Every finding on record at Willowbrooke Court-Spring Hous

Based on review of facility policy, review of clinical records, review of facility documentation, and staff interview it was determined that the facility failed to provide adequate supervision for one of five residents reviewed (Resident R1).Findings Include: Review of facility policy titled, Elopement, Unescorted Exit last revised July 2023 states, Policy- To strive to report an unauthorized, unescorted, and/or unsafe exit of a cognitively impaired resident from the community and to locate and report any resident suspected of being missing. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), disorientation (state of mental confusion where a person loses their sense of direction, position, or awareness of time, place, and identity), Anxiety (intense, excessive, persistent worry or fear), Hypertension (high blood pressure), Insomnia (you have trouble falling asleep, staying asleep, or waking up too early), and Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Further review of Resident R1's clinical record revealed a Brief Interview for Mental Status (BIMS) assessment dated [DATE], with a documented score of 9, indicating moderate cognitive impairment. Review of facility documentation submitted to the State Survey Agency revealed on July 7, 2026, at approximately 7:49 p.m., the facility received a call from a resident of the independent living unit of the community to report that Resident R1 was on her patio. Resident R1 previously resided in the independent living unit of the community and was good friends/neighbors with this other resident. Resident R1 reported to the supervisor that it was a nice day, and he/she wanted to get some fresh air and to take a walk. Resident R1 did not sign him/herself out from the skilled unit prior to leaving and reported being unaware he/she was unable to leave on his/her own. Continued review of facility documentation submitted to the State Survey Agency revealed per a review of surveillance footage showed Resident R1 exiting through an interior door at 6:56 p.m. and entered the independent living section as an independent living resident entered through the same doorway. At 7:04 p.m. surveillance showed an environmental services employee silencing the wander guard door alarm and exiting through the doorway. The employee reported hearing the alarm, seeing no one nearby, and silencing it. Further review of facility documentation revealed staff on duty did not recall receiving pager alerts. Reviews of pagers found no elopement notifications, and several displayed garbled messages. Interview on July 23, 2026, at 10:00 a.m. with Nursing Home Administrator, Employee E1, revealed when Resident R1 was initially admitted to the unit, his/her family continued to take the resident back to his/her apartment in the independent living unit of the community. NHA, Employee E1, stated all new admissions have a wander guard applied for the first 72-hours after admission and that Resident R1's was continued due to concerns with cognition. Continued interview on July 23, 2026, at 10:00 a.m. with Nursing Home Administrator, Employee E1, revealed nursing staff carry pagers that will send an alert when the wander guard alarm is triggered. Nursing Home Administrator, Employee E1, confirmed the pagers for nursing staff did not receive an elopement notification and further confirmed the wander guard alarm (that was triggered by Resident R1) was turned off by environmental services employee, Employee E3. Review of the facility camera footage showed as independent living unit resident, Resident R2, entered through the doors into the skilled unit, Resident R1 exited the unit into the independent living unit. At 7:04 p.m. environmental services, Employee E3, is observed to disarm the alarm and continued to exit the unit. Interview on July 23, 2026, at 1:00 p.m. with the environmental services laundry aide, Employee E3, revealed he/she heard the alarm sounding at the door as he/she was leaving and subsequently turned it off. Laundry aide, Employee E3, stated he/she looked around and did not see anyone, so he/she then proceeded to leave. The Nursing Home Administrator, Employee E1, on July 23, 2026, at 1:44 p.m. confirmed Resident R1 was able to leave the unit, and wander to the adjacent independent living unit space. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on review of the facility policies, facility documentation, and staff interviews, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of one medication storage room reviewed. (Pine nursing unit) Finding include: Review of the facility policy on Storage and Expiration Dating of Medications, Biologicals, revised on August 7, 2023, indicated that facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. Review of clinical records of Resident R59, revealed that the resident was admitted to the facility on [DATE], with diagnoses including adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Review of Resident R59, January 2024 physican orders revealed an order January 4, 2024 for the anti-anxiety medication Lorazepam Intensol Oral Concentrate 2 MG/ML, give 0.25 ml, 0.5 mg, by mouth every 6 hours as needed for anxiety for 14 days. A review of facility investigation report revealed that on Friday January 5, 2024, nursing received a 30 ml bottle of liquid Ativan for the resident. It was received in a sealed bottle. No dose of Ativan were given to the resident on January 5th,6th, or 7th of 2024. The registered nurse working the 11-7 shift on January 7th, 2024, into January 8th, 2024, stated that she went to give a dose to the resident during the night; however, noticed that the bottle appeared to have been tampered with and was missing 14 MLs of medication. Continued review of the investigation report indicated that, obtained staff statements. Narcotic count was completed at the start of the 11-7 shift on January 7, 2024; however, the oncoming nurse (11-7) failed to go to the refrigerator with the 3-11 nurse to check the Ativan vial. The 3-11 nurse assumed she checked the Ativan because she came and signed off on the controlled drug inventory sheet that the count was correct. The 3-11 nurse reports that the vial of Ativan was full. The 3-11 and 11-7 nurses both report that the medication keys were never out of their possession. The 11-7 nurse is unable to provide an account of what occurred with the missing Ativan as she did not verify the contents at the start of her shift. She stated that she realized there was a problem with the vial when she went to get it from the refrigerator to administer to the resident. Toxicology screen completed for the nurse who reported the missing medication and was negative for Benzodiazepams. The 11-7 nurse is the presumed perpetrator; however, facility cannot definitively conclude that she was responsible for the missing Ativan. Facility was able to substantiate that she failed to follow the policy for completing the controlled drug inventory. Audit of all controlled substances in the facility was completed and no other medications were compromised. Interview with the Director of Nursing (DON) on May 28, 2023, at 10:07 a.m., confirmed the above stated findings. Review of the statement dated January 8, 2024, of Employee E10, a Registered Nurse, indicated as follows: I attempted to give room [ROOM NUMBER], Ativan liquid from the locked drawer, in the fridge. When I opened the box, med bottle had been opened; screw type insert was present (used for MSO4, not Ativan), and a couple of pieces of the safety paper noted under insert. The correct dropper for Ativan was present and sealed. Upon closer inspection, noted 16 cc of medicine in the bottle (should be 30 cc). Medicine was not given to resident due to tampering. DON aware. I admit I never checked medicine during narcotic count with previous Shift. Sorry . On May 28, 2024, at 10:40 a.m., tried to interview Employee E10, over telephone, but the attempt did not result in any return call. Review of the statement dated January 8, 2024, of Employee E11, a Registered Nurse, indicated as follows; I worked the Pine medication cart on the 7-3 shift on Sunday January 7, 2024. I did not go to the refrigerator to count the bottle of Ativan for [Resident R59]. I did not give [Resident R59] any Ativan during the 7-3 shift. The 3-11 Nurse did the narcotic count with me when she came onto her shift. I did not go to the refrigerator with her to count the Ativan. She went to the refrigerator herself and then came back and signed off on the narcotic count sheet that it was okay. I am unaware of any tampering that may have occurred with the Ativan bottle for [Resident R59]. On May 28, 2024, at 10:44 a.m., tried to interview Registered Nurse, Employee E11, over telephone, left message. On May 28, 2024, at 7:47 p.m. Registered Nurse, Employee E11, returned the call and stated that he I did not go to the refrigerator with the other nurse to count the Ativan, and confirmed the statement as explained above. Further review of employee statement dated January 8, 2024, of Employee E12, a Registered Nurse, indicated as follows: On Sunday January 7, 2024, I worked the 3-11 only. I counted with E11. I went to the refrigerator to check the Ativan by myself. It was full and still sealed. I signed the narcotic book with [Employee E11], indicating the count was correct. [Employee E10] came in for the 11-7 shift. We completed the narcotic count. I did not go with her to the refrigerator to check the Ativan. I believe that she went to count the Ativan in the refrigerator because she came back and signed the narcotic count log as being correct. She did not have any questions for me regarding the count. I had no idea there was any issue with the Ativan count or the Ativan bottle until I was questioned upon coming to work on January 8, 2024. Interview with the Director of Nursing on May 28, 2023, at 12:17 p.m., confirmed the findings, that the facility failed to implement procedures to promote accurate narcotic medication records . 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records and facility documentation and interviews with staff, it was determined, that the facility failed to provide an environment free of accident hazards which resulted in actual harm to one of 20 resident reviewed (Resident R16) who attempted to cut both his wrists with his own razor, requiring transfer and admission to the hospital via emergency services. Additionally, the facility failed to properly and safely provide transfer assistance from one surface to another for two of 20 residents reviewed (Resident R235) Findings include: Review of Resident R16's clinical record revealed an admission diagnosis, including but not limited to, Alzheimers' disease with dementia, (progressive brain disorder characterized by confusion and impaired memory, judgement and reasoning ability) and obsessive compulsive behavior (mental health disorder characterized by repetitive actions that seem impossible to stop). Continue review of Resident R16's clinical record revealed a person center behavioral support plan initiated (MONTH) 5, 2019 addressing the resident compulsive behaviors through the day which continue through the night. The behavior plan indicated that Resident R16 was very particular about his appearance and perseverates on fell and look of clothing and space. Review of Resident R16's psychotherapy progress note dated (MONTH) 14, 2019, indicated that Resident R16's mood was anxious and depressed. Continued review of the psychotherapy note revealed Resident R16's insight was lacking and judgement was poor. Additionally, Resident R16's [MEDICAL CONDITION] signs and symptoms were getting worse and the resident was severely depressed. The treatment plan include to increase the antidepressant [MEDICATION NAME]. Further review of Resident R16's clinical record revealed a nursing progress note dated (MONTH) 19, 2019, at 6:25 p.m. which indicated that at approximately 5:15 p.m. resident approached two nurse Resident ambulating with his walker, entered the nurses station to show us his bloody wrists . This nurse asked resident what happened and the resident stated, I tried to commit suicide. Resident indicated to Employee E13, Licensed nurse, Frustrated and fed up. Employee E13 asked R16, What he used to cut his skin, he replied, My shaving razor. Both wrists were cleaned and dressed, wound were superficial in nature. Right wrist measured a cut of 2 center meters, (cm), x 3 cm x 0.1 cm and left wrist measured a cut area of 2 cm x 1 cm x 0.1 cm. No acute distress noted, resident sat calmly in the chair while being supervised 1:1 by nursing staff. Spoke with CRNP who gave order to send resdient to (hospital) for evaluation and treatment . spoke with resident's daughter who was in agreement with plan of evaluation in the hospital . The resident remained in the nursing office with 1:1 nursing while room was searched and several razors were removed immediately as well as any other objects that could be potential harmful. 