Every finding on record at Willowbrooke Ctskdcarectr at Fortwashingtonestates

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that physician orders were followed for one of two residents observed during medication administration. (Resident R111) Findings include: On February 24, 2025, 8:20 a.m., observed that Employee E5, a Registered Nurse, administered to Resident R111, the medicine, Bicalutamide Oral Tablet 50 MG (Bicalutamide), give 50 milligrams by mouth one time a day for prostate cancer related to Malignant Neoplasm of Prostate; but, E5 administered the medicine, Bicalutamide Oral Tablet without wearing gloves when handling Bicalutamide medication and E5 did not wash her hands after. Review of physician order for Resident R111, revealed an order, dated December 11, 2024, to administer 'Bicalutamide Oral Tablet 50 mg., give 50 mg., by mouth one time a day for prostate cancer related to Malignant Neoplasm of Prostate, wear gloves when handling this medication and wash your hands after use, warning: requires special handling by those who are pregnant or suspect or anticipate pregnancy. It could potentially have an adverse effect on a male fetus'. The Registered Nurse, E5 did not follow the physician order to administer Bicalutamide Oral Tablet. On February 24, 2025, 8:21 a.m., observed that Employee E5, was going to administer to Resident R111, the medicine Torsemide Oral Tablet 10 mg., two tablets by mouth. After safely preventing Employee E5 the administration of Torsemide Oral Tablet 10 mg. two tablets; Registered Nurse was asked to double check the medicine; the nurse stated it was Torsemide Oral Tablet 10 mg., two tablets. When asked the Registered Nurse to double check the physician order; Employee E5 checked the physician order, and sated that the physician order was as follows: Torsemide Oral Tablet 20 mg., give two tablets to equal 40 mg, by mouth, in the morning, every other day; then, E5 did administer the physician ordered Torsemide Oral Tablet 40 mg, to R111. Review of physician order for Resident R111, revealed an order, dated January 14, 2025, to administer Torsemide Oral Tablet 20 mg., give two tablets to equal 40 mg, by mouth. At the time of the finding, during an interview with the Director of Nursing, confirmed the above findings.

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on July 17, 2023, at 10:30 a.m. with Employee E3, Nutrition Services Manager (NSM), which revealed the following: Observations in the receiving area revealed a dumpster/trash compactor which was designed with an open trash collection bin when the ram is in the open or resting position, which exposes the trash to the open air. There were several white/translucent bags of trash visible and exposed to the elements. Observations in the satellite kitchen in the dish washing area revealed a grey brute trash can with the lid off exposing the trash inside the can. Interview with the NSM on July 17, 2023, at 10:45 a.m. confirmed the above findings. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on clinical record review, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise one of seventeen residents reviewed (Resident R110) resulting in Resident R110 eloping from the facility. Findings include: Review of the facility policy title Clinical Guideline; Elopement revised [DATE], stated that the facility was, to strive to identify residents in Willowbrooke Court (WBC) who are at risk for wandering and potential elopement and provide a safe environment while maintaining their highest practicable level of physical, mental, and psychosocial well-being. Review of Resident R110's clinical record revealed the resident was admitted on [DATE], with diagnosis including dementia with psychotic disturbance (the mental state where someone is not sure what's real or not, which can include paranoid or delusional thoughts as well as hallucinations. Psychosis can be a complication of dementia, which is the greatest risk factor for development of psychotic symptoms in the geriatric population). Review of Resident R110's clinical record revealed a Wandering Risk Assessment (Scale) completed on [DATE], which indicated the resident was at high risk to wander. Review of Resident R110's Minimum Data Set (MDS-assessment of resident care needs) dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 12 which indicated that the resident's cognitive status was moderately impaired. Review of Resident R110's clinical record revealed a care plan dated [DATE], for being at risk for wandering which included placement of a Wander Alert device which will be checked for function and expiration weekly. Review of Resident R110's nursing note dated [DATE], at 2:25 p.m. revealed that at 11:20 a.m. the charge nurse, Employee E5, observed Resident R110 to be walking unattended in the parking lot using her walker. The resident refused to come back in. That security was notified and that after approximately 5 minutes the resident agreed to come back into the facility. A review of the facility incident investigation for the [DATE], revealed statements from the Charge Nurse which indicated that Resident R110's Wander Alert that was on her left wrist had an expiration date of [DATE], and that it had been recorded as [DATE]. Interview with Resident R110 on [DATE], at 1:15 p.m., revealed that the resident admitted that she went outside on [DATE]. That she was watching people going in and out the front door, and that there was no staff in the area so she decided that she would go outside since she was not setting off the alarm when she approached the door. She said that she knew that the nurses did not want her to go outside by herself, but that she was not a prisoner and she wanted to enjoy the fresh air. Interview with Employee E5, RN Charge Nurse, on [DATE], at 12:30 p.m. confirmed that Resident R110 was at risk for wandering, and that she had left the building through the front door and was walking unattended in the parking lot when the nurse saw her. The Charge Nurse also confirmed that the Wander Alert bracelet had been expired, and the wrong date had been written on the log. Interview with the Nursing Home Administrator, on [DATE], at 1:00 p.m. confirmed that Resident R110 had left the facility without permission on [DATE]. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 PA. Code 211.12(d)(1) Nursing services

