Every finding on record at Willowbrooke Court-Southampton

Based on observation and staff interview, it was determined that the facility failed to provide maintenance services to ensure safe water temperatures on one of two nursing units. (Willowbrooke Court) Findings include: Observation on March 22, 2023, at 10:00 a.m., on the Willowbrooke Court nursing unit revealed the following elevated water temperatures in areas accessible to residents: Public restroom across from the Administrator's office: 118.9 degrees Fahrenheit ( F). Resident room [ROOM NUMBER] bathroom sink: 120.2 F. Resident shower room sink (spa): 120.3 F. Willow dining room sink: 120.2 F. Resident room [ROOM NUMBER] bathroom sink: 115.8 F. Willow Gardens laundry room sink: 116.4 F. In an interview during that time, Employee 1 (maintenance staff) confirmed that water temperatures in areas accessible to residents should be 110 F or lower. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner during tray line service in one of two dining rooms. (Willowbrooke Court Dining Room) Findings include: Review of the policy entitled, Single Use Glove Usage, dated January 26, 2022, revealed that gloves should only be used for one task, such as ready to eat foods, and then discarded. Observation of tray line service on March 30, 2022, at 12:05 p.m. in the Willowbrooke Court Dining Room revealed the Nutrition Services Manager serving unwrapped food from the steam table, leaving the service line to rinse a knife in the sink, returning to the tray line, and serving unwrapped food without changing her gloves. Observation of tray line service on March 31, 2022, revealed dietary aide (DA1) serving unwrapped food from the steam table, leaving the tray line and opening cabinets and the gate to the steam table area to obtain items. DA1 returned to tray line and continued serving unwrapped food after touching the cabinet handle and steam table gate without changing her gloves. In an interview on March 31, 2022, at 12:02 p.m., the Director of Culinary Services confirmed staff should change their gloves whenever they change tasks. 28 Pa. Code 211.6(c)(f) Dietary services.

Based on clinical record review, facility menu review, observation, and staff interview, it was determined that the facility failed to provide therapeutic diets as ordered by the physician for two of 19 sampled residents. (Resident 19, 30) Findings include: Review of the facility lunch menu revealed that residents who were ordered a regular mechanical soft dysphagia diet were to receive items which included a crustless sloppy [NAME] sandwich on March 29, 2022, and a ground turkey burger, chopped herbed green beans, and crustless white bread on March 31, 2022. Clinical record review revealed that Resident 19 had diagnoses that included dementia and oropharyngeal dysphagia (difficulty swallowing) and had a physician's order to receive a regular diet with mechanical soft dysphagia texture (may have Cheerios). Observation during lunch on March 31, 2022, at 12:17 p.m., revealed that the resident received pureed texture turkey and green beans. In addition, the resident was not offered crustless white bread. Clinical record review revealed that Resident 30 had diagnoses that included dementia and oropharyngeal dysphagia and had a physician's order to receive a regular diet with mechanical soft dysphagia texture (minced/moist). Observation during lunch on March 29, 2022, at 12:08 p.m. revealed that the resident received pureed texture sloppy [NAME] sandwich. Observation during lunch on March 31, 2022, revealed that the resident received pureed texture turkey and green beans. In addition, the resident was not offered crustless white bread. Observation of the food preparation area revealed that mechanical soft dysphagia texture foods were not available. During an interview on March 31, 2021, at 12:21 p.m., dietary aide (DA2) was plating the food for residents and confirmed that residents with physicians' orders for a mechanical soft dysphagia diet were routinely served pureed consistency items and that ground items were not available. 28 Pa. Code 211.6(b)(c) Dietary services. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and a review of incident reports, it was determined that the facility failed to implement recommended fall interventions for one of six sampled residents at risk for falls. (Resident 73) Findings include: Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], and had diagnoses that included dementia, history of falling, and rhabdomyolysis (breakdown of skeletal muscle due to muscle injury). Review of the Minimum Data Set assessment, dated March 14, 2022, revealed the resident was cognitively impaired and required extensive assistance from staff for bed mobility and toileting. Review of the care plan revealed the resident was at risk for falls due to impaired balance, weakness, and dementia. Review of incident reports revealed that on January 14, 2022, Resident 73 fell from his recliner and the interdisciplinary team recommended an Occupational Therapy (OT) evaluation. On January 15, 2022, the resident again fell from his recliner. The interdisciplinary team stated to continue OT, although therapy services had not been started. The resident was not evaluated by the occupational therapist until January 24, 2022, when he experienced an additional (third) fall from the recliner. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined the facility failed to ensure that refrigerators in common areas were properly maintained on two of four nursing units. (Willowbrooke Court Team one and WillowBrooke Court Team two) Findings include: Review of facility policy entitled, Common Area Refrigerator Maintenance, dated February 9, 2021, revealed refrigerators in common areas were to remain clean at all times. There should be no items that have reached their expiration date. If any item was opened it was to be dated with an expiration date. Liquids should be discarded seven days after opened and foods should be discarded three days after opened. The 11:00 p.m.to 7:00 a.m. nursing staff was responsible for inspecting all common area refrigerators daily for items, unopened and opened and dated, reaching their expiration date. All expired items should be discarded. Observation of nourishment refrigerator number two on [DATE], at 12:19 p.m., revealed a container of honey thick orange juice with a use by date of [DATE], a container of honey thick apple juice with a use by date of [DATE], an open container of honey thick water that was not dated with an open or use by date, an open container of nectar thick cranberry juice that was not dated with an open or use by date, and an open container of honey thick orange juice that was not dated with an open or use by date. Observation of nourishment refrigerator number three revealed a container of apple juice with a use by date of [DATE], a container of cranberry juice with a use by date of [DATE], an open container of apple juice with no open or use by date, and an open container of cranberry juice with no open or use by date.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure the policy and procedure for monthly drug regimen reviews included timeframes for the different steps in the process and ensure pharmacy recommendations were acknowledged timely by the attending physician for one of 18 sampled residents. (Resident 39) Findings include: Review of the facility policy entitled, Drug Regimen Review, dated February 9, 2021, revealed that when potentially or actual clinically significant medication issues were identified, they must be promptly communicated (via two way communication) to the physician/prescribing practitioner. Documentation in the clinical record was to include when the review was conducted, whether there were any potential clinically significant medication issues identified, when the physician was notified, any physician recommendations/orders, and when those orders were carried out. Clinical record review revealed that Resident 39 had diagnoses that included heart failure, and type two diabetes mellitus with other diabetic kidney complications. On December 31, 2020, the pharmacist made recommendations to obtain a serum [MEDICATION(S)] (a test to determine the level of [MEDICATION(S)], a heart medication, in the blood), recheck a basic metabolic panel (a blood test to determine chemical balance and metabolism in the body), and monitor hemoglobin A1c (a blood test that measures the amount of glucose, a type of sugar, attached to a portion of red blood cells). There was no documented evidence in Resident 39's medical record that the physician was notified of the pharmacy recommendations prior to February 5, 2021. In an interview on July 22, 2021, at 11:23 a.m., the Administrator stated there was no documentation in Resident 39's record to indicate when the physician was notified of the recommendations from December 31, 2020. During the same interview, it was confirmed the facility policy did not include a timeframe that defines the expectation of when the physician is notified of pharmacy recommendations that are determined to be either clinically significant or not clinically significant, or the amount of time expected for the Physician to respond to the recommendations. 28 Pa. Code 211.12(d)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the residents' representative(s) of the transfer and the reasons for transfer in writing for six of 18 sampled residents who were transferred to the hospital. (Residents 35, 41, 46, 48, 60, 76) Findings include: Clinical record review revealed that Resident 35 was transferred and admitted to the hospital on April 29, 2021, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 41 was transferred and admitted to the hospital on May 17, 2021, and on May 23, 2021, after changes in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital on either occassion. Clinical record review revealed that Resident 46 was transferred and admitted to the hospital on May 28, 2021, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 48 was transferred and admitted to the hospital on May 8, 2021, and on May 30, 2021, after changes in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital on either occasion. Clinical record review revealed that Resident 60 was transferred and admitted to the hospital on April 6, 2021, after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 76 was transferred and admitted to the hospital on May 12, 2021, and on June 29, 2021, after changes in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital on either occasion. In an interview on July 21, 2021, at 1:53 p.m., the Administrator stated that the residents and/or resident's representatives were not notified in writing of the transfer to the hospital.