911 was called . Resident departed the facility at 6:25 p.m. Review of hospital history and physical dated (MONTH) 28, 2019 revealed that the resident had been thinking about it for about an our before he took a razor bald to his wrist. States he reported ot the staff that he had tried to cut himself. Did not required sutures. denies any suicidal ideation at present. Further review of the history and physical noted that the resdient states had passive wish to die before attempting to cut himself. Review of the discharged instruction from the hospital confirmed that the resident came to the hospital for a suicidal gesture by attempting to wrist superficially with a safety razor. Interview with the Assistant Director of Nursing on (MONTH) 19, 2019, at 11:30 a.m. confirmed review of Psychotherapy progress note dated (MONTH) 14, 2019, indicated that Resident R16, was anxious, lacked insight, was with poor judgement and was severly depressed. Assistant Director of Nursing further confirmed five days after Resident R16 was seen by psychotherapy, he cut the anterior sides of his right and left wrists. The facility failed to ensure that Resident R16's environment remained free from accident hazards, resulting in actual harm to Resident R16 who attempted to cut both his wrists with his own razor, requiring transfer and admission to the hospital via emergency services. A review of Resident R235's clinical record revealed that the resident was admitted to the facility on (MONTH) 5, 2019, with a [DIAGNOSES REDACTED]. A review of Resident R 235's fall risk assessment evaluation dated (MONTH) 5, 2019, revealed that the resident was at a high risk for falls. A review of the resident's care plan titled I am a fall risk. I have impaired vision, I am on antidepressants and I have a decrease in my mobility dated (MONTH) 7, 2019, revealed that the resident should have appropriate footwear on when ambulating or in the wheelchair. A review of the resident care plan titled I have potential for impairment to skin integrity, dated (MONTH) 7, 2019, revealed use caution when you are transferring and moving me to prevent striking my arms, legs and hands against any sharp or hard surfaces. A review of Resident R235's admission Minimum Data Set (MDS- a periodic review of resident care needs) dated (MONTH) 12, 2019, revealed that the resident was independent in decision making skills. Further review of the MDS revealed that the resident needed extensive assistance with bed mobility, transfers, dressing, and toilet use. Additionally, the MDS indicated that the resident needed the physical assistance of two staff persons for bed mobility, transfers, dressing and toilet use. A review of nurse's notes dated (MONTH) 13, 2019, revealed that Resident R235 was an attempted transfer from the bed to the wheelchair for toileting by CNA (nursing assistant) care giver without assistance of another CN[NAME] The resident's feet were bare. Upon transfer, the resident's left foot which was recently surgically repaired, came into contact with the wheelchair wheel and or castor frame causing a laceration between the fourth and fifth toes. First aid provided. CRNP made aware. Review of the facility investigation of the incident sustained by Resident R235 determined that there was improper procedure and staff handling as predisposing environmental factors to the incident. Further review of the investigation noted that the resident had improper foot wear during transfer. Interview with Employee E7, a nurse, on (MONTH) 20, 2019, at 10:00 a.m. confirmed that he had written the nurse's note on (MONTH) 13, 2019, and that the resident required the assistance of two staff persons for transfers. Interview with the Employee E8, the registered nurse assessment coordinator (RNAC), on (MONTH) 20, 2019, at 12:00 p.m. confirmed that Resident R235 needed the physical assistance of two staff members for transfers and that this was documented on the admission MDS dated (MONTH) 12, 2019. The facility failed to ensure that Resident 235 received the physical assistance of two staff persons during transfer from bed to wheelchair and was provided with the proper footwear which resulted in Resident 235 sustaining a laceration between her fourth and fifth toe on her left foot. Review of Resident R62's comprehensive Minimum Data Set (MDS-an assessment of care needs) dated (MONTH) 17, 2019, indicated that the resident was cognitively intact. The assessment further indicated that Resident R62 required extensive physical assistance from two staff persons for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Review of the comprehensive care plan for Resident R62 dated May, 2019, through September, 2019, revealed that Resident R62 was care planned to receive physical assistance from two staff with transfers. The care plan also indicated that the resident was to be transferred via mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair by the use of electrical or hydraulic power). A review of a nursing progress note dated (MONTH) 13, 2019, indicated that Resident R62 reported being improperly transferred by a nursing assistant. Resident R62 indicated that a nursing assistant lost their balance during the transfer, falling onto the resident's bed and landing on Resident R62's foot. Resident R62 reported being in pain after the incident and that it felt as though his ankle was broken. On (MONTH) 13, 2019, nursing documentation indicated that an examination of the resident R62's left foot was done. As the nurse removed the sock from the resident's foot the resident yelled out in pain. The nurse indicated that Resident R62 continued to yell out in pain when the nurse attempted gentle range of motion. The physican was notified and ordered that Resident R62 be administered Tylenol ([MEDICATION NAME]- pain reliever) 500 milligrams, two tablets every four hours, as needed for pain management. The physician also ordered that ice be applied to the left ankle. A review of facility documentation dated (MONTH) 13 and 14, 2019, revealed that Employee E12, nursing assistant, assigned to provide care and services for Resident R62 failed to follow the comprehensive care plan for Resident R62's transfer. Review of a statement obtained from the resident revealed that Resident R62 reported that he was supposed to be transferred with two persons and a mechanical lift; however, on (MONTH) 13, 2019, the nursing assistant performed a one person transfer and subsequently fell on top of the resident's foot. He clarified that he was not dropped but that the staff member fell on top of his foot during the one person transfer. Interview with the Director of Nursing, Employee E2, on (MONTH) 19, 2019, at 10:00 a.m., confirmed that Employee E12 Resident R62's was not transfer via mechanical lift as established on the resident's care plan on (MONTH) 13, 2019. The facility failed to properly transfer Resident R62 from the wheelchair to bed. 42 CFR 483(h) Free of Accident Hazards/Supervision/Devices. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 201.18(b)(1)(3) Management. 28 Pa Code 201.18(b)(3) Management. 28 Pa Code 211.10(d) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(5) Nursing services. 28 Pa Code:211.12 (d)(1)(5)Nursing services.