Based on observation, interviews with a resident and staff, review of clinical records, review of facility documentation, and review of facility policies and procedures, it was determined that the facility failed to ensure that each resident's environment remained free of accident hazards by failing to test the temperature of hot coffee prior to being served to residents. This failure resulted in an Immediate Jeopardy situation to Resident R1 who spilled hot coffee on the left upper thigh and developed a second degree burn for one of two residents reviewed. (Resident R1). Findings include: Review of the facility's policy titled, Service of Hot Beverages, Soup and Cereal in the Skilled Care Center and Assisted Living Residence revised on August 2020, states, To strive to ensure that residents . are served hot beverages, soup, and cereal at a safe and palatable temperature. The same policy further states, Hot beverages, soup, and cereal will be served to the resident at temperatures not exceeding 155F (Fahrenheit) at point of service. Review of Resident R1's quarterly Minimum Data Set (MDS is periodic assessment of the resident's needs) dated August 18, 2022, revealed the resident was independent in making decisions regarding tasks of daily life. Further review of the resident's MDS revealed that the resident was assessed as independent with eating, requiring no additional help from staff except for setup help only, no upper extremities limitation and no swallowing disorder. The resident's diagnoses listed in the MDS assessment included anemia (low iron), heart disease and high blood pressure. Review of facility documentation dated November 5, 2022, stated on November 4, 2022, the facility's activity's department, Life Enrichment, offered coffee and pastries to the residents during an activity they call Coffee Klatch. As Life Enrichment staff was leaving Resident R1's room, the resident dropped the coffee in her lap. The next day, on November 5, 2022, nursing reported a Grape size, intact blister on the resident's left upper thigh. The documentation continued to state that prior to serving the coffee to Resident R1, The temperature of the coffee was not checked by the main kitchen. Review of Resident R1's nursing notes revealed on November 4, 2022, the resident spilled coffee on her lap, her clothes were removed, her bilateral thighs were noted as reddened and cool compresses were applied. On November 5, 2022, a grape size blister was noted on her upper left thigh. On November 11, 2022, the blister was first noted to be open and an order for Silvadene and a dressing were applied. Interview with the Nursing Home Administrator (NHA) on November 17, 2022, at 11:28 a.m. stated that Coffee Klatch is considered a social event so the Main kitchen prepared the coffee instead that at the skilled satellite kitchen. The NHA stated, When I started investigating the incident, I wasn't aware the Main kitchen does not have a policy for hot beverages. They were not taking the temperatures of the hot beverages for Coffee Klatch. Life Enrichment staff was also not taking the temperatures during Coffee Klatch. Our kitchen does have a policy, and we take the temperatures of all food and hot liquids before being served to the residents. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on November 17, 2022, at 3:50 p.m. for the facility's failure to ensure hot beverage were served at a safe temperature. This failure resulted in Resident R1 developing a second degree burn on her left upper thigh from spilling hot coffee on her left thigh. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on November 17, 2022, at 4:07 p.m. The facility's corrective action plan dated; November 18, 2022, included the following interventions: Resident was provided with treatment of cold compresses at the time the redness of skin was noted. Physician was notified on November 4, 2022, and the POA (Power of Attorney) notified. On the following day, November 5, 2022, physician was notified of blister and treatment applied as ordered. POA notified. WBC (Willowbrooke Court) coffee klatch process was updated to include the following: All WBC Life Enrichment requests for hot beverages will be provided by the WBC/skilled satellite kitchen. WBC culinary staff will check, verify, and document that temperature does not exceed 155 Fahrenheit prior to the beverages leaving the WBC satellite kitchen. Culinary will provide all requested supplies including cups with handles. WBC Life Enrichment staff will verify that temperature of hot liquids does not exceed 155 Fahrenheit prior to initiating the activity program. Review of documentation provided by the facility revealed that on November 8, 2022, a 100% of life enrichment staff were educated on the updated coffee klatch process. The staff were educated on how to check the temperature of hot liquids and gave return demonstration. On November 10, 2022, 58% of Willowbrooke Court/SNF (skilled nursing facility) satellite kitchen total staff were re-educated on the updated coffee klatch process and on the required temperature check for hot beverages served in the SNF setting. 100% of full-time staff have been reeducated and the remaining part time SNF staff was to be re-educated prior to working there (sic) next scheduled shift. 100% of the culinary staff in the main kitchen were re-educated on the updated coffee klatch process and on the required temperature check for hot beverages served in the skilled nursing setting. Interviews were conducted on November 7, 2022 with 7 staff members from all departments. All staff members reported that they received education regarding food temperature monitoring. The education was conducted by the Nursing Home Administrator and included the Coffee Klatch New Process. which indicated food and beverage temperatures will be monitored to minimize potential for injury. Review of food temperature logs confirmed that the temperature of hot beverages have been recorded to ensure safety. Following the verification of the immediate action plan, The Immediate Jeopardy was lifted on November 18, 2022, at 3:12 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to a thermal burn of one of two clinical records reviewed (Resident R1). Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed duties that included, Administers fiscal operation, such as budget planning, monthly reports, and accounting for health care services. Fulfills maximum capacity requirements of Personal Care Wing and Skilled Nursing Center. Directs hiring and training of management personnel under Nursing Home Administrator supervision. Negotiates for improvement of and additions to buildings and equipment. 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. Attends community meetings, department head meetings, and corporate meetings. Shares responsibility of 24 hour/7 day per week coverage with Executive Director. Directs department heads in the absence of the Executive Director. Identifies safety hazards and emergency situations and initiates corrective action immediately. May perform other duties as assigned. Review of the facility's policy titled, Service of Hot Beverages, Soup and Cereal in the Skilled Care Center and Assisted Living Residence revised on, August 2020, states, To strive to ensure that residents . are served hot beverages, soup, and cereal at a safe and palatable temperature. The same policy further states, Hot beverages, soup, and cereal will be served to the resident at temperatures not exceeding 155F at point of service. Review of Resident R1's quarterly Minimum Data Set (MDS is periodic assessment of the resident's needs) (pick one, before burn) dated August 18, 2022 revealed the resident was independent in making decisions regarding tasks of daily life. Further review of the resident's MDS revealed that the resident was assessed as independent with eating, requiring no additional help from staff except for setup help only, no upper extremities limitation and no swallowing disorder. The resident's diagnoses listed in the MDS assessment included anemia (low iron), heart disease and high blood pressure. Review of