Based on facility policy review, observation, staff interview, facility documentation review, and clinical record review, it was determined that the facility failed to provide an environment and adequate supervision to prevent accidents related to elopement (unauthorized departure from the facility), resulting in actual harm and death for one of four sampled residents. This failure resulted in an Immediate Jeopardy situation (Resident CL1). Findings include: Review of the facility policy entitled, Skilled Nursing Admission Staff Assignment, written March 4, 2021, noted, Prior to or upon admission of a resident to Willowbrooke Court, the Nursing Supervisor will assign the new resident to a nurse and a certified nursing assistant immediately. If the nursing supervisor is unavailable, it is the responsibility of the charge nurse on that neighborhood to make the assignment. At the beginning of each shift the Nursing Supervisor, or Charge Nurse will ensure that all residents have an assigned nurse and certified nursing assistant. During an interview on March 4, 2021, the Director of Nursing (DON) reported that, although not a written policy, this was a procedure in place prior to February 27, 2021. Clinical record review revealed that Resident CL1 had diagnoses that included a history of falling, [CONDITION(S)] ([CONDITION(S)]) and collapse, hearing loss in both ears, difficulty in walking, lack of coordination, generalized muscle weakness, and altered mental status and was admitted to the facility (room 15) from the hospital on February 27, 2021. During an interview on March 4, 2021, at 10:00 a.m., the Nursing Home Administrator (NHA) reported that admission time was approximately 8:00 p.m. The resident had a physician's order for a regular diet. Medications ordered by the physician on February 27, 2021, included the following to be given in the morning: aspirin EC 81 milligrams (mg) for [CONDITION(S)] (narrowing of the exit of the left ventricle of the heart), [MEDICATION(S)] 25mg .5 tab for [CONDITION(S)] (high blood pressure), and [MEDICATION(S)] 40 mg for GERD (occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach). A fall risk evaluation completed on February 27, 2021, noted that Resident CL1 was at high risk for falls and had intermittent confusion, poor vision, a history of falling in the past month, and gait problems requiring the use of an assistive device. Clinical record review revealed that the resident's vital signs had been recorded at 3:30 a.m. and a treatment had been administered to the left heel at 3:50 a.m. Documentation by a nurse aide (NA1) dated March 2, 2021, noted that the employee had Resident CL1 on her assignment until 7:00 a.m. on February 28, 2021, and last observed the resident during the time of her rounds which started at 5:00 a.m and ended at 6:30 a.m. Review of nursing schedule assignments for the 7 a.m. to 3 p.m. (day) shift on February 28, 2021, revealed that no nurse aide had been assigned to Resident CL1's room (15). During an interview on March 4, 2021, the DON confirmed that the resident was not included in the nurse aide assignments for the day shift on February 28, 2021. There was no documentation in the clinical record to support that the resident was observed after 6:30 a.m., that morning medications were administered, or that the breakfast meal was offered to her. Observation on March 4, 2021, revealed that resident room 15, previously occupied by Resident CL1, was located adjacent to the meeting/dining room which contained two sets of exterior doors leading to a patio, walkway, and the parking lot. The NHA reported that staff were using those doors to enter and exit the building. Review of the facility incident report revealed that the resident was noted as missing from her room on February 28, 2021, at 9:20 a.m. (A written statement by the assigned Registered Nurse (RN1), dated February 28, 2021, indicated that the resident was identified to be missing at 9:10 a.m. to 9:15 a.m.) There was no evidence that the facility had provided any level of supervision to the resident or visual checks since 6:30 a.m. Documentation revealed that the resident was found at 9:41 a.m., behind a storage container in the parking lot. She was laying on her right side on a sheet on the ground wearing an incontinence brief and no other clothing, outerwear, or footwear. It was noted that upon assessment, the resident, had no vital signs, was cool to the touch, and had abrasions to both shins. Observation of the location on March 4, 2021, revealed that it was at the end of the walkway leading from the patio outside the meeting/dining room. During an interview on March 4, 2021, the NHA reported that the autopsy findings indicated the resident's cause of death was hypothermia (the condition of having an abnormally low body temperature, typically one that is dangerously low) due to exposure (cold conditions). On March 4, 2021, at 6:10 p.m., the NHA, the DON, and the Regional Clinical Director were notified that the failure to provide an environment and adequate supervision to prevent accidents constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on March 4, 2021, at 7:09 p.m. The facility's action plan contained the following: 1. An inservice training was conducted on March 2, 2021, by the DON and the Assistant Director of Nursing (ADON) with nursing staff to review the elopement policy, wandering assessment, the nurse aide report from the charge nurse each shift, walking rounds between the outgoing and incoming nurse/sign out sheet to be completed with signatures (staff are to walk room to room to observe every resident at the beginning and end of each shift), being on time for a scheduled shift, observation and charting for all new admissions for the first nine shifts, and nurse aide schedule updates to reflect all occupied resident rooms. As of March 4, 2021, 98 percent of nursing staff had been educated. The remaining staff members were on leave. Staff not educated will remain off of the schedule until training has been completed. 