Based on observation, staff and resident interviews, and a review of facility documentation, it was determined that the facility failed to serve food at a safe temperature. Findings include: A review of the facilities policy titled Food Temperatures, date revised (MONTH) 2013, stated to strive to ensure proper serving temperatures, food temperatures will be obtained and recorded prior to meal service and any inappropriate temperatures will be corrected. Procedure: using a sanitized calibrated food thermometer, obtain final temperatures for all menu items, hot or cold, prior to serving. Further review of the facility policy titled Service of hot beverage, soup and cereal in the skilled care center, date revised (MONTH) 2010, stated to strive to ensure that residents in the skilled care center are served hot beverages, soup, and cereal at a safe and palatable temperature. Holding temperatures of hot beverages, soup, and cereal will be recorded on the meal record log by the cook or medical diet aide. Each community will establish serving temperatures controls to maintain food at the desired temperature. Hot beverages, soup, and cereal will be served to the residents at temperatures not exceeding 155 degrees fahrenheit at point of service ( when the resident receives the food item). If the hot beverage, soup or cereal is above 155 degrees fahrenheit at point of service, the item will be held for several minutes to allow to cool until the temperature of the item falls to 155 degrees fahrenheit. To expedite the cooling process, the item may be stirred or be placed into bowls or mugs, and the temperature re-checked prior to serving. An observation of the lunch meal on Willow Spring dinning room, on (MONTH) 17, 2019, at 12:10 p.m. revealed that Resident R55 received her soup and stated oh this soup is hot. When asked at what temperature the soup was being served, Employee E3, a dietary aide stated I am new I will get another employee to help you. Employee E5, dietary aide got a thermometer and took the temperature of the soup that was on the cart about to be served, the soup temperature was 163 degrees fahrenheit. When Employee E3 was asked what is done when soup is hot, he stated that I will hold it for a few minutes and let the soup cool. Employee E4, the nutritional service manager, was interviewed on (MONTH) 17, 2019, at 2:00 p.m. and confirmed that the soup should have been served below 163 degrees fahrenheit. When asked when the soup temperature was taken and what is was, Employee E4 stated that the soup temperature was taken at the steam table and it was 176 degrees fahrenheit. When asked if the soup temperature was taken right before being served to the resident. Employee E4 stated no. A review of food temperature control logs for the month of (MONTH) 2019, on the Willow Springs dinning room revealed that food temperatures were recorded at the steam table but on the following days there were no serving temperatures recorded at the point of service: (MONTH) 2, 2019, (MONTH) 3, 2019, (MONTH) 5, 2019, (MONTH) 6, 2019 (MONTH) 7, 2019, (MONTH) 8, 2019, (MONTH) 13, 2019, (MONTH) 16, 2019,September 17, 2019. On the following days food temperatures were not recorded for all three meals: (MONTH) 2, 2019, (MONTH) 8, 2019, (MONTH) 14, 2019 . And on the following days food temperatures were not recorded for certain meals: (MONTH) 6, 2019-dinner food temperatures were not recorded, (MONTH) 13, 2019- breakfast and lunch food temperatures were not recorded and (MONTH) 18, 2019- dinner food temperatures were not recorded. The facility failed to ensure that soup was served at a safe temperature. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1) Management.

