Every finding on record at William Hood Dunwoody Care CTR

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a change in the condition of a resident's urinary status for one of the three residents reviewed (Resident 39). Findings include: A review of the facility's policy titled Change in Resident status Notification, revised on May 17, 2023, revealed that the charge nurse will notify the resident's physician or on-call physician when there has been a significant change in the resident physical/mental/emotional condition, and a need to alter the resident's medical treatment. Notification will be made promptly with the exemption of non-emergency incidents on the 11-7 shift. Notification of non-emergent incidents on the 11-7 shift may be passed on to the 7-3 shift for a morning notification. Clinical record review revealed Resident 39 had an Indwelling Urethral Catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine) for diagnosis of urinary retention and neuromuscular dysfunction of the bladder. A review of the Resident laboratory report dated March 5, 2025, revealed a normal WBC (White Blood Cell count) result (Normal range 4.8-10.8). (a blood test that measures the number of white blood cells in your blood, helping to identify infections, inflammation, and other conditions.) A review of the nursing progress notes dated March 9, 2025, at 1:47 a.m., revealed that during the start of the shift, resident's family member reported feeling something was off with the resident. Further assessment revealed no urine output in the urine drainage bag, but the resident's brief was wet twice. The same note revealed that the catheter (tube) was outside the body more than normally should be. The same note revealed the following, Indwelling cath (catheter) removed and new 18Fr/10cc (size of the tube) placed with immediate [NAME] red bloody urine, then odorous amber colored urine, ending with tan sludge - 1700 cc. The responsible party was notified. The review of the clinical records failed to reveal that the physician was notified of the significant change in the resident's urinary status and change in the condition of urine. A review of the physician's note dated March 13, 2025, at 4:55 p.m., revealed that during the visit, the resident was noted to be somnolent (sleepy, lethargic, drowsy), not as vocal as his baseline. The condition was discussed with the wife and nursing, urine, and blood work was ordered. A review of Resident 39's blood work dated March 15, 2025, revealed WBC was 21.6 and the urine had (+) 3 Leucocytes (indicative of a urinary tract infection). Urine culture and sensitivity (test to determine the kind of bacteria causing the infection and the antibiotics that are effective against the bacteria) were pending. Clinical records review revealed that the physician was notified of the laboratory result and ordered to start the Resident with Macrobid (antibiotic) 100mg twice daily for seven days while waiting for the culture and sensitivity. The physician's order was followed. An interview was conducted with the Director of Nursing on April 4, 2025, at 10:00 a.m. The DON confirmed that there was no documented evidence that the physician was notified when Resident 39 had 1700 cc of bloody, with tan sludge and odorous urine output on March 9, 2025. The facility failed to ensure physician was notified of Resident 39's significant change in urinary status resulting in a delay in treatment. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

Based on clinical records review and staff interview, it was determined that the facility failed to ensure wound treatment for a pressure ulcer was provided for one of five residents reviewed (Resident 39). Findings include: A review of the nursing progress notes dated March 13, 2025, at 7:40 a.m., revealed that a new DTI (Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration) was observed on the resident's left lower back. The wound was cleansed with a wound cleanser and Desitin (An ointment used to treat and prevent a rash) was applied. The Nurse practitioner was notified. A review of the skin assessment dated [DATE], revealed a DTI to the left lower back measuring 8.9 x 4.5 cm (centimeters). A review of Resident 39's March TAR (Treatment Administration Record) failed to reveal a wound treatment was done for the identified DTI on the resident's left lower back from March 14, 2025, until the time the resident was sent to the hospital for an abnormal laboratory result on March 17, 2025. An interview with the DON (Director of Nursing) conducted on April 4, 2025, at 10:00 a.m., confirmed that there was no documented evidence that the Resident's identified DTI to the left lower back on March 13, 2025, was treated from March 14, 2025, until March 17, 2025. The facility failed to ensure wound treatment was provided for Resident 39's DTI to the left lower back. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure a significant weight change was timely addressed for one 10 residents (Resident 42). Findings include: A review of the facility's policy titled Weights, last revised on October 11, 2024, revealed the facility will have the residents' weights monitored as an indicator of their health and wellness. Residents will be weighed weekly for a total of four weeks to monitor health status. Weights will be reviewed by the nurse and dietitian. Weights that are three pounds greater than or less than the resident's prior weight will be reweighed within 24 hours to verify accuracy. Weights that are less than 5% of the previous weight will be reported to the physician and noted on the resident record. A plan of care will be developed to address residents with weight concerns. Clinical records review revealed resident was admitted to the facility on [DATE], with a diagnosis of Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Dysphagia (Difficulty in swallowing). A review of the resident nutritional care plan initiated on December 30, 2024, revealed: Screening Score 7-Malnourished (Resident 42) have the potential for continued alteration in nutrition r/t (relate to) history of dysphagia. Interventions include monitoring the need for the addition of appropriate high-calorie/protein house supplements within the limits of the therapeutic diet order. A review of Resident 42's weights revealed an admission weight of 122.6 pounds on December 27, 2024. Weekly weights were done with the following result: 124.3 pounds on December 31, 2024, 124 pounds on January 1, 2025, and 116.8 pounds on January 10, 2025, an 8.8 pounds (5.81%) weight loss in five days. Clinical record review failed to reveal that the resident was reweighed within the 24-hour period to verify the significant weight loss. There was no documented evidence that a nurse and/or the dietitian reviewed the resident's identified weight loss. There were no interventions put in place to prevent further weight loss. There was no documented evidence that the physician was notified of the significant weight loss until January 30, 2025. A review of Resident 42's weight and vitals revealed a weight of 113.6 on March 24, 2025, a 7.34 % weight loss from admission. There were no interventions put in place upon identifying further weight loss within tthree-month period from December 27, 2024, until March 24, 2025. An interview with the Dietitian and the DON (Director of Nursing) conducted on April 4, 2025, at 11:00 a.m., confirmed that there were no interventions put in place for the significant weight loss identified on January 10, 2025, and further weight loss from admission identified on March 24, 2025. The facility failed to ensure Resident 42's significant weight loss was addressed. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

Based on review of facility policy and clinical record review, it was determined that the facility failed to ensure one of 18 residents was treated for constipation in a timely manner (Resident 12). Findings include: Review of facility policy, Bowel Protocol, last reviewed/revised June 2, 2022, revealed: If a resident has not moved their bowels for 6 shifts .the 3-11 charge nurse is to give Milk of Magnesia at [bedtime] to the resident with an order. Review of Resident 18's physician's orders revealed an order dated April 4, 2024, for Milk of Magnesia 400mg/5ml - give 30ml by mouth every 24 hours as needed for constipation. Review of Resident 18's bowel records revealed the resident had no recorded bowel movement from April 22, 2024, through April 26, 2024, for a total of 15 shifts. Review of Resident 18's April 2024 Medication Administration Record revealed the resident was not given Milk of Magnesia until April 27, 2024. Interview with Licensed Nurse Employee E3 confirmed the facility failed to administer Resident 12's Milk of Magnesia after 6 shifts with no bowel movement. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of 24 residents reviewed was free of accidents related to activities of daily living care. (Resident 44). Findings include: Review of information dated March 20, 2024 submitted by the facility on March 20, 2024; revealed Resident 44 was receiving morning care from non licensed staff, Employee E1. Employee E1 was performing a morning care with Resident 44 when Employee E1 rolled Resident 44 over, subsequently Resident 44 rolled out of the bed and fell on to the floor. Review of clinical record for Resident 44 revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Anemia (deficiency of healthy red blood cells in blood), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 44's clinical record including his/her care plan (provides direction on the type of nursing care the individual needs) revealed an intervention dated January 20, 2023, stating Nursing staff are to provide paired care (2 staff members). Review of facility investigation dated, March 20, 2024, revealed Resident 44 While receiving AM care by (Employee) E4, resident rolled out of bed onto the floor onto [his/her] left side, Small abrasion 1.5 x 1.0 cm (centimeters) noted on left upper forehead, Resident 44 reported no pain. Review of written statement from non licensed, Employee E4 dated March 20, 2024, states the following I [Employee E4] was giving care to [Resident 44] and I didn't get any report that [Resident 44] was a two assist and giving [his/her] care [Resident] rolled out of bed. Interview conducted with Nursing Home Administrator (NHA) on May 2, 2024, at 11:20 a.m. confirmed Resident 44 rolled out of bed due to Employee E4 not following the care instructions indicated on care plan of Resident 44. NHA also reported that Employee E4 was reeducated on following resident care plans. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of the facility policy and clinical record, and staff interview, it was determined that the facility failed to thoroughly assess and provide treatment timely to an identified wound and also failed to notify the physician timely of a change in condition and worsening sacral wound resulting in actual harm of advanced stage pressure ulcer to one of 18 residents reviewed (Resident 162). Findings include: A review of the facility policy titled Skin Integrity, with a revision date of May 11, 2018, revealed that the nurses are responsible for documentation of wound appearance, measurements of wounds, improvements/deterioration, changes in the plan of care, and communication with physicians with recommendations for changes in treatment. A review of Resident 162's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 162's clinical record revealed an admitted [DATE]. An admission assessment revealed the following skin impairments: Pin-point opening on the sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity); and MASD (moisture-associated skin damage) to the right buttock and anal region. A review of Resident 162's Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care) dated April 28, 2021, revealed that the resident required extensive assistance with two people with bed mobility. The same MDS revealed that the resident was frequently incontinent of bowel and had an indwelling Foley catheter (thin rubber tube inserted into the bladder to drain urine out of the body) related to [CONDITION(S)]. A review of Resident 162's Braden Risk Assessment (a tool used to determine risk factors for pressure sore development) completed on April 24, 2021, revealed that the resident had a score of 14 which placed the resident as moderately at risk for developing pressure ulcer. A review of the 48 Hour Post-Admission Skin Check, dated April 26, 2021, revealed pinpoint open area and MASD to right buttocks. Review of Resident 162's clinical record failed to reveal that the identified skin impairments of the resident upon admission and the 48 Hour Post-Admission Skin Check, was thoroughly assessed. The clinical record also failed to reveal that treatment was provided on the resident's sacrum and right buttock upon identification of the wound impairment on April 24, 2021, and that treatment was not provided until April 27, 2021. A review of Resident 162's current skin care plan developed on April 24, 2021, revealed the resident was at risk for impaired skin integrity due to decline in mobility and needing assistance with ADL's (activities of daily living) and functions. Interventions included: Keep skin dry and clean; Observe skin during toileting and hygiene, Provide assistance with transfers and ambulation; and Twice weekly skin check. During an interview on June 17, 2021, at 1:00 p.m. the Unit Manager, Licensed Employee E3 revealed that a wound assessment must include a description of the wound, measurement, drainage, and any odor. Licensed Employee E3 confirmed that Resident 162's skin impairments on the sacrum and right buttock were not thoroughly assessed when identified during admission. Licensed Employee E3 stated that an ointment was applied to the resident's open area, but the employee confirmed that there was no documented evidence that treatment was provided to the resident's sacrum and right buttock from April 24, 2021, until April 27, 2021. A review of Resident 162's skin and wound evaluation dated April 27, 2021, revealed a DTI (Deep Tissue Injury-Persistent, non-blanchable, deep red, maroon, or purple discoloration), in-house acquired, with a measurement of 8.2 centimeters (cm) x 8.5 cm, with a total wound area of 34.3 cm. A wound care order of Allevyn foam dressing (a dressing indicated for drainage absorption and the management of partial-to full-thickness loss wounds) was made. A review of the April 2021, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Licensed Employee E3 on June 17, 2021, at 1:00 p.m. revealed that a weekly wound round was conducted by a wound care team which consisted of the unit manager, dietitian, and a Registered Nurse (RN) that was wound care certified. The wound round was done weekly. Licensed Employee E3 explained that during the wound round on April 27, 2021, the sacral and right open areas had fused and were now identified as a sacral DTI. Licensed Employee E3 explained to the surveyor through a drawing that the combined DTI to the sacrum and right buttocks was surrounded by a MASD. Licensed Employee E3 stated that the changes on Resident 162's wounds were not entirely documented because there was no space to write in the wound evaluation section. A review of Resident 162's skin and wound evaluation dated April 28, 2021, at 2:10 p.m. revealed the DTI to the sacrum, with a measurement of 9.4 cm x 9.2 cm, with a total wound area of 58.2 cm. A review of the physician's order dated April 28, 2021, revealed an order to change the wound treatment to [MEDICATION(S)] 20% with [MEDICATION(S)] (a compound ointment used for severe rash) apply to the sacrum every shift and as needed with incontinent care. A review of the nursing progress notes dated May 1, 2021, at 2:53 p.m. revealed that the pressure area on the sacrum was getting larger, with sanguineous (bloody) drainage. [MEDICATION(S)] treatment was applied to the affected area. An interview with Licensed Employee E3 was conducted on June 17, 2021, at 1:00 p.m. who confirmed that the sacral wound was not thoroughly assessed and that the physician was not notified of the identified wound change on May 1, 2021. A review of the skin and wound evaluation on May 2, 2021, at 11:33 a.m. revealed a DTI to the sacrum, with a measurement of 5.2 cm x 8.0 cm, with total wound area of 28.3 cm, 20% slough (separation of dead tissue from living tissue, yellow, tan, gray, green, or brown). The same note revealed that the wound was deteriorating and the practitioner was notified. A review of the Nurse Practitioner's (NP) progress notes dated May 3, 2021, at 9:42 a.m. revealed that the resident was seen for the following, nursing was in to evaluate sacral wounds and revealed several DTIs sacrum/buttocks, surrounding shearing. A review of the skin and wound evaluation dated May 4, 2021, at 7:28 a.m. revealed a DTI to the sacrum, with a measurement of 7.3 cm x 6.8 cm, with a total wound area of 26.1 cm., 20% slough, and now with 10% eschar (dry, scab, tan, brown, or black in wound bed, dead tissue) with sanguineous drainage. The wound was treated with [MEDICATION(S)] 20% with [MEDICATION(S)]. A review of the NP's progress notes dated May 4, 2021, at 9:10 a.m. revealed that the resident was seen due to the family's request for an antidepressant for the resident. The note indicated that the resident had a sacral and buttock wound and was being followed by the wound team, with no other mention regarding condition/worsening of the wound. An interview with Licensed Employee E3 on June 17, 2021, at 1:00 p.m. confirmed that the physician/NP was not notified of Resident 162's identified wound change on May 4, 2021, thus the resident remained on the same wound treatment to the sacrum. A review of the NP's progress notes dated May 7, 2021, at 9:10 a.m. revealed DTI to right buttocks with hardened areas, right buttock wound with beginning granulation, and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress note dated May 8, 2021, at 8:06 p.m. revealed that a skin check was made and observed no new areas, resident's sacrum and right buttock wound being followed. [MEDICATION(S)] cream continues. A review of the nursing progress notes dated May 9, 2021, at 9:04 p.m. revealed that [MEDICATION(S)] treatment to the sacrum and right buttocks were done. An interview with Licensed Employee E3 on June 17, 2021, at 1:00 p.m. who was unable to provide an answer as to why the nursing progress notes dated May 8, and 9, 2021, indicated that treatment was done for sacral and right buttock. Skin evaluations only revealed an open sacral wound. A review of Resident 162's current care plan revealed an additional focus written on May 9, 2021, for an unstageable wound (full thickness tissue loss in which the base of the ulcer is covered by slough and eschar) to the sacrum. A review of the same care plan revealed no interventions written for the identified unstageable sacral wound on May 9, 2021. A review of the clinical record failed to reveal that an assessment was conducted, and that the physician was notified of the identified unstageable sacral wound on May 9, 2021. The wound was continuously treated with [MEDICATION(S)] with [MEDICATION(S)]. A review of the nursing progress note dated May 10, 2021, at 11:31 a.m. revealed that a new wound treatment order of [MEDICATION(S)] (a wound treatment that supports the removal of dead tissue and aids in wound healing) was obtained from the NP. The treatment was for the wounds on the coccyx/sacrum and right buttock, two times a day. Continue with [MEDICATION(S)] to gluteal folds due to incontinence. The same note revealed that the appointment for the wound center was scheduled for May 13, 2021. An interview with Licensed Employee E3 on June 17, 2021, at 1:00 p.m. revealed that May 13, 2021, was the earliest scheduled appointment given to the facility by the wound center. A review of the skin and wound evaluation dated May 11, 2021, at 7:38 a.m. revealed a DTI to the sacrum, with a measurement of 6.8 cm x 6.8 cm x 1.5 cm, with a total wound area of 29.1 cm., 40% slough, 60% eschar. A review of the same assessment revealed that the wound was deteriorating and that the box that indicated, MD/provider had diagnosed wound infection was checked. The assessment did not reveal a description/condition of the right buttock wound. A treatment order of [MEDICATION(S)] to Coccyx/sacral and right buttock twice daily was continued. A review of the nursing progress note dated May 13, 2021, at 7:36 a.m. revealed that the wound care consult was canceled due to transportation availability. The wound care consult was rescheduled for May 17, 2021. Clinical record review failed to reveal that the facility notified the NP/physician