2. Director of Physical Plant Services, or designee, will change access codes on all alarm pads on exit doors monthly beginning March 5, 2021. (Codes were changed March 4, 2021) Codes will be changed the first Monday of each month. All security and staff will be educated on the key pads and codes. Security is available on the premises 24 hours a day, seven days a week. Audits of the doors started on March 1, 2021, and an outside contractor provided an audit of the doors on March 2, 2021. 3. The nursing supervisor or charge nurse will conduct rounds of resident rooms at the start of each shift to ensure the safety of each resident. 4. The ADON or nursing supervisor will ensure that nurse aides will receive a verbal report from the charge nurse at the beginning of each shift. 5. The DON or the ADON will ensure that there is a shift-to-shift report between professional nurses at the start of each shift. 6. The DON, or designee, will ensure that all staff are aware of the assignment of new admissions. This will be directed by the nursing supervisor. 7. An audit was completed for every resident to ensure that wander risk assessments were current and accurate. 8. The charge nurse will ensure that resident Wanderguard pendants (a security apparatus worn by an at risk resident that prevents doors from opening to prevent elopement when the resident is nearby) are checked for placement every shift. The functionality is checked weekly. 9. Security and maintenance staff have been educated on inspection of door alarms. 10. Alarms were installed on interior doors leading into the dining rooms on March 3, 2021. Training will be provided to all departments by the NHA, or designee, on the operation of the alarms. Training is in progress and will be completed no later than March 8, 2021. 11. Security/maintenance staff will inspect operation of all door alarms on each shift. This will be ongoing and results will be evaluated and reviewed through the facility QAPI (Quality Assessment and Performance Improvement) process. 12. Staff are no longer permitted to use the meeting/dining room doors to enter/exit the building. All staff must use the main entrance doors and are required to use a key code to enter and exit. Signs have been posted and staff members have been educated. 13. The NHA will review all of the above areas as part of the facility's QAPI program. The survey team validated that the Immediate Jeopardy was removed on March 5, 2021, at 2:00 p.m., through observation, interviewing staff post inservice training, and review of facility policies and procedures following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at a D (isolated with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. 483.12(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.18(a) Management. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(d) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 212.12(c) Nursing services. 28 Pa. Code 212.12(d)(1) Nursing services. Previously cited 2/15/19 28 Pa. Code 212.12(d)(3) Nursing services. 28 Pa. Code 212.12(d)(5) Nursing services. Previously cited 2/15/19, 1/31/20

Based on facility documentation review and staff interview, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of a resident which resulted in the death of Resident CL1. This was identified as an Immediate Jeopardy situation for one of four residents reviewed. Findings include: Review of the job description for the Administrator revealed that the Administrator Directs administration of health care services under the authority of the Governing Board, Executive Director, and Corporate Director. Essential job functions include: Directs and coordinates activities of Skilled Nursing Center, Resident Nursing, Nutrition, Activities and Social Services, Recommends policies and procedures for Skilled Nursing Center, Resident Nursing, Nutrition, Activities and Social Services, and Identifies safety hazards and emergency situations and initiates corrective action immediately. Review of the job description for the Director of Nursing (DON) revealed that the DON Administers nursing program in facility to maintain standards of resident care and advises medical staff, department heads, and executive directors in matters related to nursing services. Essential job functions include: Directs the planning, implementing and evaluation of the nursing care for all Residents on a 24-hour basis, 7 days a week, Manages and develops written, dated and posted, work schedule for all Nursing personnel to assure the required needs of the resident are met, Ensures that the corporate policies and procedures governing resident's care are implemented and followed at all times, and Understands and follows all Federal, State, and Local Rules and Regulations governing medical and nursing care of Residents in the medical facility. Resident CL1 who was admitted to the facility on the evening of February 27, 2021, and