What is LANCASTER NURSING AND REHABILITATION CENTER's CMS rating?

LANCASTER NURSING AND REHABILITATION CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does LANCASTER NURSING AND REHABILITATION CENTER have?

LANCASTER NURSING AND REHABILITATION CENTER has 43 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at LANCASTER NURSING AND REHABILITATION CENTER?

LANCASTER NURSING AND REHABILITATION CENTER has a two-star staffing rating from CMS with 0.33 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is LANCASTER NURSING AND REHABILITATION CENTER located?

LANCASTER NURSING AND REHABILITATION CENTER is located in LANCASTER, PA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LANCASTER NURSING AND REHABILITATION CENTER have?

LANCASTER NURSING AND REHABILITATION CENTER has 446 certified beds.

Who owns LANCASTER NURSING AND REHABILITATION CENTER?

LANCASTER NURSING AND REHABILITATION CENTER is a for profit - corporation facility and is part of the IMPERIAL HEALTHCARE GROUP chain.

Is LANCASTER NURSING AND REHABILITATION CENTER safe?

LANCASTER NURSING AND REHABILITATION CENTER has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at LANCASTER NURSING AND REHABILITATION CENTER stick around?

LANCASTER NURSING AND REHABILITATION CENTER has average staff turnover at 52%, which is typical for the nursing home industry.

Was LANCASTER NURSING AND REHABILITATION CENTER ever fined?

No, LANCASTER NURSING AND REHABILITATION CENTER has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is LANCASTER NURSING AND REHABILITATION CENTER on any federal watch list?

No, LANCASTER NURSING AND REHABILITATION CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at LANCASTER NURSING AND REHABILITATION CENTER?

Medicare inspectors have found 43 deficiencies at LANCASTER NURSING AND REHABILITATION CENTER: 43 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting LANCASTER NURSING AND REHABILITATION CENTER?

Families visiting LANCASTER NURSING AND REHABILITATION CENTER should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does LANCASTER NURSING AND REHABILITATION CENTER compare to other nursing homes?

LANCASTER NURSING AND REHABILITATION CENTER has a 1-star overall rating, which is below average compared to other nursing homes in PA. Families should carefully review inspection findings and consider alternatives.

LANCASTER NURSING AND REHABILITATION CENTER | 40/100 (Grade D)

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Based on resident and staff interviews, it was determined that the facility failed to protect and facilitate the resident's right to receive unopened mail for two of two residents interviewed (Residen...

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Based on resident and staff interviews, it was determined that the facility failed to protect and facilitate the resident's right to receive unopened mail for two of two residents interviewed (Resident 16 and Resident 17).Findings include:Review of Resident 16 comprehensive annual Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated February 8,2025, revealed a score of 15 out of 15 on the BIMS (Brief Interview of Mental Status) which places the resident as cognitively intact. During an interview with Resident 16 on July 11,2025 at approximately 12:15 p.m., resident stated that they received mail that was opened against their wishes. Review of Resident 17 comprehensive annual Minimum Data Set (MDS- assessment of a resident's abilities and care needs) dated June 28,2025, revealed a score of 15 out of 15 on the BIMS (Brief Interview of Mental Status) which places the resident as cognitively intact.During an interview with Resident 17 on July 11, 2025, at 12:30pm, resident stated that they received mail that was opened. Resident 17 revealed open mail was stamped with a date of 5/2/2025 and initial on the back of the envelope.An interview with the Nursing Home Administrator (NHA) on July 11, 2025, at 1:30 p.m. confirmed that Business Office had opened residents' mail. 28 Pa Code 201.29 (j) Resident rights

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding showers for 1 of 5 resident's reviewed (Resident 1). Findings inc...

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Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding showers for 1 of 5 resident's reviewed (Resident 1). Findings include: Review of Resident 1's physician orders revealed the resident is scheduled for shower every Monday evening shift and PRN (as needed). Review of Resident 1's clinical records revealed a 30-day shower task form, dated from May 29, 2025, through June 16, 2025, documenting the resident received a shower on May 29, 2025, at 11:07 a.m., May 30, 2025, at 11:26 a.m., and June 3, 2025, at 8:55 p.m. Further review of the shower task form revealed documentation that the resident refused to shower on June 16, 2025, at 9:48 p.m. Interview with Licensed Practical Nurse Employee E14 and Registered Nurse Unit Manager Employee E15 on June 26, 2025, at 12:18 p.m., E14 stated the resident has received a shower since June 16, 2025. E15 confirmed no shower was documented on the resident's shower task form or clinical records since June 3, 2025. Interview conducted with Nursing Home Administrator (NHA) or Director of Nursing (DON) on June 26, 2025, at 2:15 p.m. when the above information was presented the DON confirmed there was no documentation to prove that the resident has had a shower since June 3, 2025. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Apr 2025 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observations, clinical records review, and staff interview, it was determined that the facility failed to ensure dignity was maintained during meals for one of the 35 residents reviewed (Resi...

