] R (respirations) 52 SPO2 (pulse oximetry- measure of oxygen in the blood) 78 on RA (room air- no supplementary oxygen). The nurse put the resident on 2L/02 (2 liters per minute of oxygen) nursing judgement, her son was called and the resident was sent out 911 to BMH. Further review of the progress notes revealed a nursing note on [DATE] at 11:03 p.m. stating that the resident died at the hospital. Review of the resident Vital Signs revealed the last time vital signs were documented for this resident were a set of monthly vital signs in [DATE]. The Director of Nursing was asked to provide vital signs for this resident and presented to the surveyor a sheet of paper with the title July Monthly Vital Signs which was a list of every room number and a set of vital signed for the resident in the room. This was not a part of the clinical record. Interview with the Director of Nursing on [DATE] at 1:00 p.m. confirmed that there were no vital signs for this resident documented on the clinical record by nursing since [DATE]. Review of Resident R2's hospital records revealed that the resident was admitted to the hospital on [DATE], at 3:51 p.m. Resident R2 was assessed with [REDACTED]. Laboratory test completed at the time of admission to the hospital revealed a white blood count of 16.70 (Normal 3.8 to 10.5). Resident's admitting [DIAGNOSES REDACTED]. Further interview with the Director of Nursing on [DATE] at 2:45 p.m. revealed there was no evidence in the clinical record that the facility monitored Resident R2, who had a change in condition with new onset of diarrhea and vomiting for a period of four days until the resident was observed with vital signs that were abnormal and needed to be transferred to the hospital for emergency care. The facility failed to monitor the status of a resident with signs and symptoms of infection causing actual harm to Resident R2. 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE]