Every finding on record at Willowbrooke Court SKD Care Center at Lima Estates

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for one of 13 residents reviewed (Resident 35). Findings include: Review of Resident 35's clinical record revealed a physician's order dated January 5, 2022, for [MEDICATION(S)] (narcotic pain reliever) Patch 72 Hour 12 micrograms/hour - Apply 1 patch transdermally (to the skin) every 72 hours for pain and remove per schedule and an order dated August 4, 2021, to check the placement of the patch every shift. Review of Resident 35's progress notes revealed a nurse's note dated February 21, 2022, which stated, Upon checking the pain patch, was noted that most staff had stated that it was on the RUB [(right upper back)] but was on the LUB [(left upper back)] and had not been changed since 2/16. It was omitted on 2/19. Therefore, a new patch was applied to the RUB and the old patch from 2/16 was removed from the LUB. Review of Resident 35's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 35's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m. confirmed staff failed to follow physician's orders in changing Resident 35's [MEDICATION(S)] patch and checking for placement of the patch each shift. 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure two of 13 residents reviewed received adequate supervision resulting in an elopement and a fall during a transfer using a lift (Residents 33 and 35). Findings include: Review of facility policy Elopement/Wandering Risk Assessment reviewed June 13, 2022, revealed that When responding to an alarm, if it cannot be determined what triggered the alarm, immediately verify that every resident is safe and accounted for by conducting a visual head and name reconciliation Review of Resident 33 progress notes dated June 1, 2021, at 11:46 p.m. revealed Approx. 7 p.m. this Nurse investigated a door alarm coming from Admin (administration) area; alarm computer was checked but did not indicate a code alert (alert notifying staff that a resident wandered outside of their designated area by a wearable tracker); this Nurse followed the sound to the door near Administration offices; no one was observed outside or inside. A surgical mask was found on the floor near the steps by the BR (bathroom) door in the same area. Review of Resident 33's progress notes dated June 1, 2021, at 11:46 p.m. revealed Approx. 7:20 p.m., this Nurse arrived @ (at) Res (resident) room to admin (administer) meds (medications) & (and) discovered Res was not in her room nor in her BR (bathroom). Call light was not on. Immediately, Activities Area was checked & all rooms/BR's on unit were checked for Res. When Res not found on unit, Security was notified. Review of Facility's investigation documentation for Resident 33's elopement dated June 1, 2021, revealed that staff did not conduct a visual head and name reconciliation when a door alarm was triggered by unknown means. Interview with the facility's Nursing Home Administrator and the Assistant Director of Nursing on June 10, 2022, failed to provide any documentation showing that staff conducted a visual head and name reconciliation as per facility policy Elopement/Wandering Risk Assessment. The facility failed to provide Resident 33 with adequate supervision, which resulted in Resident 33 eloping from the facility for 20 minutes before the facility recognized resident was missing. Review of facility policy Lifting/Transferring/Repositioning Resident Safely, last revised December 2018 revealed: Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance. Review of Resident 35's annual Minimum Data Set (MDS - periodic assessment of resident's needs) dated February 18, 2022 revealed the resident required an extensive assistance with two staff persons for transfers and had impairment to both upper and lower extremities. Review of Resident 35's care plan revealed the resident was at risk for falls due to unsteady gait and poor balance, with an intervention added October 23, 2018 to Please allow me to have assistance with 2 staff persons using Hoyer lift during transfers, toileting and [activities of daily living.] Review of Resident 35's progress notes revealed a nurse's note dated April 7, 2022, which stated, On 4/6/22 at [7:30 p.m.]. The nurse was called into the residents room by staff. The resident was assisted to the floor by [nurse aide.] The resident was on the VERA LIFT. While on the lift the resident let go of the handles and began to fall. The [nurse aide] then assisted the resident to the floor. The resident was free from injury. The note further indicated the root cause of Resident 35's fall was: The resident was being transfer using a lift with only one person. All lifts required 2 staff members. The facility's failure to have two staff persons present while assisting Resident 35 during a transfer in the lift which resulted in a fall was discussed with the Nursing Home Administrator and Director of Nursing on June 10, 2022, at 9:35 a.m. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on a review of clinical records and facility policy and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse and injury of unknown origin for three of 14 residents reviewed (Closed Record Residents CL1, CL2, and Resident 12) Finding include: A review of the facility's policy and procedure titled Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Property Prevention, with a revision date of October 2019, revealed that the executive director, administrator, or designee will immediately initiate an investigation of the alleged incident and include the following: Type of allegation being reported; Resident's description of the abuse, neglect, mistreatment, exploitation, or misappropriation of property; Description of the Injury; Accused employee's statement or explanation of what happened; Statements from any witness to the event; Interview with all potential witness; Cognitive status of the victim and residents who are witnesses; If the allegation involves sexual abuse, documentation if the alleged victim was examined and if so a copy of the examination or statement from the examiner. A review of Resident CL1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident CL1's Minimum Data Set (MDS-a periodic assessment of resident care needs) dated November 15, 2019, revealed that the resident had a BIMS (Brief Interview for Mental Status- a screen used to assist with identifying a resident's current cognition) score of eight which placed the resident as having moderate cognitive impairment. A review of Resident CL2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident CL2's MDS dated [DATE], revealed that the resident had a BIMS of seven which placed the resident as having moderate cognitive impairment. A review of the facility documentation, Event Details, revealed that on January 7, 2020, at 12:30 a.m., Resident CL1 called 911. EMT (Emergency Medical Technician) and state police arrived on the unit and spoke with the resident and staff. Resident CL1 claimed that he/she and his/her roommate was raped. Resident CL1 was appeased when officers accompanied him/her and the staff to his/her room to check the roommate (Resident CL2). Resident CL1 yelled at the police for leaving and stated that they were bad police. A review of the same documents revealed that the official did not find any evidence of the allegation. Resident CL1 had a Urinary Tract infection (UTI) and was receiving antibiotics. The physician was informed. A review of the facility documentation, unsigned and unnamed statement completed on January 7, 2020, revealed that at 11:00 p.m. on January 6, 2020, Resident CL1 was upset for not helping his/her roommate (Resident CL2). Resident CL1 accused the previous shift (3-11 shift) of letting the roommate out of the hallway naked. Resident CL1 pushed Resident CL2 ' s wheelchair down the hall and became agitated when the staff intervened. Resident CL1 was redirected and both residents were brought back to their room. Resident CL2 was put back to bed to sleep. The documentation revealed that Resident CL1 kept on going to the main door to look for his/her son and the police. The resident kept yelling at the staff to get away from his/her room. At around 12:30 a.m. the resident was on the phone calling 911 then went to the hall and accused previous shift staff (3-11 shift) of molesting and drugging their roommate. State police arrived and spoke to Resident CL2 and informed the police that he/she was ok. The statement indicated that the staff (writer of the statement) stayed with the residents to settle them down and showed Resident CL1 that Resident CL2 was fine. Resident CL2 had taken off their clothes. Review of the facility documentation, that included a statement from Nurse Aide (NA) Employee E4 revealed that Resident CL1 was trying to push Resident CL2 down the hall in a wheelchair. NA Employee E4 stated that he/she took Resident CL2 back to the room and laid him/her to bed. Resident CL1 came into the room and questioned the staff why Resident CL2 was put back to bed if it is not yet their sleeping time. Resident CL1 said that he/she will call 911 for help. Review of Resident CL2's progress note dated January 7, 2020, at 4:41 p.m. revealed resident was found on the floor, claimed he/she slid off the bed. Nightgown was in the wheelchair, resident refused to put nightgown on, the resident had undershirt and pull-ups on. Review of the clinical records, facility's documentation, investigation report, staff, and resident's statements, did not include that statements were obtained from the 3-11 shift staff. A comprehensive statement for Resident CL1 regarding the incident on the day of the incident was not completed, there was no documentation of Resident CL2's statement, and record that both residents were assessed post rape allegation. An interview with the Director of Nursing (DON) on May 12, 2021, at 1:00 p.m., revealed that both Nursing Home Administration and DON who did the investigation were no longer in the facility. The documents provided to the surveyor was the only thing found. A review of Resident CL1's progress note dated January 7, 2020, at 10:45 a.m., revealed that the Social Worker (SW) Employee E3, was notified by nursing regarding the resident calling 911 last evening with accusatory statements of potential rape. Accusations were unfounded by the officers however resident was still anxious and verbalizing issues. SW Employee E3 visited the resident and stated that he/she was not raped. The daughter was notified. An interview with SW Employee E3 on May 12, 2021, at 1:30 p.m., confirmed that it was Residents CL1 and Resident CL2 were the residents involved on January 7, 2020 rape allegation submitted by the facility to the state agency. SW Employee E3 stated that an interview was conducted with Resident CL1 on the morning of January 7, 2020. SW Employee E3 stated that Resident CL1 informed him/her that he/she was not raped. When asked if Resident CL2 was interviewed, SW Employee E3 stated that they did not feel the need to interview Resident CL2 since Resident CL1 rectified the incident. The above was conveyed to the DON on May 12, 2021, at 2:30 p.m. The facility failed to thoroughly investigate an allegation of abuse for Residents CL1 and Resident CL2. Review of Resident R12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R12's MDS dated [DATE], revealed that the resident required limited one-person assistance with transferring and ambulation in the room. Review of a progress note for Resident R12 dated January 22, 2021, at 4:18 p.m. revealed that at 10:30 a.m., the resident was found on the floor. The resident stated that she/he was going to the bathroom but fell backward while walking. The resident was assessed, and order of right hip and pelvic x-ray was made by the physician. Review of the x-ray result dated January 22, 2021, revealed bilateral hips replacements but no acute fracture. Review of Resident R12's progress notes dated January 24, 2021, at 11:31 a.m. revealed resident is alert, oriented, and confused at times, post-fall with no visual injuries, had loose stool this morning. Review of Resident R12's progress notes dated January 27, 2021, at 1:23 p.m. revealed that the resident was out of bed into wheelchair with the maximum assist of one person. The resident complained of increased pain, the physician was notified and ordered another x-ray of both hips and pelvis. A review of the same note revealed that the daughter was notified and during the notification, the daughter stated that the resident was more confused when talking to her on the phone, the daughter stated that the resident was unable to redirect or reoriented during the conversation on the phone. A review of the x-ray results dated January 27, 2021, revealed an acute left pubic rami fracture (fractures of the anterior pelvic ring). Review of Resident R12's progress note dated January 28, 2021, revealed that the physician and daughter were aware of the x-ray result. The physician ordered WBAT (Weight Bearing as Tolerated) and ok to do physical therapy tomorrow. Review of Resident R12's clinical record lacked evidence that the facility had investigated an injury of unknown cause. An interview with the NHA on May 13, 2021, at 10:00 a.m. confirmed that an investigation was not conducted for Resident R12's injury of unknown origin identified on January 27, 2021. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10(a)(d) Resident Care Policies

Based on a review of employee personnel records and staff interview, it was determined that the facility failed to complete annual performance reviews for five of five Nurse Aides reviewed (Employee E4, E5, E6, E7 and E8). Findings include: A list of Nurse Aides provided by the facility for review failed to reveal that the following employees had an annual performance review completed by the facility: Employee E4 (Date of Hire-March 11. 2019), Employee E5 (Date of Hire - November 22, 2011), Employee E6 (Date of Hire- June 14, 2016), and Employee E7 (Date of Hire-April 19, 2011), and Employee E8 (Date of Hire-February 11, 1988) An interview with the Nursing Home Administrator on May 12, 2021, at 3:00 p.m. confirmed that the annual performance reviews of the above employees was not conducted in the year 2020. The facility failed to complete the annual performance reviews for Nurse Aide Employees E4, E5, E6, E7, and E8. 28 Pa. Code 201.19 Personnel policies and procedures

Based on observation and staff interview, it was determined that the facility failed to store foods that were labeled and dated and failed to maintain a juice dispenser in a sanitary manner in the kitchen. Findings include: During the initial tour of the kitchen on (MONTH) 28, 2019 at approximately 12:40 p.m., accompanied by Employee E5, the Director of Culinary Services and Nutrition, the following observations were made: A plastic tub, approximately one gallon in size, was dated with a discard date of (MONTH) 25, 2019; a package of corn meal, with an opened date of (MONTH) 20, 2019 with no discard date and a box of cream of wheat, opened and placed in a plastic bag, with no open or discard date. An additional observation was made of a juice dispenser machine with the dispensing tube observed with a black substance and various colors of residue around the base of the dispenser. Interview with Employee E5, at the time of the tour, confirmed the aforementioned observations. 28 PA Code 201.14(a) Responsibility of licensee 28 PA Code 201.18(b)(1)(3) Management 28 PA Code 201.18(e)(1) Management 28 PA Code 211.6(f) Dietary services

Based on review of facility policy and procedure and clinical record review, it was determined that the facility failed to ensure that physician's orders were followed for the administration of medication for two of 14 residents reviewed (Resident #14 and Resident #38). Findings include: Review of facility policy and procedure titled Medication Administration and Management revealed Prior to Medication Administration: All authorized community staff should adhere to the following guidelines: a. Verify the correct drug, correct dose, correct route, correct rate, correct time and correct resident prior to each medication administration; b. Confirm that the Medication Administration Record [REDACTED]. Review of Resident #14's [DIAGNOSES REDACTED]. Review of Resident #14's (MONTH) (YEAR) physician's orders revealed an order dated (MONTH) 2, (YEAR) for [MEDICATION NAME] (medication used to treat high blood pressure) 12.5 milligrams (mg) to be administered twice daily in the morning and evening, hold if systolic blood pressure (SBP - measure of blood pressure while heart is beating) was below 100 mm Hg (millimeters of mercury) or heart rate was below 60 beats per minute. Review of Resident #14's nursing notes dated (MONTH) 5, (YEAR) revealed BP (blood pressure) 104/52 this morning before [MEDICATION NAME] 12.5mg; dose given. No other meds given at that time. When remainder of meds administered, [MEDICATION NAME] inadvertently given again. bp 90/60. Review of facility documentation revealed that licensed nurse Employee E3 administered Resident #14's [MEDICATION NAME] 12.5 mg at 7:30 a.m. and again at 9:45 a.m. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 31, 2019 at 1:10 p.m. confirmed that licensed nurse Employee E3 failed to follow Resident #14's physician's orders by administering [MEDICATION NAME] 12.5 mg twice in the morning of (MONTH) 5, 2019. Further review of Resident #14's physician's orders revealed an order for [REDACTED]. Review of Resident #14's progress notes revealed a nurse's note dated (MONTH) 22, (YEAR) which stated that the resident received Aspirin 325 mg at approximately 9:40 p.m. for complaints of having a headache. The note further revealed Unable to document (aspirin), as it was discovered to have been (discontinued related to) pending surgery. Review of facility documentation revealed that licensed nurse Employee E4 was educated to administer medications utilizing the facility's electronic Medication Administration Record [REDACTED]. Interview with the Nursing Home Administrator and Director of Nursing at 1:10 p.m. confirmed that licensed nurse Employee E4 administered discontinued Aspirin 325 mg to Resident #14. Review of Resident #38's [DIAGNOSES REDACTED]. Review of Resident #38's physician's orders revealed an order dated (MONTH) 25, 2019 for [MEDICATION NAME] (narcotic pain medication) 50 milligrams (mg) to be administered every day. Review of Resident #38's Controlled Substance Prescription dated (MONTH) 13, 2019 revealed a new order for [MEDICATION NAME] 50 mg to be administered two times per day. Review of Resident #38's nursing progress note dated (MONTH) 27, 2019 revealed attempted to contact this resident's daughter regarding medication error but the phone sounds like a fax machine, and the son is out of the country. Review of Resident #38's (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 31, 2019 at approximately 2:00 p.m. confirmed that Resident #38 received the wrong dose of medication from (MONTH) 13, 2019 through (MONTH) 27, 2019. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that appropriate interventions, assessments, and documentation were provided to prevent pressure ulcer development for one of five residents reviewed for pressure ulcers (Resident #4). Findings include: Review of facility policy Skin Integrity - Impaired, undated, revealed that when impaired skin integrity is identified, the facility will have and initial wound assessment and weekly wound assessment completion and evaluation of treatment interventions using the Wound Assessment form. Further review of the policy revealed that unstageable pressure ulcers were defined as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. The policy further stated that avoidable pressure ulcers occur when the staff do not define and implement interventions consistent with resident's needs/goals and standards of practice, monitor and evaluate the impact of the interventions, (and) revise the interventions as appropriate. Review of Resident #4's Braden Scale for Predicting Pressure Score Risk assessment dated (MONTH) 20, (YEAR) revealed the resident had a score of 19, placing the resident as not at risk for developing pressure ulcers. Review of Resident #4's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 23, (YEAR) revealed under section G - Functional Status that the resident required limited assistance by one staff person for bed mobility. Further review of Resident #4's MDS revealed under Section M - Skin Conditions that the resident was at risk for developing pressure ulcers. Review of Resident #4's progress notes revealed that on (MONTH) 21, 2019, nursing discovered a wound to the resident's right lateral foot (the outer side of the right foot.) Review of Resident #4's initial wound assessment by nursing revealed that nursing identified the wound as a State 2 (superficial break/blister, partial skin loss) measuring 1.2 centimeters (cm) by 1.3 cm, and unable to determine depth due to a scab within the wound measuring 0.7 cm by 0.5 cm. Further review of Resident #4's progress notes revealed the resident was seen by podiatry on (MONTH) 21, 2019 and assessed the wound as a stage 1 with stable eschar scab (stage 1 pressure ulcers are intact skin with non-blanchable redness). The progress note further revealed Resident sleeps on her right side only which contributes to the problem and finding a solution. Review of Resident #4's care plan initiated on (MONTH) 1, (YEAR) identified the resident as having a potential impairment of skin integrity. Review of the interventions in place prior to (MONTH) 21, 2019 revealed the following interventions: consult therapies as indicated for skin related issues (January 7, 2019), educate the resident and family/care givers of causative factors and measures to prevent injury to skin (June 1, (YEAR)), help resident avoid scratching and keep resident hands and body free from excessive moisture; keep fingernails short (June 1, (YEAR)), consult dermatology as recommended (November 27, (YEAR)), and make sure the resident's nails were cut short with each bath day (June 1, (YEAR)). Review of the resident's care plan failed to reveal any interventions addressing resident's feet or the resident sleeping only on the right side. Review of Resident #4's (MONTH) 2019 physician's orders [REDACTED]. Secure with tape. Remove in morning. Further review of Resident #4's progress notes revealed a nurse's note on (MONTH) 29, 2019 stating noted a new area of skin breakdown on left heel medial aspect (inner part of left heel). Area measures 1.5 x 3.0 with red/yellow eschar. Review of Resident #4's podiatry note from the same date revealed New wound on left foot plantar medial heel. Area is dry with apparent stable eschar .No known trauma. In a location that pressure wound note likely. Trauma? Wound left foot. Review of Resident #4's initial wound assessment from (MONTH) 29, 2019 identified the wound as a question mark (?). Review of Resident #4's weekly wound assessments revealed the wound was continuously identified as a question mark each week until (MONTH) 1, 2019, when it was called an unstageable pressure ulcer. Further review of Resident #4's progress notes revealed on (MONTH) 30, 2019, staff provided a large piece of sheepskin under the sheet in the area where resident kept her feet to provide pressure relief. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on (MONTH) 31, 2019 at approximately 10:30 a.m. confirmed that Resident #4 always slept on the right side. The NHA and DON were asked to provide evidence that interventions were attempted to prevent skin breakdown to Resident #4's feet prior to the development of the right foot wound on (MONTH) 21 2019. The NHA confirmed at 12:05 p.m. that there was no documented evidence that there were interventions attempted prior to the (MONTH) 21, 2019 development of the right foot wound. Further discussion with the NHA and DON at approximately 1:00 p.m. confirmed that there were no interventions in place to prevent breakdown to the left heel on (MONTH) 29, 2019 following the development of the right heel wound on (MONTH) 21, 2019. Further discussion confirmed the inconsistencies in assessing and documentation regarding both wounds. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide appropriate treatment and services to maintain mobility for one of one resident reviewed (Resident #1). Findings include: Observation of Resident #1 on (MONTH) 29, 2019 at approximately 10:30 a.m., revealed resident's right hand contracted. Review of resident's quarterly assessment, dated (MONTH) 18, (YEAR) revealed [DIAGNOSES REDACTED]. The quarterly assessment also indicated in Section G 400, Functional Limitation in Range of Motion, that the resident had no impairment in the upper extremities. Review of resident's annual assessment, dated (MONTH) 17, (YEAR), Section G 400, revealed that the resident had impairment in one side of the upper extremities. Review of Section O, Restorative Nursing Programs, for both the quarterly and the annual assessments revealed no evidence services received. Review of nursing notes, dated (MONTH) 19, (YEAR), revealed that the resident was noted to have an inability to open right hand with recommendation for x-ray and occupational therapy evaluation. Review of occupational therapy evaluation, which was not completed until (MONTH) 3, (YEAR), revealed that resident presents with right wrist and hand in hyperflexion (flexion or bending of a limb or part beyond the normal limit) and all five digits in fist with severe grimacing with attempt to open digits. The evaluation further indicated that the goal was for the resident to tolerate a right hand orthotic for four hours per day and that caregiver staff would be trained on donning/doffing the orthotic, wearing schedule and assessment for skin breakdown. Review of care plan for decreased mobility and risk for skin breakdown and inability to open hand fully, which was developed on (MONTH) 27, (YEAR), revealed no interventions related to the resident's inability to open hand fully until (MONTH) 2, 2019 when an intervention indicating that the resident was unable to fully open her right hand, had been seen by occupational therapy and had trialed the carrot with no success. Review of initial wound assessment documentation, dated (MONTH) 10, 2019, revealed a new wound related to moisture associated skin disease (MASD) on the resident's right hand contracture. Review of weekly wound assessment revealed that this area healed on (MONTH) 4, 2019. Review of initial wound assessment, dated (MONTH) 17, 2019, revealed a recurrent MASD on the palm of the resident's right hand contracture with brown foul smelling drainage. Review of weekly wound assessment revealed that this area was resolved on (MONTH) 26, 2019. Further review of the care plan for decreased mobility and risk for skin breakdown and inability to open hand fully revealed no evidence of any interventions to address these MASD areas until (MONTH) 2, 2019 when there was an intervention for polymem (dressing containing a cleanser, moisturizer and refined cornstarch) to be placed in the resident's right hand palm and to try to clean the wound when the resident was able to keep her hand open long enough and that premedication was necessary prior to the treatment. This intervention was resolved on (MONTH) 31, 2019. Further review revealed an intervention initiated on (MONTH) 6, 2019 when an intervention to check the right hand for odor or obvious breakdown with weekly skin assessment was initiated. Interview with the nursing home administrator and director of nursing on (MONTH) 31, 2019 at approximately 1:30 p.m. confirmed that the right hand contracture was noted on (MONTH) 19, (YEAR), a recommendation was made for occupational therapy evaluation which was not completed until (MONTH) 3, (YEAR) and that there was no evidence of any restorative treatment in place to prevent further decrease in range of motion. The director of nursing further indicated that possibly the occupational therapy evaluation was pending approval from hospice but then confirmed that it would not take six weeks to receive approval from hospice so could not explain for the delay in the evaluation. The facility failed to provide appropriate treatment and services to maintain mobility for one resident. 28 PA Code 201.18(b)(1) Management 28 PA Code 211.10(a)(c)(d) Resident care policies 28 PA Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records, review of facility documentation, staff interview and review of facility policies and procedures, it was determined that the facility failed to ensure that adequate monitoring, supervision and interventions were provided to prevent falls and injuries for three of 14 residents reviewed (Resident B14, Resident C16, and Resident D4) which resulted in actual harm to Resident B14 sustaining a fall with injuries and transfer to the hospital. Findings include: Review of the facility policy and procedure titled, Incident Reporting/Injury Investigation Residents and Visitors, revised July 2017, revealed the facility was to ensure that, incidents involving a resident or visitor are recorded, patterns, or trends of occurrences are investigated, and measures are implemented to alleviate or decrease further occurrences. Review of the facility policy and procedure titled, Falls Reduction and Management, revised February 2016, revealed, the licensed nurse will assess all residents for risk of falls upon admission to the skilled care center, quarterly and with any significant change; after the resident has been assessed and potential causes for falls have been identified, the interdisciplinary care plan team will identify appropriate preventive measures and interventions; resident falls will be reviewed at the stand-up meeting. Further review of this policy and procedure revealed, discussion at the weekly meetings included investigation regarding the causes of the fall, review appropriate strategies to reduce falls, determination of patterns of falls, development of individual interventions/approaches and recommendations for prevention of future occurrences. Review of Resident B14's [DIAGNOSES REDACTED]. Review of Resident B14's clinical record revealed that the resident was admitted to the facility on [DATE], from an acute care facility after sustaining a fall at home and fracturing the left hip and cervical vertebrae (bone of the neck). Review of Resident B14's discharge orders from the hospital revealed that Resident B14 was to maintain Total Hip Precautions as follows: maintain pillow between knees; no bending more than 90 degrees at the waist; do not bend forward when sitting; do not raise or position knees higher than your hip when sitting; no crossing legs; no turning operative leg inward toward center of body and that the resident needed assistance for bed mobility Further review of Resident B14's discharge orders from the hospital revealed that Resident B14 was to wear an Aspen Collar (hard collar worn around the neck for stability after a neck fracture) at all times. Review of Resident B14's physician admission orders [REDACTED]. Review of Resident B14's clinical progress note dated August 12, 2016, revealed that the resident requires constant supervision for safety and 1:1. (visual supervision of one staff person) Review of the Activities of Daily Living daily documentation dated August 13 and August 14, 2016, revealed that Resident B14 was assessed as requiring total dependence on staff for bed mobility. Further review of the resident's clinical record revealed that Resident B14's initial care plan after admission did not include the resident's need for total dependence with bed mobility. Review of the information dated August 14, 2016, submitted by the facility revealed that Resident B14 was provided incontinence care in the resident's bed on August 14, 2016, at approximately 6:30 a.m. The information noted that during the incontinence care, Resident B14 was instructed by the nurse aide to turn onto the resident's side. Resident B14 turned in the bed and proceeded to roll off the side of the bed onto the floor from a height of approximately three feet. Resident B14 sustained a hematoma (bruise) on the right side of the forehead measuring 7 centimeters (cm) x 2.5 cm; an abrasion to the right side of the forehead measuring 0.5 cm x 0.2 cm; a laceration to the left elbow measuring 4.5 cm x 2.5 cm; a skin tear to the left forearm measuring 2 cm x 1 cm; a skin tear to the right forearm measuring 2.5 cm x 0.7 cm; a skin tear to the left inner knee measuring 2 cm x 1 cm; a skin tear to the right forearm measuring 1.5 cm x 0.7 cm; a skin tear to the left inner knee measuring 2 cm x 1 cm; an abrasion to the right knee measuring 4 cm x 0.2 cm and a reddened area to the left lower shin measuring 4.5 cm x 2 cm. Resident B14 was transferred to the hospital for evaluation. During an interview with Licensed Nurse, Employee E4, on July 31, 2017, at approximately 11:00 a.m. revealed that two staff members are required to turn, reposition and provide incontinence care for residents who are totally dependent. During an interview with Nursing Assistant, Employee E5, on July 31, 2017, at approximately 11:15 a.m. revealed that two staff members are required for turning, repositioning and providing incontinence care to residents who required total dependence. During an interview with the Nursing Home Administrator and the Director of Nursing on August 1, 2017, at approximately 9:00 a.m. confirmed that Resident B14 did not have two staff members to assist in turning, repositioning and incontinence care on August 14, 2016, which resulted in actual harm to Resident B14 who sustained a fall, subsequent injuries and transfer to the hospital. Review of Resident C16's [DIAGNOSES REDACTED]. Review of Resident C16's Fall Risk Evaluations dated June 16, 2016, through June 14, 2017, revealed that Resident C16 was a high risk for falls. Review of Resident C16's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated December 16, 2016, and Annual MDS dated [DATE], revealed that Resident C16 required extensive assistance of one staff member for transferring, bed mobility, ambulation and toileting. Review of Resident C16's clinical record revealed that on October 16, 2016, Resident C16 was found by incoming staff on the floor of the lounge area in front of a recliner chair. On November 5, 2016, Resident C16 was placed in a resident lounge area chair at 9:45 p.m. and at 10:00 p.m. Resident C16 was found sitting on the floor in front of a recliner chair. On February 17, 2017, at 4:05 p.m. Resident C16 was found sitting on the floor of the lounge between the wheelchair and lounge chair. On July 26, 2017, at 7:00 p.m. Resident C16 was seen by a visitor attempting to transfer from a wheelchair to a porch lounge chair and the resident fell on to the floor. During an interview with the Director of Nursing and the Nursing Home Administrator on July 31, 2017, it was revealed that the staff members should be present in the lounge area to monitor the residents at all times while residents are occupying the lounge. Review of Resident C16's clinical record failed to reveal that a staff member was present in the lounge area when Resident C16 was placed in the lounge on the above stated dates, which resulted in the resident sustaining four falls in the lounge area. Review of Resident D4's nursing notes revealed that on February 4, 2017, at 8:00 a.m. a nursing assistant was in a resident room and heard a loud noise. The nursing assistant went over to the next room to find the resident lying on floor near her bed and was face down with her head near bottom of the bed. The resident was sent to the hospital trauma center at 8:15 a.m. On February 4, 2017, at 1:46 p.m. the facility called the hospital emergency room and was told that Resident D4 had been admitted to the trauma ICU (Intensive Care Unit) with possible Traumatic Brain Injury (TBI - also known as intracranial injury which occurs when an external force injures the brain). Further review of Resident D4's clinical record revealed that on February 8, 2017, at 4:45 p.m. resident was readmitted to the facility. Review of Resident D4's clinical record revealed that on June 16, 2017, at 2:00 p.m. the resident was found lying on the floor on her right side in a partial upright position at the right side of the bed and in front of the night stand. A bruise was noted posterior to the right shin measuring 7 centimeters by 3.4 centimeters. An interview conducted with the Nursing Home Administrator and Director of Nursing on August 1, 2017, at approximately 3:30 p.m. revealed that after the fall, a fall mat (a cushioned mat placed on the floor when a resident is in bed) was to be placed on the floor next to the bed at the left side. An observation of Resident D4 on July 28, 2017, at 10:30 a.m. revealed the resident was lying in bed with the fall mat folded in half and standing upright between the head of the bed and night stand. Further observation of Resident D4 on July 28, 2017, at 11:00 a.m. revealed the resident was still lying in bed with the fall mat folded in half and standing up between the head of the bed and night stand. The aforementioned findings were reported to the Nursing Home Administrator and the Director of Nursing on August 1, 2017, at approximately 3:30 p.m. who acknowledged the floor mat should have been placed on the floor at the side of the bed. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.5(f) Clinical records Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/01/15, 05/06/16

Based on review of facility policy, observations and interview with staff, it was determined that the facility failed to prepare, maintain and store food in a sanitary manner and the facility failed to have a system implemented to label and date food supplies. Findings include: Review of the facility policy titled, Date Marking Ready-To-Eat Foods, revised October 2011, revealed that all ready-to-eat foods will be labeled to include the following information: All ready-to-eat foods will be date marked to strive to ensure appropriate rotation and prevent foodborne illness. Product name and date (month, day, year) the product was prepared or opened and the date the product should be used by. Label all ready-to-eat, potentially hazardous foods that are prepared on-site. Label any processed, ready-to-eat, potentially hazardous foods when opened. Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use the time limits on the food storage chart unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1 (first 24 hours). Serve or discard refrigerated, ready-to-eat, potentially hazardous foods within 3 days. Calculate the 3-day period by counting only the days that the food is under refrigeration. Food Storage Chart: In Dry Storage area, Bread and rolls - if not dated by the manufacturer, add a sticker with an expiration date of 4 days from delivery or removed from freezer. Observation of the dietary department during the initial tour on July 26, 2017, at approximately 12:15 p.m. accompanied by the Director of Culinary Services, revealed the following: - The Director of Culinary Services, Employee E12, was not wearing a beard guard, throughout the initial tour of the main kitchen. - The handwashing sink located in the main food preparation area had no paper towels in the paper towel dispenser and did not have a trash bag in the covered step-on trash receptacle. - In the #1 Walk in Refrigerator, there was a package of Parmesan Cheese not dated when received and was not dated with a shelf life (use by date); there was a block of Romano Cheese dated June 4, 2017, with a shelf life of June 11, 2017; there was a bag of fresh carrots dated July 20, 2017, with a shelf life of July 25, 2017; and there was a container of stewed tomatoes dated July 28, 2017, and the lid was not closed tightly. -In the dry storage area, there were four loaves of raisin bread, five loaves of whole wheat bread, including two opened loaves and eleven loaves of white bread which were not dated. -In the reach-in refrigerator, there was an open box of frozen fish fillets which was not securely wrapped. There were six sweet potatoes which were found in a metal pan with no label. -There was a cardboard box of Idaho potatoes, one third full and dated July 10, 2017, which contained a rotten potato, and gnats were observed around box. A plastic container containing Buckwheat had a lid with a large amount of dirt and debris on it. -There was a sugar bin dated July 13, 2017, which was one third full with hard large clumps of sugar inside the bin and a broken lid. The bin and lid was covered with dirt and debris. -The flour bin was half full and was covered with dirt and debris. -There were three scoop holders above the bins that were covered with dirt and debris inside and out. I -In the produce refrigerator was a plastic container labeled pasta salad which was not covered. During an observation on July 26, 2017, at approximately 12:45 p.m. the Director of Culinary Services proceeded to test the sanitizer solution in the three-compartment sink, which was being used to clean pots and pans, which revealed the chemical concentration of 50 ppm (parts per million). During an interview with Director of Culinary, at the time of this testing, it was confirmed the test strip should read between 200 to 400 ppm. During an observation on July 31, 2017, at 8:20 a.m. Dietary Aide, Employee E11 proceeded to test the sanitizer solution in the red bucket which was used to wipe down the food prep area, which revealed the chemical concentration of 50 ppm, acknowledged the reading was not in the right range. During an interview with the Director of Culinary Services on July 31, 2017, at approximately 8:25 a.m., it was confirmed the test strip should read between 150 to 200 ppm. 42 CFR 483.60(i)(1)-(3) Food Procure, Store/Prepare/Serve-Sanitary Previously cited 05/06/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 06/01/15, 05/06/16

Based on clinical record reviews and staff interview, it was determined that the facility failed to complete teh monthly pharmacy medication reviews and failed to timely act upon pharmacy recommendations for four out of 14 residents reviewed (Residents A11, C5, C11 and D4). Findings include: Review of Resident A11's consultant pharmacist medication regimen review report revealed that there was no documented evidence in the resident's clinical record that the resident's medication review had been reviewed for the months of April, May, June and July 2017. Interview with the Director of Nursing on July 31, 2017, at approximately 11:45 a.m. confirmed there was no documented evidence in Resident A11's clinical record that the consultant pharmacist had reviewed the resident's medications for the months of April, May, June and July 2017. Review of Resident C5's Pharmacy Consultation Report revealed a report dated June 28, 2017, which recommended that instructions for the ordered Tylenol (pain medication) be added to the order. Review of the response revealed there was only a note that stated that this was documented on the Tylenol order already, however, there was no signature or date and time of the response. Review of Resident C11's Pharmacy Consultation Reports revealed a report dated March 23, 2017, with a comment stating there was no [DIAGNOSES REDACTED]. Under the physician's response was written the word restlessness, however, there was no signature or date and time that this concern was addressed by the physician. Further review of Resident C11's Pharmacy Consultation Reports revealed a report dated May 31, 2017, that stated the resident received Melatonin (a sleep aid) 3 milligrams, can a GDR (Gradual Dose Reduction) be completed. Under the physician's response there was no response from the physician. During an interview with the Director of Nursing on July 31, 2017, at 11:45 a.m. it was confirmed that the pharmacy consultant reports were not addressed timely and completely by the physician. Review of Resident D4's clinical record revealed a recommendation from the facility's consultant pharmacist dated June 28, 2017, that revealed Resident D4 was on a routine opioid analgesic, Oxycodone HCL (a narcotic used in treatment of [REDACTED]. Further review of Resident D4's clinical record revealed that the recommendation from the facility's consultant pharmacist was not reviewed and signed by Resident D4's physician until July 31, 2017. During an interview with the Director of Nursing on August 1, 2017, at approximately 10:45 a.m. it was confirmed Resident D4 was changed to a new physician and had not signed the pharmacy recommendation yet, but ordered Colace (medication for the treatment of [REDACTED]. The facility failed to ensure that pharmacy medication reviews were completed monthly and pharmacy recommendations were acted upon timely for Residents A11, D4, C5 and C11. 28 Pa. Code 211.12(a) Physician services 28 Pa. Code 211.5(h) Clinical records

Based on observation, staff interview and review of manufacturer guidelines, it was determined the facility failed to ensure that medications were properly stored, labeled and safely secured according to professional standards on three of three medication carts and failed to maintain an accurate narcotic reconciliation for one of 14 residents reviewed (Resident CL1). Findings include: Review of manufacturer's guidelines for Novolog Insulin (medication used to treat high blood sugar) FlexPen revealed that unopened Novolog FlexPens should be stored in the refrigerator. Further review of manufacturer's guidelines for Novolog FlexPen revealed that the medication must be discarded 28 days after opening and/or removal from refrigeration. During an observation on July 26, 2017, at approximately 12:05 p.m. the Brandywine Junction medication cart revealed one unopened, unrefrigerated Novolog FlexPen (insulin medication). Interview with Licensed Nurse, Employee E3, on July 26, 2017, at approximately 12:05 p.m. confirmed that the Novolog FlexPen was unopened and unrefrigerated. This interview also revealed that there was no information regarding when the Novolog FlexPen was removed from refrigeration and placed in the medication drawer. During an observation on July 26, 2017, at approximately 12:00 p.m. the Meadows Run medication cart revealed one unlabeled medicine cup containing nine unlabeled pills. Observation on July 27, 2017, at 11:15 a.m. during a wound treatment, Licensed Nurse, Employee E7, removed a tube of Santyl 250 unit/1 gram ointment (used to help the healing of skin ulcers) and a tube of Mupirocin 2% ointment (an antibiotic used topically to prevent bacteria from growing on skin) from the drawer of the medication cart. Employee E7 then placed the two tubes of medication on the top of the cart and left the medication cart to retrieve treatment supplies from the nurses station, which was approximately 30 feet from Resident A11's room, where the treatment was to occur and out of sight of the medication nurse. Employee E7 then entered Resident A11's room, closed the door and proceeded to disinfect the over-bed table. Employee E7 then checked her pockets for the two tubes of ointment, excused herself and left the room to find the two tubes of ointment lying on top of the medication cart. Employee E7 failed to keep biologicals in a locked drawer, for a total of ten minutes (11:20 to11:30 a.m.). Review of Resident CL1's April 2017 physician orders [REDACTED]. Review of Resident CL1's Medication Administration Record [REDACTED]. Further review of Resident CL1's Controlled Medication Utilization Record dated April 2017 revealed that on April 8, 2017, Oxycodone 5 mg was removed from the narcotic control box at 1:00 a.m. and 9:00 p.m. Further review of Resident CL1's April 2017, MAR indicated [REDACTED]. Continued review of Resident CL1's Controlled Medication Utilization Record dated April 2017 revealed that on April 9, 2017, at 8:45 p.m. one dose of Oxycodone 5 mg was removed from the narcotic control box. Further review of Resident CL1's April 2017, MAR failed to reveal that a dose of Oxycodone 5 mg was administered to the resident on April 9, 2017. Further review of Resident CL1's Controlled Medication Utilization Record dated April 2017 revealed that on April 13, 2017, Oxycodone 5 mg was removed from the narcotic control box at 12:15 a.m. and 7:05 p.m. Further review of Resident CL1's April 2017 MAR indicated [REDACTED] Observation of a medication cart on July 28, 2017, at 12:32 p.m. revealed the medication cart was unlocked and the medications were accessible to the residents. Further observation revealed the cart was directly across from the dining room and two residents were observed walking past the medication cart from the dining room back to their rooms. During an interview with the Director of Nursing on July 28, 2017, at 12:37 confirmed that the when the medication cart was unattended, it should be locked and secured. 42 CFR 483.45(b)(2)(3)(g)(h) Drug Records, Label/Store Drugs & Biologicals Previously cited 05/06/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.9(g)(h) Pharmacy services 28 Pa. Code 211.12(c) Nursing services Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/06/16, 04/05/17

Based on observations, it was determined that the facility failed to maintain resident's privacy while providing care for two of 14 residents reviewed (Residents C5 and A11) Findings Include: During an observation of Resident C5's recently healed pressure ulcer area to the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) on July 27, 2017, at 10:30 a.m. it was observed that the resident was in a first floor room in a double occupancy room in the bed next to the window. Licensed Nursing Employees E2 and E3 pulled down the resident's sheet, blanket and the resident's incontinence brief and turned Resident C5 onto their right side. Resident C5 was uncovered from the waist down and the window in the room did not have the curtains drawn, allowing for anyone walking by to be able to see Resident C5's sacral area. A medication pass observation on July 27, 2017 at 9:35 a.m. for Resident A11, revealed the resident lying in bed on her right side, facing toward the window. Resident A11 was uncovered from the waist down exposing the resident's left hip and buttocks. Resident A11's door to the room was opened allowing for anyone walking by to be able to see Resident A11's left hip and buttock area. These findings were brought to the attention of the Nursing Home Administrator and the Director of Nursing on August 1, 2017 at 3:15 p.m. 42 CFR 483.10(h)(1) Personal Privacy/Confidentiality of Records Previously cited 06/01/15 28 Pa. Code 201.29(j) Resident rights

Based on review of facility documentation, facility policy and procedure,and clinical record reviews, it was determined that the facility failed to ensure that injuries of unknown source were thoroughly and timely investigated for two of 14 residents reviewed (Resident B1 and Resident B14). Findings include: Review of the facility policy and procedure entitled, Abuse, Neglect, Involuntary Seclusion, Exploitation and Misappropriation of Property Prevention, revised December 2016, revealed anyone who finds an injury of unknown origin must immediately report the incident to his/her department supervisor. Review of the facility policy entitled, Incident Reporting/Injury Investigation Residents and Visitors, revised June 2016, revealed if the incident was of unknown etiology and further investigation was needed for any incident including unwitnessed falls, staff on the three shifts over the twenty-four hours preceding the incident will be interviewed and will complete written statements concerning their observation of the incident. Further review of this policy revealed that completed incident reports are to be reviewed by the Director of Nursing as soon as completed, but no later than the next business day following the incident. Review of Resident B1's [DIAGNOSES REDACTED]. Review of Resident B1's facility documentation revealed that on June 23, 2016, a bruise was discovered on the resident and one staff statement was not completed until August 10, 2016. On September 14, 2016, a bruise was discovered on the resident and two staff statements were not obtained until October 1, 2016. Another bruise was discovered on September 18, 2016, and two staff statements were not obtained until October 1, 2016. On January 16, 2017, a reddened area was noted on Resident B1's left flank area and no investigation or incident report was initiated. Review of Resident B14's [DIAGNOSES REDACTED]. Review of facility documentation revealed that a bruise of unknown origin was discovered on Resident B14 on October 30, 2016. Further review of facility documentation revealed that two staff statements obtained for the investigation of the bruise were not signed or dated. One staff statement obtained for the investigation was dated November 13, 2016 and the completed investigation was not reviewed, signed or dated by the Director of Nursing upon completion. Review of facility documentation dated January 24, 2017, revealed Resident B14 sustained a bruise of unknown origin. Further review of the facility documentation revealed that one staff statement obtained for the investigation of the bruise was not obtained, signed or dated until February 7, 2017. Review of facility documentation dated July 21, 2017, revealed Resident B14 sustained a bruise of unknown origin. Further review of facility documentation revealed that one staff statement obtained for the investigation of the bruise was incomplete and undated. During an interview with the Director of Nursing on July 31, 2017, at approximately 2:00 p.m. it was confirmed that the investigations of injuries of unknown origin were incomplete. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 06/01/15, 05/06/16 28 Pa. Code 201.29(a)(c) Resident rights Previously cited 05/06/16 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(c) Nursing services Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 06/01/15, 05/06/16

Based on review of facility policy and procedure, review of clinical records and observations, it was determined that the facility failed to ensure that care plans were developed or updated to reflect the needs for two of 14 residents reviewed (Resident C16 and Resident CL2). Findings include: Review of Resident C16's [DIAGNOSES REDACTED]. Review of Resident C16's Fall Risk Evaluations dated June 16, 2016, through June 14, 2017, revealed that Resident C16 was a high risk for falls. Review of Resident C16's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated December 16, 2016, and Annual MDS dated [DATE], revealed that Resident C16 required extensive assistance of one staff member for transferring, bed mobility, ambulation and toileting. Review of Resident C16's clinical record revealed that on October 16, 2016, Resident C16 was found by incoming staff on the floor of the lounge area in front of a recliner chair. On November 5, 2016, Resident C16 was placed in a resident lounge area chair at 9:45 p.m., and at 10:00 p.m. Resident C16 was found sitting on the floor in front of a recliner chair. On February 17, 2017, at 4:05 p.m. Resident C16 was found sitting on the floor of the lounge between the wheelchair and lounge chair. On July 26, 2017, at 7:00 p.m. Resident C16 was seen by a visitor attempting to transfer from a wheelchair to a porch lounge chair and the resident fell on to the floor. Observations of Resident C16 from July 26, 2017, through August 1, 2017, during activity programs in the lounge area, revealed that Resident C16 either was not participating in the activities or was sleeping in the wheelchair. Review of Resident C16's clinical record failed to reveal that an active care plan for falls with appropriate interventions was put into place to reduce or eliminate Resident C16's falls in the lounge area of the facility. Review of physician's orders [REDACTED]. Review of Resident CL2's lab reports revealed the resident was positive of [MEDICAL CONDITION] (a bacterial infection of the colon) on April 22, 2017, and the physician ordered the resident to be on [MEDICATION NAME] (an antibiotic used for the treatment of [REDACTED]. Review of Resident CL2's care plan revealed there was no care plan developed with interventions and services to care for this resident with a [MEDICAL CONDITION] infection. Interview with Licensed Nurse, Employee E6, on August 1, 2017, at 12:30 p.m. confirmed there was no care plan developed for this resident regarding her active [MEDICAL CONDITION] infection. 42 CFR 483.20(d); 483.21(b)(1) Develop Comprehensive Care Plans Previously cited 05/06/16 28 Pa. Code 211.5(f) Clinical records Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 05/06/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 06/01/15, 05/06/16

Based on policy and procedure review, staff interviews and clinical record reviews, it was determine the facility failed to follow physician orders [REDACTED]. Findings include: Review of facility policy and procedure titled, Medication Administration and Management, revised July 2017, revealed that prior to medication administration all authorized community staff should adhere to the following guidelines: verify the correct drug, correct dose, correct route, correct rate, correct time and correct resident prior to each medication administration. Review of Resident B1's June 2016 physician's orders [REDACTED]. Review of Resident B1's clinical progress notes dated June 28, 2016, stated, it was discovered at 3:20 p.m. that resident mistakenly received [MEDICATION NAME] 10 mg (2 tabs) at 10:30 a.m. instead of [MEDICATION NAME] HCL 5 mg (2 tabs). Review of facility documentation dated June 29, 2016, confirmed Resident B1 received [MEDICATION NAME] 10 mg ER two tabs for a total of 20 mg instead of [MEDICATION NAME] 5 mg two tabs for a total of 10 mg. Interview with the Director of Nursing on July 31, 2017, at approximately 9:00 a.m. confirmed that the facility failed to follow the physician's orders [REDACTED]. Review of Resident CL2's Medication Administration Record [REDACTED]. Review of Resident CL2's March 2017 physician orders [REDACTED]. Review of Resident CL2's MAR for March and April 2017, revealed the resident received the as needed Tylenol at the following times for the indicated pain levels: March 29, 4:45 a.m. Pain Level 9 March 29, 9:30 a.m. no Pain Level indicated March 30, 11:30 a.m. Pain Level 8 March 30, 7:30 p.m. no Pain Level indicated March 31, 9:40 a.m. Pain Level 8 March 31, no time indicated Pain Level 8 April 7, 12:45 a.m. Pain Level 5 April 7, 5:45 a.m. Pain Level 5 April 8, 2017 8:00 p.m. Pain Level 5 April 9, 12:00 p.m. Pain Level 5 April 11, 9:05 a.m. Pain Level 8 April 13, 6:30 p.m. Pain Level 8 April 25, 5:33 p.m. Pain Level 9 April 26, 7:10 p.m. Pain Level 9 During an interview with Licensed Nurse, Employee E6, on August 1, 2017, at 1:00 p.m. it was confirmed that pain levels from 5-9 were not indicative of mild pain and Resident CL2 did not receive the as needed Tylenol as ordered by the physician. Also there was no attempt by the staff to clarify the order with the physician and obtain a pain medication for the resident's severe and moderate pain. 28 Pa. Code 211.10(c) Resident care policies Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/06/16, 04/05/17