of the canceled wound consult. An interview with Licensed Employee E3 on June 17, 2021, at 1:00 p.m. confirmed that the physician was not notified that the wound care consult was canceled and rescheduled to four days later. A review of the skin and wound evaluation dated May 14, 2021, at 11:32 a.m. revealed a DTI to the sacrum, with a measurement of 9.1 cm x 6.4 cm, with a total wound area of 34.9 cm, 10% slough, and 80% eschar with serosanguineous drainage (contains both blood and a clear yellow liquid known as blood serum). A review of the wound care center consult on May 17, 2021, revealed a new treatment order to the sacrum. An order of [MEDICATION(S)] and Aqua cell (treatment designed to lock in harmful bacteria, absorbs wound fluid, and creates a soft gel, maintaining a moist wound environment) and dry abdominal dressing daily was made. Follow-up appointment on May 24, 2021. A review of the skin and wound evaluation dated May 18, 2021, at 7:19 a.m. revealed an unstageable wound to the sacrum, with a measurement of 8.5 cm x 7.2 cm x with a total wound area of 40.1 cm., 10% slough, 70% eschar, serosanguineous drainage. The treatment recommended by the wound care center was followed. A review of the dietitian's progress note dated May 20, 2021, revealed that the resident's sacral wound was debrided (a surgical procedure to cut away dead tissue) at the wound clinic on May 17, 2021. A review of the wound care consult dated May 24, 2021, revealed that the pressure injury to the sacral region is now a Stage Three (ulcer involving the full thickness of skin loss, exposing tissue). Recommended to continue treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the skin and wound evaluation dated May 25, 2021, at 8:45 a.m. revealed an unstageable wound to the sacrum, 9.9 cm x 9.1 cm, with a total wound area of 60.4 cm., 10% slough, 80% eschar, and light serosanguineous drainage. [MEDICATION(S)] and Aqua cell treatment was continued. A review of the nursing progress notes dated May 27, 2021, at 11:22 a.m. revealed eschar to the lower area of the sacrum was softening and beginning to show depth, presence of serosanguineous drainage. NP was present during wound assessment, discussed changing to Santyl (an ointment that removes dead tissue from wounds so they can start to heal). The NP approved the Santyl treatment if the wound center approves the change. A review of the same note revealed that the nurse will follow up. A review of the NP's progress notes dated May 27, 2021, at 12:05 p.m. revealed that a recommendation to change treatment to Santyl was made, nursing to discuss with wound center. A review of the nursing progress notes dated May 27, 2021, at 1:41 p.m. revealed that a call was made to the wound care center, reviewed request to change the treatment, awaiting a return call. Clinical record review failed to reveal that a follow-up call was made to the wound care center after the May 27, 2021, call. The resident was maintained on the [MEDICATION(S)] and Aqua cell treatment daily. A review of the skin and wound evaluation dated June 1, 2021, at 9:04 a.m. revealed an unstageable wound to the sacrum, with a measurement of 11.2 cm x 9.4 cm x 2.2 cm with a total wound area of 79.1 cm and 3.5 cm undermining (refers to wound being open underneath the lip of the border). The wound had 30% slough, 60% eschar, with moderate serosanguineous drainage. A review of the same note revealed that the resident had a scheduled appointment at the wound center in the morning, but the resident refused to go. A review of Resident 162's physician's order sheet revealed an order made June 1, 2021, at 11:29 a.m. to cleanse the sacral wound with Dakin's solution (a solution to cleanse wound to prevent infection), apply skin prep to the peri-wound, then apply Santyl to eschar/slough, cover with Alginate (a dressing that absorbs wound fluids), abdominal pads. A review of the nursing progress notes dated June 2, 2021, at 3:18 p.m. revealed that Resident 162 had a temperature of 101.4 F (normal range: 97-99 F). A new order for urinalysis and culture and sensitivity was ordered. A review of the physician's progress note dated June 4, 2021, at 9:42 a.m. revealed that the resident was followed up for fever, leukocytosis (elevated white cells, frequently a sign of an [CONDITION(S)] response, most commonly the result of infection), discussed hospitalization to the resident for wound and infection, resident agreed. A review of the nursing progress note dated June 4, 2021, at 2:30 p.m. revealed sacral treatment completed, eschar was soft, starting to peel with light brown drainage. A review of the nursing progress note dated June 4, 2021, at 5:17 p.m. revealed that the resident was transferred to the hospital, the responsible party was notified. A review of the hospital record dated June 4, 2021 (encounter date), revealed a Stage Four (ulcer involving loss of skin layers, exposing muscle and bone) sacral ulcer with purulence (pus) concerning infection. The assessment revealed: [CONDITION(S)] (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) with fever, leukocytosis, possible sources include necrotic sacral ulcer culture and debridement of the sacral ulcer versus urinary tract infection. The plan included IV antibiotics (Vancomycin and Ceftazidime) while waiting for blood culture and urine culture and debridement of sacral ulcer. A review of the hospital records, wound drainage culture swabbed on June 5, 2021, revealed a **positive culture** (+Proteus Mirabilis). The above was conveyed to the Director of Nursing and Nursing Home Administrator on June 17, 2021, at 3:00 p.m. The facility failed to assess Resident 162's wounds thoroughly and accurately and failed to provide wound treatment timely. The facility also failed to notify the physician of the wound changes/deterioration timely which resulted in a delay of appropriate wound treatment resulting in actual harm of advanced stage ulcer (DTI to Stage Four) with debridement, infection and hospitalization . 483.25(b)(1) Previously cited state deficiency 8/29/19 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based upon clinical record review and review of documentation provided to the State Agency by the facility, it was determined that the facility failed to timely identify a pressure ulcer which required surgical debridement resulting in actual harm to one of four residents reviewed (Resident #10). Findings include: Review of Resident #10's clinical record revealed Resident #10 was admitted to the facility on (MONTH) 27, 2019 after sustaining a fall and a subsequent femur fracture which required surgical repair. Review of Resident #10's Admission Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 27, 2019 revealed a score of 17 which indicated Resident #10 was at risk for developing pressure ulcers. Review of Resident #10's care plan dated (MONTH) 27, 2019 revealed Resident #10 was at risk for skin breakdown with interventions including assisting the resident to turn and reposition frequently and to perform a Braden assessment on admission and per facility protocol. Review of Resident #10's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 4, 2019 revealed Resident #10 had a Brief Interview for Mental Status Score of 9 indicating moderately impaired cognition, required extensive assistance from two staff members to reposition in bed and was totally dependent on two staff persons for transfers between bed and wheelchair. Further review of Resident #10's Admission MDS also revealed Resident #10 was at risk for developing pressure ulcers. Review of Resident #10's Weekly Skin Evaluation dated (MONTH) 9, 2019, revealed that the resident had a skin tear of the right elbow, but no other skin issues. Review of documentation provided by the facility to the State Agency dated (MONTH) 9, 2019 revealed Resident was changed by CNA prior to OT (occupational therapy) at approximately 9:30 a.m. Further review of this documentation revealed This nurse was called to the room by OT. Resident was noted to have an open area. Resident was evaluation and an opening of the coccyx measuring 2 cm x 2 cm x 0 cm with a sloughy wound bed and pink area surrounding the wound bed. Review of Resident #10's progress note dated (MONTH) 9, 2019 revealed Resident is 1/9 for an open area to the Coccyx. At approximately 10:15 a.m. during OT this nurse was called to the room. Resident was noted to have an opening to the coccyx measuring 2 cm (centimeters) x 2 cm x 0 cm with a sloughy wound bed. Area was cleansed with wound cleanser and [MEDICATION NAME] and CDD (clean dry dressing) applied. MD (physician) and R/P (responsible party) made aware. Review of Resident #10's Plastic/Reconstructive Surgery initial consult dated (MONTH) 16, 2019 revealed Stage III (full thickness loss of skin; slough and/or eschar may be visible) midline sacral pressure wound with moist overlaying eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) and extension to the level of the sacral fascia (connective tissue underneath the skin) with purulent (thick, pus) fluid under the eschar evacuated. Further review of this consult revealed Wound size was 2.5 cm depth x 2.5 cm length and 2.5 cm width. Further review of this consult revealed After application of 1% [MEDICATION NAME] gel (topical pain relieving gel), sterile instruments were used to elevate and remove the layer of tissue slough (separation of dead tissue from living tissue, yellow, tan, gray, green or brown) exposing a fluid collection beneath it and extension to a Stage IV (full thickness skin and tissue loss with exposed fascia, muscle and/or bone) sacral pressure wound down to the sacral fascial layer and involving a portion of the medial (middle) bilateral (both sides) gluteal muscle. As much separated slough tissue was removed in reference to patient tolerance. Aggressive surgical debridement was not performed due to the patient's anticoagulation status and sensitivity in the wound area. The facility failed to identify Resident #10's sacral pressure ulcer during incontinence care. When the area was identified it was noted to have slough (a layer or mass of dead tissue separated from surrounding living tissue - associated with a stage III pressure ulcer). The pressure ulcer was not identified in a timely manner and required surgical debridement, resulting in actual harm to Resident #10. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on (MONTH) 29, 2019 at approximately 12:00 p.m. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 8/31/17 28 Pa. Code 211.12(d)(3)(5) Nursing Services Previously cited 8/31/17

