Every finding on record at Willowbrooke Court-Granite

Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide appropriate staff supervision resulting in a fall for one of the nine residents reviewed (Resident 161). Findings include: A review of Resident 161's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 5, 2023, revealed resident was cognitively impaired. The same MDS revealed resident required extensive with two people assistance with transferring. Review of the resident's ADL (activities of daily living) care plan revealed an intervention as follows: Transfer-require extensive assistance by two staff to move between surfaces. Review of the nursing progress notes dated February 8, 2023, revealed the resident's leg buckled and was lowered to the floor during transfer. Review of the facility's documentation, Incident Report dated February 8, 2023, revealed that at 4:40 p.m., Nursing Assistant (NA) reported to the nurse that while assisting the resident off the toilet, the resident's legs buckled and were lowered to the floor. NA's statement dated February 8, 2023, revealed that at around 4:00 p.m., the resident was assisted to go to the toilet, when it was time to get him up, the resident stood up again, but his/her legs gave out and he/she was lowered to the floor. The nurse was called and together assisted the resident back to the chair. No injury was sustained. The care plan was updated on February 9, 2023, to use a total lift for transferring with two staff assistants. An interview with the Nursing Home Administrator on May 11, 2023, at 11:00 a.m., confirmed that the facility failed to provide appropriate supervision of a two-person staff for Resident 161 during a transfer resulting in a fall. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22

Based on clinical record review and interviews with staff the facility failed to follow physician orders for one of 24 residents (R1). Findings include: Observations during the initial environmental tour, on May 8, 2023, revealed that Resident R1 was using oxygen provided through a concentrator. The nasal canula was attached to a canister of water dated April 10, 2023. The tubing for the nasal canula was not dated. An interview with the Nursing Home Administrator(NHA) revealed that the canister and tubing is changed monthly per the facility policy. Review of Resident R1's clinical record revealed a physician's order dated June 10, 2022, states to change O2 tubing one time a day every Friday. An interview with the NHA on May 11, 2023, agreed that the facility was not following the physicians order. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a wound treatment medication order was available for one of the 13 residents reviewed (Resident 159). Finding Include: Review of the facility's policy titled Pharmacy Services revealed, that the pharmacy ensures the provision of pharmaceutical services in an accurate, effective, and safe manner. Also, to provide routine and emergency medications and supplies to meet the needs of each resident following state and federal guidelines. Review of Resident 159's physician order sheet revealed an order on May 2, 2023, for A Dakin's solution to sacral wound, wet to dry cover with dressing daily. Review of the nursing progress notes dated May 3, 2023, at 11:32 a.m., revealed Dakin's not on hand, physician was made aware. Review of the nursing progress notes dated May 5, 2023, at 8:10 a.m., revealed Dakin's solution was not available from the pharmacy, will follow up. Review of the May 2023, Treatment Administration Record (TAR) revealed the ordered Dakin's solution treatment to the resident's sacral wound was not done from May 3, 2023, until May 8, 2023. Review of the pharmacy records revealed that Dakin's solution ordered on May 2, 2023, was not delivered to the facility until May 8, 2023. Interview with the Nursing Home Administration conducted on May 11, 2023, at 11:00 a.m., confirmed the Dakin's solution treatment to the resident sacral wound was not followed due to the unavailability of the medication. The facility failed to ensure medication for wound treatment to Resident 159 sacral wound was available. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22

Based on clinical record review and staff interview it was determined the facility failed to complete laboratory studies as ordered by the physician for one of one residents reviewed. (Resident 43) Findings Include: Review of Resident 43's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was asked to provide the results of the PT/INR test but were unable to produce evidence the test was completed. Interview with the physician who ordered the laboratory study on June 24, 2022 at 1:00 p.m. confirmed after checking with the laboratory that the study had not been completed as ordered. 20 Pa Code 211.2 Physician services 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to follow a physician's order regarding medication administration for two of 14 residents reviewed (Resident 22, and 44). Findings include: Review of Resident 22's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 22's Physician's Order (POS) dated May 2, 2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The same order had administration parameter order to hold the medications for SBP (systolic blood pressure) less than 110. Review of Resident 22's May 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator (NHA)was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 22's blood pressure was checked before administration of [MEDICATION(S)]. The NHA confirmed the lack of documented evidence that Resident 22's physician's order to administer [MEDICATION(S)] with blood pressure parameter was followed. Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 36's POS revealed an order on June 4, 2022, for [MEDICATION(S)] (medication used to treat and prevent blood clots and prevent stroke) tablet 5 mg, give one tablet by mouth two times a day for DVT (Deep Vein [CONDITION(S)]) prophylaxis. Review of Resident 36's June 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator on June 24, 2022, at 10:00 a.m., was conducted. The NHA was unable to provide explanation as to why Resident 36's [MEDICATION(S)] was not administered on the dates mentioned above. Review of Resident 36's POS revealed an order on May 25, 2022, for a [MEDICATION(S)] tablet (medication to treat a kind of low blood pressure that causes severe dizziness and [CONDITION(S)]) 2.5 mg. Give one tablet by mouth in the morning for [CONDITION(S)] (low blood pressure) and hold for SBP (Systolic Blood Pressure) greater than 140. Review of Resident 36's May 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 36's blood pressure was checked prior to the administration of [MEDICATION(S)]. The NHA confirmed that there was no documented evidence that Resident 36's physician's order to administer [MEDICATION(S)] with blood pressure parameter was followed. The facility failed to follow the physician's medications order for Resident 22, and 36. 28 Pa. Code 211.5(f) Clinical records Previously cited 5/27/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/27/21

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 14 residents reviewed (Resident 22). Findings include: Review of the facility's policy titled Incident Reporting/Injury Investigation Residents and Visitors, undated, revealed all staff shall be responsible for promptly reporting all injuries/incidents to the charge nurse on duty. Upon receipt of a report of incident/injury, the charge nurse or supervisor shall immediately evaluate the resident, provide any needed intervention, and complete all areas of the Incident Investigation Form. The same policy indicated that if the incident is of unknown etiology and further investigation is needed for any incident including unwitnessed falls, staff on the three shifts over the 24 hours preceding the incident will be interviewed and will complete written statements concerning their observation of the incident. Review of Resident 22's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 22's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 4, 2022, revealed resident had severe cognitive impairment. Review of the progress notes dated May 24, 2022, revealed Resident 22 was with confusion and need redirecting at the time. The same note revealed resident was able to self-propel a wheelchair and required moderate assistance with ADLs (activity of daily living). Observation conducted on June 22, 2022, at 11:00 a.m., revealed Resident 22 with a bruise on his/her right forearm, close observation of the bruise revealed the bruise was above the wrist to forearm, dark purple in the inner part of the arm extending to the outer part of the arm. Interview with licensed nurse, Employee E3 conducted on June 22, 2022, at 11:10 a.m., Employee E3 reported that she/he was not a regular employee of the facility but was familiar with Resident 22's care. Employee E3 reported that she/he worked on the morning of June 21, 2022, and observed Resident 22's bruise on the right arm but does not know how it happened. Employee 3 looked at the resident's bruise, left then came back to inform the surveyor that she was informed by other staff that the resident had a fall over the weekend. Observation conducted on June 24, 2022, at 10:30 a.m., with the presence of licensed nurse Employee E4. Resident 22's right arm bruise was measured by Employee E4 and revealed 12 x 11 cm (centimeter) in size, the color remained dark purple from the inner arm extending to the outer arm. Interview with licensed Employee 4 conducted on June 24, 2022, at 10:30 a.m., revealed no knowledge of the bruise and its origin. Interview with the Director of Nursing (DON) on June 24, 2022, at 11:00 a.m., was conducted. The facility failed to provide documented evidence the bruise on Resident 22's right arm was investigated upon discovery. The DON confirmed that Resident 22's right arm bruise was not investigated. The facility failed to investigate Resident 22's right arm bruise. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/27/21 28 Pa. Code 211.5(f) Clinical records Previously cited 5/27/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/27/21 28 Pa. Code 211.10(c) Resident care policies

Based on clinical record review, staff interview and policy and procedure review it as determined the facility failed to notify the physician of a change in resident's status for one of 24 residents reviewed. (Resident 43) Findings Include: Review of facility policy and procedure titled Physician Notification, revised June 2014, revealed the licensed nurse is responsible for notifying the resident's physician at a minimum when there is: a significant change in the resident's physical, mental or psychosocial status. A need to significantly alter treatment. A decision to transfer or discharge the resident from the community. Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident. Review of resident 43's progress notes revealed a nursing entry dated May 27, 2022 at 7:41 a.m. stating resident noted with slight nose bleed. MD (Medical Doctor) was notified and ordered to hold [MEDICATION(S)] (blood thinner) tonight and to continue with weekly labs for PT/INR (blood test to determine the effectiveness of [MEDICATION(S)]). Review of progress note dated May 28, 2022 at 11:51 a.m. stated at 9:00 a.m. CNA (certified nurse aide) summoned this nurse to the resident's room, arrived to find resident with active nose bleed. Resident stated it started as soon as he got out of bed. MD gave order to hold todays [MEDICATION(S)] (blood thinner) and to hold tonight's [MEDICATION(S)] dose and obtain a stat PT/INR in a.m. and call MD with results. Further review of the resident clinical record including Progress Notes revealed a nursing entry on May 28, 2022 at 8:39 p.m. stating resident had a nose bleed after dinner this evening. This nurse used a tampon to help with stopping bleeding and it worked. Review of the clinical record revealed the PT/INR (blood test to determine the effectiveness of [MEDICATION(S)] a blood thinner) was completed on May 29, 2022 and was a high result of 30.8/3.34 indicating the resident blood is too thin. A progress note dated May 29, 2022 at 10:13 revealed the MD was notified and they were awaiting a call back. Review of resident's Progress note dated May 29, 2022 at 11:57 p.m. stated, resident complained of right leg and thigh pain. Will pass on to oncoming nurse to follow-up with complaint in the morning. Review of progress notes dated May 30, 2022 at 7:19 a.m. revealed the resident complained of pain of right thigh. Repositioning in bed did not relieve pain. Message left for on call clinician regarding pain. Oncoming shift made aware to follow up. Review of progress notes dated May 30, 2022 at 3:15 p.m. revealed the resident complained of right thigh/buttock pain. As needed Tylenol was administered due to pain intolerance. This note made no mention of talking to a physician. Review of progress notes dated May 30, 2022 at 7:38 p.m. revealed the resident's daughter came to the nursing station saying Resident 43's leg pain had increased. The pain was now in the right groin. Resident stated the pain was a 10 on the pain scale (most intense pain), and was unable to straighten his leg. Daughter and resident informed that resident should be evaluated in the ER and resident agreed. Resident sent via EMT at 6:30 p.m. Review of progress note dated May 31, 2022 at 1:43 a.m. stated off going nurse informed this nurse that resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator on June 24, 2022 at approximately 11:00 a.m. confirmed there was documented evidence the resident physician had never been notified after Resident 43 had the second nosebleed or with the elevated PT/INR result obtained on May 29th, 2022 or when the resident developed leg pain unrelieved by medications. 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 observations, review of facility policy and procedure, and staff interview it was determined the facility failed to label and date opened containers of food products in the main kitchen. Findings include: A review of the facility policy and procedure titled Date Markings Ready-To-Eat Foods, with a revision date of February 2017, revealed all ready-to-eat foods will be the date marked to strive to ensure appropriate rotation and prevent foodborne illness. All ready-to-eat foods will be labeled to include the following information: product name and date the product was prepared or opened and the date the product should be used. Observations of the main kitchen with the Dietary Director were conducted on May 24, 2021, at 9:05 a.m. and revealed the following in the kitchen's main refrigerator: 1. Two 30 pound white bucket containers of beef base, opened, used, with no date. 2. One 15 pound white bucket container of clam base, opened, used, and with no date. 3. One 30 pound white bucket container of turkey base, opened, used, and with no date. 4. One 30 pound white bucket container of the vegetable base, opened, used, and with no date . 5. One 30 pound white bucket container of ham base, opened, used, and with no date. 6. One 15 pound white bucket container of crab base, opened, used, and with no date. 7. One bottle of thousand island dressing, used and undated. An interview with Dietary Director on May 24, 2021, at 9:10 a.m. confirmed that the food products identified above should have been dated with an opened date and a used by date. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the use of a PRN (as needed) anti-anxiety medication for one of 12 residents reviewed (Resident 32). Findings include: A review of Resident 32's diagnosis list revealed delusional disorder, anxiety disorder, major depressive disorder, and Alzheimer's disease (an irreversible, progressive [CONDITION(S)] disease of the brain, resulting in loss of reality contact and functioning ability). An interview with Licensed Nurse, Employee E4 was conducted on May 27, 2021, at 1:30 p.m. who stated a non-pharmacological intervention should be provided to the resident. Anti-anxiety medication would be administered if the non-pharmacological intervention was ineffective. Employee E4 stated that the facility monitors and documents resident's behavior on a Behavior Monitoring Psychoactive Flow Record Sheet. A review of Resident 32's Physician Order Sheet (POS) revealed an order on January 29, 2021, for [MEDICATION(S)] (an anti-anxiety medication) 0.25 milligrams (mg) one tablet every eight hours as needed for anxiety. A review of Resident 32's February 2021, Medication Administration Record (MAR) revealed that [MEDICATION(S)] was administered seven times between February 2, 2021 through February 7, 2021; February 2 (one time), February 4 (two times), February 5 (one time), February 6 (one time), and February 7 (two times), with no documented evidence that an alternative behavior intervention was attempted prior to the medication administrations. A review of Resident 32's February 2021 Behavior Monitoring Psychoactive Flow Record Sheet revealed that Resident 32 had no documented behaviors related to the administration of the PRN medication for the dates identified above. A review of Resident 32's POS revealed an order made on February 25, 2021, for [MEDICATION(S)] 0.25 mg at HS (hours of sleep) for anxiety and sleep disturbance. A review of Resident 32's March and April 2021 POS revealed an order for [MEDICATION(S)] 0.25 mg one tablet every eight hours for anxiety from March 31, 2021, until April 12, 2021. The PRN order of [MEDICATION(S)] was reordered on April 12, 2021, for 30 more days. A review of Resident 32's April 2021 MAR revealed that the [MEDICATION(S)] was administered five times from April 12, 2021 through April 16, 2021; April 12 (one time), April 16 (two times), April 17 (one time), and April 18 (one time), with no documented evidence that an alternative behavior intervention was attempted prior to the medication administration. A review of Resident 32's April 2021 Behavior Monitoring Psychoactive Flow Record Sheet revealed that Resident 32 had no documented behaviors related to administration of PRN medication for the the dates identified above. An interview with Licensed Nurse Employee E4 on May 27, 2021, at 1:00 p.m. was conducted who confirmed that there was no behaviors documented for Resident 32 on the dates identified above and no documented evidence that alternative behavior interventions were attempted prior to administering PRN [MEDICATION(S)] for Resident 32. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dry storage area and maintain the kitchen in a sanitary condition. Findings include: Observation during the initial tour of the kitchen on (MONTH) 17, 2019 at approximately 12:16 p.m., accompanied by the Director of Culinary and Nutrition Services, Employee E3, revealed a hole the approximate size of a 50 cent coin in between the loading dock doors (leading into the kitchen area). Additionally, the following was observed: there was a scoop stored in the flour bin, one of two sanitizing buckets and the three compartment sink did not meet the 200 ppm requirement for the cleaning solution as per the testing strip used by Employee E3. Observation of the dry storage area at this same time revealed a bag partially filled with orzo (pasta), and another bag partially filled with chopped walnuts, neither of which was labeled or dated. Interview with Employee E3 at the time of the observations confirmed the aforementioned findings and indicated that there was an issue with the tubing for the EcoLab sanitizing solution. F812 483.60(i) FOOD SAFETY REQUIREMENT 28 PA Code 201.14(a) Responsibility of licensee Previously cited 9/13/2019; 1/15/2019 28 PA Code 201.18(b)(1)(3) Management Previously cited 9/13/2019; 1/15/2019 28 PA Code 201.18(e)(1) Management Previously cited 9/13/2019; 1/15/2019 28 PA Code 211.6(f) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were followed regarding pain medication for two of 16 residents reviewed (Residents 24 and 31). Findings include: Review of Resident 24's physician's orders revealed an order dated (MONTH) 3, 2019 for [MEDICATION NAME] HCl (narcotic-like pain reliever) tablet 50 milligrams (mg) - give 1 tablet by mouth every 4 hours as needed for moderate pain. Review of Resident 24's (MONTH) 2019 Medication Administration Record [REDACTED] Interview with the Director of Nursing on (MONTH) 20, 2019 at approximately 2:00 p.m. confirmed that Resident 24 received [MEDICATION NAME] 50 mg outside the pain parameters prescribed by the physician on (MONTH) 12, 2019. Review of Resident 31's physician's orders revealed an order dated (MONTH) 22, 2019 for [MEDICATION NAME] HCl (narcotic pain reliever) tablet 5 mg - give 1 tablet by mouth every 4 hours as needed for severe pain. Review of Resident 31's (MONTH) MAR indicated [REDACTED] November 9, 2019 at 1:00 a.m. for a pain rating of 7 November 10, 2019 at 12:56 a.m. for a pain rating of 5 November 11, 2019 at 1:43 a.m. for a pain rating of 4 November 13, 2019 at 3:25 a.m. for a pain rating of 5 November 14, 2019 at 3:48 a.m. for a pain rating of 4 November 19, 2019 at 3:55 a.m. for a pain rating of 4 Interview with the Director of Nursing on (MONTH) 20, 2019 at approximately 2:00 p.m. confirmed that Resident 31 received [MEDICATION NAME] 5 mg outside the pain parameter prescribed by the resident's physician six times in November, 2019. 28 Pa. Code 211.10(c) Resident care policies Previously cited 9/13/19 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Previously cited 1/15/19, 9/13/19

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure interventions were in place to prevent falls for one out of five residents, resulting in Resident #39 sustaining a fall, transfer to the hospital and [DIAGNOSES REDACTED]. Findings include: Review of facility policy and procedure titled, Falls reduction and Management, last revised (MONTH) (YEAR), revealed the licensed nurse will assess all residents for risk for falls upon admission to the skilled care center. After the resident has been assessed and potential causes for falls have been identified, the interdisciplinary care plan team will identify appropriate preventative, individualized resident-centered measures and interventions. The fall care plan and approaches will be updated after each fall and will include current and appropriate individualized resident-centered preventative measures and interventions. Review of Resident #39's [DIAGNOSES REDACTED]. Review of Resident #39's Fall risk evaluation dated (MONTH) 24, (YEAR), revealed the resident was assessed as high risk for falls. Review of Resident #39's admission MDS (Minimum Data Set- periodic assessment of resident needs), dated (MONTH) 30, (YEAR), revealed a BIMS (Brief Interview for Mental Status) score of 10 out of 15 indicating moderate cognitive impairment. Further review of Resident #39's admission MDS revealed the resident was coded as needing extensive assistance from two people for transfers and needing supervision with one person assist for walking in his room and corridor. Review of Resident #39's care plan revealed a care plan for self-care performance deficit related to weakness with an intervention initiated on (MONTH) 7, (YEAR), to encourage the resident to use the call bell for assistance as needed and keep it in reach at all times. Further review of the resident's care plan revealed that there was no care plan developed for falls. Review of Resident #39's progress notes revealed a nursing entry on (MONTH) 27, (YEAR), at 6:26 a.m. stating, Resident #39 out of bed, attempting to use bathroom without calling for assistance despite being encouraged to do so. Review of Resident #39's investigation of fall incidents sustained by the resident revealed a fall incident on (MONTH) 15, (YEAR), at 2:25 p.m. in which the resident was found on the floor in his room. There was no injury associated with this fall. Review of the fall incident documentation for this fall revealed the only corrective action put in place for this resident after this fall was to encourage the resident to use his call bell for assistance. This intervention had been in place in the resident's care plan since (MONTH) 7, (YEAR), and no other corrective actions were identified on this fall investigation. Further review of Resident #39's progress notes revealed a nursing entry on (MONTH) 22, (YEAR), at 8:03 a.m. stating, CNA (nursing assistant) alerted nursing of resident lying on the floor. Nurse in to assess resident lying on right side adjacent to bathroom with walker beside him. Resident states he was attempting to use the bathroom when his walker tipped over causing him to lose balance and fall. Review of History and Physical completed at an acute care hospital dated (MONTH) 23, (YEAR), revealed the resident was brought in from Granite Farms Estate after unwitnessed fall yesterday. Yesterday was complaining of pain in right knee and x-ray did not show any acute fractures. Today they noticed patient had pain right hip x-ray showed femoral neck fracture (hip). Patient sent to ER for ORIF (surgical repair) for palliative pain control. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 15, 2019, at 11:30 a.m. confirmed Resident #39 did not have interventions in place to prevent a fall prior to the fall on (MONTH) 22, (YEAR), causing major injury. The facility failed to develop interventions for Resident #39 who was assessed at risk for falls resulting in Resident #39 sustaining a fall, transfer to the hospital and [DIAGNOSES REDACTED]. Free Of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 01/31/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/31/18 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 01/31/18 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 03/31/17, 12/28/16 28 Pa. Code 211.12(c)(d)(5) Nursing services Previously cited 01/31/18 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observations, resident interview and staff interview, it was determined the facility failed to obtain a physician's order for oxygen therapy for one of two residents reviewed (Resident 57). Findings include: Observation of Resident #57 on (MONTH) 11, 2019, at 10:24 a.m. revealed the resident was wearing a nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Interview with Resident #57 on (MONTH) 11, 2019, at 10:24 a.m. revealed the resident wears the oxygen all the time and while in the facility has it hooked up to an oxygen concentrator. Review of Resident #57's clinical record revealed there was no physician's order for the resident to be receiving oxygen therapy via a nasal cannula. Interview with the Director of Nursing on (MONTH) 15, 2019, at 10:43 a.m. confirmed there was no order for the resident to have oxygen therapy via nasal cannula. The facility failed to obtained a physician's order for oxygen therapy for Resident #57. 28 Pa. Code 211.5(f) Clinical records Previously cited 01/31/18 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services Previously cited 01/31/18 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to develop a care plan for falls for one of 24 residents reviewed (Resident #39). Findings include: Review of the facility policy and procedure titled, Falls reduction and Management, last revised (MONTH) (YEAR), revealed the fall care plan and approaches will be updated after each fall and will include current and appropriate individualized resident-centered preventative measures and interventions. Review of Resident #39's [DIAGNOSES REDACTED]. Review of Resident #39's Fall risk evaluation dated (MONTH) 24, (YEAR), revealed the resident was assessed as high risk for falls. Review of Resident #39's admission MDS (Minimum Data Set- periodic assessment of resident needs), dated (MONTH) 30, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 10 out of 15 indicating moderate cognitive impairment. Further review of Resident 39's admission MDS revealed the resident was coded as needing extensive assistance from two people for transfers and needing supervision with one person assist for walking in his room and corridor. Review of Resident #39's care plan revealed a care plan for self-care performance deficit related to weakness with an intervention initiated on (MONTH) 7, (YEAR), to encourage the resident to use the call bell for assistance as needed and keep it in reach at all times. Further review of the care plan revealed there was no care plan developed for falls. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 15, 2019, at 11:30 a.m. confirmed Resident 39 did not have a falls care plan developed upon admission and after being identified at risk for falls. The facility failed to ensure that a care plan for Resident #39 risk of falls was developed. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 03/31/17, 12/28/16 28 Pa. Code 211.12(c)(d)(5) Nursing services Previously cited 01/31/18 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility failed to obtain a physician's order in accordance with the resident's Advanced Directive for one of 18 residents reviewed (Resident #21). Findings include: Review of Resident #21's clinical record revealed the following [DIAGNOSES REDACTED].) with [MEDICAL CONDITION] (An absence of enough oxygen in the tissues to sustain bodily functions), Perforation (the escape of digestive tract contents into the peritoneal cavity as the result of trauma or a disease condition) of intestine, Dysphagia (inability/difficulty swallowing) and dementia (Irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident #21's physician's orders for the months of (MONTH) and (MONTH) (YEAR), revealed there was no code status ordered by the physician. Further review of Resident #21's clinical record revealed a copy of the resident's Durable Power of Attorney for Health Care which was signed by the resident on (MONTH) 31, 2011. This document shall be made a part of my permanent medical record upon my admission to a health care facility. Further review of the document indicated the resident Being a competent adult of sound mind, having the capacity to make health care decisions, willfully and voluntarily declare that this is my Advanced Health Care Directive. This document shall be made a part of my permanent medical record upon my admission to a health care facility. If I am diagnosed with [REDACTED]. In the absence of my ability to give directions regarding the use of such life-sustaining treatment, it is my intention that this Directive shall be honored by my family and my physician (s). Interview with Director of Nursing on (MONTH) 14, 2019, at 1:45 p.m. confirmed there was no documented code status ordered by the physician for Resident #21 and according to the facility protocol the resident would be considered a full code (all possible measures would be taken to revive the resident and sustain life). The facility failed to follow Resident 21's wishes in regard to life sustaining treatment. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.2(a)(b) Physician services 28 Pa. Code 211.5(f) Clinical records Previously cited 01/31/18

Based on clinical record review, it was determined that the facility failed to notify the State Long-Term Care (LTC) Ombudsman's office of residents transferred to acute care facilities for four of 16 residents reviewed (Residents #18, #21, #39 and #65). Findings include: Review of Resident #18's clinical record revealed a nursing progress note dated (MONTH) 3, (YEAR), that indicated the resident was transferred to the hospital due to a change in mental status, found slumped over, minimally responsive and having difficulty breathing. Resident #18 was admitted to the hospital for a [DIAGNOSES REDACTED]. Further review of Resident #18's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident #18's transfer from the facility to the hospital. Review of Resident #21's clinical record revealed a nursing progress note dated (MONTH) 6, (YEAR), which indicated the resident was complaining of abdominal pain and transferred to the hospital. A CT Scan (a series of X-ray images taken from different angles around the body that uses computer processing to create cross-sectional images) of the Pelvis and Abdomen was completed on (MONTH) 6, (YEAR), which revealed inflammation of the cecum (a pouch or large tubelike structure in the lower abdominal cavity that receives undigested food material from the small intestine to the colon). Resident #21 was admitted to the hospital for a [DIAGNOSES REDACTED]. Further review of Resident #21's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident #21's transfer from the facility to the hospital. Review of Resident 39's clinical record revealed a nursing progress notes stating the resident had a fall on (MONTH) 22, (YEAR), and an x-ray of the hip showed a fracture and the resident was transferred to the hospital and admitted for surgical repair on (MONTH) 23, (YEAR). Further review of Resident 39's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 39's transfer from the facility to the hospital. Review of Resident #65's nursing progress note dated (MONTH) 14, (YEAR), revealed the resident presented with weakness and lethargy. The resident's family was on the unit and concerned with the resident's lethargy. The physician was in to see the resident and ordered the resident sent to the hospital for evaluation. The resident was subsequently admitted with [MEDICAL CONDITION]. Review of Resident #65's progress note dated (MONTH) 8, (YEAR), revealed the resident was unresponsive, but became responsive within two minutes. Family requested the resident be sent to the hospital for evaluation. Resident was admitted for evaluation of [MEDICAL CONDITIONS], hypertension, shortness of breath, and bilateral lower extremity [MEDICAL CONDITION]. Review of Resident #65's nursing progress note dated (MONTH) 15, (YEAR), revealed the resident had increased wheezing, increased respirations and was short of breath. 911 (Emergency Medical Services) was called and resident was sent to the hospital. Resident was admitted with [DIAGNOSES REDACTED]. Review of Resident #65's nursing progress note dated (MONTH) 4, (YEAR), indicated the resident had increased shortness of breath, [MEDICAL CONDITION], and complained of right hand weakness accompanied with swelling. The physician was on site and ordered the resident sent to the hospital. Resident was admitted with shortness of breath. Review of nursing progress note dated (MONTH) 20, (YEAR), revealed the resident was short of breath and complained of right flank pain. The physician was called and ordered the resident sent to the hospital for evaluation. Further review of Resident #65's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident 65's transfer from the facility to the hospital for these five occasions. Interview with the Nursing Home Administrator on (MONTH) 15, 2019, at approximately 12:45 p.m. revealed that the facility did not notify the State Ombudsman's office when residents were transferred or discharged . The facility failed to notify the State Ombudsman's office of Residents #18, #21, #39 and #65 transfers to an acute care facility. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/31/18 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(3) Management Previously cited 01/31/18 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident's environment was free of accident hazards, which resulted in actual harm of a resident ingesting a toxic substance for one of 18 residents reviewed (Resident 323). Findings include: Review of Resident 323's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident 323's Quarterly Minimum Data Set (MDS- resident assessment of care needs) completed on October 27, 2017, revealed that the resident was identified with a BIMS (Brief interview of Mental status) score of 10, which indicated moderate cognitive impairment. Review of Resident 323's plan of care initiated on August 4, 2017, identified the resident with impaired cognitive function related to the disease process, impaired decision making, and the use of [MEDICAL CONDITION] drugs. Interventions included for the resident to be observed by staff every 15 minutes. Review of Resident 323's clinical record revealed a psychologist consultation report dated October 16, 2017, indicating that the resident was provided psychological services for the treatment of [REDACTED]. Resident 323's clinical record revealed a nurse's note dated November 26, 2017, that at 6:20 a.m., the RN (registered nurse) heard the resident making a grunting noise and having a persistent cough. On arrival to the room, the RN noted that Resident 323 was sitting on the side of her bed. The RN noted Res is AAx0 (alert and oriented zero percent of the time) and able to respond to verbal commands but unable to describe pain location or discomfort. Resident 323 was noted on acute resp. (respiratory) distress with labored/rapid breathing 24-28 (normal breathing rate is 12-20 breaths per minute). Resident 323's face was flushed and clear secretions were coming from her nose and mouth. The RN indicated that it appeared Resident 323 ingested detergent; however, the RN was unable to account for how much. When the RN asked what happened, Resident 323 replied, Water, and pointed to her night table. The RN noted there was a 16 oz (ounces) cup with a lid and straw on the night table and next to it was an open container of liquid detergent (Tide) with aprox. (approximately) 60 ml (milliliters) of detergent poured into the measuring/lid. Resident 323 was given a glass of water and the Poison Control Center was called. The facility followed the first aid instructions. Resident 323 was placed on O2 (oxygen) for SPO2> 84% (blood oxygen saturation level, normal is greater than 90%). The oxygen was titrated to increase the SPO2 to 92-94%. Resident 323's blood pressure was 183/110 mm/Hg (millimeters of mercury, normal blood pressure is 120/80), and her heart rate was 112 bpm (beats per minute, normal heart rate is 60-100). Resident 323 was sent to the ER (emergency room ) for evaluation. The facility notified the physician and the family. Nursing documentation dated November 26, 2017, revealed that Resident 323 was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. Review of Resident 323's hospital records dated December 14, 2017, revealed a discharge summary written by the resident's physician that indicated the resident had ingested more than a capful of laundry detergent with bleach alternative in an attempt to commit suicide. The resident was discharged to inpatient hospice (a type of care that focuses on chronically ill, terminally ill, or seriously ill resident's pain and symptoms, and attending to their emotional and spiritual needs) on November 29, 2017. Review of the facility's investigation dated November 26, 2017, revealed a statement obtained from Employee E11 (nurse aide), which indicated that the resident was washed and dressed at 6:00 a.m. by Employee E11. Resident 323 asked for something to drink and Employee E11 gave her a cup of water. Further review of Employee E11's statement noted 20 minutes later the nurse informed me that she drank the laundry (detergent) that was up on the shelf. Interview with the Nursing Home Administrator on January 30, 2018, at 8:45 a.m. revealed that Resident 323's family did the resident's laundry and the laundry detergent was in the resident's room. The facility failed to ensure a resident's environment was free of hazards, which resulted in actual harm to Resident 323 who ingested laundry detergent and required hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/29/16, 01/14/16 28 Pa. Code 201.18(b)(1) Management Previously cited 06/29/16, 01/14/16 28 Pa. Code 210.18(b)(3)(e)(1) Management Previously cited 01/14/16 28 Pa. Code 211.12(c) Nursing services Previously cited 03/31/17, 12/28/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 01/14/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 03/31/17, 12/28/16, 01/14/16

Based on clinical record review and staff interview, it was determined that the facility failed to complete assessments that accurately reflected the resident status for three of 18 residents reviewed (Residents 1, 73, 13). Findings include: Review of Resident 1's Minimum Data Set (MDS - periodic assessment of resident needs) revealed the resident had an unplanned discharge to the community on July 12, 2017. Interview with the Director of Nursing on January 31, 2018, at 1:30 p.m. confirmed that this was a planned discharge for the resident to the community and that the MDS for July 12, 2017, was inaccurate for the type of discharge. Review of Resident 73's progress notes revealed a nursing note on November 9, 2017, indicating that the resident was transferred to another skilled nursing facility per the request of the resident. A review of the discharge MDS assessment indicated that the resident was discharged to an acute care hospital. Interview with the Director of Nursing on January 31, 2018, at 1:30 p.m. confirmed that Resident 73's discharge MDS was inaccurate for the destination of the resident. Review of Resident 13's clinical record revealed that Resident 13 was admitted to the facility on [DATE], from an assisted living facility. Further review of Resident 13's clinical record revealed nursing documentation that the resident was admitted to the facility with associated hospice service effective November 10, 2017, for terminal prognosis of [MEDICAL CONDITION] disease (arteries supplying oxygen and nutrients to the brain are damaged). Review of Resident 13's admission MDS assessment dated [DATE], revealed that in the section titled Special Treatments, Procedures and Programs, the assessment indicated the response No for hospice care while a resident and No for hospice care while not a resident. Interview with the Registered Nurse Assessment Coordinator, Employee E4, on January 31, 2018, at1:29 p.m. confirmed that Resident 13's MDS needed to be corrected as the information regarding hospice services was inaccurate. Accuracy of Assessments CFR(s): 483.20(g) Previously cited 01/14/16 28 Pa. Code 211.5(f) Clinical records Previously cited 01/14/16 28 Pa. code 211.12(c) Nursing services Previously cited 03/31/17, 12/28/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited: 01/14/16 28 Pa. code 211.12(d)(5) Nursing services Previously cited 03/31/17, 12/28/16, 01/14/16

Based on observation and interview, it was determined that the facility failed to ensure that residents were served meals in a safe and sanitary environment for one of three dining rooms (dining room B). Findings include: Observation of dining service in dining room B on January 26, 2018, at 12:14 p.m. revealed that Employee E3, culinary aide, walked out of the country kitchen with gloves on. Employee E3 put their left gloved hand into their pocket, and adjusted their apron and pants. Employee E3 picked up a used serving tray and proceeded back into the kitchen area to begin serving two more residents food without changing their dirty gloves. Further observations conducted of dining service on January 26, 2018, at 12:26 p.m. revealed that Employee E3 left the country kitchen area, adjusted their pants, touched the wall several times, and picked up a second used serving tray before proceeding back to the country kitchen. Employee E3 handled clean plates and put unused utensils away without changing their dirty gloves. Interview with the Nursing Home Administrator on January 31, 2018, at 8:56 a.m. confirmed that dietary staff should have changed their gloves before serving meals to residents or handling clean utensils and plates after touching other surfaces and their clothing. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited on 06/29/16, 01/14/16 28 Pa Code 201.18(b)(1) Management Previously cited 06/29/16, 01/14/16 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 01/14/16

Based on observation, and review of facility policy, it was determined that the facility failed to ensure that food stored in one of one walk-in refrigerators in the main kitchen was disposed after the expiration date. (Main kitchen) Findings include: Policy entitled Food Storage Chart, revised in October 2014, revealed that hard-cooked eggs must be used four days after opening, and that sausage must be used within seven days after opening. Observations during the environmental tour at the Willowbrooke Court at Granite Farms food services department on December 22, 2016, at approximately 12:25 p.m. revealed that the walk-in refrigerator located in the main kitchen, contained an opened large plastic container of cooked eggs labeled with a received date of December 14, 2016, but the used by date was not written on the container (eggs had been opened for nine days). A sausage sealed in cellophane was observed labled four months and use by three days. No other information was written on the sausage package. Futher observations revealed that the foods stored in this walk-in unit was not labled with a use-by date. Interview on December 22, 2016 at approximately 1:00 p.m. with the Director of Culinary Services, Employee E4 revealed that the Food Storage Chart, remains posted on the outside of the refrigerator's door at all times for employees to calculate when to use foods or discard foods. There was no statement on how this policy was being monitored and tested for accuracy in calculating use-by or discard dates. CFR 483.60(i) Food safety requirements. 28 Pa Code 211.6(c) Dietary services.

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide supervision and a safe environment on one of two nursing units (Cherry Blossom Nursing Unit) by allowing residents access to an unlocked and unalarmed door which exited to an outside courtyard. In addition, the facility failed to ensure that the country kitchen and pantry areas located on this nursing unit were secured and supervised, allowing confused and wandering residents easy access to the hazardous equipment placing the health and safety of these residents in Immediate Jeopardy. Additionally, other safety concerns were identified in one of two nursing units (Cherry Blossom Nursing unit). Findings include: Review of weather data from the National Weather Service on the date of January 6, 2014, indicated that the lowest calculated temperature at the Philadelphia International Airport was a low of 13 degrees Fahrenheit and at the Suburban West Chester weather station indicated the lowest temperature was 1 degree Fahrenheit. These temperatures did not include the wind chill factor. The facility is located between these two geographical areas. Interview with Licensed Nurse, Employee E4, on January 7, 2014, at approximately 1:00 p.m., confirmed that nine residents of the current 14 residents, residing on the Cherry Blossom Nursing Unit, were described as either confused, not oriented or forgetful. Observations of the initial tour of the Cherry Blossom Nursing Unit on January 6, 2014, at 5:15 p.m., revealed an exit door which exited to an outside enclosed courtyard area. Signage on this door indicated that during an emergency, this door would open and alarm when the release bar was pushed for 15 seconds. When the surveyor leaned against the glass of this exit door, the door opened without any manual pressure to the release bar and the door alarm failed to sound. Interview with Licensed Nurse, Employee E10, on January 6, 2014, at 5:30 p.m. and at 5:50 p.m., confirmed that this exit door was not locked and was not set to alarm when opened. Employee E10 further confirmed that this door was also not fully installed with the hardware needed to alert staff if a resident with a wander alert bracelet had exited through the door into the outside courtyard. Employee E10 confirmed that cognitively impaired Resident E4, who was at risk for attempting to the leave the unit, was wearing a wander alert bracelet. Employee E10 related that she did not know why the door alarms were not activated but became aware of this finding approximately seven months ago. Employee E10 confirmed that the staff were not always supervising the courtyard. Interviews with nursing Employees E3 and E7 on January 6, 2014, at 5:55 p.m. and 6:05 p.m. respectfully, revealed that they did not routinely observe the courtyard for any residents who would be outside. Employee E3 stated she thought the courtyard door locked after 8:00 p.m. Employee E3 indicated that last week Resident E12, who is alert and oriented and resides on the Cherry Blossom Nursing Unit, was in the courtyard when it was snowing. Interview on January 7, 2014, at 9:20 a.m., with cognitively intact Resident E6, a resident of the Cherry Blossom Nursing Unit, also confirmed that Resident E12 goes into the courtyard. Interview with Maintenance Director Employee E11, on January 7, 2014, at 10:50 a.m., revealed that when the Cherry Blossom building was constructed, the door exiting into the courtyard was set up to allow residents independent access into the courtyard area. Employee E11 confirmed that this door was never checked by the maintenance staff because the alarms for the door were never set to function. Employee E11 also indicated that this exit door was never fully wired for the wander alert bracelet system that the facility uses at other exits. Observations on January 6, 2014, at 4:35 p.m. and at 8:30 p.m. of the country kitchen, revealed an open kitchen that had steam tables, a range and oven and other equipment that was homelike and included a seated serving area for residents to eat from on the opposite side of the country kitchen. The entrance to the country kitchen from the resident living area revealed a Dutch door (a half door that swings both ways) which led into the country kitchen area. This door was closed but not secured with an existing metal latch. One Dietary Aide, Employee E5, was observed on January 6, 2014 at 4:35 p.m., inside the perimeter of the country kitchen, but left shortly after the surveyor began touring the area at the 4:35 p.m. observation. Observations of the country kitchen area on January 6, 2014 at 4:35 p.m., revealed the storage of three large knives in a drawer. The stove and oven were turned off but when the control knobs were tested by the surveyor, the electricity was not locked out to this cooking area. Three of three steam wells were also able to be turned on by the surveyor. The control knobs for the steam wells were visible and accessible. One of three steam wells still contained standing hot water as evidenced by the steam that escaped from the well when the lid was lifted off by the surveyor. When the surveyor exited the country kitchen on January 6, 2014 at approximately 5:00 p.m., the metal bar latch to the Dutch door that led to the resident living area was not able to be secured properly because the height of the half door was not aligned to connect with the latch. No general nursing staff or dietary staff were visible to these areas during the surveyor observations, which was after Employee E5 was seen leaving the country kitchen area.. Observations of the Cherry Blossom country kitchen and the dietary pantry on January 6, 2014 at 8:30 p.m., revealed that the Dutch door was again closed but not secured with the metal bar latch. The following items were observed being stored in the cabinet area under the kitchen sink, of the country kitchen: four 17 ounce cans of a non-stick cooking spray; one 16.5 ounces of a buttery flavored cooking spray; one 32 ounce bottle of lemon juice; one 12 ounce spray bottle of glass cleaner with a label that read, "Do Not Drink"; one bottle of stainless steel cleanser/polisher and two, one gallon bottles of grease cleaner. Within the country kitchen was a door that led surveyor into the dietary pantry. The pantry door was wired to a keyless entry pad and was observed to be left open, allowing full view into the pantry area. The door leading into this dietary pantry, was observed to be open, allowing full view into the pantry area. The pantry area contained a dishwasher which was not in use but the digital temperature gage measured the interior temperature at 164 degrees Fahrenheit. When the dishwasher door was opened by the surveyor, hot steam escaped and the interior well of the dishwasher was observed with standing, hot water. Items being observed stored under the hand sink were two, one gallon bottles of multipurpose lime cleaner, one 64 fluid ounces bottle of bleach. Also being stored on a metal four tier shelving unit was a 10 fluid ounce spray bottle of food contact surface sanitizer with a label that read, "Do Not Drink", one, eight ounce container of pipe cement and one, eight ounce container of pipe primer paint. No general nursing staff or dietary staff was visible to these areas during the surveyor observations. A revisit observation on January 7, 2014, at 10:00 a.m., of the Cherry Blossom country kitchen area and the dietary pantry, revealed that the Dutch door was again closed but not secured with the metal bar latch. The door leading into the dietary pantry, was again observed to be open, allowing full view into the pantry area. The counter was observed with one, 64 fluid ounce bottle of bleach. The pantry area contained a dishwasher which was not in use but the digital temperature gage again measured the interior temperature at 164 degrees Fahrenheit. When the dishwasher door was opened by the surveyor, hot steam escaped and the interior well of the dishwasher was observed with standing, hot water. The items observed stored under the hand sink were two, one gallon bottles of multipurpose lime cleaner. Still being stored on the metal four tier shelving unit was a 10 fluid ounce spray bottle of food contact surface sanitizer with a label that read, "Do Not Drink", one, eight ounce container of pipe cement and one, eight ounce container of pipe primer paint. Observations of the country kitchen area revealed the continued storage of three large knives in a drawer. The stove and oven were turned off but when the control knobs were tested by the surveyor, the electricity was not locked out to this cooking area. Three of three steam wells were also able to be turned on by the surveyor. The control knobs for the steam wells were visible and accessible. Items still being observed stored in the cabinet area under the kitchen sink of the country kitchen included: four 17 ounce cans of a non-stick cooking spray; one 16.5 ounces of a buttery flavored cooking spray; one 32 ounce bottle of lemon juice; one 12 ounce spray bottle of glass cleaner with a label that read, "Do Not Drink"; one bottle of stainless steel cleanser/polisher and two, one gallon bottles of grease cleaner. No general nursing staff or dietary staff was visible to these areas during the surveyor observations. Interview with Employee E11 on January 7, 2014, at 10:50 a.m., revealed that maintenance had not received a work order from the staff on Cherry Blossom Nursing Unit or the dietary staff, requesting a repair to the latch that secured the Dutch door of the country kitchen. Employee E11 stated, "I was never told it wasn't working." Employee E11 also confirmed that approximately two years ago the staff broke the double doors that provided access to the electric panel of the hot steam wells and these doors were never repaired and never replaced. Interview with both the Nursing Home Administrator and Director of Nursing on January 7, 2014, at 5:30 p.m., confirmed that Resident E12, was an alert and oriented resident and may utilize the country kitchen after hours. Review of Resident E9's clinical record included a [DIAGNOSES REDACTED]. Resident E9's significant change in status MDS assessment dated [DATE], listed the resident's BIMS score (brief interview for mental status) as seven out of 15 which indicated severe impairment. Review of a nurses' note dated December 17, 2013, at 1:14 p.m., documented "Resident is alert and oriented in beginning of today but after lunch was confused, observed resident in bathroom with door locked asked her to open it up which she did and was standing there behind her wheelchair with her brief off... Resident turned her alarm off was not sounding at the time Staff instructed to monitor resident when she goes into her room so that they are aware of her activity." Review of Resident E9's nurses' note dated December 24, 2013, at 9:42 p.m., documented that during the dinner hour this evening, resident was in resident's bathroom and had pulled the light for help. Resident E9 resides on the Cherry Blossom Nursing Unit. The nurses' note dated December 24, 2013, further stated, "The CNA said that when she went to help the resident she was unable to access the bathroom because the door was locked. The resident unlocked the bathroom door and saw the resident walking backward towards the toilet to sit back down." The surveyor observation of Resident E9's bathroom on January 8, 2014, at 9:45 a.m., accompanied by nursing staff, Employee E15, confirmed that the resident's bathroom locks on the inside. Employee E15 confirmed that Employee E15 has been employed by facility for the past nine years and that maybe a butter knife could be used to get into Resident E9's locked bathroom. Employee E15 further confirmed no knowledge of having received any facility staff training or any facility procedure regarding unlocking bathroom doors which were able to be locked on this nursing unit (Cherry Blossom Nursing Unit). Employee E15 believed that Resident E9's and another resident's bathroom (but unable to identify second bathroom) were the only two bathrooms on Cherry Blossom Nursing Unit with a lock. Tour of the Cherry Blossom Nursing Unit, accompanied by Employee E15, confirmed that bathroom door locks were in place and functioning for resident room bathrooms 300, 301, 302, 303, 304, 305 and 306. For those seven resident bathrooms, it was further determined that seven residents were described by Employee E4 on January 7, 2014, at approximately 1:00 p.m., as confused, not oriented or forgetful, and had immediate access to a bathroom with a functioning lock. Interview with Licensed Nurse Employee E4 on January 8, 2014, at 10:00 a.m., confirmed that she received no previous facility education regarding unlocking resident room bathroom doors and thought only one resident bathroom had a lock. Employee E4 reported that a butter knife would be used to open a locked bathroom or a paperclip could be used and that in the past, a butter knife was used to unlock Resident E9's bathroom. The facility failed to ensure adequate supervision and safety for confused and wandering residents who could readily gain assess to an outside courtyard, through an unlocked and unalarmed exit door, on one of the two nursing units (Cherry Blossom Nursing Unit), at any time of the day or night in any weather conditions resulting in Immediate Jeopardy identified. The facility was asked to provide an acceptable action plan for the courtyard door on January 6, 2013, at 6:45 p.m. to immediately put systems into place to ensure supervision and resident safety. The facility was informed on January 7, 2014, at approximately 10:15 a.m. that Immediate Jeopardy had been identified on January 6, 2014, at 6:45 p.m, when they were asked for an action plan. The facility failed to ensure that the country kitchen and pantry areas located on the Cherry Blossom Nursing Unit were secured and supervised, therefore allowing confused and wandering residents access to hazardous equipment and chemicals, and placing the health and safety of these residents at risk resulting in another issue of Immediate Jeopardy being identified on January 7, 2014, at 2:00 p.m. An action plan was requested on January 7, 2014, at 2:00 p.m., to immediately put systems into place to ensure adequate supervision and safety of the residents. The facility submitted and implemented acceptable plans of action and the Immediate Jeopardy was removed on January 9, 2014, at 1:15 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 1/26/12. 28 Pa. Code 201.18(b)(3)(e)(3) Management. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 12/07/12, 1/26/12. 28 Pa. Code 211.10(c) Resident care policies Previously cited 6/11/13, 12/07/12. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/07/12. 28 Pa. Code 211.12 (c) Nursing services Previously cited 12/07/12, 1/26/12. 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 6/11/13, 12/07/12. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/11/13, 12/07/12, 1/26/12.

