Every finding on record at Willowbrooke Ctskdcarectr Atnormandy Farms Estates

Based on staff interview and review of facility documentation, it was determined that the facility failed to enusure that comfortable air temperature levels for residents on 2 of 2 nursing units (Cherry and Magnolia units). Findings include: Review of information submitted to the State Survey Agency on November 20, 2024 at 3:00 p.m. indicated that the facility was currently experiencing an issue with their Heating, Ventilation, and Air conditioning system (HVAC) that operates the rooms on the Cherry and Magnolia nursing units. The information submitted by the facility to the State Survey Agency indicated that the facility increased the heat in the hallways to supplement the temperatures in the rooms, and that the heating system for resident hallways and dining rooms were not affected. Continued review of the information submitted by the facility to the State Survey Agency indicated that the facility was monitoring temperatures in the resident rooms, and that the facility would be taking temperatures until the heating is restored. Information submitted to the State Survey Agency on December 10, 2024 reported concerns about the period of time in which the facility's heating system was inoperable, and the temperatures in the building during that time. During an interview with the Nursing Home Administrator (NHA) on December 18, 2024 at 12:00 p.m. the NHA confirmed that the concern regarding the heating system started on November 19, 2024 some time in the late afternoon. The NHA reported that she saw the thermostat in her office flashing on the above referenced date, so she went over to the Cherry and Magnolia, nursing units to check on the thermostats in resident rooms and noticed that those thermostats were flashing as well. The NHA reported that she went to those particular units because the individual heating units in each of the resident rooms on those units share the same heating system as her (NHA) office. The NHA reported that approximately 21 residents resided both unit (e.g. approximately 10 residents on 1 unit and approximately 11 residents on another unit). The NHA reported that she contacted the Director of Plant Services (Employee E3) who came over to the facility to try to figure out if the problem with the thermostats/heating system was something that his department could fix. The NHA reported that Employee E3 contacted the facilities outside contractor on November 20, 2024 and that the contractor came over to the facility on [DATE] to try to repair the heating system. Continued interview with the NHA revealed that the outside contractor needed to order parts to repair the system and that the contractor notified the facility of it when he left on November 20, 2024. The NHA reported that the heating units for residents came on November 21, 2024 sometime in the morning, and that the facility purchased heating units from 2 home improvement stores, in addition to obtaining 4 heating units from other facilities within the company. Review of information provided by the NHA and reviewed with the Director of Plant Operations on December 18, 2024, at 12:15 p.m. indicated that there were approximately 15 individual heating units purchased. Review of temperature logs provided by the NHA indicated that temperatures were being taken by the facility in resident rooms on the Cherry and Magnolia units: rooms 33, 34,36,37,39,43,44,45,46,47,48,49,50, and room [ROOM NUMBER] (all single occupnancy), starting on November 19, 2024 at 6:00 p.m. through November 20, 2024 at 3:00 p.m. indicated that on the 2 units the heating temperatures in resident rooms were taken every hour starting at 6:00 p.m. on November 19, 2024 through 3:00 p.m. on November 20, 2024 the heating temperature ranged from 61.1-70.5. room [ROOM NUMBER] was the only room that was found to have a temperature of 71.4 degrees Fahrenheit at 9:00 p.m. on November 19, 2024 and at 71.9 Fahrenheit at 10:00 p.m. on November 19, 2024. Aside from the above, the other temperature readings for room [ROOM NUMBER], were also below 71 degrees. During an interview with Resident R1 12:13 p.m. Resident R1 reported that she was notified that the heat was broken and stated it was cold in this room before they gave us those heaters. 28 Pa. Code 201.18 (b)(1)(2)(3) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on observations, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was transferred from bed to chair with the assistance of two staff members. This failure resulted in actual harm to Resident R1 whose left foot twisted under the resident and sustained a trimalleolar fracture of the left ankle. (Resident R1) Findings include: Review of Resident R1's clinical record review revealed that the resident was admitted to the faciltiy on September 17, 2020 with the diagnoses of Alzheimer's Disease (progressive degenerative disease of the brain) and chronic kidney disease, osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone) unsteady feet and spinal stenosis. Review of Resident R1's Minimum Data Set (MDS- assessment of resident's needs) dated May 30, 2024, revealed that the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for mobility with the assistance of two or more helpers. Continued review of the MDS revealed that the resident was assessed required substantial/maximum assistance to roll left and right; sit to lying, lying to sitting on side of bed, sit to stand, and bed-to-chair transfers. Review of occupational therapy notes dated May 15, 2024, and end of care dated May 31, 2024, indicated a discharge plan of maximum assistance x 2 (76-99% assist with 2 people), maximum assistance x 2 (76-99% assist with 2 people) for transfers from bed to wheelchair. Review of Resident R1's care plan initiated December 15, 2023 and updated on June 3, 2024, revealed that the resident required extensive to total assistance of two staff persons to move between surfaces. Review of nursing note dated July 17, 2024, at 7:09 a.m. revealed that while Resident R1 was being transferred from bed to the wheelchair the residents legs gave out and resident twisted her left foot under her while being lowered to the floor. Residents leg bent under her with her foot under residents bottom and Resident sitting against side of bed. Resident did not hit her head when lowered to the floor. This nurse called for assist of CNA (nurse aide). When we layed resident down on her back, to use hoyer lift (mechanical device use to transfer a resident from one surface to another), it was noted that her left ankle was bleeding and was not aligned properly. Resident noted with a 3 inch open laceration to her ankle. Dressing applied and ankle supported while assisted onto bed with hoyer lift. 911(Emergency Medical Services) called. Continued review of nursing notes dated July 17, 2029 at 1:33 p.m. revealed that the resident was admitted to hospital with a diagnosis of type 1 or 2 trimalleolar fracture (a break on the lower leg-sections of the ankle joint). Nursing note dated July 17, 2024 at 3:45 p.m. stated that the resident had surgery to ankle which is now casted and is NWB ( non weight bearing). Interview with Employee E4, the Registered Nurse on July 31, at 12:32 p.m., who transferred Resident R1, on July 17, 2024, at 6:05 a.m. revealed that while the resident was being transferred from bed to the wheelchair her legs gave out and twisted her left foot under her, when being lowered to the floor. Resident R1's leg bent under her with her foot under her bottom, and Resident R1 sat against the side of the bed. Resident R1 did not hit her head. Resident was then assisted back to bed. Resident R1 was sent out via 911, to the hospital. Registered Nurse, Employee E4 added that she was unaware of the care plan updates pertaining to Resident R1, at the time of the incident. The facility failed to to ensure that Resident R1 was transferred from bed to chair with the assistance of two staff members. This failure resulted in actual harm to Resident R1 whose left foot twisted under her and sustained a trimalleolar fracture of the left ankle. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d)(1) Nursing services 28 Pa. Code 211.12 (d)(3) Nursing services

Based on the Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, review of clinical records, review of facility documentation, review of facility policy, and staff interview, it was determined that the facility failed to meet professional standards of quality nursing during administration of the influenza vaccine for one of four clinical records reviewed. (Resident R1) Findings include: The Pennsylvania Code, Title 49, Professional Vocational Standards, Chapter 21, State Board of Nursing dated April 6, 2013, in Subchapter A, Registered Nurses, section 21.11 (a)(1)(2)(4)(6)(b)(d) General functions, listed as the reponsibilities of the Registered Nurse as being able to assess, implement and evaluate nursing care and performs all of the folllowing functions: Collects complete and ongoing data to determine nursing care needs; analyzes the health status of the individuals in determining nursing care needs; caries out nursing care actions which promote, maintain and restore the well being of individuals; and evaluates the effectiveness of of the quality of nursing care provided. The Registered Nurse is responsible for all actions as a Licensed Nurse and is accountable to individuals for the quality of care provided and for assuring safe and effective practice. Section 21.14 Administration of Drugs reads that a Licensed Registered Nurse may administer a drug ordered in the dosage and manner prescribed. section 21.18(a)(5)(b)(8) Standards of nursing conduct, reads that a Registered Nurse shall document and maintain accurate records and shall not falisfy or knowingly make incorrect entries into the individual's record or other related documents. Review of facility policies and procedures title Medication Administration and Management revised date October 2019 stated that following medication administration all authorized staff should adhere to the following guidelines: Document medication administration on the medication administration record. Review of Resident R1's clinical records revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R1's September 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing notes dated September 24, 2021 at 4:49 p.m. entered by Director of Nursing, stated that Resident R1 received the flu vaccine in left arm. Further review of nursing documentation revealed a nurses note dated September 27, 2021 at 11:31 p.m. completed by licensed nurse, Employee E5 stated that Resident R1 received flu shot on 7 to 3 shift however the medication was not signed by the nurse who administered this flu vaccine. As a result of that flu vaccine was given on the 3 to 11 shift as ordered hence it was not signed on the computer and also no report about it. Review of Resident R1's September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility documentation title Medication Error report dated September 24, 2021 revealed that Resident R1 received a extra dose of influenza vaccine intramuscularly on September 24, 2021. The contributing factors were frequent distractions and emergency situation. Under the section title Patient outcome indicated that an error occurred that reached the patient but did not cause patient harm. Review of statements from Licensed nursing staff Employee E5 revealed that on September 24, 2021 during the 3pm-11 pm shift Employee E5 gave Resident R1 the flu vaccine. After giving and signing the flu vaccine, while trying to document on the progress notes, I realized that the flu vaccine was given during the 7 a.m. to 3 p.m. shift. Meanwhile, the 7 a.m. to 3 p.m. nurse did not mention that the flu vaccine was given on her report. Also, she did not sign that the flu vaccine was given during the morning shift. Thus, no nurse mentioned to me that the resident received the flu vaccine in the morning shift. Review of statement from the Director of Nursing revealed that on September 24, 2021 she gave Resident R1 the flu vaccine. On 09/24/2021, influenza shots were completed on Ivy South Memory Care Unit. This nurse was in the process of entering and documenting all the influenza shots that were given. At that time, this nurse was notified of a possible COVID-19 exposure to our residents. I stopped what I was doing and went to swab all residents and the employees. Upon return to my office, I was notified by RN (Register Nurse) that she had given the influenza vaccine to resident. Interview with the Director of Nursing on October 7, 2021, confirmed that Resident R1 had received two doses of the influenza vaccine on September 24, 2021. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's finishing kitchen and in the main kitchen. Findings include: An observation on August 10, 2021, at 11:30 AM in the finishing/serving kitchen, revealed the following: The filter on the front of the ice machine was covered in dust buildup. Multiple open shelf storage units were observed in the finishing kitchen, the shelves were sticky and dusty. The slotted bottom shelves located 6 inches from the floor, contained pots, pans, and inverted plastic bins. There was no solid barrier to prevent the contamination from mop water splash or sweeping debris from the items to be used in food preparation/service. Continued observation in the facilities main kitchen area revealed the following: Shelving units throughout the main kitchen, walk in coolers, freezer, and dry storage area, contained shelving units with food and food preparation supplies stored on the bottom shelves six inches from the floor. There was no solid barrier on the bottom shelves to prevent the potential contamination from mop water splash and sweeping debris. Multiple shelving units in the dry storage area and the unit where spices/herbs were stored in the preparation area were soiled with dried brown sticky substances, and dust and debris buildup. Flooring throughout the main kitchen contained a significant amount of dirt, debris, dried food, and trash (papers, cups, etc.), under shelving units, equipment, and along wall edges. The walk-in freezer condenser unit was covered in thick ice buildup on the front and back of the unit, and around the pipes. Ice was observed on the floor under the unit. Two of the four fans of the unit were not spinning, and large pieces of ice were observed around the blades. Walk-in cooler number two contained two cases of sole labeled with a received date of August 5, 2021. One of the boxes was open with the interior bag wide open and not secured. The product was partially frozen. There was no evidence to indicated when the product was placed in the cooler to thaw or when it needed to be used by. The wall area located by the reach in cooler in the preparation area was covered in dried food splatter. A small reach in freezer located under the cooler in the preparation area contained food debris and ice buildup on the bottom interior base of the freezer. A bag of French fries, chicken tenders, ravioli, and a case of cubed beef sirloin fritters were observed wide open to air, in the freezer with no date to indicate when they were placed there or when they needed used by. The interior base of the blast chiller contained a significant amount of dried food debris. The line room contained dried food debris in the floor drain in the preparation area, as well as under the tables, and equipment. The bottom shelves of the preparation tables contained dried spills and debris. Ice cream freezer number one located in the line room contained thick ice buildup on the interior of the unit. The glass door to the freezer contained a black mold-like substance surrounding the perimeter of the door. The above findings were reviewed concurrently with Employee 4 (director nutrition and culinary services), the Nursing Home Administrator, and Director of Nursing on August 11, 2021, at 2:30 PM. 483.60(i)(2) Food Procurement, Store/Prepare/Serve-Sanitary Previously cited 6/28/19 28 Pa. Code 211.6 (c) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weight monitoring for one of 16 residents reviewed (Resident 54). Findings include: Clinical record review for Resident 54 revealed current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 54's weight documentation and July and August 2021 MAR (Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] July 19, 2021 July 21, 2021 July 22, 2021 August 4, 2021 August 5, 2021 August 9, 2021 On the following dates, staff indicated N/A (not applicable) for Resident 54's daily weight documentation: July 26, 2021 July 29, 2021 August 2, 2021 August 10, 2021 Interview on August 12, 2021, at 1:07 PM with the Director of Nursing acknowledged the above findings. 28 Pa. Code 211.10(a)(c)(d) Resident care policies

Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide supplemental oxygen care consistent with professional standards of practice for two of two residents reviewed for supplemental oxygen use (Residents 38 and 56). Findings include: The facility policy entitled, Oxygen Administration/Safety, last reviewed on January 20, 2021, revealed that oxygen cylinders must be stored in racks with chains, sturdy portable carts, and/or oxygen stands. Staff are to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the flow rate administration is above four liters, add distilled water to the humidifier bottle. Nasal cannulas, masks, and humidifiers, which are used to deliver oxygen or inhalation treatments are changed monthly or more frequently if needed. When not in use, cannulas, masks, and humidifiers should be rinsed, dried, and stored in a plastic bag. Clinical record review for Resident 38 revealed a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g., one-half liter per minute) while periodically assessing the finger pulse oximeter, small device placed on the fingertip to assess the percentage of oxygen in the blood) oxygen as tolerated, and to keep Resident 38's oxygenation saturation greater than 92 percent. Review of Resident 38's plan of care developed by the facility to address her shortness of breath and use of supplemental oxygen revealed instructions for staff to administer the oxygen per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions specifically noted for Resident 38's comfort, were to wean the oxygen to achieve a 93 percent saturation. Observation of Resident 38's room on August 10, 2021, at 3:19 PM revealed a room concentrator (machine used to concentrate the oxygen from room air to supply oxygen-[MEDICATION(S)] air back to the resident) with a setting at 4.5 liters per minute. A humidification bottle (equipment containing distilled water that is attached to the flow of concentrated oxygen to prevent excessive dryness of the supplied oxygen) and oxygen tubing included a date of June 12, 2021 (more than eight weeks earlier). Interview with Employee 1 (licensed practical nurse) on August 10, 2021, at 3:23 PM, confirmed the observation; and confirmed that staff are to change the oxygen equipment monthly. Clinical record review for Resident 38 revealed the most recent oximeter assessment on August 10, 2021, at 10:00 AM, indicated a 97 percent oxygen saturation. There was no evidence in the clinical record that staff attempted to wean the oxygen administration rate following this assessment. Clinical record review of pulse oximetry assessments for Resident 38 revealed the following: August 9, 2021, assessments of 98 and 99 percent August 8, 2021, assessments of 95 to 99 percent August 7, 2021, assessments