Based on review of facility policy, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure adequate supervision to prevent accidents for two of 16 residents reviewed (Residents #17 and #21). Findings include: Review of facility policy Alcoholic Beverages - Resident, last reviewed (MONTH) 6, 2019, revealed that alcoholic beverages were only to be administered with a physician's orders [REDACTED]. The policy further revealed all alcoholic beverages are to be poured by the licensed nurse. Review of Resident #17's progress notes revealed a nurse's note dated (MONTH) 12, 2019 which stated Resident found to have a half empty bottle of vodka hidden in her room. It was placed in locked med room along with her other bottle. She is prescribed 2oz. (ounces) prn (as needed) daily. Review of Resident #17's physician's orders [REDACTED]. Review of Resident #17's progress notes revealed a nurse's note dated (MONTH) 4, 2019 stating Resident is 1/9 found sitting on the floor be side her bed, appears drunk. Able to move all extremities to her limit. No apparent injury or bruise noted at present. Resident denies hitting her head on any object, unable to say how she fell when asked. Review of facility documentation from (MONTH) 4, 2019 revealed that Resident #17 smelled of alcohol at the time the resident was found. Further review of Resident #17's progress notes revealed a progress note from (MONTH) 10, 2019 stating Late entry from 5/7/19: Falls management committee: (Resident #17) sustained a fall in her room following a Kentucky Derby party where she consumed alcohol. (Resident #17) states that she did not get drunk at this party but this is questionable, per staff observation. Review of Resident #17's (MONTH) 2019 Treatment Administration Record for (MONTH) 2019 revealed that on (MONTH) 4, 2019, the order for 2 oz. of alcohol was not signed off, indicating that nursing did not give the resident any alcohol that day. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 29, 2019 at 10:35 a.m. revealed that the activity that Resident #17 attended on (MONTH) 4, 2019 was in the facility's independent living and that there were no methods in place to communicate between activities and nursing as to how much alcohol the resident was allotted to consume or did consume at the activity. The administrator further confirmed that a resident with a history of alcohol dependency such as Resident #17 should have staff supervision at activities where alcohol would be served. Review of Resident #21's clinical record revealed a [DIAGNOSES REDACTED].) Review of Resident #21's quarterly Minimum Data Set (Minimum Data Set - periodic assessment of resident care needs) dated (MONTH) 28, 2019 revealed that the resident required extensive assistance of two staff members for toileting. Review of Resident #21's progress notes revealed a nurse's note dated (MONTH) 8, 2019 stating Resident was standing in her (bathroom) holding on to the grab bar while (nursing assistant) was providing care after toilet-use when resident bumped her head on wall. Review of facility documentation failed to reveal that a second staff member was present while Resident #21 was being toileted. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on (MONTH) 29, 2019 at 1:26 p.m. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/31/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 8/31/17 28 Pa. Code 211.11(a)(d) Resident care plan Previously cited 8/31/17, 8/2/18 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 8/31/17, 8/2/18

Based upon clinical record review and review of documentation provided by the facility to the State Agency, it was determined that the facility failed to ensure that mechanical equipment was maintained in a safe operating condition for one of sixteen residents reviewed (Resident #6). Findings include: Review of Resident #6's [DIAGNOSES REDACTED]. Review of documentation provided by the facility to the State Agency dated (MONTH) 5, 2019 revealed CNA reported to this nurse that resident was sitting in hallway in wheelchair, with two care staff standing close by when resident tried to stand up and wheel chair moved backward from resident due to the lock on the chair was not working. Staff tried to stop resident from fall but was unable to bear resident weight, resident was lowered to the floor. Interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 29, 2019 at approximately 12:00 p.m. failed to provide evidence that resident wheelchairs were maintained on a regular basis and evaluated for safe operating conditions. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and procedure and clinical record review, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist and failed to ensure that residents' physicians provided clinical rationales for rejection of recommendations for eight of 15 residents reviewed (Resident 8, Resident 14, Resident 53, Resident 4, Resident 20, Resident 21, Resident 10, and Resident 22). Findings include: Review of facility's policy titled, Drug Regimen Review (Monthly Report) dated (MONTH) 29, 2010 revealed that the consultant pharmacist reviews the medication regimen of each resident at least monthly. Review of Resident 8's clinical record revealed that Resident 8 was admitted to the facility on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 8's Consultant Pharmacist Medication Regimen Reviews from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that Resident 8's medication regimen was not reviewed by the consultant pharmacist in (MONTH) (YEAR). Review of Resident 14's clinical record revealed that Resident 14 was admitted to the facility on (MONTH) 7, (YEAR). Review of Resident 14's Consultant Pharmacist Medication Regimen Reviews from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that Resident 14's medication regimen was not reviewed by the consultant pharmacist in (MONTH) (YEAR). Review of Resident 53's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 53's Consultant Pharmacist Medication Regimen Review dated (MONTH) 30, (YEAR) revealed that Resident 53 had been receiving [MEDICATION NAME] (medication used as a sedative and to treat depression) 75 milligrams (mg) daily for depression since (MONTH) (YEAR). Further review of Resident 53's Consultant Pharmacist Medication Regimen Review revealed a recommendation by the Pharmacist Consultant to consider a trial dose reduction of [MEDICATION NAME] to 50 mg daily. Further review of Resident 53's Consultant Pharmacist Medication Regimen Review revealed Resident 53's physician's response as no change. Further review of Resident 53's Consultant Pharmacist Medication Regimen Review revealed Resident 53's physician failed to provide a clinical rationale for not accepting the recommendation of the Consultant Pharmacist for a gradual dose reduction of [MEDICATION NAME]. Further review of Resident 53's clinical record failed to reveal that a Medication Regimen Review was completed by the consultant pharmacist for the month of (MONTH) (YEAR). Interview with the Director of Nursing on (MONTH) 2, (YEAR) at approximately 11:00 a.m. confirmed that no Consultant Pharmacist Medication Regimen Reviews were completed in the month of (MONTH) (YEAR) and further confirmed that no clinical rationale was provided by Resident 53's physician for not accepting the recommendation of the consultant pharmacist for a gradual dose reduction of [MEDICATION NAME]. Review of Resident 4's clinical record revealed the [DIAGNOSES REDACTED]. Further review of Resident 4's clinical record failed to reveal that a Consultant Pharmacist Medication Regimen Review was performed by the consultant pharmacist for the month of (MONTH) (YEAR). Review of Resident 21's clinical record revealed that resident was admitted on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 21's (MONTH) (YEAR) Consultant Pharmacist Medication Regimen Review dated (MONTH) 8, 2108 revealed [MEDICATION NAME] Concentrate 2 MG/ML (milligrams per milliliter), 0.25 milliliters (ml) to be administered every four hours as needed for anxiety. Further review of Resident 21's Consultant Pharmacist Medication Regimen Review revealed a recommendation to add continue for three months, then re-evaluate and to document rationale for use beyond 14 days. Continued review of Resident 21's Consultant Pharmacist Medication Regimen Review revealed that Resident 21's physician failed to provide a clinical rationale for continuation of [MEDICATION NAME]. Further review of Resident 21's clinical record revealed that a Consultant Pharmacist Medication Regimen Review was not performed by the consultant pharmacist for the month of (MONTH) (YEAR). Review of Resident 20's clinical record revealed the [DIAGNOSES REDACTED]. Review of Resident 20's clinical record failed to reveal that a Consultant Pharmacist Medication Regimen Review was performed by the consultant pharmacist for the month of (MONTH) (YEAR). Interview with the Director of Nursing on (MONTH) 2, (YEAR) at approximately 11:20 a.m. confirmed with that no Consultant Pharmacist Medication Regimen Reviews were completed for the month of (MONTH) (YEAR) for Residents 4, Resident 20, and Resident 21 and further confirmed that no clinical rationale was provided by Resident 21's physician for continuation of [MEDICATION NAME] as recommended by the consultant pharmacist . Review of Resident 10's clinical record revealed the [DIAGNOSES REDACTED]. (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability); Hearing loss; Dementia (memory loss); Dysphagia (difficulty swallowing); [MEDICAL CONDITION](poor circulation of the extremities); Depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine). Review of Resident 10's clinical record failed to reveal a Medication Record Review in (MONTH) (YEAR). Review of Resident 22's clinical record revealed resident was admitted on (MONTH) 3, 3018. Further review of clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 22's clinical record failed to reveal a Medication Record Review in (MONTH) (YEAR). Interview with Nursing Home Administrator and Director of Nursing on (MONTH) 1, (YEAR) at approximately 1:20 p.m. confirmed that medication record reviews were not conducted by a pharmacist for (MONTH) (YEAR) for Resident 10 and Resident 22. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.9(k) Pharmacy Services 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 8/31/17