Based on resident interview, clinical record review, facility documentation, facility policy and procedure and staff interview, it was determined that the facility failed to provide restorative nursing services for ambulation and range of motion for one of 20 residents reviewed (Resident R17). Findings include: Review of facility policy and procedure, titled, Restorative Nursing, dated, April, 2014, indicated, The restorative process is based on the premise that basic human needs are universal and fulfillment of those needs is imperative to the resdient's well-being. During an individual interview with Resident R17, on (MONTH) 17, 2019, at 10:30 a.m. it was stated by the resident the desire to walk more often. The resident additionally indicated that staff are so busy or not enough staff to help me walk. Clinical record review revealed a quarterly MDS, (Minimum Data Set - periodic assessment of needs), dated, (MONTH) 21, 2019, which indicated Resident R21 required extensive assistance, (resident involved in activity, staff provide weight bearing support) with one person physical assist. Review of therapy progress notes, revealed Resident R17, was discharged from therapy services on (MONTH) 4, 2019, at the time of the review of therapy progress notes, an interview with Physical/Occupational Therapy (PT/OT) Director, Employee E11 on (MONTH) 20, 2019, at 1:00 p.m. indicated, Resident R17 was to receive a Restorative Nursing Program (RNP- a daily program, with oversite by a staff person to assist a resident in maintaining functional status that improved, as a result of receiving therapy services, such as daily walking), on an ongoing basis after discharge from therapy services. Further review of therapy progress notes, revealed a RNP - Recommendations, dated, (MONTH) 25, 2019, which indicated, Resident R17, would facilitate daily functional ambulation on the unit hallway, (10-20 feet), using a rolling waker and facilitate daily active range of motion of lower extremities, by all major planes of motion in seated position. A follow up interview with Employee E11, PT/OT Director, on (MONTH) 20, 2019, 9:15 a.m. indicated that RNP for Resident R17, would have maintained daily living skills such as walking and range of motion. An interview with the Director of Nursing on (MONTH) 20, 2019, at 11:15 a.m. revealed that the facility had not had a designated staff person to fulfill Restorative Nursing Program duties for residents including, Resident R17, during the time period of (MONTH) 17, (YEAR) to (MONTH) 12, 2019 and (MONTH) 30, 2019 to the time of the interview with the Director of Nursing, (September 20, 2019, at 11:15 a.m.). The facility failed to provide restorative nursing services for ambulation and range of motion to Resident R17. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observation and staff interviews, it was determined that the facility failed to post survey results on three of four nursing units. (Apple, Maple and Pine Nursing Units) Findings include: Observations on (MONTH) 19, 2019, at 12:00 p.m. of the Apple, Maple, Pine Nursing Units revealed that there were no survey results posted in a prominent location with easy access for residents and visitors. Interview with the Administrator on (MONTH) 19, 2019, at 12:30 p.m., where she confirmed that there were no survey results posted in a prominent location with easy access for resident and visitors. The facility failed to provide survey results and easy access for survey results to resident. 28 Pa. Code 201.29(b) Resident rights

Based on observations, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to follow and clarify physician's orders [REDACTED]. Findings include: Review of Resident R38's clinical record revealed a quarterly Minimum Data Set (MDS - assessment of need), dated July 15, 2016, which indicated that the resident had [DIAGNOSES REDACTED]. Further review of Resident R38's clinical record revealed physician's orders [REDACTED]. sugar was less than 60 mg/dl or greater than 300 mg/dl. Review of the Medication Administration Records (MAR's) from May 1, 2016 through July 28, 2016, revealed that the Accu-check result on May 12, 2016 at 4:00 p.m. indicated that the resident's blood sugar was 394 mg/dl. The Accu-check result on July 23, 2016 at 4:00 p.m. indicated that the resident's blood sugar was 341 mg/dl. There was no evidence on either occasion that the physician was notified as ordered. An interview with Employee E3, a nurse, on July 28, 2016, at 4:10 p.m. confirmed that the physician was not notified. Review of facility policy, Medication Administration & Management, dated March 2012, revealed that prior to medication administration, nursing staff would verify the correct dose of a drug and confirm that the Medication Administration Record [REDACTED]. Review of the clinical record for Resident R64 revealed a recapitulation (recap) of physician's orders [REDACTED]. Further review of the July 2016 recaps instructed staff to administer [MEDICATION NAME] 0.1 percent (medicated eye drops used to treat [MEDICAL CONDITION]), one drop in the left eye, twice daily. Review of the MAR for July 2016, revealed documentation that the [MEDICATION NAME] 0.1 percent was administered per physician's orders [REDACTED]. Observation of the medication cart in the presence of the Director of Nursing on July 28, 2016, at approximately 2:30 p.m., revealed the [MEDICATION NAME] bottle labeled with Resident R64's name was, [MEDICATION NAME] 0.2 percent, not [MEDICATION NAME] 0.1 percent as indicated in the July 2016 physician's orders [REDACTED]. Further review of the clinical record for Resident R64 revealed no documentation that the physician's orders [REDACTED]. Interview with the Director of Nursing on July 28, 2016, at approximately 4:30 p.m., confirmed Resident R64's labeled [MEDICATION NAME] bottle in the medication cart was 0.2 percent (not 0.1 percent as indicated in the physician's orders [REDACTED]. The facility failed to follow and clarify physician's orders [REDACTED]. 483.25 Quality of Care. Previously cited state deficiency 9/01/15. 28 PA Code: 211.10(c) Resident care policies. Previously cited 9/01/15. 28 PA Code: 211.12(d)(1)(5) Nursing services. Previously cited 9/01/15.