facility documentation dated November 5, 2022 stated on November 4, 2022, Life Enrichment offered coffee and pastries to the residents during an activity they call Coffee Klatch. As Life Enrichment staff was leaving Resident R1's room, the resident dropped the coffee onto her lap. The next day, on November 5, 2022, nursing reported a Grape size, intact blister on the resident's left upper thigh. The documentation continued to state that prior to serving the coffee to Resident R1, The temperature of the coffee was not checked by the main kitchen. Review of Resident R1's nursing progress notes revealed on November 4, 2022, the resident spilled coffee on her lap, her clothes were removed, her bilateral thighs were noted as reddened and cool compresses were applied. On November 5, 2022, a grape size blister was noted on her upper left thigh. On November 11, 2022, the blister was first noted to be open and an order for Silvadene and a dressing were applied. The Nursing Home Administrator (NHA) on November 17, 2022, at 11:28 a.m. explained that Coffee Klatch is considered a Social event so the Main kitchen prepares the coffee instead of Willowbrooke Court. The NHA stated, When I started investigating the incident, I wasn't aware the Main kitchen does not have a policy for hot beverages. They were not taking the temperatures of the hot beverages for Coffee Klatch. Life Enrichment staff was also not taking the temperatures during Coffee Klatch. Our kitchen does have a policy, and we take the temperatures of all food and hot liquids before being served to the residents. Based on the deficiencies identified in this report the Nursing Home Administrator failed to fulfill essential duties and responsibilities their position, contributing to an Immediate Jeopardy situation. Refer to F689. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(b)(1)(3)(d) Management 28 Pa Code 211.12(c)(d)(3)(5) Nursing Services

Based on review of clinical records, staff interview and facility documentation, it was determined that the facility failed to implement safety measures to prevent accidents for one of 12 residents reviewed.(Resident R24) This failure resulted in actual harm to Resident R24 who sustained a fall from bed, required transfer to the hospital and a diagnosis of a right parietal scalp hematoma. (Resident R24) Findings include: Review of Resident R24's clinical record revealed the resident was admitted to the facility on September 13, 2018, with diagnoses of Alzheimer's Disease (progressive [CONDITION(S)] disease of the brain), [CONDITION(S)] (improper functioning of the vein valves in the leg, causing swelling and skin changes) Spinal Stenosis (the space inside the backbone is too small causing pressure on the spinal cord and nerves), [CONDITION(S)] (increased eye pressure resulting in the inability of fluid to drain from the inner eye), and Mixed Incontinence. Review of Resident R24's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated July 14, 2022, revealed that the resident was assessed with long and short term memory impairment. Continue review of the assessment revealed that the resident required extensive assistance of two people for bed mobility and transfers and had no ambulatory capabilities. Resident R24 was assessed as always incontinent of bowel and bladder. Review of Resident R24's plan of care initiated on October 28, 2018 and continuing revealed a care plan for activities of daily living related to Alzheimer's disease. Review of interventions revealed that the resident required a two person assistance for bed mobility. On July 23, 2019 the resident care plan interventions were updated to include I need more assist with toileting from the staff. My toileting talk will be performed in bed by the staff. Review of facility reported incident revealed on August 8, 2022, at 8:50 p.m. Resident R24 was provided incontinence care by nursing aide, Employee E9. Resident R24 was in bed during incontinence care and Employee E9 placed resident on her side. Employee E9 stepped away to retrieve wipes located in Resident R24's bathroom. As Employee E9 turned away, Resident R24 fell to the floor. Resident R24 was observed laying on her right side with bleeding noted coming from the right side of the head. The resident's bed height was noted to be at nursing aide care level. The resident's physician notified and ordered for the Resident R24 to be sent out to hospital for evaluation and treatment. Resident R24 was diagnosed with right parietal scalp hematoma. Interview on September 21, 2022, at approximately 1:00 p.m. with nursing aide, Employee E9, confirmed that she failed to gather all the necessary equipment prior to the provision of incontinence care to Resident R24. Further during interview Employee E9 stated that she individually has provided care to the resident in the past without the assistance of another nursing staff member. Interview conducted on September 21, 2022, at approximately 12:30 p.m. with Nursing Home Administrator, revealed that the facility's investigation determined that nurse aide, Employee E9, who was assigned to provide incontinence care to Resident R24 left the resident unattended and the resident fell to the floor and sustained a parietal scalp hematoma to the head. The facility failed to failed to provide two person physical assistant during the provision on incontinence care to Resident R24 which resulted in actual harm to Resident R24 who sustaining a fall from bed, required transfer to the hospital and a diagnosis of a right parietal scalp hematoma. Refer F600 28 Pa. Code 201.14 (a)(e) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.29 (c) Resident Rights 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa Code 211.12 (d)(5) Nursing Services

Based on review of clinical records, staff interview, review of facility policy and facility documentation, it was determined that the facility failed to ensure one of 12 residents reviewed was free of neglect. (Resident R24). This failure resulted in actual harm to Resident R24 who sustained a fall from bed, required transfer to the hospital and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of facility policy, Abuse, Neglect, Involuntary Seclusion, Exploitation, and Misappropriation of Property Prevention, dated as revised May 2021, defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of Resident R24's clinical record revealed the resident was admitted to the facility on September 13, 2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R24's quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated July 14, 2022, revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R24 was assessed as always incontinent of bowel and bladder. Review of Resident R24's plan of care initiated on October 28, 2018 and continuing revealed a care plan for activities of daily living related to Alzheimer's disease. Review of interventions revealed that the resident required a two person assistance for bed mobility. On July 23, 2019 the resident care plan interventions were updated to include I need more assist with toileting from the staff. My toileting talk will be performed in bed by the staff. Review of facility reported incident revealed on August 8, 2022, at 8:50 p.m. Resident R24 was provided