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Based on observations, clinical records review, and staff interview, it was determined that the facility failed to ensure dignity was maintained during meals for one of the 35 residents reviewed (Resident 51). Findings include: A review of Resident 51's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated March 11, 2025, revealed that Resident 51 had a moderate cognitive impairment. The same MDS revealed that the resident had a diagnosis of Traumatic Brain Injury (A brain dysfunction caused by an outside force, usually a violent blow to the head). An observation conducted on April 9, 2025, at 9:16 a.m., revealed Resident 51 was sitting on a recliner in the hallway outside of his/her room. The resident was alert to themself with difficulty finishing words. When the resident was asked by the surveyor if they could talk inside his room, non-licensed Employee E5 who was passing another resident's breakfast meal tray suddenly interrupted and stated No, he's going to have breakfast. Instead of placing the meal tray and setting up the resident for breakfast, Employee E5 opened the top lid of the resident's breakfast plate that was still in the tray on the food cart, and with bare hands picked up half of a peice of French toast and handed it to the resident's right hand. The resident started eating the French toast placed by the staff in his/her hands. Employee E5 proceeded to pass the breakfast trays of the other residents. The above was conveyed to the NHA (Nursing Home Administrator) on April 11, 2025, at 10:00 a.m. The facility failed to ensure dignity was maintained during breakfast for Resident 51. 28 Pa. Code: 211.12(d)(1)(5) Nursing services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on a review of the facility's policy, clinical records, and facility documentation, as well as staff interviews, it was determined that the facility failed to timely notify the physician of an u...

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Based on a review of the facility's policy, clinical records, and facility documentation, as well as staff interviews, it was determined that the facility failed to timely notify the physician of an unwitnessed fall with a facial bruise for one of 35 residents reviewed (Resident 305). Findings include: A review of the facility's policy titled Change in Resident's Condition or Status, with a revision date of February 2021, revealed that the facility promptly notifies the resident, attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been an: Accident or incident involving the resident; and need to alter the resident's medical treatment significantly. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Clinical records review revealed Resident 305's diagnosis list includes Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety, and Heart Failure. The clinical records also revealed Resident 305 was on Eliquis (An anticoagulant medication) for Afib (Atrial Fibrillation irregular, often rapid heart rate that commonly causes poor blood flow). A review of the nursing progress notes dated April 1, 2025, at 7:45 a.m., revealed Resident 305 had an unwitnessed fall in her/his room while attempting to toilet self. Injury details revealed right eye swollen, hematoma (A collection of blood outside of blood vessels, often within tissues, typically caused by injury). A review of the facility's documentation Incident Report, revealed that on April 1, 2025, at 7:20 a.m., the resident's roommate alerted the staff that Resident 305 had fallen. The resident was observed on the floor with their head at the end of the bed. The resident stated that she/he was attempting to go to the bathroom but fell and hit her/his right eye. The same report revealed that the Nurse Practitioner and the family were notified via VM (voicemail). A review of the Nurse Practitioner's progress notes dated April 2, 2025, at 6:40 p.m., revealed that the patient was seen due to reports from therapy that the resident had a change in breathing status. The same note revealed that nursing reported that the resident had a fall yesterday which resulted in bruising over the right eye. The resident was assessed, and the order was made and followed. An interview with the Nurse Practitioner was conducted on April 10, 2025, at 1:38 p.m. The NP reported not being notified of the fall that occurred on the morning of April 1, 2025. The NP reported that she/he was notified of the April 1, 2025, fall on April 2, 2025, at around lunchtime after she/he observed the bruise on the resident's right eye during the visit. The NP reported that she/he would have ordered to hold the resident's Eliquis for a day if notified timely. An interview conducted with licensed nurse Employee E7 on April 11, 2025, at 9:05 a.m., revealed that she/he completed the fall incident report on April 1, 2025, and the one who notified the family and the NP of the fall with injury to the face. Employee E7 reported that she/he notified the NP [stated the name of the NP] on the day of the fall by sending the NP a text message via personal mobile phone but Employee E7 was unable to provide any evidence that the notification had occurred. Employee E7 stated, I thought I did. The above occurrence was conveyed to the NHA on April 11, 2025, at 10:00 a.m. The facility failed to timely notify the physician of Resident 305's unwitnessed fall with facial injury. 28 Pa Code 483.25 Quality of Care Previously cited 5/22/24 28 Pa. Code 201.18(b)(1) Management Previously cited 5/22/24 28 Pa. Code 211.5(f) Clinical records Previously cited 5/22/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/22/24

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on housekeeping routine schedule, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 40 s...