Based upon review of facility policy and procedure, clinical record review, review of documentation provided by the facility to the State Agency, it was determined that the facility failed to implement their policy and procedure for investigation into injuries of unknown origin for one of one resident reviewed (Resident 8). Findings include: Review of facility policy and procedure entitled Incidents of Unknown Origin dated (MONTH) 19, 2007 revealed that the purpose of the policy was to investigate all incidents of unknown origin fully to promote safety for the residents and ensure that no abuse has occurred. Further review of this policy and procedure revealed The charge nurse and/or supervisor must get statements in writing from all staff interviewed. If the origin of the injury is not determined by the initial interviews, the Director of Nursing or designee will interview the staff who was assigned to the resident in the previous 24 hours. Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Review of documentation provided by the facility to the State Agency dated (MONTH) 4, (YEAR) revealed that Resident 8's right wrist was red and warm to touch. Further review of documentation provided by the facility to the State Agency dated (MONTH) 4, (YEAR) revealed that only one witness statement was obtained for the investigation into the injury of unknown origin. The facility failed to implement their policy and procedure for investigation into Resident R8's injury of unknown origin. 28 Pa. Code 201.29(a)(j) Resident Rights 28 Pa. Code 201.29(c) Resident Rights

Based upon review of facility policy and procedure, clinical record review, review of documentation provided by the facility to the State Agency and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of one resident reviewed (Resident 8). Findings include: Review of facility policy and procedure entitled Incidents of Unknown Origin dated (MONTH) 19, 2007 revealed that the purpose of the policy was to investigate all incidents of unknown origin fully to promote safety for the residents and ensure that no abuse has occurred. Further review of this policy and procedure revealed The charge nurse and/or supervisor must get statements in writing from all staff interviewed. If the origin of the injury is not determined by the initial interviews, the Director of Nursing or designee will interview the staff who was assigned to the resident in the previous 24 hours. Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 8's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 15, (YEAR) revealed that Resident 8 had a Brief Interview for Mental Status (BIMS) score of 9 which indicates moderately impaired cognitive ability; required the extensive assistance of one staff member for bed mobility (moving to and from lying position, turning side to side and positioning of body while in bed), transfer (movement between surfaces including to or from bed, chair, wheelchair and standing position); and required the assistance of one staff member for balance during transitions and walking. Review of Resident 8's Quarterly MDS dated (MONTH) 11, (YEAR) revealed that Resident 8 had a BIMS score of 5 which indicates severe cognitive impairment; required the extensive assistance of one staff member for bed mobility and transfer; and required the assistance of one staff member for balance during transitions and walking. Review of documentation provided by the facility to the State Agency dated (MONTH) 4, (YEAR) revealed that Resident 8's right wrist was red and warm to touch. Further review of documentation provided by the facility to the State Agency dated (MONTH) 4, (YEAR) revealed that one witness statement was obtained for the investigation into the injury of unknown origin. Interview with the Director of Nursing on (MONTH) 2, (YEAR) at approximately 11:00 a.m. confirmed that the facility did not conduct a thorough investigation into the injury of unknown origin for Resident 8. 28 Pa. Code 201.29(a)(j) Resident Rights 28 Pa. Code 201.29(c) Resident Rights

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that care plans were developed and updated to reflect the individual needs for three of seventeen residents reviewed (Resident 21, Resident 23 and Resident 315). Findings include: Resident 21's [DIAGNOSES REDACTED]. Review of Resident 21's physician orders [REDACTED]. Review of Resident 21's (MONTH) (YEAR) and (MONTH) (YEAR), Treatment Administration Record (TAR) revealed Resident 21 was receiving oxygen two liters every night. Review of Resident 21's person centered nursing care plan failed to reveal focus, goals or interventions for sleep apnea or use of oxygen. Interview with the Director of Nursing on (MONTH) 1, (YEAR) at approximately 1:30 p.m. confirmed that a comprehensive care plan was not developed for Resident 21's sleep apnea and oxygen use. Review of Resident 23's clinical record revealed Resident 23 was admitted to the facility on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. At the time of admission, Resident 23 was placed on contact isolation precautions related to the active [DIAGNOSES REDACTED]. Review of Resident 23's comprehensive care plan failed to reveal that a care plan was developed for Resident 23's contact isolation precautions until (MONTH) 30, (YEAR) seven days after admission to the facility and the commencement of isolation precautions. Interview with the Director of Nursing on (MONTH) 2, (YEAR) at approximately 10:00 a.m. confirmed that Resident 23 had no comprehensive care plan developed for contact isolation precautions until (MONTH) 30, (YEAR), seven days after admission. Review of Resident 315's clinical record revealed resident was admitted on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 315's (MONTH) (YEAR) physician's orders [REDACTED]. Further review of Resident 315's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident 315's person centered care plan failed to reveal any goal for fluid restriction. Interview with Resident 315 on (MONTH) 30, (YEAR) at approximately 2:12 p.m. confirmed that resident was on fluid restriction. Interview with Licensed Employee E3, on (MONTH) 1, (YEAR) at approximately 11:47 a.m. confirmed that staff did not initiate a care plan for fluid restrictions for Resident 315. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11 (a)(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(3) Nursing services

Based upon observation, it was determined that the facility failed to label and store medications appropriately and failed to discard expired medications in two of five medication carts observed (Fairlee A Medication Cart and Pavilion Medication Cart). Findings include: Observation of the Fairlee A Medication Cart on (MONTH) 31, (YEAR) at approximately 8:08 a.m. revealed one yellow oval pill in an unlabeled medication cup sitting in the top drawer of the medication cart. Observation of the Pavilion Medication Cart on (MONTH) 31, (YEAR) at approximately 8:23 a.m. revealed one bottle of [MEDICATION NAME] (ophthalmic medication used to treat [MEDICAL CONDITION]) eye drops with the following label do not use after 6/30/18. Interview with the Director of Nursing on (MONTH) 2, (YEAR) at approximately 11:45 a.m. confirmed that the above-mentioned medication should not have been placed unlabeled in a medication cup in the top drawer of Fairlee A Medication Cart and the bottle of [MEDICATION NAME] eye drops should have been discarded on (MONTH) 30, (YEAR). 28 Pa. Code 211.9(a)(1)(g)(h) Pharmacy Services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on resident interviews, clinical record reviews, and review of education provided to facility staff, it was determined that the facility failed to properly manage a resident's pain in a timely manner resulting in actual harm to one resident (Resident F6) who continued to experience pain with a [DIAGNOSES REDACTED]. The facility failed to follow physician's orders [REDACTED]. Findings include: Review of education documentation provided to facility staff titled, Pain Scale, revealed that the pain scale for mild pain is levels 1-3; the pain scale for moderate pain is levels 4-6 and the pain scale for severe pain is 7-10. Further review of this education documentation revealed physician's orders [REDACTED]. Review of Resident F6's annual Minimum Data Set assessment (MDS- assessment of care needs) dated March 3, 2017, identified the resident's BIMS (Brief Interview of Mental Status) as a score of 15 out 15 which indicated that the resident was cognitively intact. Further review of the resident MDS assessment revealed that the resident was identified as requiring limited assistance of one person for ambulation and transferring. An interview conducted with Resident F6 on August 30, 2017, at approximately 8:30 a.m. revealed that the resident sustained [REDACTED]. Further interview with the resident revealed that the resident stated, she was in pain for about a week until the facility discovered the pelvic fracture. The resident further stated, they just kept giving me Tylenol for the pain, but it was ineffective. Review of Resident F6's clinical record revealed a nursing note dated April 19, 2017, that stated, At 4:45 p.m. resident was heard calling for help from her room. Nurse went to resident room and upon arrival observed resident in a supine (lying face up) position on the floor by her bed with her (wheelchair) by her side .