incontinence care by nursing aide, Employee E9. Resident R24 was in bed during incontinence care and Employee E9 placed resident on her side. Employee E9 stepped away to retrieve wipes located in Resident R24's bathroom. As Employee E9 turned away, Resident R24 fell to the floor. Resident R24 was observed laying on her right side with bleeding noted coming from the right side of the head. The resident's bed height was noted to be at nursing aide care level. The resident's physician notified and ordered for the Resident R24 to be sent out to hospital for evaluation and treatment. Resident R24 was diagnosed with right parietal scalp hematoma. Interview on September 21, 2022, at approximately 1:00 p.m. with nursing aide, Employee E9, confirmed that she failed to gather all the necessary equipment prior to the provision of incontinence care to Resident R24. Further during interview Employee E9 stated that she individually has provided care to the resident in the past without the assistance of another nursing staff member. Interview conducted on September 21, 2022, at approximately 12:30 p.m. with Nursing Home Administrator, revealed that the facility's investigation determined that nurse aide, Employee E9, who was assigned to provide incontinence care to Resident R24 left the resident unattended and the resident fell to the floor and sustained a parietal scalp hematoma to the head. The facility failed to ensure Resident R24 was free of neglect which resulted in actual harm to Resident R24 who sustained a fall from bed, required transfer to the hospital and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14 (a)(e) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.29 (c) Resident Rights 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa Code 211.12 (d)(5) Nursing Services

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department conducted on September 19, 2022, at 9:30 a.m. with Employee E6, Food Service Director (FSD), revealed the following: Observation in the main dry storage area revealed multiple boxes, stainless steel stock pots and plastic catering equipment stored on the top shelf less than the required 18 from sprinklers heads and the ceiling. Observation in the main kitchen hot production area revealed two steam kettles, a tilt skillet and the steamer all with the exterior surfaces covered in dark black and brown burned on food spatter stains. Observations in the Willowbrook Court food service pantry revealed that the wall above the dish counter behind the glass and cup racks had a build-up of dark colored substance on the wall. Interview on September 19, 2022, at 9:50 a.m. with the FSD, confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 PA Code: 201.18(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management

Based on observation, clinical record review and interviews with staff, it was determined the facility failed to treat residents with dignity and respect for one of 39 residents reviewed (Resident R25). Findings include: Review of a facility policy titled Abuse, Neglect, Involuntary Seclusion, Exploitation and Misappropriation of Property Prevention revised 6/18 revealed it is the policy of the facility to strive to ensure residents will be safeguarded and protected from any form of abuse, Including, but not limited to mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Further review of the policy revealed that the policy defines abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain and/or mental anguish, or deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be committed by employees, other residents, family members, visitors, and/or others. Mistreatment is defined in the policy as, mistreatment includes the use of physical or chemical restraints not required to treat the resident's symptoms. Mistreatment includes 'rough handling'. Neglect is defined in the policy as, failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Additionally, it was noted that, under Reporting, anyone who witnesses and/or suspects an incident of resident abuse (verbal, sexual, mental or physical), neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of property must immediately report the incident to his/her department supervisor. Review of the facility Position Description for CNA (nursing assistant) revealed three of the essential job functions are to, 12. Follows established guidelines and performs duties per the Nursing Policy and Procedure Manual, 14. Identifies safety hazards and emergency situations and initiates corrective action immediately and 15. Reports changes in resident's condition, complaints or concerns immediately to the Licensed Nurse. The last page of the position description requires the employee to sign off that I understand that I am responsible for performing the duties and responsibilities of my position in a manner that is consistent with the ACTS Culture of Loving-Kindness. I will observe safety guidelines and perform tasks in line with the company's safety policy and procedures. Review of the facility Position Description for Registered Nurse revealed three of the essential job functions are to, 7. Participates in the training and supervision of nursing personnel, 8. Adheres to Federal/State and Corporate guidelines in the delivery of nursing care, 10. Identifies potential safety hazards and the noncompliance with corporate guidelines as set forth in the Policy & Procedure Manual and implements corrective action if needed, 24. Evaluates nursing activities to ensure resident care, staff relations and efficiency of service are in accordance with ACTS standards and 28. Responds to residents' needs, concerns or complaints and implements corrective action as indicated and reports the above to the Director of Nursing or Administer of the Healthcare Center. The last page of the position description requires the employee to sign off that I understand that I am responsible for performing the duties and responsibilities of my position in a manner that is consistent with the ACTS Culture of Loving-Kindness. I will observe safety guidelines and perform tasks in line with the company's safety policy and procedures. Review of clinical record for Resident R25 revealed [DIAGNOSES REDACTED].