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Based on housekeeping routine schedule, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of 40 sampled residents (Resident R197). Findings include: The facility's ISH Health Services, Job Routine H4 states that housekeeping is scheduled to clean Resident R197's room between 8:00 a.m. and 9:00 a.m. An interview with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that housekeeping had not cleaned his room for several days. Observations of Resident R197's room revealed a dried, light brown substance under the resident's urinary drainage bag. Resident R197 reported that the substance had been there for over four days. Further observations on April 9, 2025, at 9:16 a.m. and 12:43 p.m. confirmed that housekeeping had not cleaned the room, as the dried light brown substance remained under the urinary drainage bag. Additional observations on April 10, 2025, at 9:59 a.m. showed the same dried light brown substance under the urinary drainage bag. A review of Resident R197's clinical record found no documentation indicating that Resident R197 had refused housekeeping services. An interview with the Nursing Home Administrator (NHA) on April 11, 2025, at 1:15 p.m. confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, and staff interview it was determined the facility failed to ensure Minimum Data Set Assessme...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, and staff interview it was determined the facility failed to ensure Minimum Data Set Assessments (MDS) were completed accurately for two of two residents reviewed (Resident 193 and Resident 244). Findings include: Review of Resident 193's diagnosis list revealed diagnoses including traumatic brain injury, diabetes mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), protein calorie malnutrition, gastrostomy (feeding tube) and tracheostomy (breathing tube). Review of Resident 193's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated January 25, 2025, revealed Resident 193 had a significant weight loss. Review of Resident 193's Weight Summary failed to reveal evidence of a significant weight loss. Interview with Licensed Employee E11 on April 10, 2025, at 12:15 p.m. revealed that Resident 193's Quarterly MDS was completed in error regarding the significant weight loss and Resident 193 did not have a significant weight loss. Review of Resident 244's MDS (Minimum Data Assessment - periodic assessment of resident needs) assessment dated [DATE], section O0110 - Special Treatments, Procedures, and Programs revealed Resident 244 was not receiving hospice care. Review of Resident 224's physician's orders revealed Resident 244 was receiving hospice care since December 11, 2024. Interview on April 11, 2025, at 9:40 a.m. with Licensed Employee E11 confirmed Resident 244's MDS assessment was marked incorrectly. 28 Pa. Code 211.5(f) Clinical Records Previously cited 5/22/2024

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of the 35 residents reviewed (Resident 23 an...

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Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of the 35 residents reviewed (Resident 23 and 111). Findings include: A review of Resident 23's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated February 16, 2025, revealed that the resident had severe cognitive impairment. The same MDS revealed that the resident utilizes a wheelchair for mobilization. A review of the nursing progress notes dated March 19, 2025, at 4:00 p.m., revealed Resident 23 was found on the ground floor of the building with clothes stating she/he was leaving. An Alpha Watch (device that triggers alarms if they approach restricted areas or attempt to leave) was applied to the resident's wheelchair. A review of Resident 23's Elopement Evaluation dated March 19, 2025, revealed a Yes check mark for the following questions: Resident with a history of elopement or attempted leaving the facility without informing the staff; Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; Resident wander; and Resident's wandering behavior a pattern, goal-directed. The evaluation revealed Resident 23 was at risk for elopement. A review of Resident 23's care plan failed to reveal a care plan for the resident's exit-seeking behavior was developed. An interview with the NHA (Nursing Home Administrator) on April 11, 2025, at 1:00 p.m., confirmed a care plan for Resident 23's exit-seeking behavior was not developed. An observation conducted on April 8, 2025, at 10:15 a.m., revealed Resident 111 was lying on the bed with a wound vac machine (A medical device that uses negative pressure to help heal wounds) on the bedside table. A review of Resident 111's physician order dated March 12, 2025, revealed an order for a wound vac to the sacrum continuously setting 125 mm/Hg every shift. Check placement and function every shift, and change canister as needed. A review of Resident 111's care plan failed to reveal that a comprehensive plan of care was developed for Resident 111's use of a continuous wound vac. An interview with the NHA on April 11, 2025, at 10:00 a.m., confirmed that a comprehensive care plan for Resident 111's continuous use of a wound vac was not developed. The facility failed to ensure a comprehensive care plan was developed for Resident 23's exit-seeking behaviors and Resident 111's continuous use of a wound vac. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Based on observation, interview with residents and staff, it was determined that the facility failed to ensure resident call bells were answered and addressed in an appropriate amount of time for one ...