(complained of) pain rate of 3/10 to (right) hip .Resident was given 2 tabs (tablets) of Tylenol at 9:30 a.m. Further review of Resident F6's nursing notes revealed a note on April 20, 2017, at 10:51 a.m. that stated the resident complained of, left hip pain while seated in wheelchair this AM (morning ) .Resident experiencing increased pain with weight bearing to (left lower extremity) .New order to obtain total left hip and pelvic x-ray. Review of Resident F6's radiology report from April 20, 2017, at 2:45 p.m. revealed no injury. Review of Resident F6's nursing progress notes revealed a note on April 20, 2017, stating, At 5 pm resident was observed on the floor in a supine position. Further review of the nursing progress notes revealed a note on April 21, 2017, at 11:20 a.m. stating, Resident did not want to get out of bed for breakfast .grimaced when nurse put (head of bed) up. She then said she had pain radiating from back left hip/pelvic area to front area of left hip/pelvic. Tylenol given for pain (4 out of 10). Another nursing progress note on April 21, 2017, at 8:17 p.m. stated that the resident complained of, mild pain to (left) leg. Review of Resident F6's physician's orders [REDACTED]. The pain medication was marked with an I for ineffective on both April 20, 2017, and April 22, 2017. There was no documented evidence that the physician was notified of the resident's pain that was rated higher than a 3 on April 20, April 21, or April 22, 2017, or that the Tylenol was ineffective on April 20 and 22, 2017. Review of Resident F6's nursing progress notes revealed a note on April 22, 2017, that stated that at 11:00 p.m., staff heard resident hollering from help from the hallway. Rushed into resident's room to find resident's upper body lying on the bed with her knees resting on the floor. Further review of Resident F6's nursing notes revealed a note on April 24, 2017, at 2:20 p.m. stating that the resident, did not want to get out of bed in the (morning.) Did sit on side of bed for meals. She was given Tylenol for pain left side hip area. She said she could not stand due to weakness .(doctor) will be in tomorrow to see resident. Review of Resident F6's physician's notes revealed a note from April 25, 2017, in which the physician stated that, if pain persists repeat x-ray. There was no documented evidence that the resident's pain medication was evaluated at the time. Further review of Resident F6's nursing notes revealed a note from April 26, 2017, which stated, Resident is having pain and weakness in (left lower extremity) since her fall last week .(physician) ordered x-ray to (left) hip and (left) pelvic to (rule out) fracture. Review of the radiology report from April 28, 2017, at 2:53 p.m. revealed the resident had a nondisplaced [MEDICAL CONDITION] pubic ring (a bone in the pelvis - the large bony structure near the base of the spine to which the legs connect). The facility failed to properly manage a resident's pain in a timely manner resulting in actual harm to one resident (Resident F6) who continued to experience pain with a [DIAGNOSES REDACTED]. Further review of Resident F6's physician's orders [REDACTED]. Review of Resident F6's clinical record revealed a Medication Administration Record [REDACTED]. On May 17, 2017 at 9:28 p.m. the resident received [MEDICATION NAME] for a pain level of 3. There was no evidence that the facility communicated to the physician the resident's level of pain of 3 to ensure that a pain medication appropriate for the level of pain the resident was experiencing was ordered. Review of Resident A6's April and May 2017 physician's orders [REDACTED]. Review of Resident A6's April 2017 Medication Administration Record [REDACTED]. Review of Resident A6's clinical nursing notes failed to reveal any physician notification that Resident A6's pain levels were beyond the parameters as set forth in the physician orders [REDACTED]. Review of Resident A6's May 2017 MAR indicated [REDACTED]. Review of Resident A7's August 2017 physician's orders [REDACTED]. Review of Resident A7's August 2017 MAR indicated [REDACTED]. Review of Resident A7's clinical nursing notes failed to reveal a clinical indication of why Resident A7 received [MEDICATION NAME] 50 mg for a pain level of 0 (zero). Review of Resident B3's physician's orders [REDACTED]. There was no pain scale with this physician's orders [REDACTED]. [REDACTED]. Review of Resident B3's clinical record revealed no evidence that the facility contacted Resident B3's physician to obtain the pain scale parameters for [MEDICATION NAME]. Review of Resident B3's June 2017 Medication Administration Record [REDACTED]. Review of Resident B3's July 2017 Medication Administration Record [REDACTED]. There was no pain scale documented in the month of July. Review of Resident B3's August 2017 Medication Administration Record [REDACTED]. Further review of Resident B3's August 2017 Medication Administration Record [REDACTED]. On August 9, 2017, the resident received Tylenol for a pain level of 6. On August 13, 2017, the resident received Tylenol for a pain level of 8. On August 24, 2017, the resident received Tylenol for a pain level of 8. On August 27, 2017, the resident received Tylenol for a pain level of 5. Review of Resident J6's July 2017 and August 2017 physician's orders [REDACTED]. Review of Resident J6's August 2017 Medication Administration Record [REDACTED]. Review of Resident J6's clinical nursing notes failed to reveal that the physician was notified of Resident J6's pain level of 8 which was beyond the parameters set forth in the physician's orders [REDACTED].>Further review of Resident J6's August 2017 MAR indicated [REDACTED]. Review of Resident CL1's physician's orders [REDACTED]. Review of Resident CL1's May 2017 Medication Administration Record [REDACTED]. Review of Resident CL1's nursing notes revealed a nursing on dated May 29, 2017, at 2:57 p.m. which stated that the resident, Told (the nurse) he was constipated so 2 PM [MEDICATION NAME] was held. Review of Resident CL1's clinical record revealed no indication that the physician was notified that the [MEDICATION NAME] was not given per the physician's orders [REDACTED]. Interview with the Director of Nursing on August 31, 2017, at approximately 12:15 p.m. confirmed that the [MEDICATION NAME] was not given per the physician's orders [REDACTED]. Further review of Resident CL1's physician's orders [REDACTED]. Review of Resident CL1's May 2017 Medication Administration Record [REDACTED]. Further review of Resident CL1's nurses notes revealed a note dated May 29, 2017 that the resident, requested and was given 'strongest pain med' this (morning) before therapy. Further review of Resident CL1's May 2017 Medication Administration Record [REDACTED]. The May 29, 2017, administration of [MEDICATION NAME] 5mg for a pain level rated as 1 was the medication that was given prior to therapy as requested by the resident. Further review of Resident CL1's physician's orders [REDACTED]. The facility failed to contact the physician to obtain an order for [REDACTED]. Further review of Resident CL1's June 2017 Medication Administration Record [REDACTED]. The facility failed to ensure that Resident CL1 was adminsitered the appropriate dosage of pain medication in accordance with the resident pain level. Review of Resident CL2's May 2017 physician's orders [REDACTED]. Review of Resident CL2's May 2017 MAR indicated [REDACTED]. Further review of Resident CL2's May 2017 MAR indicated [REDACTED]. The above mentioned findings were discussed with the Nursing Home Administrator and Director of Nursing on August 31, 2017, at approximately 12:15 pm. 42 CFR 483.24, 483.25(k) Provide Care/Services for Highest Well Being Previously cited 09/07/16 28 Pa. Code 211.5(f) Clinical records Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(d)(3) Nursing servicesPreviously cited 07/27/15

Based on clinical record reviews, review of facility documentation and review of facility policies and procedures, it was determined that the facility failed to ensure that interventions to prevent falls were developed for two of 15 residents reviewed (Resident G6 and Resident F6) which resulted in actual harm to Resident G6, whom sustained a fracture of the left proximal fibula, and failed to provide supervision and implement safety interventions for one of fifteen residents reviewed (Resident G4). Findings include: Review of facility policy and procedure titled, Fall Management Program, revised September 2012, revealed the Fall Management Program develops, implements and maintains plans to manage a safe environment for residents through the following: assess residents for fall risk on admission, quarterly and as needed to identify fall preventative interventions. Further review of this policy and procedure revealed that the committee reviews fall incidents daily, evaluates fall circumstances, implements interventions to decrease chance of fall and injuries associated with falls and communicates these to the staff through the care plan and assesses the effectiveness on an on-going basis. Resident G6 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident G6's [DIAGNOSES REDACTED]. Review of Resident G6's admission Minimum Data Set assessment (MDS - periodic assessment of a resident's needs) dated March 19, 2017, revealed that Resident G6 required the extensive assistance of one person to ambulate in the corridor and the extensive assistance of two persons for transfer from a sitting position to a standing position. Further review of Resident G6's admission MDS revealed that Resident G6 had an impairment in the lower extremity with regard to functional limitation in range of motion. Review of the facility's Fall Evaluation form revealed that a score of greater than 9 indicated that a resident was at high risk for falls. Resident G6's Fall Evaluation dated March 9, 2017, revealed a score of 14. Review of facility documentation dated April 2, 2017, at 11:50 a.m. revealed that on April 2, 2017, Resident G6 sustained a fall in the corridor while ambulating with a rolling walker and contact guard by a nursing assistant. Review of facility documentation dated May 14, 2017, revealed that on May 14, 2017, at 8:19 a.m. Resident G6 sustained another fall while ambulating in the hallway with a nursing assistant. Review of nursing notes dated May 16, 2017, revealed that Resident G6 was complaining of pain in the left lower leg. Further review of nursing progress notes dated May 16, 2017, revealed that an X-ray of the left lower leg was ordered by Resident G6's physician. Review of nursing progress notes dated May 17, 2017, revealed that the X-ray of the left lower leg revealed that Resident G6 sustained a fracture of the left proximal fibula (bone in the lower leg). Review of Resident G6's plan of care between April 2, 2017, and May 14, 2017, failed to reveal that interventions were developed and implemented to prevent falls and injury to Resident G6 following the resident fall incident on April 2, 2017. Review of Resident G6's active plan of care initiated May 15, 2017, failed to reveal any fall interventions developed to prevent further falls and injury to Resident G6. Interview with the