(any disease or disorder of the circulatory system outside of the brain and heart), [MEDICAL CONDITION] (inflammation or loss of cartilage in the joints due to wear and tear), and age-related [MEDICAL CONDITION] (weakened bone strength with susceptibility to fracture) without a fracture. Further review of clinical record for Resident R25 revealed a care plan with a focus for My daily care assist varies from supervision to extensive assist due to my forgetfulness secondary to my Dx. ([DIAGNOSES REDACTED]. not ambulate very much and only short distances. I need extensive assist from the staff. Still offer me the opportunity to walk especially if you see me try to stand from my wheelchair. I might just need to stretch my legs a little. Date Initiated: 07/25/2018. Revision on: 08/19/2018. Observation on (MONTH) 19, (YEAR), at 4:10 p.m. revealed Resident R25 shouting at Employee E3, nursing assistant, stop, no I don't want to go, let me go back. The resident was sitting in a black wheelchair on the left side of the memory care unit corridor as one stands next to the nursing station with their back to the entrance of the memory care unit. Resident R25 was holding onto the wooden arm rail that runs the length of the hallway with both hands and had her feet on her wheelchair footrests. The initial observation revealed Employee E3, nursing assistant, peeling back the fingers of Resident R25 to remove her hands from the hand rail and Resident R25 expressing incoherent noises. Both of Resident R25's hands were removed from the railing and as the resident reached out to grab the rails again, Employee E3, nursing assistant, pulled the wheelchair backwards to try and prevent her from holding onto the bars. Resident R25 removed her feet from the footrest plates, as if to stand from the wheelchair, and Employee E3, nursing assistant, returned Resident R25's feet to the foot rest plates; However, as Employee E3, nursing assistant, was doing this, Resident R25 started to lean forward to grab the bar again and Employee E3, nursing assistant, grabbed the left forearm of Resident R25 with her right hand and pulled the resident backwards to prevent her from holding onto the arm rail. Resident R25 shouted. Further observation on (MONTH) 19, (YEAR), at 4:10 p.m. revealed Employee E4, Registered Nurse, approached and positioned herself behind the resident. As Resident R25 started to lean forward in the chair again with both feet on the footrests, Employee E4, Registered Nurse, put her right arm around the resident's chest from behind and restrained Resident R25 backwards in the wheelchair to stop the resident leaning forwards in the wheelchair. Resident R25 let out a muffled scream-like noise. Resident R25 was visibly distressed and whimpering. Further observation on (MONTH) 19, (YEAR), at 4:10 p.m. revealed Employee E2, Director of Nursing, arrived and directed Employee E4, Registered Nurse, to return Resident R25 to her room. In the entranceway to the resident's room, Resident R25 started to lean forward in her wheelchair again and Employee E4, Registered Nurse, applied her right arm across the body of Resident R25 and pulled the resident back in the wheelchair to prevent her from leaning forwards. Resident R25 was audibly distressed as evidenced by incoherent whimpering noises. Employee E2, Director of Nursing, instructed Employee E4 to stop, by stating, please stop and leave the room but Employee E4, Registered Nurse, ignored this request and continued to be present for a further 15 seconds before again being asked to leave the room by Employee E2, Director of Nursing. At this point Employee E4, Registered Nurse, left the room and Resident R25 remained in the room with Employee E2, Director of Nursing, and one other unidentified employee. Both remaining employees proceeded to provide the resident with reassurance that she had been returned to her room. Resident R25 stated, I want to go back to bed and started to stand up from her wheelchair. Employee E2, Director of Nursing, and the unidentified employee removed the footrest plates from the wheelchair, secured the wheelchair with wheel locks, provided reassurance to the resident, provided standing and mobility assistance and supported Resident R25 back to her bed. Interview with Employees E1, Nursing Home Administrator, E2, Director of Nursing, and E5, Regional Director of Nursing on (MONTH) 19, (YEAR), at 4:38 p.m. revealed Employee E2, Director of Nursing, stating (regarding the above witnessed incident), yes, I saw this as a problem. I educated the employees at the time that it was the resident's (Resident R25) choice not to eat in the dining room and to return to her room. Employee E2, Director of Nursing, confirmed at this time the observation that Employee E4, Registered Nurse, had applied her right arm across the body of Resident R25 and pulled the resident back in the wheelchair to prevent her from leaning forwards while the resident was seated in her wheelchair just inside the entrance to her room on the memory care clinical nursing unit. Interview on (MONTH) 20, (YEAR), at 9:05 a.m. with Employee E2, Director of Nursing, revealed the employees had not wanted Resident R25 to fall which is why they prevented her from holding onto the hand rails and held her back into the wheelchair. Employee E2, Director of Nursing, revealed Resident R25 went to sleep after she had been returned to bed and later ate her dinner and was calm. Employee E2, Director of Nursing, revealed the resident was pleasant during the night and had no further issues. Employee E2, Director of Nursing, stated, a lesson was learned for the staff to be more mindful of doing things. The facility failed to treat Resident R25 with dignity and respect. §483.12 Freedom from Abuse, Neglect, and Exploitation Previously cited 8/2/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/2/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 8/2/17, 7/1/16 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/2/17

Based on review of facility policy and procedure, observation, clinical record review, review of facility documentation and staff interview it was determined that the facility failed to assure the accurate receipt and labeling, as required, of medications brought into the facility from outside sources for four of 10 residents reviewed.(Residents R14, R20, R36 and R33). Findings include: Review of facility policy Medications Supplied by Resident/Responsible Party , M-04.19 stated Purpose: To strive to facilitate the resident's right to obtain medication from providers other than ACTS' contracted vendors, yet ease the community's ability to safeguard a resident's property, maintain the integrity of the medication and promote the efficiency of medication administration. Review of Resident R36's clinical record revealed resident received daily medications that included Amlodipine (blood pressure medication), aspirin (blood thinner) and miralax (medication for constipation). Observation of the medication pass on August 1, 2017, at approximately 8:00 a.m. revealed that Resident R36's bottle of Amlodipine tablets had the label of a community pharmacy name on it. Employee E3, registered nurse, stated in an interview at that time that the Amlodipine, aspirin and miralax had been purchased by the family of Resident R36, that the family routinely purchased her medications at a community pharmacy, brought them to the facility and gave them to a charge nurse. Review of facility documentation revealed that Residents R14, R20, and R33 also received routine medications that were brought into the facility from outside sources. There was no evidence available at the time of the survey that indicated a review of the medications by the facility's consultant pharmacy for labeling had been completed. The Administrator confirmed in an interview on August 2, 2017, at approximately 2:00 p.m. that the consultant pharmacy did not review medications purchased by residents/family outside of the facility and administered by the facility. The facility failed to coordinate pharmacy services between the Residents, community pharmacies and the facility pharmacy. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 PA Code 201.18(b)(1) Management. 28 Pa. Code: 211.9 (f)(1)(2) Pharmacy services.

