**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for three of 12 sampled residents. (Residents 22, 23, 30) Findings include: Clinical record review revealed that the physician directed staff to administer the following bowel protocol for Residents 22, 23, and 30: staff was to administer prune juice on day shift (7:00 a.m. to 3:00 p.m.) if the resident had no bowel movement (BM) in 72 hours. If prune juice was ineffective, staff was to administer milk of magnesia 24 hours later on evening shift (3:00 p.m. to 11:00 p.m.). If milk of magnesia was ineffective, a bisacodyl suppository was to be administered on night shift (11:00 p.m. to 7:00 a.m.). If the suppository was ineffective, an enema was to be administered on night shift, 24 hours later. Clinical record review revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses that included dementia and constipation. On August 17, 2023, the physician directed staff to follow the bowel protocol as needed. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Record review revealed that from October 7 through 11, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 11, 2023, at 10:39 p.m. Further review of the clinical record revealed that from October 11 through 15, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 15, 2023, at 1:29 p.m. Clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included dementia, stroke, and constipation. On November 24, 2020, the physician directed staff to follow the bowel protocol as needed. The MDS assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Review of nurse aide documentation revealed that the resident had a BM on October 18, 2023, at 9:15 p.m. Record review revealed that from October 18 through 24, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a bowel movement until October 24, 2023, at 7:40 p.m. Clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included dementia and constipation. On April 27, 2022, the physician directed staff to follow the bowel protocol as needed. The MDS assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Review of Resident 30's medication administration record for September 2023, revealed that the resident had a BM after administration of prune juice on September 23, 2023, at 10:39 a.m. Further review revealed that from September 23, 2023, through October 1, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 1, 2023, at 3:43 p.m. Additionally, from October 1 through 8, 2023, the bowel protocol was not followed as ordered by the physician, and the resident did not have a BM until October 8, 2023, at 10:44 a.m. Record review revealed that from October 15 through 21, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 21, 2023. In an interview on October 26, 2023, at 9:31 a.m., the Director of Nursing stated that staff did not follow the bowel protocol per the physicians' orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a confidential group interview, it was determined that the facility failed to administer vaccinations in a dignified manner to two of four residents at resident council. Findings include: During a confidential group interview on November 3, 2021, at 10:30 a.m., two residents stated that during the month of October 2021, the pharmacist entered the facility during lunch to administer the booster vaccine to all the residents. The residents stated, We felt like we were rounded up like cattle during our meal time to receive a booster vaccine. The residents stated that there was no privacy provided and that they were afraid to express their feelings about the situation. The residents felt the situation could have been handled in a more dignified manner. 28. Pa Code 201.29(i) Resident rights.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented and in place for one of 16 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included abnormalities of gait and mobility and history of falling. The current care plan identified that the resident was at risk to fall related to gait balance problems, poor safety awareness, history of falls, anxiety, and wandering. On September 6, 2021, Resident 42 fell in the dining room. Review of the incident report revealed the resident was to be placed in a stationary chair in the dining room as an intervention to prevent future falls, however there was no documented evidence that this intervention was implemented. On September 29, 2021, Resident 42 was lowered to the floor in the hallway when walking with a nurse aide. Review of the incident report revealed that to prevent recurrence, the resident was to walk with staff with a wheelchair readily available behind the resident. On November 2, 2021 at 11:34 a.m., Resident 42 was observed walking in the hallway with Nurse Aide 1 with no wheelchair available behind the resident. In an interview on November 4, 2021 at 12:25 p.m., the Director of Nursing confirmed that the stationary chair intervention was not implemented. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain mediation prescribed on an as needed basis for three of 16 sampled residents. (Residents 22, 28, 43) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included arthritis, gout, and Myelodysplastic syndrome (dysfunctional blood cells). The resident had a physician's order for pain medication, Tramadol to be administered every six hours as needed for breakthrough pain. Review of the medication administration record (MAR) revealed that the resident received the as needed Tramadol four times in July 2021, one time in August 2021, 16 times in September 2021, 21 times in October 2021, and two times in November 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication Clinical record review revealed that Resident 28 had diagnoses that included hypertension and osteoporosis (a condition when bone strength weakens). The resident had a physician's order dated September 15, 2021, for a narcotic pain medication, Tramadol, to be administered every six hours as needed for moderate pain. The resident's care plan instructed staff to provide non-pharmacological interventions such as: music, relaxation, and positioning for comfort. Review of the MAR revealed that the resident received the as needed narcotic pain medication 21 times in October 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. Clinical record review revealed that Resident 43 had diagnoses that included diabetes and gout (inflammation of the joints). The resident had a physician's order dated October 12, 2021, for a narcotic pain medication, oxycodone, to be administered every four hours as needed for moderate-severe pain. The resident's care plan instructed staff to provide non-pharmacological interventions such as: music, relaxation, positioning for comfort, and snacks. Review of the MAR revealed that the resident received the as needed narcotic pain medication 32 times in October 2021. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. In an interview on November 4, 2021, at 9:05 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions were offered to Residents 22, 28, and 43 prior to or in conjunction with the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5)Nursing services.