Based on observations, review of facility policy, review of clinical records and interviews with facility staff, it was determined that the facility failed to provide the necessary care and services to prevent pressure ulcers causing actual harm to two out of four residents reviewed with pressure ulcers (Residents A6 and A16). Findings include: Review of the facility policy titled, "Non-Impaired Skin Integrity", revised February 2012, stated that the facility will identify residents at risk and initiate an appropriate care plan. The policy further stated that the licensed staff will integrate risk factors such as diseases, infection, cancer, recent surgery and hospitalization s and initiate appropriate interventions according to the level of risk. Review of Resident A6's quarterly Minimum Data Set assessment (MDS-an assessment of resident status and care needs) dated October 3, 2013, revealed that the resident had severe cognitive impairment. The assessment also revealed that the resident was at risk for pressure ulcer development (localized injury to the skin or underlying tissue). In addition, the resident required the extensive assistance of one staff member for turning and repositioning in bed. Resident A6's nurses notes dated November 12, 2013, related that during am shower, staff member "noticed an open red area on right side of resident back no, bleeding noticed then alerted nurse to do a shower check. No bleeding to area, measurment 2 cm x 1 cm. Nurses note dated November 13, 2013 related "Open area to right back." Resident A6's nurses notes dated November 15, 2013, revealed "new wound noted right heel. New air mattress applied on bed." An order was obtained for heel protectors on at all times. Wound documentation on November 15, 2013, indicated that a purple, suspected deep tissue injury (injury to tissue below the skin's surface) measuring 1.5 cm by 1.5 cm was identified on the resident's right heel. On November 19, 2013, Resident A6's nursing progress notes indicated that the wound on the right heel measured 1.5 centimeters by 2.0 centimeters. Review of the care plan for skin breakdown updated on November 15, 2013 included additional interventions of an air mattress, float heels (prevent heels from resting directly on the mattress to reduce pressure) and skin prep to right heel as ordered. Another intervention of heel boots on at all times was added to the care plan on November 19, 2013. The additions to the care plan were confirmed with Licensed Nurse, Employee E21, on January 9, 2014, at 11:15 a.m. Employee E21 further stated that the mattress used before the air mattress was initiated on November 15, 2013, was the same type mattress that was used by all residents on the unit. Review of Resident A6's nursing progress notes dated November 26, 2013, indicated that hospice services were started. Review of Resident A6's significant change assessment (assessment of care needs and current status) dated December 11, 2013, revealed that the resident had an unstageable pressure area on the right heel measuring 1.3 cm by 2.0 cm (full thickness tissue loss in which the base of the ulcer is coverd by slough (separation of dead tissue from living tissue) and eschar (dry scab, tan brown or black in the wound bed; dead tissue). An interview with the Director of Nursing (DON), on January 9, 2014, at 2:30 p.m., confirmed that there was no documented evidence that pressure relieving interventions were in place for Resident A6. The DON further confirmed that Resident A6 was identified as being at risk and was dependent on staff for repositioning. Review of the nursing progress notes dated October 29, 2013, for Resident A16, revealed that the resident had returned to the facility after abdominal surgery and hospitalization for eight days. The note stated that the resident would be turned every two hours. Posey boots (pressure relieving boots) were in place at that time secondary to the resident complaining of, "sore heels". The nursing notes dated October 30, 2013, indicated that an air mattress was added to the bed and "Resident moving very minimally in bed." Review of Resident A16's significant change in status assessment dated [DATE], revealed that the resident had a BIMS score of 8 ( Brief Interview for Mental Status) which indicated moderate cognitive impairment. The assessment also revealed that the resident was at risk for pressure ulcer development. In addition, the resident required the extensive assistance of two staff members for turning and repositioning in bed. Review of nursing progress notes dated November 23, 2013, revealed that staff checked Resident A16's heel because she was complaining of pain and staff identified a 3.7 centimeter by 2.0 centimeter purplish/brown ruptured blister on the left heel. A physician's order was obtained on November 23, 2013, for skin prep (a liquid film dressing applied to the skin) to bilateral heels every shift and heel protector boots on at all times. Review of the treatment record dated from October 29, 2013 through November 23, 2013, failed to reveal any documentation for the application of the heel boots to reduce pressure prior to the skin breakdown. Interview with Employee E14, on January 9, 2014 at 2:30 p.m., revealed that staff should have been documenting the placement of heel protectors. The Director of Nursing confirmed that beginning on October 29, 2013 when the resident returned from the hospital and complained of sore heels, until November 23, 2013, when the open area was identified, that there was no documented evidence that staff placed the heel protectors on the resident to reduce pressure and repositioned the resident who required two staff members for moving. In addition, review of the nursing documentation failed to reveal that professional nursing staff were monitoring and documenting the placement of heel protectors resulting in actual harm to Resident A16. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 1/26/12. 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/11/13, 12/07/12, 1/26/12. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 6/11/13, 12/07/12. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/07/12. 28 Pa. Code 211.12(c) Nursing services. Previously cited 12/07/12, 1/26/12. 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 6/11/13, 12/7/12. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/11/13, 12/07/12, 1/26/12.