of 97 and 99 percent August 6, 2021, assessments of 94 and 95 percent August 5, 2021, assessments of 96 to 99 percent August 4, 2021, assessments of 93 to 96 percent August 3, 2021, assessments of 94 to 96 percent August 2, 2021, assessments of 94 to 99 percent August 1, 2021, assessments of 97 to 99 percent Interview with Employee 1 on August 12, 2021, at 11:23 AM revealed that she was unaware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the above findings for Resident 38 during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2021, at 2:30 PM. Information provided by the facility the morning of August 13, 2021, revealed that staff revised current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 56's room on August 11, 2021, at 10:28 AM revealed oxygen administration tubing hanging from a portable oxygen tank secured to her walker. The tubing was not bagged, and the nasal prongs were exposed to environmental surfaces and/or potential contaminants. The room concentrator was functioning at a rate of 2.5 liters per minute. Observation of Resident 56's room revealed a used, discontinued, oxygen administration set of tubing and humidifier bottle (previously removed from the concentrator) stored on Resident 56's bedside stand with a date of August 10, 2021 (the administration set currently in use included a date of August 11, 2021). An open, partially used, gallon of distilled water stored on the bedside stand, did not have a date when staff opened it on the container. Observation and interview with Employee 1 on August 11, 2021, at 11:10 AM confirmed the observation findings in Resident 56's room. Employee 1 stated that she would obtain a new administration set for Resident 56's portable oxygen. Employee 1 confirmed that staff must have removed the oxygen administration set from the room concentrator and placed the old one on Resident 56's bedside stand; however, that staff forgot to discard the used equipment. Observation of Resident 56's room on August 12, 2021, at 9:42 AM revealed the portable oxygen tank did not have oxygen tubing attached to the tank; however, the nasal canula tubing was coiled, not in a bag, and stored directly on the seat of the walker. The tubing had a label dated August 11, 2021. Interview with Resident 56 revealed that she was incapable of securing the oxygen tubing to the portable oxygen tank and she activated her call bell to obtain staff assistance. A facility employee entered Resident 56's room on August 12, 2021, at 9:42 AM, and deactivated Resident 56's call bell. Observation of Resident 56's room on August 12, 2021, at 9:45 AM, with Employee 7, nurse aide, verified the nasal canula tubing dated August 11, 2021, remained coiled and stored on the seat; but was now connected to the portable tank ready for use. Employee 7 confirmed that Resident 56 should have a bag to store the oxygen tubing in between uses. The surveyor reviewed the above findings regarding Resident 56's supplemental oxygen use during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2021, at 2:30 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate medication security for two of five nursing units (Cherry Lane and Apple Alley Nursing Units; Residents 10, 21, and 44). Findings include: The facility policy entitled, Medication Administration and Management, last reviewed without changes on January 20, 2021, revealed that all individuals dispersing medications to residents will receive training on medication administration and management procedures. Competency will be validated upon hire, annually, and as indicated. Staff should avoid leaving medications or chemicals unattended. Medication carts or medications retained in resident rooms must be locked at all times when unattended. Observation of an Apple Alley Nursing Unit medication administration pass on August 12, 2021, at 8:57 AM revealed that Employee 5, registered nurse, indicated that the locking mechanism was partially pushed into the cart and had a red circle/dot showing (a visual indication that the medication cart was unlocked) on the side of the lock. Employee 5 was not in direct sight of the medication cart and had her back turned to the cart. When Employee 5 returned from passing medications to Resident 21, she pulled on the medication cart locking mechanism with her fingers. She did not utilize the medication cart keys to unlock the cart. Employee 5 prepared the medications for, then passed them to Resident 44. Employee 5 left her medication cart unlocked in the hallway and turned her back to the cart while passing Resident 44's medications in the Apple Alley Nursing Unit's Dining Room. Employee 5 returned to the medication cart and prepared Resident 10's medications. Employee 5 then removed a bulk container of Tylenol (for mild pain) 325 milligram (mg) from the medication cart and placed it on top of the cart. She collected Resident 10's medication cups and proceeded to his room, which was down the hall, around the corner, and out of sight of the medication cart. She did not secure the bulk bottle of Tylenol from resident access prior to going to Resident 10's room. Interview on August 12, 2021, at 9:08 AM and 9:49 AM with Employee 5 revealed that she acknowledged the above observations. Observation of the Cherry Lane Nursing Unit's medication cart on August 12, 2021, at 9:10 AM revealed that the locking mechanism was not fully pushed into the cart and had a red circle/dot showing on the lock. This surveyor was able to pull the lock open and have access to resident medications without a key. There was no licensed staff in-sight of the medication cart. The medication cart was locked by the surveyor. At the same time, Employee 3, registered nurse, assistant director of nursing, who was assigned to Cherry Lane's medication cart was observed coming out of the administrative offices at the end of Cherry unit. These offices were not in view of Cherry Lane Nursing Unit's medication cart. Observation of the Cherry Lane Nursing Unit's medication cart on August 12, 2021, at 11:00 AM with the Director of Nursing (DON) present revealed that the medication cart was in the hallway again with the locking mechanism not fully pushed into the cart and showing a red circle/dot on the lock. This surveyor was again able to pull the lock open and have access to resident medications without a key. There was no licensed staff in sight of the medication cart. The medication cart was locked by the surveyor with concurrent acknowledgment by the DON. At the same time, Employee 3 came out of a resident room that was not in view of the medication cart. The surveyor reviewed the above findings during an interview with the Director of Nursing on August 12, 2021, at 11:05 AM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on three of five nursing units (Dogwood, Residents 32, 28, 14, 41, 13, and 15; Apple Alley, Residents 4, 10, 19, 21, 44, and 46; and Cherry Lane, Residents 11, 35, and 54). Findings include: The facility policy entitled, Handwashing and Hand Hygiene last reviewed without changes on January 20, 2021, revealed that staff will prevent infections through adequate handwashing and hand hygiene. Staff must wash their hands with soap and water before and after instilling any eye medications. When washing hands with soap and water, staff should dry their hands thoroughly with a disposable towel. If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands. Staff must decontaminate hands before and after direct resident contact, after contact with a resident's intact skin, and after removing gloves. The use of gloves does not eliminate the need for hand hygiene, likewise the use of hand hygiene does not eliminate the need for gloves. Observation of the Dogwood nursing unit on August 11, 2021, at 9:05 AM revealed Employee 1 (licensed practical nurse) washed her hands in Resident 32's bathroom. Employee 1 obtained paper towels to dry her hands from those stacked on top of a wall mounted paper towel dispenser. These paper towels were not covered or contained in a device to protect them from potential contamination while using wet hands to obtain a paper towel off the stack. Interview with Employee 1 on the date and time of the observation confirmed that the paper towel used was not protected against contamination; and she could not confirm that she did not inadvertently contaminate the towels when obtaining one with wet hands. Observation of Resident 28's medication administration pass on August 11, 2021, at 9:32 AM revealed Employee 1 removed her disposable gloves after administering a nasal spray medication and immediately donned new gloves to administer an eye drop medication to both of Resident 28's eyes. Employee 1 did not wash her hands or perform hand hygiene between the glove doffing and donning. Following Resident 28's eye medication administration, Employee 1 removed her gloves and used Resident 28's bathroom to wash her hands. Observation of Resident 28's bathroom revealed a stack of paper towels on top of the wall mounted paper towel dispenser. Interview with Employee 1 on August 11, 2021, at 9:45 AM confirmed that she did not wash her hands in between glove changes; and confirmed that the storage of paper towels on top of the dispensers in residents' rooms creates the potential for contamination from staff and/or residents. Observation of Resident 14's bathroom on August 11, 2021, at 12:17 PM revealed stacked paper towels on top of the dispenser. Observations of the Dogwood nursing unit on the following dates and times revealed the storage of paper towels on top of the wall mounted dispensers in the following resident bathrooms: August 12, 2021, at 11:39 AM, Resident 41 August 12, 2021, at 11:39 AM, Resident 13 August 12, 2021, at 11:40 AM, Resident 32 August 12, 2021, at 11:41 AM, Resident 28 August 12, 