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Based on observation, interview with residents and staff, it was determined that the facility failed to ensure resident call bells were answered and addressed in an appropriate amount of time for one of one resident (Resident R197). Finds include: Review of Resident R197's clinical record revealed the following diagnoses: unspecified injury at an unspecified level of the cervical spinal cord (spinal cord injury), quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down), and muscle wasting and atrophy (thinning of muscle tissue). Review of Resident R197's care plan revealed the following interventions: TRANSFER: Resident is dependent on the assistance of two staff members using a mechanical lift (Hoyer lift) for all transfers; non-ambulatory. This care plan had a start date of March 4, 2019. An interview conducted with Resident R197 on April 8, 2025, at 9:45 a.m. revealed that when he activates his call bell (a system used to notify staff that assistance is required), staff will enter his room, turn off the call bell, and then leave without providing further assistance. Review of Resident R197's clinical record revealed a progress note dated April 1, 2025, at 3:01 p.m., which stated: Resident rang for assistance to get out of bed (OOB) four times, all within approximately 15-minute intervals. Resident was informed each time that the CNA assigned to provide care was also training a new CNA that day, so it would take her longer to complete her duties in order to ensure proper training. Resident was unhappy with this explanation. We will continue to communicate with the resident regarding their assignments and any changes to them. An interview conducted with the Nursing Home Administrator (NHA) on April 11, 2025, at 1:15 p.m. confirmed the above. 28 Pa. Code 211.12(d)(1(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based upon clinical record review and interview, it was determined the facility failed to follow physician orders for medication administration and fluid restrictions for 3 of 3 residents reviewed (Re...

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Based upon clinical record review and interview, it was determined the facility failed to follow physician orders for medication administration and fluid restrictions for 3 of 3 residents reviewed (Resident 1, Resident 27 and Resident 371). Findings include: Review of Resident 1's diagnosis list includes Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) and Acute Respiratory Failure. Review of Resident 1's physician order dated October 21, 2024, revealed an order for 2000 ml fluid restriction every 24 hours. 1020 ml- dietary, and 980 ml - nursing. Review of April 2025 Medication Administration Record (MAR) revealed no documentation that the fluid restriction was followed. Review of Resident 27's care plan revealed resident had a diagnosis of hyponatremia (low blood sodium level) with a need for fluid restriction. Review of physician's orders included an order for 1000 milliliter (mL) fluid restriction (Nursing total=280 ml in 24 hours; Dining total=720 ml in 24 hours). Review of the March 2025 and April 2025 Medication Administration Record (MAR) revealed no documentation that the fluid restriction was followed. Interview with the Nursing Home Administrator on April 11, 2025, at 10:57 a.m. confirmed that there was no documentation indicating that the fluid restriction was followed for Resident 27. Review of Resident 371's diagnosis list revealed diagnoses including coronary artery disease (narrowing of the blood vessels which supply the heart with blood and oxygen), hypertension (high blood pressure) and carotid artery stenosis (narrowing of the carotid artery). Review of Resident 371's physician orders revealed an order for Amlodipine (high blood pressure medication) 2.5 milligrams (mg) to be administered daily for hypertension and to give the medication if the systolic blood pressure (measure of blood pressure while heart is beating; amount of force that blood exerts on the walls of the blood vessels) is greater than 140 mm Hg (millimeters of mercury). Review of Resident 371's February 2025 Medication Administration Record (MAR) revealed Resident 371 received Amlodipine 2.5 mg 19 times from February 1, 2025, through February 28, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. Review of Resident 371's March 2025 MAR revealed Resident 371 received Amlodipine 2.5 mg 16 times from March 1, 2025, through March 31, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. Review of Resident 371's April 2025 MAR revealed Resident 371 received Amlodipine 2.5 mg four times from April 1, 2025, through April 11, 2025, when Resident 371's systolic blood pressure was less than 140 mm Hg. The above information was conveyed to the Nursing Home Administrator on April 11, 2025, at 1:00 p.m. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/22/2024