identified by the facility as at high risk for falls and exhibiting intermittent confusion, eloped (left the facility without the knowledge of staff) from the facility some time after 6:30 a.m. on February 28, 2021. The resident had not been added to a nurse aide assignment on the day shift and was not identified as missing until between 9:10 a.m. and 9:20 a.m. Resident CL1 was found outside, laying on the ground without vital signs at 9:49 a.m. In an interview on March 4, 2021, the Administrator provided that the autopsy report indicated the cause of death to have been hypothermia (the condition of having an abnormally low body temperature, typically one that is dangerously low) due to exposure (cold conditions). Based on the deficiencies identified in this report, the Administrator and DON failed to fulfill essential job functions and responsibilities of their positions, contributing to the Immediate Jeopardy situation. Refer to F689. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(a) Management. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review, observation and interview, it was determined that the facility failed to provide equal access to services to promote each resident's quality of life during meal time for three of 20 sampled residents. (Residents 6, 45, 51) Findings include: Observation of lunch in the Sunshine Gardens dining room on January 28, 2020, at 12:35 p.m., revealed that one of the two menu choices for the main entree was beef pot pie and this item for the regular diet consisted of beef, vegetables, and gravy with a crust topping. In addition, lentil and ham soup was served. Clinical record review revealed Resident 6 had [DIAGNOSES REDACTED]. The resident was observed to receive the beef pot pie entree with no crust included and no substitution. Clinical record review revealed Resident 45 had [DIAGNOSES REDACTED]. The resident was observed to receive the beef pot pie entree with no crust included and no substitution. Clinical record review revealed Resident 51 had [DIAGNOSES REDACTED]. The resident was observed to receive the beef pot pie entree with no crust included and no substitution. The resident was in the dining room while soup was being served to other residents and was not offered any soup. NA1 was assisting Resident 51 to eat and reported that she was unaware of any reason that the resident would not be offered soup. During an interview on January 30, 2020, at 12:18 p.m., the resident's family member stated that the resident liked soup and preferred crust on beef pot pie. During an interview on January 28, 2020, at 1:00 p.m., the culinary director confirmed that each resident on a regular diet was to receive a piece of pastry crust with the beef pot pie entree. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.6(a)(c) Dietary services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/15/19

Based on clinical record review, review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that the interdisciplinary team assessed a resident's capabilities to self administer medications for one of one sampled resident who self administered medications. (Resident 357) Findings include: Review of facility policy entitled Self-Administration of Medication, dated (MONTH) (YEAR), revealed that the facility was to strive to ensure that the resident was properly prepared and clinically appropriate to self -administer medications. Staff was to complete a self-administration evaluation form to determine if the resident was able to self administer medications. The facility was to ensure that the physician's order and care plan reflected the residents ability to self administer medications. In addition, all medications to be self administered were to be stored in a locked medication drawer in the residents room or another designated area and the licensed nursing staff was to monitor parameters and lab values as needed. Clinical record review revealed that Resident 357 was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. Observation on (MONTH) 13, 2019, at 10:45 a.m., revealed that there was an Aerosol inhaler (Breo Elipta Aerosol) stored in an unlocked bathroom cabinet in the resident's bathroom. Resident 357stated that she was able to use the inhaler on her own. Further observation on (MONTH) 14, 2019, at 10:00 a.m., and 12:35 p.m., revealed that the Aerosol inhaler was still stored in the unlocked cabinet. Review of the physician's orders revealed that on (MONTH) 12, 2019, there was an order for [REDACTED]. There was no documented evidence that the facility completed the evaluation for the resident to be able to self administer medications, there was no physician's order or care plan for the resident to self administer and the medication was not stored in a locked area as per facility policy. In an interview on (MONTH) 15, 2019, at 11:35 a.m., the Director of Nursing stated that the facility had not completed an evaluation, care plan, physician's order nor had the medication stored as per facility policy for the resident to self administer the Aerosol inhaler. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/30/18