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to follow infection control standards in providing wound care to one resident (Resident A11) and failed to follow physician's orders [REDACTED]. Findings include: Review of facility's guidelines entitled, Dressing Changes, undated, provided guidance for the application of dry, clean dressings. Have another staff member with you to assist. Wash hands and dry thoroughly. Clean the bedside table and assemble the table for dressing change on top of a disposable washcloth or Chux (a disposable underpad with an absorbent top layer and waterproof backing to prevent leakage). Open dry, dressings, ointments or creams and bottle of saline. Position resident. Wash and dry hands thoroughly. Put on clean gloves and loosen tape and remove soiled dressing. Discard gloves and old dressing into plastic or biohazard bag. Wash hands and put on clean gloves. Pour saline (sterile mixture of salt and water) or ordered cleansing agent on dry four by four and cleanse wound. Use a clean gauze for each cleansing stroke. Clean from the least contaminated to the most contaminated area. Observe the wound and surrounding skin. Use dry gauze to pat dry the wound. Wash hands and dry thoroughly. Apply gloves. Apply the treatment and dressing and secure with tape. Write initials, date and time on dressing change. Discard disposable items into plastic bag or biohazard bag. Remove gloves and place in bag. Wash and dry hands thoroughly. Observation of Resident A11's wound treatment and observation of Licensed Nurse, Employee E7, on July 27, 2017, at 11:25 a.m. revealed during treatment to Resident A11's left ischium (forms the lower and back part of the hip bone), Employee E7 disinfected the resident's over-bed table, draping a paper covering over the over-bed table setting up a clean field. Employee E7 then washed hands and donned a pair of gloves. Employee E7 then placed the Dermal Wound Cleanser (aids in the removal of foreign materials such as dirt and debris), one packaged sterile four by four, approximately five unsterile four by four's, a tube of Santyl ointment (used to help the healing of skin ulcers) and a tube of Mupirocin ointment (an antibiotic used topically to prevent bacteria from growing on skin) on to the clean field. Employee E7 then proceeded to remove the soiled dressing from the resident's left ischium and placed it into a trash bag in the trash can and then removed soiled gloves placing them into the trash bag in the trash can. Employee E7 then went back into the bathroom and proceeded to wash hands, Nursing Assistant, Employee E8 proceeded to leave the resident's room to obtain an incontinence brief and a pair of scissors, which she handed to Employee E7, who without disinfect the scissors placed the scissors on the clean field. Employee E7 then donned gloves and assisted by Employee E8 with incontinence care. Employee E7 then proceeded to spray dermal wound cleanser onto several unsterile gauze pads and cleansed the wound. Employee E7 then opened the packaged sterile gauze pad, used scissors to cut a piece of the gauze approximately two inches by one-half inch in size, mixing a dime size drop of Santyl and Mupirocin ointment onto the piece of gauze, then lightly packed the gauze inserting it into the wound. Employee E7 covered the wound with a secondary dressing. Employee E7 then closed Resident A11's brief, removed soiled gloves placing them into the trash bag. Facility staff failed to disinfect the scissors prior to placing them on the clean field and used the scissors to cut gauze, which was packed lightly into Resident A11's wound. During an observation of Resident A11's wound treatment to a pressure wound of the left ischium on July 31, 2017, at 11:15 a.m. revealed Licensed Nurse, Employee E9, washed her hands, donned gloves, and set up the bed side table and placed all the needed dressings on the table. Employee E9 then took a marker out of a plastic bin containing all the unopened bandages and medicated creams for Resident A11 without cleaning the marker and wrote the date and her initials on the bandage that was the outside covering of the wound dressing and the date and her initials on a newly opened bottle of normal saline solution (sterile mixture of salt and water) while picking it off the table, potentially contaminating the outside of the container. Employee E9 did not change her gloves after potentially contaminating them from the uncleaned marker. Employee E9 then went to a cabinet in the resident's room and removed a pair of scissors. The scissors were not cleaned by Employee E9 and they were used to cut a 4-inch by 4-inch piece of sterile gauze in half. While cutting Employee E9 picked the gauze up with the gloves potentially contaminated by the marker and the uncleaned scissors potentially contaminating the sterile gauze. Further observation revealed Employee E9 then took the gauze which was cut in half and placed it into a plastic cup and poured normal saline solution over the gauze soaking and it potentially contaminating her hands. Employee E9 then picked up the soaked gauze in her left hand and then used her right hand to get a tube of Santyl ointment (used to help the healing of skin ulcers. It works by helping to break up and remove dead skin and tissue) touching the box it was contained in and potentially contaminating her right hand. The Santyl was placed on the soaked gauze and using her right hand again Employee E9 took a tube of Mupirocin ointment (an antibiotic used topically to prevent bacteria from growing on skin) out of the box, touching the box, and potentially contaminating her right hand. After the Mupirocin was placed on the soaked gauze, Employee E9 used both hands to place the soaked gauze with the medicated ointments into the wound and potentially contaminating the wound. During an interview with Licensed Nurse, Employee E6, on August 1, 2017, at 11:30 a.m. it was confirmed that Employee E9 had potentially contaminated Residents A11's wound while providing wound care by not following proper infection control techniques. Review of Resident B2's Annual Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated January 7, 2017, revealed Resident B2 was at risk for developing pressure ulcers. Review of Resident B2's Braden Scale for Predicting Pressure Sore Risk dated January 7, 2017, April 7, 2017 and July 7, 2017, revealed that Resident B2 was at risk for developing pressure ulcers. Review of Resident B2's Initial Wound assessment dated [DATE], revealed a treatment order dated June 6, 2017, that stated, spot duoderm every 3 days and PRN (as needed). Review of Resident B2's clinical progress notes dated June 6, 2017, revealed, area on resident bottom open. Spot duoderm (a [MEDICATION NAME] (a substance that forms a gel with water) dressing used for wounds) applied. Review of Resident B2's June 2017 and July 2017, Treatment Administration Record and clinical progress notes failed to reveal that any treatments were completed on Resident B2's sacral wound. During an interview with the Director of Nursing on July 31, 2017, at approximately 10:00 a.m. it was revealed that there was no evidence that Resident B2 received treatments to a sacral wound as ordered by the physician. 28 Pa. Code 211.10(c) Resident care policies Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(c) Nursing services Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/06/16, 04/05/17

Based on observations, policy and procedure review, staff interview, and clinical record review, it was determined the facility failed to ensure infection control practices were maintained during care for three of 14 residents reviewed (Residents C5, CL2, and C14). Findings Include: Review of the facility policy and procedure titled, Isolation Decision Making Tool, revealed for a resident with a C (Clostridium) Difficile (a bacteria that causes infection of the bowel) Toxin positive diarrhea: Isolation is contact isolation (people making contact with a patient on contact isolation are required to wear gloves and a gown). Review of the physician's orders for Resident CL2 revealed an order on April 21, 2017, for a stool for[DIAGNOSES REDACTED] (lab study to determine if there is an infection of [DIAGNOSES REDACTED]icile present). Review of resident CL2's laboratory reports revealed the resident was positive of[DIAGNOSES REDACTED] on April 22, 2017, and the physician ordered [MEDICATION NAME] (an antibiotic used for the treatment of [REDACTED]. The resident was discharged to home on April 27, 2017. Review of the entire clinical record revealed there was no evidence that the resident was placed on contract precautions after being diagnosed with [REDACTED]. Interview with Licensed Nurse, Employee E6, on August 1, 2017, at 11:30 a.m. confirmed that there was no documented evidence that this resident was placed on contact isolation while diagnosed with [REDACTED]. During an observation of Resident C5's area of a healed pressure ulcer on the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) on July 27 2017, at 10:30 a.m. it was revealed that prior to providing the care to Resident C5, Licensed Nurses, Employees E2 and E3, did not wash their hands. Interview with Licensed Nurse, Employee E6, on August 1, 2017, at 11:30 a.m. confirmed that all employees should wash their hands before providing care to a resident. Observations conducted during a medication pass on July 26, 2017, at 4:45 p.m. revealed Licensed Nurse, Employee E10, while administering medications to Resident C14, dropped a pill that landed on Resident C14's leg. Employee E10 then scooped up the potentially contaminated pill and proceeded to administer it to the resident. 42 CFR 483.80(a)(1)(2) Infection Control, Prevent Spread, Linens Previously cited 06/01/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 06/01/15, 05/06/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/06/16, 04/05/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/01/15, 05/06/16

Based on observations, staff and resident interview, it was determined the facility failed to ensure that contact information was displayed for the state survey agency on one of one skilled nursing units. Findings Include: During an interview which was conducted with six residents in a group setting on July 27, 2017, at 11:00 a.m. it was revealed the residents did not know of the state agency or how to contact them if they had any concerns about the care at the facility. Observations of the facility on July 27, 2017, at 1:00 p.m. revealed there was a 6 x 10 frame on the wall, next to the entrance to the facility, that had the state agency and the phone number, however, it did not contain the address of the local state agency office. Interview with the Nursing Home Administrator on August 1, 2017, at 12:30 p.m. confirmed that the posted information about contacting the state agency did not contain the address. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.18(e)(1) Management Previously cited 06/01/15, 05/06/16 28 Pa. Code 201.29(i)(n) Resident rights

Based on observations, and staff and resident interviews, it was determined the facility failed to ensure that the state agency survey results were clearly identifiable for residents and visitors of the facility. Findings Include: Observations made of the facility on July 27, 2017, at 9:30 a.m. revealed there was a book sitting on a table in front of the nurses' station labeled, Visitor Information Book. Further observations revealed there was a sign posted on a bulletin board in the hallway stating that survey results were at the nurses' station. An interview was conducted with six residents in a group setting on July 27, 2017, at 11:00 a.m. During the interview, it was revealed the residents were not aware of the survey results or that they were posted in the building and should be accessible without asking the staff. Observations on July 28, 2017, at 1:00 p.m. and August 1, 2017, at 12:00 p.m. revealed that a nursing medication cart was pushed in front of the sign on the bulletin board which obscured the view from visitors and residents. During an interview with the Nursing Home Administrator on August 1, 2017, at 12:30 p.m. it was confirmed that the medication cart was placed in an area that covered the survey results sign and the book containing the survey results was not correctly labeled and could be misleading to someone looking for the survey results. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/01/15, 05/06/16, 04/05/17 28 Pa. Code 201.29(j) Resident rights