2021, at 11:42 AM, Resident 15 Observation of the Apple nursing unit on the following dates and times revealed the storage of paper towels on top of the wall mounted dispensers in the following resident bathrooms: August 12, 2021, at 11:44 AM, Resident 44 August 12, 2021, at 11:45 AM, Resident 4 August 12, 2021, at 11:46 AM, Resident 46 Interview with Employee 2, housekeeper, on August 12, 2021, at 11:39 AM revealed that she denied that it was part of her training to store paper towels on top of the wall mounted paper towel dispensers; however, she did this routinely as she believed it made it easier for resident access to the towels (even though the paper towels normally dispensed from the bottom of the paper towel dispenser and were closer to a resident in a seated position such as wheelchair access). Interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2021, at 2:30 PM confirmed that housekeeping staff are to replenish the paper towel supply in residents' bathrooms by stocking the wall mounted dispensers. It is not the facility's expectation that staff store paper towels, unprotected, on top of the dispensers. The interview also confirmed that it is the facility's expectation that staff wash their hands or perform hand hygiene after removing disposable gloves. Observation of Resident 19's bathroom on August 10, 2021, at 12:59 PM revealed that there was an unbagged urine collection container used to empty a Foley catheter bag sitting on a paper towel on the back of Resident 19's toilet and a urine catheter leg collection bag hanging on an enabler bar to the right of Resident 19's toilet. Resident 19 was in bed asleep and there was no urine catheter bag hanging on the side of Resident 19's bed. Interview with Resident 19 on August 10, 2021, at 2:26 PM revealed that her urine catheter was discontinued four to five weeks ago due to re-occurring infections. Clinical record review for Resident 19 revealed that her physician discontinued her Foley urinary catheter on June 8, 2021. Observation of Resident 19's urinary collection container and urinary catheter leg bag occurred 63 days after Resident 19's catheter was discontinued. This surveyor reviewed the above information during an interview on August 11, 2021, at 2:30 PM with the Nursing Home Administrator and the Director of Nursing. Observation of an Apple Alley Nursing Unit medication administration pass on August 12, 2021, at 8:57 AM revealed that Employee 5, registered nurse, administered medications to Residents 21, 44, and 10. Employee 5 wore gloves during Resident 10's medication administration. Employee 5 did not decontaminate her hands by either washing with soap and water or an alcohol based hand rub in between each Resident's medication administration or prior to donning gloves and pouring Resident 10's medications. During an interview on August 12, 2021, at 9:08 AM and 9:49 AM with Employee 5 and with the Director of Nursing on August 12, 2021, at 11:05 AM the surveyor reviewed the above observations. Observation of the following Resident rooms on the Cherry Lane Nursing Unit revealed that staff had placed additional paper towels on top of the paper towel dispensers in each resident room. The additional paper towels were exposed to the environment and potential contamination by staff and/or residents: On August 12, 2021, at 12:30 PM, Resident 54 On August 12, 2021, at 12:31 PM, Resident 11 On August 12, 2021, at 1:26 PM, Resident 35 This surveyor reviewed the above information during an interview on August 12, 2021, at 2:30 PM with the Nursing Home Administrator and the Director of Nursing. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control Previously cited deficiency 11/18/2020 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing care services

Based on observation, review of select policies, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet residents' needs for three of three residents reviewed (Residents 48, 15, and 56). Findings include: A review of the facility policy entitled Call Light Responding, last reviewed on January 20, 2021, indicated facility staff are to strive to ensure call lights are answered on a timely basis by all nursing personnel. In an interview with Resident 48 on August 10, 2021, at 3:20 PM the resident stated she waits at times 45 minutes for staff to answer her call bell. Resident 48 stated, Staff think they know what you want when you ring your bell, so they know how long they can wait before they come to you, but at times they are wrong, how can they know what I want? A review of Resident 48's call bell response time record for July 26 to August 12, 2021, revealed the following call bell activation times and staff response times: July 26, 2021, activated time of 7:39 PM, with a response time of 39 minutes and 25 seconds. July 29, 2021, activated time of 8:25 PM, with a response time of 16 minutes and 15 seconds. July 30, 2021, activated time of 10:28 AM, with a response time of 23 minutes and 19 seconds. August 1, 2021, activated time of 2:17 AM, with a response time of one hour, 56 minutes and 34 seconds. August 1, 2021, activated time of 2:22 PM, with a response time of 19 minutes and 48 seconds. August 5, 2021, activated time of 7:08 PM, with a response time of 16 minutes and 51 seconds. August 6, 2021, activated time of 9:35 AM, with a response time of 23 minutes and 36 seconds. August 7, 2021, activated time of 8:42 AM, with a response time of 25 minutes and 57 seconds. August 7, 2021, activated time of 11:23 AM, with a response time of 56 minutes and 54 seconds. August 11, 2021, activated time of 9:07 AM, with a response time of 17 minutes and 42 seconds. The call bell response times were reviewed in an interview with the Nursing Home Administrator and Director of Nursing on August 12, 2021, at 2:30 PM. Interview with Resident 15 on August 11, 2021, at 11:23 AM revealed that a normal call bell response time is approximately 15 minutes. Resident 15 stated that a worst case scenario would be a call bell response time of approximately 40 minutes. Resident 15 reported that his issue is that staff are not available to get him up early enough in the morning for breakfast. Resident 15 stated that sometimes he waits until after 10:00 AM before staff are available to get him up, dressed, and out of bed to his chair for breakfast. This results in his eating breakfast just a few hours before lunch is scheduled and he is not hungry for lunch. Interview with Resident 56 on August 11, 2021, at 10:33 AM revealed that she reported she was experiencing pain in her left shoulder. Resident 56 activated her call bell at that time. No staff reported to Resident 56's room until 10:57 AM (24 minutes later), when Employee 6, nurse aide, stated that he and Employee 1 (licensed practical nurse) are the only staff available for the 16 (private) resident rooms on the Dogwood unit. Employee 6 stated that he was toileting other residents and was not able to respond to Resident 56 before this time. Employee 6 stated that if there was an additional nurse aide on the Dogwood unit, that person would have answered the call bell quicker while he was otherwise occupied with the other residents. Employee 6 left the room to report Resident 56's pain to the licensed nurse on the unit. Employee 1 responded to Resident 56's room at 11:03 AM (30 minutes after she first activated her call bell) with pain medication for Resident 56. Resident 56 reported her pain level as a seven on a one (least severe) to 10 (most severe) scale at that time. The surveyor reviewed the above findings on the Dogwood nursing unit (Residents 15 and 56) during an interview with the Nursing Home Administrator and the Director of Nursing on August 12, 2021, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to monitor antibiotic use for one of two residents reviewed for urinary tract infections (Resident 15). Findings include: The surveyor conducted an entrance conference interview with the Nursing Home Administrator, the Director of Nursing, and Employee 3 (assistant director of nursing), on August 10, 2021, at 11:14 AM. The interview indicated that the Director of Nursing and Employee 3 shared the responsibility of implementing the facility's infection control and prevention program. The facility policy entitled, Infection Data Collection, Surveillance, and Monitoring, last reviewed on January 20, 2021, revealed that when an infection is identified, a report is initiated by the licensed nurse caring for the resident. This report, once completed, is forwarded to the infection preventionist or his/her designee for analysis to ensure the proper, effective, control measures are implemented. The facility policy entitled, Antibiotic Stewardship, last reviewed on January 20, 2021, revealed that it is the facility's policy to strive to improve antibiotic use in order to protect residents, reduce adverse events, prevent emergence of antibiotic resistance, and lead to better resident outcomes. The leadership commitment is to demonstrate support and commitment to safe and appropriate antibiotic use in the community. Medical directors should review antibiotic use data and ensure best practices (e.g., the right drug at the right dose for the right amount of time) are followed. Directors of Nursing should, in collaboration with the medical director, help ensure antibiotics are prescribed only when appropriate and educate the front-line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use. The infection preventionist should keep track of antibiotic use, including the type, indication, start date, and duration. Consultant pharmacists should review microbiology culture results and provide feedback to prescribers on initial selection to let them know if it is the right drug to treat the infection or if the bacteria may be resistant to the