Based on review of personnel records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to conduct pre-employment criminal background checks for one of six personnel records reviewed (Employee E4). Findings include: Review of facility policy, Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention, dated revised February 2014, revealed that employees would have appropriate background screening per state and federal guidelines. Review of the personnel record for Employee E4, occupational therapist, revealed that the employee's date of hire was May 26, 2016. Further review of the employee's personnel file indicated no documentation that the facility had requested a criminal background check (PATCH-Pennsylvania Access To Criminal History) through the Pennsylvania State Police, prior to Employee E4's hire with the facility. Interview with the Nursing Home Administrator and Director of Nursing on August 1, 2016, at approximately 2:00 p.m., confirmed that the criminal background check for Employee E4 had not been obtained as required. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited 9/01/15. 28 PA Code: 201.18(b)(1) Management. Previously cited 9/01/15. 28 PA Code: 201.19 Personnel policies and procedures.

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that emergency procedures were performed for a resident exhibiting signs and symptoms of choking, for one of 18 residents reviewed (Resident CL3), resulting in actual harm to that resident. Findings include: Review of facility policy, Choking ([MEDICATION NAME] Maneuver), dated last revised [DATE], revealed that if a resident is choking, facility staff would strive to dislodge or expel a foreign body lodged in a resident's airway, and staff would document the exact time the choking began and when unconsciousness occurred. Review of facility policy, Incident Reporting/Injury Investigation Residents and Visitors, dated last revised [DATE], revealed that all types of incidents require completion of an incident report including documentation and description of the resident's incident/injury and any relevant observations, and what was observed by the witness. Review of the clinical record for Resident CL3 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the plan of care for risk of losing weight due to swallowing difficulty, dated initiated on [DATE], and updated on [DATE], indicated a goal for Resident CL3 was to keep the resident free of aspiration (inhalation of food or fluid into the airway). Review of a physician's orders [REDACTED]. Review of a speech therapy daily treatment note, dated [DATE], revealed a [DIAGNOSES REDACTED]. was upright with head forward. Review of a nursing progress note dated [DATE], effective time of 11:18 a.m., and created time of 11:26 a.m., and written by Employee E3, nursing supervisor, revealed that earlier that morning, the charge nurse was called to Resident CL3's room by the certified nursing assistant (CNA) who reported the resident started coughing during the breakfast meal while sitting upright in bed. The note further indicated that, Nurse responded immediately and observed agonal breathing (abnormal pattern of breathing characterized by gasping and labored breathing), abnormal involuntary jerky body movements, deviated line of vision to the left, unresponsive to both verbal and painful stimuli, and no palpable pulse or blood pressure. The note additionally stated that CPR (cardiopulmonary resuscitation-manual compressions on the chest to keep the heart beating) was not initiated due to the resident's advance directives/living will (the right to accept or refuse medical/surgical treatment), that the resident's physician and family were notified, and post mortem care (care after a person dies) was provided. Review of physician's discharge summary, signed and dated by the physician on [DATE], revealed that the resident, died suddenly thought to be related to aspiration. Review of the Certificate of Death for Resident CL3, date of death [DATE], and time of death 9:15 a.m., revealed immediate cause of death was aspiration pneumonitis (inhalation of food and fluids contents into the lungs). Upon surveyor request to review the facility's investigation documentation and employee witness statements regarding the circumstances surrounding Resident CL3's death on [DATE], interview with the Assistant Director of Nursing on [DATE], at 11:25 a.m., revealed that the facility had not completed an investigation because staff thought the resident had a, neurologic event that caused the resident's death, not from choking. There was no documentation available for review describing the event regarding what possible factors were present that may have caused the resident to exhibit signs of choking (coughing during breakfast meal) including observation and documentation of what was on the resident's breakfast tray, if the food on the tray was of mechanical soft consistency per physician's orders [REDACTED]. Further interview with the Assistant Director of Nursing revealed that the charge nurse as indicated in the nursing progress note was a different person than the nursing supervisor who wrote the note describing the resident's death. Further review of the clinical record revealed no documentation regarding if the charge nurse (who responded to the call from the CNA who reported the resident started coughing during the breakfast meal) attempted the [MEDICATION NAME] Maneuver (manual way to dislodge an item stuck in a person's throat) or any other measure to assess the resident for a blocked or partially blocked airway. The facility failed to provide care, assessment and interventions to a resident, identified as at risk for aspiration, who exhibited signs of choking during a breakfast meal and expired. This failure caused actual harm to Resident CL3. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(b)(1)(3)(e)(1) Management. 28 PA Code: 211.5(f) Clinical records. 28 PA Code: 211.10(c) Resident care polices. 