Based on review of clinical records, review of facility policies and procedures and facility documentation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation into a resident injury of unknown origin for one of ten records reviewed (Resident R23). Findings include: Review of facility policy, Abuse, Neglect, Involuntary Seclusion, Exploitation and Misappropriation of Property Prevention, dated revised 12/16 revealed . Injuries of Unknown source: . 1. The source of the injury was not observed by any person or the source of the injury cannot be explained by the resident AND the injury is suspicious because of . the location of the injury. The policy further stipulated that the facility . will immediately initiate an investigation of the alleged incident and include the following: . j. Interviews with all potential witnesses. and . 3. Witnesses should submit written statements. and . G The results of the investigation. Review of the clinical record for Resident R23 revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS- assessment of resident needs), dated November 1, 2016, revealed that the resident had physical impairments to both the upper and lower areas of her body and that she was totally dependent on two or more staff persons to be transferred (moved from one area to another). Further review of Resident R23's clinical record revealed progress notes dated January 9, 2017, at 22:01(10:01 p.m.) which revealed .Called to resident's (Resident R23) room by cna (nurse's aide). When I arrived cna showed me a skin tear to the resident's right shin sustained during a transfer from the w.c. (wheelchair) to the bed using a whole body lift (mechanical device used to move people who are unable to move themselves). Review of facility investigation related to the skin tear sustained by Resident R23 revealed that on January 9, 2017, at approximately 7:00 p.m., following a transfer from a wheelchair into bed via a full body lift, Resident R23 sustained a skin tear to the right shin. The investigation indicated that the resident had bumped her leg against the lift while being transferred. Further review of the facility's investigation revealed no documentation of the size of Resident R23's skin tear. A review of Resident R23's Initial Wound Assessment, dated January 9, 2017, revealed that the facility had identifed Resident R23 with a new traumatic skin tear. The wound was noted as 3.5 centimeters in length, 5.0 centimeters in width and 0.1 centimeters in depth. Review of Resident R23's Weekly Wound Assessment revealed that it took seven weeks for the wound to heal. Continued review of the clinical record for Resident R23 revealed a physician order [REDACTED]. Further review of the facility's investigation related to the new skin tear found on January 9, 2017, revealed no documentation if the resident was wearing the dermasavers at the time of the transfer. Interview with Employee E5, cna (nurse's aide) on August 2, 2017, at approximately 11:15 a.m., confirmed that she had been assigned to Resident R23 on January 9, 2017, and had assisted in transferring the resident with the full body lift. Employee E5 reported that the resident had been wearing her dermasavers at the time of the transfer. Further interview with Employee E5 revealed that the resident had not complained of pain to her shin during or immediately following the transfer. Additionally Employee E5 stated that she did not recall the lift bumping into any piece of furniture or any loud sounds occuring during the transfer. Employee E5 denied the resident crying out in pain during the transfer and indicated that she had not observed that anything unusual had occurred during the transfer and was unaware that the resident had been injured. Continued interview with Employee E5 revealed that the resident's skin tear was not noted until some time later during the shift and that she was not the staff person who had noted the skin tear. Employee E5 further reported that she did not know which cna had found the injury and reported it. Further review of the facility's investigation revealed no documentation of the identity of the staff person who actually found the injury, no documentation of the time that the injury had been noted or the details of how the injury had been discovered. Additionally, the investigation did not contain an interview with the employee who actually found the injury. Interview with Employee E2, director of nursing, on August 2, 2017, at 11:20 a.m. confirmed that the facility's investigation of Resident R23's skin tear on January 9, 2017, contained incomplete documentation related to the mechanism of the injury and the employee interviews. The facility failed to complete a complete and thorough investigation into one resident's skin tear. 28 Pa Code: 201.18(b)(1)(3) Management. Previously cited 7/1/16 and 8/5/15 28 Pa Code: 211.12(d)(1)(5) Nursing services. Previously cited 8/5/15