antibiotic. The antibiotic stewardship program should review patterns in prescribing to include agents prescribed for a particular infection, obtained cultures and relevant tests prior to initiating antibiotics, and modified antibiotic choices appropriate to microbiological findings. Clinical record review for Resident 15 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 15's physical medical record and electronic medical record contained no evidence of a culture and sensitivity report from the urine sample obtained on July 23, 2021. Interview with the Director of Nursing on August 13, 2021, at 8:18 AM confirmed that neither Resident 15's physical medical record or electronic medical record contained the laboratory report from the urine sample obtained on July 23, 2021; and that Resident 15 had completed the full course of the [MEDICATION(S)] antibiotic. The interview did not provide evidence that staff reviewed the laboratory report or reported the findings to Resident 15's physician. Interview with Employee 3, on August 13, 2021, at 11:10 AM revealed that facility staff had to contact the consultant laboratory service to obtain the report from Resident 15's urine sample on July 23, 2021; and that she now identified that the urine sample was resistant to the antibiotic [MEDICATION(S)]. Employee 3 confirmed that although she was partially responsible (in addition to the Director of Nursing) for antibiotic stewardship in the facility, she did not have a mechanism in place to ensure the timely receipt of laboratory reports following physician ordered testing to verify that the organisms identified through the testing were susceptible to the antibiotics ordered by the physician. Review of Resident 15's laboratory report from a urine specimen collected July 23, 2021 (faxed to the facility on [DATE]), confirmed that the proteus mirabilis (bacteria frequently in the urinary tract) organism identified in the urine culture was resistant to the antibiotic [MEDICATION(S)]. Interview with the Director of Nursing and the Nursing Home Administrator on August 13, 2021, at 11:18 AM confirmed that the facility had no evidence that anyone obtained Resident 15's urine culture report before the surveyor's questioning; or reported to the physician that the organism identified was resistant to the antibiotic prescribed for the diagnosed urinary tract infection. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of facility policies, professional literature and facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the implementation of infection control recommendations for COVID-19 on four of four nursing units observed (Dogwood Drive, Apple Alley, Cherry Blossom and Ivy South). Findings include: Review of facility policy titled, Coronavirus Outbreak Prevention and Treatment Residents and Staff, dated September 2020, revealed, To strive to provide guidance to residents and staff, at risk as identified by the Centers for Disease Control, (CDC - The Centers for Disease Control and Prevention) and to implement procedures to aid in prevention of the potential spread of COVID - 19, in the community. Further review of the policy indicated, Staff will wear appropriate Personal Protective Equipment, (PPE-gowns, gloves, mask and face shields), as recommended by the CDC when conducting a clinical assessment or otherwise interacting with a resident. The policy further indicated, The following precautions should generally be followed by all to reduce transmission of respiratory illness, such as COVID-19, Proper hand washing technique, (20 seconds), use alcohol- based gel rub for hand hygiene often and use appropriate PPE. Review of the Pennsylvania Department of Health Update: Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (COVID-19) in a Healthcare Setting (2020-PAHAN-524-09-10-UPD) dated September 10, 2020, revealed the recommendation that Healthcare personnel should adhere to using universal eye protection, in addition to a facemask, for all patient care encounters. Initial tour of the facility completed on November 18, 2020, from 9:30 a.m. to 1:00 p.m. revealed the following observations: Upon entering the inside the facility no hand sanitizer was available for use. Interview with Employee E3, entrance greeter, at the time of checking in, confirmed that no hand sanitizer was available for use. Upon entering the Cherry Blossom Nursing Unit with the Nursing Home Administrator, observation of Employee E9 Maintenance Staff, revealed that the employee had no face mask and/or face shield in place. Interview with Employee E9, at the time of the observation, confirmed that the employee did not have the appropriate PPE in place. Observation of the outside family visitor area revealed no to hand sanitizer available for visitor use. Observation of the Red Zone entrance (Dogwood Unit-nursing unit used to segregate COVID positive residents from other residents) with the Director of Nursing, revealed that no hand sanitizer and/or hand washing sink was available for staff/visitor use. Further observation of this area revealed that no PPE, (gowns, gloves, face masks, eye shields), were readily available for staff or visitor use. Observation of Employee E4, nurse aide, before entering the Red Zone revealed the employee removing his PPE and gown, then using his bare hands lifted the lid of the biohazard box to dispose of his gown. Interview with Employee E4, upon entering the Red Zone, confirmed that the employee did not wash his hands after touching the lid of the biohazard box. Observation of Employee E5, Housekeeping, with Employee E2, Director of Nursing, going in and out of three Resident rooms on the Yellow Zone, (Dogwood Unit- nursing unit designated for residents who are recent admissions into the facility, that are being monitored for 14 days, or residents who have been in contact with a person with COVID-19), revealed that Employee E5 did not have PPE eye wear in place. Interview with Employee E5, at the time of the observation, revealed that her PPE eye wear was inside her cleaning cart. Observation of a resident activity on Ivy South unit being led by Employee E6, Life Enrichment staff, revealed that the employee was not wearing the required PPE eye wear, while leading the group activity. Continued observation revealed that Employee E7, companion to Resident R1, was observed to be wearing a home-made face mask while caring for the resident and was noted without PPE eye wear in place. Review of a facility Educational Form and interview with the Nursing Home Administrator, during the exit interview November 17, 2020 at 2:15 p.m., revealed that Employee E7 had never received in-servicing (training) from the facility related to the proper use of PPE. The Administrator further revealed that Resident R1, who resides on Apple Alley had four personal companions. The facility did not have any additional documentation related to in-service and/or education of any of the four companions to the facility's COVID-19 policies. Observation of Employee E8, licensed nurse, administering medication to Resident R2, via a cup of vanilla pudding, revealed that the employee was not wearing gloves while administrating the medication. Interview with Employee E2, Director of Nursing, at the time of the observation, confirmed that employees should be wearing gloves when administering medication with food, such as pudding. Interview with the Nursing Home Administrator on November 18, 2020, at 2:30 p.m. confirmed that the observations during the initial tour of the Nursing units and that effective infection control practices were not in place related to COVID-19. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety. Findings include: Review of facility policy Food Storage Chart dated (MONTH) 2014 revealed that expiration dates printed by the manufacturer apply until the product is opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1 (first 24 hours). Refrigerated Storage - 4 days - Deli meats - pre-sliced and whole (if delivered frozen, use within 4 days of thawing under refrigeration and raw meat. Observation on (MONTH) 25, 2019, of the facility's main kitchen refrigerator revealed the following: - two large bins of raw chicken products with no date - seven pounds of bologna meat marked sell by (MONTH) 29, 2019 - approximately two pounds of Capicola meat with no date - approximately three pounds of pork meat with a use by date of (MONTH) 1, 2019 - two trays of ground hamburger meat with a use by date of (MONTH) 23, 2019 - 88 pounds of tenderloins meat with a packed date (MONTH) 29, 2019 and no refrigeration date - a tray of cinnamon buns marked use by (MONTH) 20, 2019 Interview conducted with Employee E3 Dietary Director on (MONTH) 25, 2019, at 11:00 a.m. confirmed the above mentioned expired food products. The facility failed to store food in accordance with professional standards for food service safety. Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 207.2(a) Administrator's responsibility

Based on observations, interviews with staff and reviews of the consulting pest control operator's reports, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observation on (MONTH) 25, 2019, of the facility's main kitchen's dishwasher area revealed puddles of water had accumulated on the floor. An insect, that resembled a roach, was observed where the dirty dishes were located. Further, observation on (MONTH) 25, 2019, of the main kitchen's dry storage room revealed an opened container of onions that had flying insects in and around the onions. The pest control operator's report of the main kitchen dated (MONTH) 1, 2019, revealed as an open recommendation that a small accumulation of food and trash product under beverage dispenser line provides a food source and harborage and needs to be cleaned daily. The facility failed to maintain an effective pest control program, so that the facility was free of pests. CFR(s): 483.90(i)(4( Pest Control Program 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 201.18(b)(1) Management Previously cited 5/11/17 28 Pa.Code 201.18(b)(3) Management Previously cited 5/24/18, 5/11/17