28 PA Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of clinical records, facility documentation, and facility policies and procedures, and interviews with staff, it was determined that the facility failed to thoroughly investigate incidents regarding signs and symptoms of choking, falls and bruising, for three of 18 residents reviewed (Residents CL3, R66 and R15). Findings include: Review of facility policy, Incident Reporting/Injury Investigation Residents and Visitors, dated last revised [DATE], revealed that all types of incidents require completion of an incident report including documentation and description of the resident's incident/injury and any relevant observations, and what was observed by the witness. Review of facility policy, Falls Reduction and Management, dated last revised [DATE], revealed that an investigation regarding the cause of a resident's fall would be conducted. Review of facility policy, Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention, dated last revised February 2014, revealed that suspicious occurrences, patterns and trends that may constitute abuse or neglect will be identified and monitored (i.e., bruising of residents), that an investigation will be conducted for the alleged incident, and investigative procedures taken and outcomes of those procedures must be documented in detail. The policy further clarified that the investigative summary report must include sufficient detail to document the facility conducted a thorough investigation and shall include, but not limited to, the results of the investigation. Review of the clinical record for Resident CL3 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the plan of care for risk of losing weight due to swallowing difficulty, date initiated, [DATE], and updated on [DATE], indicated a goal for Resident CL3 was to keep the resident free of aspiration (inhalation of food or fluid into the airway). Review of a physician's orders [REDACTED]. Review of a speech therapy daily treatment note, dated [DATE], revealed a [DIAGNOSES REDACTED]. was upright with head forward. Review of a nursing progress note dated [DATE], effective time of 11:18 a.m., and created time of 11:26 a.m., and written by Employee E3, nursing supervisor, revealed that earlier that morning, the charge nurse was called to Resident CL3's room by the certified nursing assistant (CNA) who reported the resident started coughing during the breakfast meal while sitting upright in bed. The note further indicated that, Nurse responded immediately and observed agonal breathing (abnormal pattern of breathing characterized by gasping and labored breathing), abnormal involuntary jerky body movements, deviated line of vision to the left, unresponsive to both verbal and painful stimuli, and no palpable pulse or blood pressure. The note additionally stated that CPR (cardiopulmonary resuscitation-manual compressions on the chest to keep the heart beating) was not initiated due to the resident's advance directives/living will (the right to accept or refuse medical/surgical treatment), that the resident's physician and family were notified, and post mortem care (care after a person dies) was provided. Review of physician's discharge summary, signed and dated by the physician on [DATE], revealed that the resident, died suddenly thought to be related to aspiration. Review of the Certificate of Death for Resident CL3, date of death [DATE], and time of death 9:15 a.m., revealed immediate cause of death was aspiration pneumonitis (inhalation of food and fluids into the lungs). Upon surveyor request to review the facility's investigation documentation and employee witness statements regarding the circumstances surrounding Resident CL3's death on [DATE], interview with the Assistant Director of Nursing on [DATE], at 11:25 a.m., revealed that the facility had not completed an investigation because staff thought the resident had a, neurologic event that caused the resident's death, not from choking. There was no documentation available for review describing the event regarding what possible factors were present that may have caused the resident to exhibit signs of choking (coughing during breakfast meal) including observation and documentation of what was on the resident's breakfast tray, if the food on the tray was of mechanical soft consistency per physician's orders [REDACTED]. Further interview with the Assistant Director of Nursing revealed that the charge nurse as indicated in the nursing progress note was a different person than the nursing supervisor who wrote the nursing progress note describing the resident's death. Further review of the clinical record revealed no documentation regarding if the charge nurse (who responded to the call from the CNA who reported the resident started coughing during the breakfast meal) attempted the [MEDICATION NAME] Maneuver (manual way to dislodge an item stuck in a person's throat) or any other measure to assess the resident for a blocked or partially blocked airway. The facility failed to conduct a complete and thorough investigation into a resident, identified as at risk for aspiration, who expired during a breakfast meal. Review of the clinical record for Resident R66 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Fall Risk Evaluation, dated [DATE], scored the resident as a 14, with a score of 10 or greater indicating Resident R66 was at high risk for falls. Review of a physician's orders [REDACTED]. Review of a nursing progress note dated [DATE], revealed that at 2:00 a.m., Resident R66 was awake, restless and unable to be redirected by staff. The note further stated that the resident's as needed anxiety medication ([MEDICATION NAME]) was adminstered by staff with a positive effect noted. The note additionally stated that at 3:00 a.m., Resident R66 was seated in a wheelchair in the nursing unit's common room with a CNA present in the same room, then the resident was observed by the CNA on the floor with a laceration (cut) to the left side of the resident's scalp. The note clarified that the resident was sent to an acute care hospital emergently for evaluation. Review of another nursing progress note, dated [DATE], at 8:22 a.m., indicated Resident R66 returned from the hospital with five staples to the left scalp laceration. Review of the information dated [DATE], submitted by the facility revealed that Resident R66 was sitting in a wheelchair at the Activity table in the common area for increased supervision by staff, that staff was momentarily assisting another resident, and Resident R66 stood up and fell . Review of the facility's investigation report revealed no witness statement from the CNA who was supervising Resident R66 in the nursing unit's common room which would have described what the resident's mental status and demeanor was at the time the CNA left the resident unattended, if the resident's wheelchair was locked, or what circumstances were present to prompt the CNA to leave the common area. Further review of the facility's investigation report revealed no conclusion that neglect was ruled out by the facility by the CNA leaving the resident unattended in the common area. Interview with the Assistant Director of Nursing on [DATE], at 1:30 p.m., confirmed there was no witness statement