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ased on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a woun...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ased on observations, clinical records review, and staff interviews, it was determined that the facility failed to follow a wound treatment order for one of the four residents reviewed (Resident 111). Findings include: Clinical records review revealed Resident 111 was admitted to the facility on [DATE], with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the sacrum (The triangular bone just below the lumbar vertebrae). admission skin assessment revealed that the sacral wound measured 12 x 9.0 x 1.0 cm. with 10% slough (A non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Further review revealed that the resident has Osteomyelitis (bone infection) and was receiving Intravenous (Medication administered through a vein) Antibiotics (medication used to fight infections). A review of resident 111's physician's order dated March 12, 2025, revealed an order for a wound vac (A medical device that uses negative pressure to help heal wounds) to the sacrum continuously setting 125 mm/Hg every shift. Check placement and function every shift, and change canister as needed. An observation conducted on April 8, 2025, at 10:15 a.m., revealed Resident 111 was lying in bed, a wound vac machine was observed on the bedside table. Further observation revealed that the machine was off. The canister was observed filled with a light red gel-like substance. An observation conducted on April 8, 2025, at 12:41 p.m., and 2:15 p.m., revealed that the machine was off/not working. An interview with licensed nurse Employee E3 on April 8, 2025, at 2:20 p.m., revealed that she/he was Resident 111's nurse for the day. When asked when the last time she/he checked on the resident's wound vac, Employee E3 stated, I did not see it the whole day. Employee E3 checked the machine and found that the cord that was plugged into the wall socket was not connected to the machine's adaptor. After Employee E3 connected the cord, she/he turned the machine's power on button, but the machine did not start and started beeping. Employee E3 reported that the canister might be full which could be the reason why it was beeping. Employee E3 reported that the wound dressing/canister was changed on April 7, 2025. An interview with licensed nurse Employee E4 on April 8, 2025, at 2:25 p.m., revealed that she/he was one of the nurses on the unit and did observe Resident 111's wound vac working at around 9:44 a.m., and documented on the TAR (Treatment Administration Record) that the machine was working for the day shift. Clinical records review failed to reveal that Resident 111's wound vac machine was monitored from 10:15 a.m., until 2:10 p.m., to ensure the functioning of the machine. The above was conveyed to the Nursing Home Administrator on April 11, 2025, at 10:00 a.m. The facility failed to ensure Resident 111's order for a continuous wound vac to the sacral wound was followed. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based upon review of consultant pharmacist's Medication Review, it was determined the facility failed to provide a pain scale as recommended by the pharmacist and agreed to by the nurse practitioner f...

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Based upon review of consultant pharmacist's Medication Review, it was determined the facility failed to provide a pain scale as recommended by the pharmacist and agreed to by the nurse practitioner for the use of a narcotic and failed to provide Non-pharmaceutical Interventions prior to the administration of narcotic pain medication for one of five residents reviewed (Resident 371). Findings include: Review of Resident 371's diagnosis list revealed diagnoses including encephalopathy (swelling in brain), osteoarthritis of the left shoulder, and chronic tension headaches. Review of Resident 371's physician's orders dated January 22, 2025, revealed an order for Hydromorphone (narcotic pain medication) HCl 2 milligrams (mg) give one half tablet (1 mg) by mouth every 2 hours as needed (PRN) for pain. Review of Resident 371's consultant pharmacist's Medication Regimen Review (MRR) dated February 27, 2025, revealed the need to add a pain scale for the administration of Hydromorphone. Review of Resident 371's March 2025 and April 2025 Medication Administration Record (MAR) failed to reveal evidence that a pain scale was implemented in the physician's order as agreed to in the consultant pharmacist's recommendation. Review of Resident 371's March 2025 MAR revealed Resident 371 received Hydromorphone sixty-three times for pain levels ranging from 3 to 10. Further review of Resident 371's April 2025 MAR revealed Resident 371 received Hydromorphone twenty-one times for pain levels ranging from 0 to 8. Further review of Resident 371's March and April 2025 MAR and review of clinical documentation failed to reveal evidence that non-pharmaceutical interventions were implemented prior to the administration of the PRN Hydromorphone. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/22/2024

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observations and staff interviews, it was determined that the facility failed to ensure infection control prevention and management was practiced during medication administration and meal set...