Based on review of clinical records, hospice documentation, and interviews with staff, it was determined that the facility failed to ensure that an adequate process was established and maintained to provide continuity of care and services between the hospice provider and the facility for two of three hospice residents' records reviewed. (Resident R29 and R19). Findings include: A review of Resident R29's clinical record review revealed that the resident was admitted to the facility on (MONTH) 3, 2019, with a [DIAGNOSES REDACTED].). The resident was admitted on to hospice services (care for the terminally ill) on (MONTH) 13, 2019. A review of hospice communication notes revealed no written communication from the nursing assistant to the facility, reporting what care was provided to the resident from the nursing assistant. An interview with Licensed nursing staff, Employee E4, on (MONTH) 28, 2019 at 11:15 a.m. confirmed that there were no communication forms from the hospice nursing assistant. Review of the clinical record for Resident R19 revealed that the resident was admitted to the facility on (MONTH) 27, 2019 with [DIAGNOSES REDACTED]. Further review of Resident R19's clinical record revealed a physician's orders [REDACTED]. Further review of Resident R19's clinical record revealed a section of the clinical record designated for the hospice provider's staff documentation related to the care and services provided to the resident. Further review of the hospice section revealed that there was no documentation by the hospice nursing staff - nurses and nursing assistants - of the care and services provided to Resident R19. Interview with the Director of Nursing and Employee #6, hospice nurse, on (MONTH) 27, 2019 at approximately 1:00 p.m., that there was no process for written communication set up between the facility and the hospice provider to ensure that the needs of the resident were addressed appropriately. The facility failed to ensure that adequate communication and proper documentation was maintained between the contracted hospice providers and the facility. CFR(s): 483.70(o) Hospice services 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/11/17 28 Pa. Code 201.18(b)(1) Management Previously cited 5/11/17 28 Pa. Code 201.18(b)(3) Management Previously cited 5/24/18, 5/11/17 28 Pa. Code 211.10(a) Resident care policies Previously cited 5/24/18 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 5/11/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 5/24/18, 5/11/17

Based on observations and interviews with staff it was determined that the Food and Nutrition Department did not document and monitor heat and/or chemical sanitizing levels in the dishwasher and three compartment sink. Findings include: On (MONTH) 21, (YEAR), at approximately 9:42 a.m. in the presence of the Director of the Food and Nutrition Department, it was observed that the the dishwasher did not reach proper heat sanitization temperatures (Wash temperature of 150 degrees F (Fahrenheit) and Final Rinse temperature of 180 degrees F) and the facility was instead using a chemical sanitization method to sanitize dishes, utensils and pots and pans. It was observed that the chemical sanitizing level did not register on the test strip (litmus paper that measures the concentration of the sanitizer by the color of the strip) which would indicate that there was not enough sanitizing solution to sanitize the dishware. The FDA Food Code recommended when using chemical sanitization that the Wash temperature of the dishwasher was to be 120 degrees F and the Final Rinse be 50 ppm (parts per million) of chlorine on dish surface in final rinse. It was also recommended that the chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time. Employee E5, at approximately 3:00 p.m. stated that the test strips, that were used earlier in the morning, were ineffective because they had expired. On (MONTH) 23, (YEAR), at approximately 10:00 a.m. a new test strip was used and the results still showed no sanitizing level in the dish machine. There was no documentation to show that the sanitizing level for the chemical sanitization for the dish machine was being completed daily to monitor the effectiveness of the sanitizer level to determine if the dishware was being sanitized properly and to determine if the test strips were effective. It was also observed that the Dish Machine Temperature Log was not completed six times in (MONTH) (YEAR) during the lunch meal; five times in (MONTH) during the lunch meal and one time during the supper meal and not completed for any meal on (MONTH) 19, (YEAR) and (MONTH) 20, (YEAR). These findings were confirmed by Employee E1 on (MONTH) 24, (YEAR), at approximately 12:30 p.m. 28 Pa. Code: 201.18(b)(3) Management Previously cited [DATE], [DATE]

Based on observations and interviews with staff it was determined that the equipment in the Food and Nutrition Department was not consistently maintained to provide adequate sanitization of dishware and pots and pans. Findings include: On (MONTH) 21, (YEAR), at approximately 9:42 a.m. in the presence of the Director of the Food and Nutrition Department, it was observed that the the dishwasher did not reach proper heat sanitization temperatures. The Food and Drug Administration (FDA) Food Code recommends that the dishmachine have a Wash Temperature of 150-165 degrees F (Fahrenheit) and a Final Rinse temperature of 180 degrees F. There were nine additional days in (MONTH) (YEAR) when the heat sanitization temperatures of the dishwasher were not adequate and chemical sanitization was being used instead. Interview with Employee E5, on (MONTH) 23, (YEAR), also revealed that the drains in the three compartment sink were unable to hold water and the pots and pans were being run through the dishwasher for proper sanitation. It was also observed that the Pot Sink Sanitizer Log was not completed in (MONTH) (YEAR) and (MONTH) (YEAR). The heat sanitization component of the dishwasher to sanitize dishware and the drains in the three compartment sink to sanitize pots and pans were not being maintained. The facility also failed to document and monitor heat and/or chemical sanitizing levels in the dish machine and three compartment sink consistently to ensure dishware was being properly sanitized. This was confirmed in an interview with Employee E1 on (MONTH) 24, (YEAR), at approximately 12:30 p.m. 28 Pa. Code: 201.18(b)(3) Management Previously cited 05/11/17, 06/03/16

Based on observation, clinical record review, review of facility policies and procedures, review of facility documentation and staff interview it was determined the facility failed to ensure accurate and clear clinical record documentation, related to a wander guard, for one of 26 clinical records reviewed (Resident R15) Findings include: Review of the facility policy and procedure titled, Elopement Monitoring, dated, (MONTH) 2014, defined wandering as, The act of moving, (walking or locomotion in a wheelchair), from place to place with or without a specific course of or known direction. During the initial tour of the Magnolia nursing unit, revealed Resident R15, had a Wander guard, (a battery-operated device, that monitors the where a bout of resident that is confused and wanders, prevents a person from going out a door, an alarm sounds and the door locks, when a person wearing a Wander guard is near a door) placed on his left ankle which was confirmed with an interview with Employee E4, Licensed nurse, on (MONTH) 21, (YEAR), at 10:35 a.m. A review of Resident R15's clinical record revealed a physician order, dated, (MONTH) 1, (YEAR), which indicated the following diagnosis's; dementia, (a decline in mental ability severe enough to interfere with daily life), anxiety and [MEDICAL CONDITION] (is an abnormal condition of the mind that results in difficulties telling what is real and what is not). Continued review of the physician orders revealed an order was written on (MONTH) 18, (YEAR), for Resident R15 to have a Wander guard placed on his left ankle. Review of Resident R15's clinical record revealed nursing progress notes dated, (MONTH) 1 to (MONTH) 24, (YEAR), which did not indicate any observations of Resident R15, wandering around the facility and having exit seeking behaviors. Instead the clinical record revealed progress notes which indicated eight times, during the time frame reviewed, that Resident R15 displayed behaviors of having increased agitation with delusional thinking, nothing related to wandering and/or exit seeking. Continue review of Resident R15's clinical record revealed a consult progress note dated, (MONTH) 31, (YEAR) completed by a Neurologist. The notes from the consult indicated that Resident R15 was evaluated for dementia and depression and was found to have memory loss, with orientation to place, but not time. The consult recommended medications and activities to slow down the course of cognitive decline. The consult did not indicate any resident behaviors related to wandering or exit seeking. Review of Resident R15's clinical record revealed, Quarterly Elopement Assessments, dated, (MONTH) 14, (YEAR), (MONTH) 26, (YEAR) and (MONTH) 3, (YEAR). Continued review of these assessments revealed they were completed inaccurately related to Resident R15's, short term memory impairment that compromises safety awareness and experiences agitated behavior with inability to be redirected. Both these areas were indicated to be marked yes and no for answers related to Resident R15. An interview with the Employee E3, Licensed Nurse on (MONTH) 24, (YEAR), at 10:06 a.m. confirmed that the assessments were not accurately completed. Review of Resident R15's clinical record revealed a quarterly MDS, (Minimum Data Set - periodic assessment of needs), dated, (MONTH) 5, (YEAR), which indicated Behavior related to wandering, indicated, that Resident R15, did not display any behaviors of wandering during the look back period of the quarterly MDS, assessment. Review of another quarterly MDS, dated , (MONTH) 28, (YEAR), again indicated that Resident R15, did not display any behaviors of wandering and/or exit seeking. Review of the most recent completed annual MDS assessment dated , (MONTH) 15, (YEAR), one day before the most recent Quarterly Elopement Assessment, again indicated that Resident R15, has not displayed any behaviors related to wandering and/or exit seeking. A review of facility documentation, dated (MONTH) 1 to (MONTH) 24, (YEAR), indicated that Resident R15 was not observed with a behavior related to wandering around the facility and/or exit seeking. An interview with the Administrator and Director of Nursing on (MONTH) 24, (YEAR), at 11:30 a.m. confirmed that the documentation did not indicate that Resident R15 displayed any behaviors related to wandering and exit seeking. The facility failed to ensure that a clinical record had complete and accurate clinical documentation related to one resident with a wander guard. 