Nursing Home Administrator and the Director of Nursing on August 31, 2017, at approximately 12:15 p.m. confirmed that fall interventions were not revised and/or updated after Resident G6's fall on April 2, 2017, and prior to the fall on May 14, 2017, which resulted in actual harm to Resident G6 whom sustained two falls and a fracture of the left proximal fibula. Review of Resident F6's annual MDS assessment dated [DATE], identified the resident's BIMS (Brief Interview of Mental Status) as a score of 15 out 15 which indicated that the resident was cognitively intact. Further review of the resident MDS assessment revealed that the resident was identified as requiring limited assistance of one person for ambulation and transferring. Review of Resident F6's nursing notes revealed a progress note dated April 19, 2017, stated, At 4:45 p.m. resident was heard calling for help from her room. Nurse went in to resident room and upon arrival observed resident in supine (lying face up) position on the floor by her bed with her (wheelchair) on her side .Resident stated she was getting out of bed to (wheelchair) but forgot to lock the breaks and the (wheelchair) moved resulting (in) her fall .Re-educated resident to use call bell for assistance. Further review of Resident F6's nursing notes revealed a progress note dated April 20, 2017, stated, At 5:00 p.m resident was observed on the floor in a supine position with pants down to her ankles. The resident stated, I was trying to move close to my dinner tray and flipped out of the chair. Further review of Resident F6's nursing progress notes revealed a progress note dated April 22, 2017, stated, At (11:00 p.m.) staff heard resident hollering for help .Rushed into resident's room to find resident's upper body lying on the bed with her knees resting on the floor. Resident states she tried to transfer to the wheelchair to go turn out the light when her left knee gave out and her legs slid to the floor .Placed call bell in reach and instructed resident to call staff for assist. Resident F6's sustained three falls in four days period during the 3-11 shift. The facility failed to properly supervise and monitor Resident F6 during the evening shift to ensure the resident's safety. The above findings were discussed with the Nursing Home Administrator and the Director of Nursing on August 31, 2017, at approximately 12:15 p.m. Review of Resident G4's clinical record revealed the resident had a [DIAGNOSES REDACTED].) Review of Resident G4's Admission MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired. Review of Resident G4's Quarterly MDS assessment dated [DATE], revealed that the resident was a limited assist of one person for ambulation off the unit. Review of Resident G4's progress notes revealed a nursing note dated March 31, 2017, that stated, Wanderguard (bracelet designed to prevent persons at risk from leaving a facility unless they are accompanied) placed on right ankle of resident to prevent resident from wandering out of facility due to dementia. Review of information submitted by the facility on July 11, 2017 revealed that on July 10, 2017, at 3:08 p.m. Resident G4 was returning from an activity and exited the front door of the building. The resident's wanderguard set off the alarm and, a staff member cleared the alarm without checking for a resident. Further review of information submitted by the facility revealed that the resident was brought back to the facility at 3:30 p.m. by two visitors. Interview with the Nursing Home Administrator and the Director of Nursing on August 31, 2017, at approximately 12:15 p.m. confirmed that the staff member should not have cleared the alarm without checking for a resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 07/27/15 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.11(a)(d) Resident care plan Previously cited 07/27/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 09/07/16, 07/27/15

Based on clinical record review and review of facility documentation, it was determined that the facility failed to develop, review, revise and/or implement resident care plans for thirteen out of 15 residents reviewed (Resident A6, Resident A7, Resident B3, Resident C1, Resident C2, Resident C9, Resident F2, Resident F3, Resident F6, Resident F9, Resident G6, Resident J6, Resident CL1). Findings include: Review of Resident A6's [DIAGNOSES REDACTED]. Review of Resident A6's quarterly Minimum Data Set assessment (MDS - periodic assessment of a resident's needs) dated June 23, 2017, revealed that Resident A6 had occasional pain; was occasionally incontinent of bowel and bladder; and required extensive assistance of one staff member for activities of daily living including hygiene, bathing, dressing and bed mobility. Review of Resident A6's active plan of care failed to reveal that care plans were developed and interventions implemented for pain, incontinence of bowel and bladder, and activities of daily living. Review of Resident A6's August 2017 physician's orders [REDACTED]. Review of Resident A6's active plan of care failed to reveal that a care plan with interventions and side effects was developed to provide care specifically related to the administration of [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident A7's [DIAGNOSES REDACTED]. Review of Resident A7's annual MDS dated [DATE], revealed that Resident A7 was frequently incontinent of bladder and at risk for pressure ulcers. Further review of the MDS revealed that the Care Area Assessment Summary (CAAs) indicated that the care areas of urinary incontinence, falls and pressure ulcers were care areas triggered to be addressed in the resident's care plan. Review of Resident A7's August 2017 physician's orders [REDACTED]. Review of Resident A7's active plan of care failed to reveal that care plans with interventions for urinary incontinence, falls and pressure ulcers were developed and failed to reveal a care plans with interventions and side effects was developed to provide care specifically related to the administration of [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident B3's [DIAGNOSES REDACTED]. Review of Resident B3's annual MDS dated [DATE], revealed that the resident had occasional pain. Further review of the MDS revealed in the Care Area Assessment Summary (CAAs) that pain was a care area that was triggered and indicated that care area would be addressed in the care plan. Review of Resident B3's active plan of care failed to reveal that a care plan was developed with interventions implemented for pain. Review of Resident C1's physician's orders [REDACTED]. Review of Resident C1's progress notes revealed the resident received [MEDICATION NAME] 10 mg on August 3, 2017, and August 4, 2017, for the hiccups and it was effective both times. Review of Resident C1's active care plan revealed that a care plan for hiccups was not started until August 29, 2017, 26 days after the medication was prescribed and first administered. Further review of Resident C1's care plan revealed no care plan addressing potential side effects from the antipsychotic medication [MEDICATION NAME]. Review of Resident C2's annual MDS dated [DATE], revealed that the resident was at risk for developing pressure ulcers. Further review of the MDS revealed in the Care Area Assessment Summary (CAAs) that pressure ulcers was a care area that was triggered and indicated that care area would be addressed in the care plan. Review of Resident C2's active plan of care failed to reveal that a care plan for the prevention of pressure ulcers development. Review of Resident C9's [DIAGNOSES REDACTED]. Review of Resident C9's MDS dated [DATE], revealed that Resident C9 was occasionally incontinent of bowel and was at risk for developing pressure ulcers. Review of Resident C9's August 2017 physician's orders [REDACTED]. Review of Resident C9's active plan of care failed to reveal care plans with interventions developed for bowel incontinence and the prevention of pressure ulcers. Further review of Resident C9's active plan of care failed to reveal a care plan with interventions and side effects was developed to provide care specifically related to the administration of [MEDICATION NAME]. Review of Resident F2's [DIAGNOSES REDACTED]. optic nerve and vision loss). Review of Resident F2's annual MDS assessment (MDS - periodic assessment of a resident's needs) dated April 21, 2017, revealed that Resident F2 was occasionally incontinent of bowel and bladder and was at risk for the development of pressure ulcers. Review of Resident F2's active plan of care failed to reveal that care plans were developed and interventions implemented for incontinence of bowel and bladder, and for the prevention of the development of pressure ulcers. Review of Resident F3's [DIAGNOSES REDACTED]., behavior, feelings, and sense of well-being). Review of Resident F3's annual MDS assessment dated [DATE], revealed that Resident F3 was occasionally incontinent of bladder; and was at risk for the development of pressure ulcers and at risk for falls and receiving anti-depressant medication. Review of Resident F3's active plan of care failed to reveal that care plans were developed and interventions implemented for incontinence of bladder, and for the prevention of the development of pressure ulcers, the prevention of falls and for the interventions and side effects of a resident on anti-depression medications. Review of Resident F6's quarterly MDS assessment dated [DATE], revealed that the resident had a history of [REDACTED]. Review of Resident F6's clinical record revealed that the resident fell while transferring from the bed to the wheelchair on April 19, 2017, at 4:45 p.m. Further review of Resident F6's nursing progress notes revealed that on April 20, 2017, at 5:00 p.m. the resident fell out of her wheelchair in her room. Further review of Resident F6's nursing notes revealed that on April 22, 2017, at 11:00 p.m. the resident fell out of bed while trying to transfer to the wheelchair. Review of Resident F6's active plan of care for falls revealed an intervention added on April 21, 2017, after the falls on April 19 and April 20, 2017, which stated, offer assistance and check in with her (frequently) so that she doesn't have to reach for things. Offer to assist with transfers and walking. Further review of Resident F6's active plan of care for falls revealed an intervention