Based on observations and clinical record review, it was determined that the facility failed to ensure that a call bell was accessible to one of 26 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, indicated that the resident was alert and able to express her needs. The MDS assessment indicated that the resident was totally dependent and required a two person assist for transfers and bed mobility. The current careplan revealed that the resident was to reach the call bell at all times and was instructed to use her call bell for assistance when needed. Observations on (MONTH) 11, 2019 at 10:39 a.m.,1:30 p.m., and 1:46 p.m., revealed that the resident was in her wheelchair and that the call bell was out of her reach in the middle of her bed. Observation on (MONTH) 13, 2019 at 11:30 a.m., revealed that Resident 9 was in her wheelchair and calling out for staff assistance. The call bell cord was secured to the side bed rail and was out of reach of the resident. 29 Pa Code 211.12 (d)(5) Nursing Services Previously cited 5/4/18

Based on observation and clinical record review, it was determined that the facility failed to ensure that staff provided a resident with the required assistance to eat for one of 26 sampled residents. (Resident 91) Clinical record review revealed that Resident 91 had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated (MONTH) 22, 2019 indicated that the resident had memory impairment and required physical assistance with eating. Review of the Care Area Assessment for the eating dated (MONTH) 22, 2019, revealed that the resident requireed physical assistance to eat due to mental errors that includeed sequencing problems, incomplete performance and anxiety limitations. The intervention provide cues, supervision and assistance as needed for all meals was added to the Activities of Daily Living care plan under the eating heading on (MONTH) 12th, (YEAR). Observation during lunch on (MONTH) 11, 2019 from 12:15PM to 12:47PM and (MONTH) 13, 2019 from 12:12PM to 12:56PM, revealed Resident 91 was sleeping through the meal. Staff failed to attempt to wake the resident or provide eating assistance. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 5/4/18

Based on clinical record review and staff interview it was determined that the facility failed to notify a physician of a resident's refusal to take a medication in a timely manner for one of 26 sampled residents. (Resident 357) Findings include: Clinical record review revealed that Resident 357 was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. Review of a nursing note dated (MONTH) 8, 2019, revealed that the resident was alert and oriented and was able to clearly verbalize her needs to staff. On admission, a physician ordered for staff to administer a medication to treat the lymphocytic [MEDICAL CONDITION] ([MEDICATION NAME] ER every day). Review of the Medication Administration Record [REDACTED]. There was no documented evidence that the physician was notified in a timely manner of the resident's refusal to take the medication. In an interview on (MONTH) 15, 2019, the Director of Nursing confirmed that there was no documented evidence that the physician had been notified in a timely manner of the resident's refusal to take the medication. CFR Quality of Care 483.25 Previously cited 3/30/18 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/30/18

Based on clinical record review, review of facility policy, observation and interview, it was determined that the facility failed to ensure that pain medication was administered as per the resident's pain management program and physician's orders for one of two sampled residents who were on pain management. (Resident 357) Findings include: Review of the facility policy entitled Pain Management dated (MONTH) (YEAR), revealed that staff was to strive to recognize when a resident was experiencing pain and the potential for pain, evaluate existing pain and causes and provide appropriate pain management consistent with the care plan and the resident's goals and preferences. Clinical record review revealed that Resident 357 was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. On admission, a physician ordered for staff to administer a medication for pain ([MEDICATION NAME]) one tablet every four hours as needed for moderate pain on a pain scale (4-7) out of ten and two tablets every four hours as needed for severe pain on a pain scale of (8-10). Review of the care plan initiated (MONTH) 10, 2019, revealed that the resident had acute pain status [REDACTED]. Review of a nursing admission note dated (MONTH) 8, 2019, indicated that the resident was alert and oriented and able to clearly verbalize her needs to staff. Observation on (MONTH) 13, 2019, at 10:45 a.m., revealed that LPN1 administered medications to Resident 357. At this time, the resident expressed that she had pain in her right knee and had not received any pain medication since around 3:00 a.m., that same morning. LPN1 did not offer or administer any pain medication to the resident at this time. In an interview on the same day at 1:27 p.m., Resident 357 stated that she now had severe pain in her right leg that was radiating up to her hip and that it hurt her when she walked. Review of the Medication Administration Record [REDACTED]. At that time, the resident then required the two tablets of the [MEDICATION NAME] due to the severity level of her pain. In an interview on (MONTH) 15, 2019, at 9:30 a.m., the Director of Nursing stated that the resident had not received her as needed pain medication as ordered by the physician in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/30/18