by the CNA regarding Resident R66's fall on [DATE], and confirmed there was no facility documentation that neglect was ruled out at the conclusion of the facility's internal investigation. The facility failed to conduct a complete and thorough investigation into a resident's fall. Resident R15's comprehensive assessment (an assessment of care needs) dated [DATE] indicated that this resident was independent with decision making. Nursing progress notes dated [DATE] indicated that upon skin assessment, Resident R15 was found with fading bruises on the left thigh, right under arm and right hip. This nursing progress note also indicated that the Resident R15 was aware of all the bruises. Resident R15 reported that the bruising occurred during transfers in and out of the bed; while staff were using the mechanical lift. The facility did not complete an incident investigation for the bruising found on Resident R15's skin, during a body assessment on [DATE]. There was no documentation to indicate the size of the bruising that was found. There was no documented care planning measures established to prevent further occurrences of bruising for Resident R15. There were no documented staff interviews/statements completed related to the causative factor for the occurrence/incident, during the mechanical lift transfers. The lack of documentation to indicate that a complete investigation was available for review, for the bruises identified on Resident R15's skin on [DATE] was confirmed during an interview with the administrator at 10:00 a.m., on [DATE]. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(b)(1)(3)(e)(1) Management. 28 PA Code: 211.5(f) Clinical records. 28 PA Code: 211.10(c) Resident care polices. 28 PA Code: 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, staff interview and observations of the administration of medications to residents, it was determined that the facility failed to ensure that residents consistently received medications in accordance with physician's orders [REDACTED]. Findings include: Review of Resident R6's clinical record included September 2013, physician's orders [REDACTED]. Observation of the medication pass on September 4, 2013, at approximately 9:30 a.m., revealed Employee E1, licensed nurse, administered the [MEDICATION NAME] without food. Observation of the medication pass on September 4, 2013, at approximately 10:05 a.m., revealed Employee E1, administered 2 half tablets (each half tablet equal to 0.25 milligrams) of [MEDICATION NAME] (antianxiety medication), to Resident R2, a total of 0.50 milligrams of [MEDICATION NAME]. Employee E1 stated at that the time of the observation that the medication dose had just been increased, and that facility staff were using up the existing 0.25 milligram tablets instead of wasting them. Review of Resident R2's clinical record included a physician's orders [REDACTED]. Employee E1 stated in an interview on September 4, 2013, at approximately 11:55 a.m., that the employee had administered two half tablets, double the dose ordered by the physician, because the employee thought it had been changed. The Director of Nursing confirmed in an interview on September 6, 2013, at approximately 9:00 a.m., that Resident R6 had not been given food when receiving [MEDICATION NAME], and confirmed that Resident R2 had received the incorrect dose of [MEDICATION NAME]. 28 PA Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to ensure that aseptic technique was maintained during wound care treatment for two of 19 residents reviewed (Resident R3 & R52). Findings include: A review of Resident R3's clinical record revealed a physician's orders [REDACTED]. wrap with kling everyday. An observation of this wound treatment on August 23, 2011, revealed that Employee E4, a licensed nurse, allowed her identification (ID) badge to rub up against Resident R3's open wound on her left leg several times until Employee E5 directed Employee E4 to remove her ID badge. Employee E4 put the badge around her neck to her back leaning against her clothing. Employee E4 then preceded to apply moisturizer around Resident R3's wounds on her left leg dipping a 4 by 4 guaze twice into the container after applying the moisturizer on the resident's left leg contaminating the moisturizer jar and then reapplied the moisturizer to the other side of the left leg. An interview with Employee E4 on August 23, 2011, at 1:45 p.m., confirmed that she allowed her ID badge to rub up against the open wound several times and twice dipped the same gauze into the moisturizer container contaminating the jar. The facility failed to maintain infection control practice to prevent cross contamination of disease and infection. Review of the clinical record of Resident R52 revealed documentation of a wound consultation, dated August 16, 2011, which indicated this resident had a wound on his right shin and a wound on his left third toe. physician's orders [REDACTED]. Review of the facility ' s policy, " Wound Care and Dressing Changes, " most recently revised August 2011, revealed that a clean field is to be established on the bedside table for clean dressings in order to protect the environmental surface from possible contamination. Observation of the wound care and dressing changes provided to Resident R52, at 11:30 a.m. on August 23, 2011, revealed that Employee E6, a licensed nurse, did not provide a clean field during this care. After cleaning each of the wounds, Employee E6 handled the infectious waste bag as she disposed of used supplies into it. Without changing her gloves and washing her hands, Employee E6 repeatedly reached into a plastic bag which contained wound care supplies and medications during the treatment and dressing change. Subsequent to the wound treatment and dressing change on R52 ' s right shin, Employee E6 removed the barrier field from underneath this wound and transferred it to under the left foot prior to the wound treatment and dressing change on the left third toe where it remained while the previous dressing was removed and the wound was cleansed. At one point, an opened tube of Santyl (an agent for cleaning wounds) was placed on this barrier field and subsequently returned to the plastic bag holding supplies for future use, creating a potential for cross contamination. During the observation, the infectious waste bag was dropped on the floor; Employee E6 picked the bag up and returned it to the bed. These findings were confirmed with Employee E6 following the wound care observation. 28 Pa. Code: 211.12(c)(d)(2) Nursing services. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12 (d)(5) Nursing services.