Based on clinical record review, interviews with staff, and a review of the facility's policy, it was determined that the facilty failed to ensure that an advanced directive(written instructions letting others know the type of care one wants if they are seriously ill or dying)choice regarding cardiac-pulmonary resuscitation (CPR) had been accurately ascertained and/or reflected in the clinical record for two residents (Residents R7 and R25). Findings include: Review of the facility's policy, Advance Health Care Directive for Residents in Skilled Care Centers, Assisted Living Residences and/or Independent Living Units, revised [DATE], revealed that information concerning advance health care directives will be made available to all residents upon move-in; this policy further indicated that advance health care directive (the right to accept or refuse medical/surgical treatment) will become a part of the resident's health record. This policy further indicates that the attending physician will discuss and corroborate the directives of the resident and make appropriate notations in the Physician's Progress Notes in the health record. In addition, appropriate and related physician orders [REDACTED]. Further, the attending physician must then complete the PA Department of Health Out-of-Hospital DNR Order form in its entirety, which must include the signature of the resident and/or family member and/or legal representative. Review of the clinical record for Resident R7 revealed a Minimum Data Set (MDS - assessment of need), dated [DATE], revealed that this resident had [DIAGNOSES REDACTED]. Further review of Resident R7's clinical record revealed a living will (document that indicates one ' s end-of-life care wishes in the event that one is not able to speak for their self). Review of this document revealed that Resident R7 had indicated that s/he did not wish to have CPR performed on him/her if the resident's heart stop beating or the resident stopped breathing. Review of the current physician orders [REDACTED]. In an interview with Employee E3, she stated that, because there was no indication otherwise in the clinical record, CPR would be performed in such an event. In an interview with Employee E2, a licensed nurse, at approximately 10:00 a.m. on [DATE], it was confirmed that the facility had not obtained a physician order [REDACTED]. Review of the clinical record for Resident R25 revealed an Advance Directive Acknowledgement form (undated), signed by the resident, that indicated that the resident did not have a living will. Further clinical record review revealed a physician order, dated [DATE], indicating that Resident R25's status, in the event that the resident's heart should stop beating or the resident stopped breathing, was Do Not Resuscitate (DNR). Social service progress notes on multiple dates, including [DATE], [DATE], [DATE], and [DATE], indicated that Resident R25 did not have a living will. The facility had no documentation for review, including either a physician progress notes [REDACTED]. 28 Pa. Code: 201.18(b)(1)(3) Management. Previously cited [DATE]

Based on clinical record review, a review of policy and procedures, and interviews with staff, it was determined that the facility failed to ensure that an advanced directive choice regarding cardiac-pulmonary resuscitation (CPR) had not been ascertained and reflected in the clinical record for one resident (Resident R11). Findings included: Review of the facility's policy, Advance Health Care Directive for Residents in Skilled Care Centers, Assisted Living Residences and/or Independent Living Units, revised [DATE], revealed that information concerning advance health care directives will be made available to all residents upon move-in; this policy further indicated that advance health care directive (the right to accept or refuse medical/surgical treatment) will become a part of the resident's health record. Review of the facility's policy, Cardiopulmonary Resuscitation, revised February 2015, revealed that CPR is administered to any resident suffering a cardiac or respiratory arrest, unless tht resident has a do not resuscitate (DNR) order. Review of the clinical record for Resident R11 revealed that this resident had been admitted to the facility on [DATE]. Further review revealed a Minimum Data Set (MDS - assessment of resident needs), that indicated that the resident was cognitively intact at the time of admission. Review of the current physician orders [REDACTED]. stopped beating or the resident stopped breathing, was not indicated. In an interview with Employee E4, a licensed nurse, she stated that, because there was no indication otherwise in the clinical record, she would perform CPR in such an event. In an interview with the Director of Nursing at approximately 10:00 a.m. on [DATE], she had determined in an interview with the Resident R11 that the resident wished not to have resuscitation in such an event. In an interview with Employee E3, at approximately 11:00 on [DATE], she stated that the resident's preference regarding DNR status had not been ascertained and that this preference was neither indicated in the clinical record nor had a corresponding physician order [REDACTED]. 28 Pa. Code: 201.18(b)(1)(3) Management. 28 Pa. Code: 211.16 (a) Social Services.