added on April 24, 2017, following the fall on April 22, 2017, stated Frequent checks to observe for any unsafe behaviors or transfers. Encourage (Resident F6) to ring for assistance even though she prefers to be independent and do it on her own. Resident F6's care plan and lack of new interventions following the resident fall incidents of April 19, 2017, and April 20, 2017, were discussed with the Nursing Home Administrator and Director of Nursing on August 31, 201,7 at 12:15 pm. Review of Resident F9's [DIAGNOSES REDACTED]. machine is required to filter a patient's blood). Review of Resident F9's annual MDS assessment dated [DATE], revealed that Resident F9 was occasionally incontinent of bowel and bladder and was at risk for the development of pressure ulcers. The resident also required extensive assistance of two staff members for the activities of daily living including hygiene, bathing, dressing and bed mobility. Review of Resident F9's active plan of care failed to reveal that care plans were developed and interventions implemented for incontinence of bowel and bladder, and for the prevention of the development of pressure ulcers, falls and activities of daily living. Review of Resident G6's [DIAGNOSES REDACTED]. Review of Resident G6's quarterly MDS assessment dated [DATE], revealed that Resident G6 was frequently incontinent of bladder, had a history of [REDACTED]. Review of Resident G6's August 2017 physician's orders [REDACTED]. Review of Resident G6's active plan of care failed to reveal that care plans with interventions were developed for bladder incontinence, falls prevention and pressure ulcer development. Further review of Resident G6's active plan of care failed to reveal a care plan with interventions and side effects was developed to provide care specifically related to the administration of [MEDICATION NAME]. Resident J6 was admitted to the facility on [DATE], at approximately 6:00 p.m. with [DIAGNOSES REDACTED]. Review of Resident J6's nursing notes dated July 25, 2017, at 8:11 a.m. revealed that on July 25, 2017, at approximately 4:30 a.m. Resident J6 was observed attempting to climb out of bed. Further review of Resident J6's nursing note revealed that at approximately 4:45 a.m. Resident J6 was found lying on the floor of the resident's room next to the bed. Review of Resident J6's admission MDS assessment dated [DATE], revealed CAAs with indications that care plans were to be developed for bladder incontinence, falls and nutrition. Review of Resident J6's active plan of care failed to reveal that care plans were developed and implemented for bladder incontinence and nutrition. Further review of Resident J6's active plan of care revealed that a care plan with interventions addressing Resident J6's fall risk was not developed until July 29, 2017, five days after admission and four days after Resident J6 sustained a fall out of bed. Review of Resident CL1's Admission MDS assessment dated [DATE], revealed in the Care Area Assessment Summary (CAAs) that activities of daily living (ADLs) including urinary incontinence and pressure ulcers were care areas that were triggered and indicated that those care areas would be addressed in the care plan. Review of Resident CL1's entire plan of care failed to reveal care plans for activities of daily living, urinary incontinence, or pressure ulcers. The facility failed to ensure that care plans were developed, reviewed, revised and/or implemented for Resident A6, Resident A7, Resident B3, Resident C1, Resident C2, Resident C9, Resident F2, Resident F3, Resident F6, Resident F9, Resident G6, Resident J6, Resident CL1. 42 CFR 483.21(b)(1) Develop Comprehensive Care Plans Previously cited 07/27/17 28 Pa. Code 211.5(f) Clinical records Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.11(d) Resident care plan Previously cited 07/27/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 09/07/16, 07/27/15

Based on review of facility policy and clinical record review, it was determined that the facility failed to thoroughly investigate injuries for two of 15 residents reviewed (Resident B3 and Resident F6). Findings include: Review of the facility policy, Incidents of Unknown Origin, dated November 19, 2007, revealed that when injuries such as bruises are discovered, an incident report is to be completed, staff is to be interviewed with written statements obtained, and the resident is to be interviewed if able. Once all statements are obtained, the interdisciplinary team will review the statements and incident report to determine root cause. Review of Resident B3's progress notes revealed that on June 14, 2017, the resident complained of increased pain to the right knee. The right knee was noted to be warm, red, and swollen. The resident was sent to an urgent care center for evaluation. Review of Resident B3's consultation report from the urgent care center revealed the resident was diagnosed as having a hematoma (bruise) to the right knee. Interview with the Nursing Home Administrator and the Director of Nursing on August 31, 2017, at 11:23 a.m. confirmed that there was no investigation completed for Resident B3's right knee bruise. Review of Resident F6's clinical record revealed that the resident fell while transferring from the bed to the wheelchair on April 19, 2017, at 4:45 p. m. Review of Resident F6's nursing notes revealed that on April 20, 2017, the resident complained of, left hip pain while seated in wheelchair and increased pain with weight bearing to (left lower extremity) (left leg). The resident was sent out for an X-ray on April 20, 2017, at 2:45 p.m. which was negative for any fracture. Further review of Resident F6's nursing notes revealed that on April 20, 2017, at 5:00 p.m. the resident fell out of her wheelchair in the resident's room. Further review of Resident F6's nursing notes revealed that on April 22, 2017, at 11:00 p.m. the resident fell out of bed while trying to transfer to the wheelchair. The resident continued to complain of pain until a second X-ray was ordered and obtained on April 28, 2017 (six days since the last fall) and revealed that the resident was positive for a left pelvic fracture. Interview with the Nursing Home Administrator and Director of Nursing on August 31, 2017, at 12:15 p.m. confirmed that there was no investigation done to determine the cause of Resident F6's pelvic fracture. The facility failed to conduct a thorough nvestigation of the cause contributing to Resident F6's left pelvic fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 07/27/15 28 Pa. Code 211.5(f) Clinical records Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 09/07/16, 07/27/15

Based upon review of facility policy and clinical record review, it was determined that the facility failed to ensure that care and services were provided to restore optimal bowel control for one of fifteen residents reviewed (Resident A7). Findings include: Review of facility policy and procedure titled, Continence Management Policy, updated February 15, 2017, revealed the purpose of the policy is to promote optimal urinary and fecal elimination for the resident, which promotes dignity, maintains self-esteem and feelings of self-worth. Further review of this policy and procedure revealed that a plan of care will be developed after determining whether a toileting program would be beneficial for the resident and reduce episodes of incontinence. A care plan will be developed when appropriate to identify resident's need for a toileting schedule based on their physical and cognitive abilities. The plan of care is reviewed quarterly and with significant changes to identify the need to update and/or change the plan of care regarding a resident's elimination needs. Review of Resident A7's quarterly Minimum Data Set assessment (MDS - periodic assessment of a resident needs) dated March 24, 2017, revealed that Resident A7 was always continent of bowel function. Review of Resident A7's annual MDS dated [DATE], revealed that Resident A7 was frequently incontinent of bowel function. Review of Resident A7's clinical record failed to reveal that an assessment was completed of Resident A7's bowel function to determine whether a toileting program would be beneficial to the resident and to determine if episodes of incontinence could be reduced. Further review of Resident A7's clinical record failed to reveal that a bowel training program was attempted with regard to Resident A7's bowel incontinence. Review of Resident A7's active plan of care failed to reveal an active plan of care with interventions specifically relating to Resident A7's bowel incontinence. Interview with the Nursing Home Administrator and the Director of Nursing on August 31, 2017, at approximately 12:15 p.m. confirmed that no bowel training program was implemented and/or attempted to reduce Resident A7's bowel incontinence. The facilty failed to ensure that Resident A7 received the necessary care and services to maintain bowel function. 28 Pa. Code 211.5(f) Clinical records Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.11(d) Resident care plan Previously cited 07/27/15 28 Pa. Code 211.12(c)(d)(1)(5) Nursing servicesPreviously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(d)(3) Nursing servicesPreviously cited 07/27/15

Based on clinical record review and staff interview, it was determined the facility failed to ensure that physician visits were timely for one of 15 residents reviewed (Resident F2). Findings include: Review of Resident F2's physician notes revealed that the resident was seen by the physician on December 31, 2016, There was no documented evidence that the resident was seen by the physician 60 days after December 31, 2016 as required. The next documented visit by the physcian was on April 5, 2017, for a total of 95 days without a physcian visit. Interview with the Director of Nursing on August 29, 2017, at 12:15 p.m. confirmed that Resident F2 was not seen by the physician in the time indicated above. The facility failed to ensure that Resident F2 was seen by the physician at least every 60 days as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 07/27/15 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.5(f) Clinical records Previously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(c) Nursing servicesPreviously cited 09/07/16, 07/27/15 28 Pa. Code 211.12(d)(3) Nursing servicesPreviously cited 07/27/15