Based on observation, review of facility documentation and staff interview, it was determined that the facility failed to monitor food and beverage temperatures to ensure that safe temperatures were maintained on one of two satellite kitchens that served meals directly to residents. (Sunshine Gardens) Findings include: On (MONTH) 27, (YEAR), from 12:01 p.m., through 12:41 p.m., staff served hot and cold food items to residents from a steam table in the Sunshine Garden's dining room. In an interview at 12:20 p.m., the dietary aide (Employee 1) serving the food from the steam table stated that temperatures of food and beverages being served to residents had not been taken or recorded for the meal. The Food Service Director who was present at the meal stated it was facility policy to take food and beverage temperatures prior to and in the middle of the meal service to ensure temperatures met facility standards for resident consumption. He stated that at each meal staff was to record temperatures in the food service log. A review of the food service temperature logs revealed that staff had failed to document food and beverage temperatures at eleven of twelve meals served to residents from (MONTH) 23, (YEAR), through (MONTH) 26, (YEAR). 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review, observation and resident interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of 24 sampled residents. (Resident 86) Findings include: Clinical record review revealed that Resident 86 had [DIAGNOSES REDACTED]. During a wound care observation on (MONTH) 28, (YEAR), at 11:33 a.m. Resident 86's right lower extremity wound was uncovered and open to the air with visible red drainage and yellow slough (skin). In an interview at that time Resident 86 stated that the dressing came off while he was showering on (MONTH) 27, (YEAR), and the wound was not covered with a new dressing. Clinical record review revealed that on (MONTH) 20, (YEAR), the physician ordered Santyl ointment be applied to the resident's right lower shin and cover with a dry dressing daily during day shift. There was no documentation to support that wound care had been provided as ordered by the physician after it had dislodged on (MONTH) 27, (YEAR). In an interview on (MONTH) 30, (YEAR), at 12:45 p.m., the Director of Nursing confirmed that the resident did not receive wound care consistent with physician's orders. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review, policy review, observation, and staff interview, it was determined that the facility failed to ensure the oxygen cannula tubing was stored in accordance with policy for two of 24 sampled residents. (Resident 32, Resident 109) Findings include: Review of the facility policy entitled Oxygen Administration/Safety dated (MONTH) 2014, revealed that nasal cannulas, masks, and humidifiers were to be rinsed and dried after use and stored in a plastic bag. Clinical record review revealed that on (MONTH) 10, (YEAR), Resident 32 was ordered oxygen via nasal cannula at 2 liters per minute. Observation on (MONTH) 27, (YEAR), at 10:45 a.m., 11:45 a.m., and 1:05 p.m., revealed the nasal cannula tubing was on the resident's overbed table unprotected and not in a plastic bag. Observation on (MONTH) 28, (YEAR), at 11:35 a.m., 12:12 p.m. and 1:13 p.m., revealed the nasal cannula tubing was on the resident's overbed table unprotected and not in a plastic bag. Clinical record review revealed that (MONTH) 18, (YEAR), Resident 109 was ordered oxygen via nasal cannula at 2 liters per minute. Observation on (MONTH) 27, (YEAR), at 10:05 a.m., 10:20 a.m., and 11:40 a.m., revealed the tubing was on the resident's garbage can and the nasal cannula was on the carpeted floor and not in a plastic bag. Observation on (MONTH) 29, (YEAR), at 11:45 a.m., and 12:50 p.m., revealed the tubing was looped around the portable oxygen bottle attached to the back of the wheelchair and not in a plastic bag. In an interview on (MONTH) 30, (YEAR) at 12:45 p.m., the Director of Nursing confirmed that oxygen nasal cannulas were to be stored in a plastic bag when not in use. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to fourteen days unless the physician believed and documented in the medical record the rationale for the PRN order to be extended beyond 14 days for one of 24 sampled residents. (Resident 37) Findings include: Clinical record review revealed that Resident 37 had [DIAGNOSES REDACTED]. The current order for the PRN psychoactive medication failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the PRN order to be extended beyond 14 days or the duration the prn was to be administered. In an interview on (MONTH) 29, (YEAR), at 1:15 p.m. the Director of Nursing confirmed that the physician's orders [REDACTED]. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards in 17 of 34 rooms. (Rooms 2, 4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 22, 23, 29, 33, 34) Findings include: Observations during the initial tour on February 7, 2017, at 10:10 a.m., through February 8, 2017, at 9:30 a.m., revealed the residents' beds and linens in rooms 2, 4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 22, 23,29, 33, and 34, were in direct contact with the heaters. The resident's feet and legs were in close proximity to the heating units when they were in bed and had the potential to bump the heaters. In an interview on February 8, 2017 at 10:45 a.m., the Director of Building Services stated that the beds should not be in contact with the heaters and close proximity could cause compromised skin integrity. CFR 483.25(d) Accidents Previously cited 3/4/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 3/4/16