Based on observation, review of facility policy and interviews with staff, it was determined that the facility failed to maintain acceptable standards for infection control practices during wound care for one of 12 residents reviewed (Resident R19). Findings include: Review of facility policy, Hand Washing And Hand Hygiene, dated May 2012, revealed, b. When washing hands with soap and water: .Apply soap and lather the hands and fingers vigorously for at least 20 seconds. A review of physician orders, dated August 2015, revealed that Resident R19 was to have the wounds on both lower legs cleansed daily with normal saline (salt solution), apply Santyl (chemical [MEDICATION NAME] agent), and cover with clean dry dressing daily and as needed. Observation of wound care to Resident R19 on August 5, 2015, at 9:00 a.m., with Employee E5, registered nurse, revealed that, prior to the start of the treatment, Employee E5 performed hand washing. The employee started the procedure by turning on the faucet and wetted hands under running water. The employee then dispensed liquid soap into the palms of both hands and rubbed hands together for a period of approximately six seconds. The employee then placed both hands under the running water and continued to rub hands together for an additional seven seconds. The employee then dried both hands with paper towels before returning to the resident's room and donning clean gloves. Employee E5 removed Resident R19's dressings from both lower legs. After discarding both the dressings and removing gloves, the employee returned to the sink to perform hand washing. The employee again wetted hands, applied soap to both palms and rubbed hands together for a period of approximately six seconds. The employee then rinsed hands under running water, for a period of seven seconds, before drying hands and returning to the resident's room. After donning clean gloves, Employee E5 proceeded to cleanse the residents' wounds on both lower legs with saline and pat dry with clean gauze. Without changing gloves, the employee proceeded to apply Santyl ointment and 2 x 2 gauze dressings to each wound. Upon completing the wound care and removing gloves, the employee returned to the sink to wash hands. The employee proceeded to wet both hands with water, apply liquid soap to both palms and rubbed hands together for approximately ten seconds under running water, before drying hands with paper towels. Interview with Employee E5, immediately following the observation, revealed that the employee was unaware that the time spent on lathering and washing both hands was less than 15 seconds. The employee was also unaware that the handwashing technique of washing hands under running water was inaccurate. Interview with the Director of Nursing, on August 5, 2015, at approximately 10:30 a.m., confirmed that per facility policy, staff are expected to wash their hands for a minimum of twenty seconds. Further interview with the Director of Nursing confirmed that staff are expected to remove their gloves after cleansing wounds and apply new gloves before applying the prescribed treatment to the wound. 28 Pa Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to investigate an allegation of resident abuse for one of 12 residents reviewed (Resident R36), failed to conduct pre-employment background checks for six of 10 personnel files reviewed (Employees E4, E5, E6, E8, E9 and E10), and failed to conduct pre-employment reference checks for three of 10 personnel files reviewed (Employees E7, E8 and E10). Findings include: Review of facility policy, "Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention," dated revised June 2012, revealed that, "The executive director, administrator, or designee will immediately initiate an investigation of the alleged incident and include the following. ... Investigative procedures taken and outcomes of those procedures must be documented in detail and maintained in a separate file.". Review of Resident R36's clinical record revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS- an assessment tool) dated May 23, 2013, indicated that the resident had moderate cognitive impairments, had physical impairments of the upper and lower extremities (arms and legs) on one side of the body and required the physical assistance of one staff person for walking, dressing and personal hygiene. Review of nursing progress notes dated May 4, 2013, at 7:27 a.m., indicated that at 4:15 a.m., the resident had been found by nursing staff laying on the floor of the bathroom with a hematoma (blood blister) and laceration to the head. The resident told staff at the time of the incident that "someone had hit the resident on the head.". The resident was subsequently transferred to the emergency room for further evaluation and treatment of [REDACTED]. The hospital employee indicated that the resident had stated that "no one ever believes me.". Additional nursing documentation indicated that facility staff had told the hospital employee that staff had found the resident on the floor, that the resident had dementia (progress brain disorder resulting in a loss of contact with reality) and that there was no abuse. A review of facility document "Incident Report Residents and Visitor", dated May 4, 2013, indicated that facility staff were aware of the resident's allegation that "someone hit the resident in the head". Further review of the facility's investigation revealed no documentation related to the investigation of the resident's allegation of physical abuse. Interview with the Administrator on August 14, 2013, at 12:30 p.m., revealed that there was no additional documentation related to the facility's investigation of Resident R36's allegation of physical abuse. Further interview with the administrator confirmed that the facility had not thoroughly investigated the resident's allegation of physical abuse. Review of facility policy, "Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention," dated revised June 2012, revealed that, "Employees will have appropriate background screening per state and federal guidelines." Review of the personnel file for Employee E4, food production employee, revealed that the employee's date of hire was November 19, 2012. Further review of the employee's personnel file indicated that the facility had not requested a criminal background check for the employee until December 6, 2012, approximately two weeks after the employee's date of hire. Review of the personnel file for Employee E5, licensed nurse, revealed that the employee's date of hire was October 15, 2012. Further review of the employee's personnel file indicated that the facility had not requested a criminal background check for the employee until December 27, 2012, two months after the employee's date of hire. Review of the personnel file for Employee E6, licensed nurse, revealed that the employee's date of hire was March 11, 2013. Further review of the employee's personnel file indicated that the facility had not requested a criminal background check for the employee until April 23, 2013, one month after the employee's date of hire. Review of the personnel file for Employee E7, medical dietary aide, revealed that the employee had been hired on July 11, 2013. Further review of the personnel file revealed no reference checks had been completed for this employee at the time of hire. Review of the personnel file for Employee E8, medical dietary aide, revealed that the employee had been hired on December 26, 2012. Further review of the personnel file indicated that the facility had not requested a criminal background check on this employee until January 22, 2013, approximately one month after the employee's date of hire. Additional review of the Employee E8's personnel file revealed no reference checks had been completed for this employee at the time of hire. Review of the personnel file for Employee E9, licensed nurse, revealed that the employee had been hired on October 2, 2012. Further review of the personnel file indicated that the facility had not requested a criminal background check on this employee until December 27, 2012, two months after the employee's date of hire. Review of the personnel file for Employee E10, medical dietary aide, revealed that the employee had been hired on September 27, 2012. Further review of the personnel file indicated that the facility had not requested a criminal background check on this employee until August 14, 2013, 11 months after the employee's date of hire. Additional review of the Employee E10's personnel file revealed no reference checks had been completed for this employee at the time of hire. Interview with Employee E11, business service specialist, on August 15, 2013, at 1:30 p.m., confirmed that criminal background checks and personnel references had not been obtained on the above employees as required. 28 PA Code: 201.14(a)(e) Responsibility of licensee. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 211.12(d)(1)(5) Nursing services.