28 Pa. Code: 201.18(b)(3) Management Previously cited 5/11/17 28 Pa. Code: 211.10(a) Resident care policies 28 Pa. Code: 211.12(d)(5) Nursing services Previously cited 5/11/17, 6/3/16

Based on a review of clinical records, facility documentation, facility policy and procedures and interviews with staff, it was determined that the facility failed to prevent mistreatment and neglect for one of 17 residents reviewed (Resident R27) resulting in harm to a resident when the resident sustained [REDACTED]. Findings include: Review of the facility policy, Lifting/Transferring/Positioning Resident Safely, revised February 2014, stated that Nursing Assistants (NAs), adhere to the designated lifting/transferring/positioning techniques per assignment. Note: NA's may always choose to use more help than assigned but never less. Review of the clinical record for Resident R27 indicated that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was also prescribed medications which included aspirin (a blood thinner). A review of the resident's clinical record revealed a nursing progress note dated December 6, 2016, stating that Resident R27 was being transferred utilizing a sit-to-stand lift. The note stated that the resident caught her left hand in the hook where the sling attached, resulting in a laceration of her left hand with profound bleeding to the left thumb/inner palm to the mid palm area. The resident was sent to the Emergency Department on December 6, 2016, and returned to the facility the same day with four sutures. A review of the resident's quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs) dated November 24, 2016, verified the resident does require a two person physical assist for transfers, ambulation, dressing and eating. A review of the facilities investigation into the event revealed that the sit-to- stand lift was in use for this transfer. On December 7, 2016, the Director of Nursing (DON) interviewed Employee E6, who was the resident's nursing assistant at the time of the event. Employee E6 stated that she, asked for help for the transfer of (Resident R27) from the resident's wheelchair to the toilet. Employee E6 stated that she, got the resident into the lift belt and positioned her hands on the lift. Employee E6 admitted to the DON that she, pushed the resident into the bathroom and pushed the button for the lift without another nursing assistant present. As the lift went up, the other nursing assistant, (Employee E7), entered the bathroom and noticed the resident's hand bleeding and told (Employee E6) to stop the lift. Employee E6 acknowledged not following the facility transfer policy. Employee E6 received disciplinary action on December 8, 2016. A review of Employee E6's counseling report confirmed that the employee used a mechanical lift without a second person present resulting in injury to a resident, and did not follow the facility policy of having two people present for all mechanical lift transfers. The facility failed to prevent mistreatment and neglect related to the use of a mechanical sit-to-stand lift resulting in harm to the resident when the resident's hand was caught in the sling and sustained a laceration requiring sutures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 05/15/15, 06/03/16 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/03/16

Based on a review of clinical records, facility policy and procedure, interviews with staff and a review of facility documentation, it was determined that the facility failed to ensure that adequate supervision, monitoring and assessment was provided for two of 16 residents reviewed related to the use of mechanical lifts resulting in injury to both residents, one resident sustained [REDACTED]. Findings include: Review of facility's policy and procedure, Lifting/Transferring/Repositioning Resident Safely, revised February 2014, stated, Nursing, with input from physical therapy and/or occupational therapy as needed, will evaluate the resident to determine which type of lifting/transferring/repositioning technique is best suited to his/her needs. It stated further, that there were three occasions when the evaluation process needs to occur: new admissions, readmission's, upon a change of condition or after a fall. It also stated that supervisors/charge nurses provide re-evaluation of residents when their condition/overall strength has improved or declined and/or there is a question about the safest means of lifting/transporting a resident. It also stated stated that Nursing Assistants (NAs), adhere to the designated lifting/transferring/positioning techniques per assignment. Note: NA's may always choose to use more help than assigned but never less. Additionally the policy stated that two people would always be available when using a lift. Review of Resident R56's clinical record revealed physcian's orders dated November 2016 that indicated [DIAGNOSES REDACTED]. and hip fracture with joint replacement. In addition, the physician ordered that the staff administer Aricept (a medication used in the treatment of [REDACTED]. depression) 112.5 milligrams by mouth daily, tramadol (a pain medication) 50 milligrams by mouth twice daily for moderate pain and Ativan (a medication used to treat antianxiety) 0.5 milligram by mouth daily at 2:00 p.m. as needed for anxiety. A review of Resident R56's annual Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired and the facility was unable to complete a BIMS assessment (Brief Interview Mental Status - a tool used to assess a residents cognitive status). The resident required extensive two person assist for transfers, extensive assist of one person for dressing, eating, hygiene, used a wheelchair for mobility, was incontinent of bowel and bladder, was 64 inches tall and weighed 182 pounds. Review of Resident R56's plan of care for falls noted that the resident had previously fallen on May 4 and May 6, 2016. There was no documentation in the care plan to indicate what was to be utilized to assist the staff with transfers, such as a mechicanal lift (a mechanical device that raises a person from a sitting to a standing position and aids in transferring a resident). Plans of care for pain, dementia, depression, anxiety, psychosis and agitation noted that the side effects of the medications used to treat these issues included the increased risk for falls, confusion, lethargy and blurry vision. A therapeutic activity note dated November 9, 2016, at 2:36 p.m. stated that Resident R56 had significant confusion with forgetfulness and that she was in a wheelchair and unable to propel herself. Facility documentation failed to reveal any evidence that the resident was re-evaluated regarding their lift status after a change in cognition had been documented in a therapeutic activity note dated November 9, 2016 at 2:36 p.m. Facility documentation dated November 29, 2016, revealed that Resident R56 was being assisted to the bathroom at approximately 11:00 a.m. by two nursing assistants using a sit-to-stand lift (a lift that requires the resident to hold on the the frame as the mechanics of the lift raise the resident to a standing position). The resident stopped holding on and allowed her legs to collapse. The staff could not continue the transfer and lowered her to the floor to a sitting position. Nursing notes on November 30, 2016, at 11:30 p.m. noted that the resident had slid out of the sling the day before and the left foot looked slightly more swollen than the right one. A nursing progress note on December 1, 2016, at 3:44 p.m. stated that Resident R56 had flinched and said ouch when the left foot was touched, it was swollen, and the physician ordered an X-ray of the foot. A progress note December 1, 2016, at 11:16 p.m. noted that a portable X-ray of the left foot had noted soft tissue swelling and was negative for a fracture and recommended an ankle exam to evaluate for fracture. A second X-ray on December 2, 2017, was noted to be positive for a fracture of the lateral malleolus (the bony prominence on each side of the human ankle) above the level of the ankle with mild displacement of the distal fragment (a fractured ankle). The resident was seen by orthopedics (the branch of medicine dealing with the correction of deformities of bones or muscles) on December 6, 2016, who ordered the use of a fracture boot (a boot used to protect the foot and ankle after an injury). There was no evidence available for review at the time of the survey, to indicate that the resident had been evaluated for appropriateness prior to the use of the sit-to-stand lift. The Director of Medical Records stated in an interview on May 11, 2017, at approximately 11:45 a.m. that he was unable to find any lift assessment for Resident R56. In addition, there was no physician's order or plan of care addressing the resident's use of the sit-to-stand lift. The facility failed to insure adequate monitoring and assessment of a cognitively impaired resident, who was also receiving multiple psychoactive medications, for the use of a sit-to-stand mechanical lift that resulted in actual harm to the resident who sustained a fracture when she let go of the lift during a transfer. Resident R27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was prescribed medications which included aspirin (a blood thinner). The resident had a physician's order for a sit-to-stand lift and was care planned for a mechanical lift for transfers. A review of the resident's clinical record revealed a nursing progress note dated December 6, 2016, stating that Resident R27 was being transferred utilizing a sit-to-stand lift. The note stated that the resident caught her left hand in the hook where the sling attached, resulting in a laceration of her left hand with profound bleeding to the left thumb/inner palm to mid palm area. The resident was sent to the Emergency Department on December 6, 2016, and returned to the facility the same day with four sutures. A review of the resident's quarterly MDS dated [DATE], verified the resident does require two person physical assist for transfers, ambulation, dressing and eating. A review of the facility investigation into the event revealed that the sit-to-stand lift was in use for this transfer. On December 7, 2016, the Director of Nursing (DON) interviewed Employee E6, who was the resident's nursing assistant at the time of the event. Employee E6 stated, she, asked for help for the transfer of (Resident R27) from the resident's wheelchair to the toilet. Employee E6 stated, she, got the resident into the lift belt and positioned her hands on the lift. Employee E6 admitted to the DON that she, pushed the resident into the bathroom and pushed the button for the lift without another nursing assistant present. As the lift went up, the other nursing assistant, (Employee E7), entered the bathroom and noticed the resident's hand bleeding and told (Employee E6) to stop the lift. Employee E6 acknowledged not following the facility transfer policy. Employee E6 received disciplinary action on December 8, 2016. A review of Employee E6's counseling report confirmed that the employee used a mechanical lift without a second person present resulting in injury to a resident, and did not follow the facility policy of two people present for all mechanical lift transfers. The facility failed to provide adequate supervision, monitoring and assessment of two residents, related to the use of a mechanical sit-to-stand lift resulting in actual harm to both residents when one resident let go of the lift and fell sustaining a fracture and the second resident's hand was caught in the sling sustaining a laceration requiring sutures. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 05/15/15 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 05/15/15, 06/03/16 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 06/03/16

Based on a review of clinical records, policies and procedures, facility documentation and interviews with facility staff, it was determined that the facility failed to do comprehensive investigations involving an allegation of abuse for two of 16 residents reviewed (Residents R21 and R56). Findings include: A review of the facility's policy and procedure titled, Incident Reporting/Injury Investigation Residents and Visitors, with a revision date of July, 2016, indicated the following: Purpose: to strive to ensure that incidents involving a resident or visitor are recorded, patterns, or trends of occurrences are investigated, and measures are implemented to alleviate or decrease further occurrences. Procedure: all types of incidents require completion of an incident report and notification of the following individuals: Executive Director, Nursing Home Administrator, Director of Nursing, Director of Resident/Nursing Wellness, resident nurse on duty, or Nursing Supervisor in charge of the skilled care center, whichever is appropriate, depending on the circumstances of the incident. The incident is to be documented on the incident report, resident and visitors form, is to state exactly what was observed by the witnesses, what was described by the resident/individual affected by the incident and what was seen when the incident was discovered. All incidents will be investigated as follows: all staff shall be responsible for promptly reporting all injuries/incidents to the charge nurse on duty. Any allegation/suspicion of potential abuse/neglect must be reported to the Director of Nursing or the Nursing Home Administrator immediately. A review of Resident R21's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set assessment (MDS- a periodic review of the resident needs) dated April 20, 2017, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from BIMS assessment reveal the following guidelines: 13-15 cognitively intact: 8-12 moderately impaired: 0-7 severe impairment) score of 10 indicating that the resident was moderately impaired. Further review of the MDS revealed that the resident needed extensive assistance with transfers, dressing, bathing and hygiene. The resident was non-ambulatory. A review of the nurses' notes dated February 4, 2017, at 12:47 p.m. revealed that the resident was agitated during this shift and the resident stated, the nursing assistant left her in the bathroom after having a bowel movement and did not take care of her. She stated that she got herself cleaned up, put herself in the wheelchair and wheeled herself out of the bathroom. A review of a psychiatry (the study and treatment of [REDACTED]. The psychiatrist documented that the resident exhibited clear delusional paranoia (the fixed, false belief that one is being harmed or persecuted by a particular person or group of people). An attempt to interview Resident R21 on May 10, 2017, at 1:00 p.m. was unsuccessful as the resident could not be re-directed to talk about the above incident. A request to review the investigation into an allegation of neglect revealed that an investigation into this allegation was not conducted. An interview with the Director of Nursing on May 10, 2017, at 1:00 p.m. confirmed that the investigation into an allegation of neglect was not done. Review of Resident 56's clinical record revealed physcian's orders dated November 2016, that indicated [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] with joint replacement. A review of Resident R56's annual Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired and the facility was unable to complete a BIMS assessment. The resident required extensive two person assist for transfers, extensive assist of one person for dressing, eating, hygiene, used a wheelchair for mobility, was incontinent of bowel and bladder, was 64 inches tall and weighed 182 pounds. Facility documentation dated November 29, 2016, revealed that Resident R56 was being assisted to the bathroom at approximately 11:00 a.m. by two nursing assistants using a sit-to-stand lift (a mechanical device that raises a person from a sitting to a standing position using a sling as the person holds on the frame), that the resident stopped holding on and allowed her legs to collapse. The staff could not continue the transfer and lowered the resident to the floor to a sitting position. There was no evidence available for review, at the time of the survey, that the staff involved with the transfer had been interviewed or had given statements. Nursing notes on November 30, 2016, at 11:30 p.m. noted that the resident had slid out of the sling the day before and the left foot looked slightly more swollen than the right one. A nursing progress note on December 1, 2016, at 3:44 p.m. stated that Resident R56 had flinched and said ouch when the left foot was touched, it was swollen, and the physcian ordered an X-ray of the foot. A progress note December 1, 2016, at 11:16 p.m. noted that a portable X-ray of the left foot had noted soft tissue swelling, was negative for a fracture and recommended an ankle exam to evaluate for a fracture. A second X-ray on December 2, 2017, was noted to be positive for a [MEDICAL CONDITION] malleolus (the bony prominence on each side of the human ankle) above the level of the ankle with mild displacement of the distal fragment (a fractured ankle). The resident was seen by orthopedics (the branch of medicine dealing with the correction of deformities of bones or muscles) on December 6, 2016, who ordered the use of a fracture boot (a boot used to protect the foot and ankle after an injury). The Director of Nursing stated in an interview on May 10, 2017, at approximately 2:00 p.m. that the facility had not done an investigation into the fall from the lift and therefore left the residents at risk of not being able to hold on to the lift itself. There was no evidence available for review, at the time of the survey, to indicate that a complete and thorough investigation had been completed into a fall from a mechanical lift. The facility failed to conduct comprehensive investigations into an allegation of abuse and a fall from a mechanical lift that resulted in a fractured ankle and actual harm to a resident. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 05/15/15, 06/03/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 06/03/16