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Based on observations and staff interviews, it was determined that the facility failed to ensure infection control prevention and management was practiced during medication administration and meal set up for two 35 residents reviewed (Resident 1 and 51). Findings include: An observation of the medication administration was conducted with licensed Employee E6 on April 8, 2025, at 9:55 a.m. The observation revealed that after preparing Resident 1's medication, Employee E6 approached Resident 1 who was lying in bed to give the medication. While the resident was trying to pick up the medications in the cup, one of the pills fell on the resident's tray table. Further observations revealed Employee E6 picked up the pill that fell with bare hands without performing hand hygiene and then gave it to the resident to swallow. An observation conducted on April 9, 2025, at 9:16 a.m., revealed Resident 51 was sitting on a recliner in the hallway outside of his/her room holding a puzzle book. While talking to the resident, non-licensed Employee E5 who was observed passing another resident's breakfast meal tray said that it was time for Resident 51's breakfast. Without performing hand hygiene, and without cleaning the resident's hands, Employee E5 opened the top lid of the resident's breakfast plate that was still in the tray on the food cart, and with bare hands picked up half of a bread and handed it to the resident's right hand. The resident started eating the French toast placed by the staff in his/her hands. Employee E5 proceeded to pass the breakfast trays of the other residents without performing hand hygiene. The above was conveyed to the NHA (Nursing Home Director) on April 11, 2025, at 10:00 a.m. The facility failed to ensure infection control prevention and management were practiced during medication administration and meal set-up. 28 Pa. Code: 211.12(d)(1)(5) Nursing services

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure weights were monitored and a significant weight change was promptly ad...

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Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure weights were monitored and a significant weight change was promptly addressed for five out of 15 residents reviewed (Residents 27, 74, 158, 202, and 338). Findings include: A review of the facility's policy titled Weight Assessment and Interventions, last revised in March 2022, states Resident weights are monitored for undesireable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment must be retaken the next day for confirmation. A. If the weight is verified, nursing will notify the dietitian. Review of Resident 27's physician's orders included an order to weigh monthly every day shift every four weeks. Review of the clinical record revealed a weight of 153.9 pounds on September 16, 2024, and a weight of 139.4 pounds on September 30, 2024, indicating a loss of 14.5 pounds (9.4%). Further review of the clinical record indicated that a weight was not obtained until October 9, 2024 (9 days after the identified weight loss). Further review of Resident 27's clinical record revealed no weight was obtained in November 2024 or January 2025. Review of Resident 74's clinical record revealed that on February 14, 2025, the resident weighed 152.0 lbs. On March 11, 2025, Resident 74's weight was recorded at 137.8 lbs., indicating a 9.34% decrease in weight. Further review of Resident 74's clinical record on April 11, 2025, revealed that nursing staff did not retake the resident's weight the following day, as required by the facility's policy. An interview conducted with the Nursing Home Administrator (NHA) on March 11, 2025, at 1:15 p.m. confirmed the above. Review of Resident 158's physician's orders included an order to weigh monthly every day shift every four weeks on Friday. Review of the resident's clinical record revealed the last recorded weight was on February 21, 2024. Review of Resident 202's clinical record revealed a weight was obtained on November 27, 2024. No weight was documented for December 2024 or January 2025. A weight was obtained on February 23, 2025, with no further documentation of weights for March 2025. Interview with Employee E12 on April 11, 2024, at 10:54 a.m. revealed that the standard is for residents to be weighed monthly and reweights should be obtained within 72 hours. Review of Resident 338's clinical record revealed an order that stated, 'weigh monthly every evening shift every 4 weeks on Sun for wt (weight)'. Further review of Resident 338's clinical record revealed of monthly weights of 114.6 pounds on October 15, 2024 ;112 pounds on October 27, 2024; and 107.5 pounds on December 4, 2024. Further review of the weights revealed facility failed to weigh and record resident weight for the month of November 2024. Interview with the Nursing Home Administrator on April 11, 2025, at 1:15p.m. confirmed the above 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on a review of the facility policy, review of the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to properly store and label...

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Based on a review of the facility policy, review of the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to properly store and label medication on four of four medication carts reviewed (7th Floor South Side Cart, 7th Floor North Side Cart, 8th Floor North/South Cart and 8th Floor Southeast/Northeast Cart) Findings include: A review of the facility's policy titled Medication Labeling and Storage, revision date of February 2023, revealed that medications and biologicals are stored in the packaging, containers, or other dispensing systems they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications may not be transferred between containers. Multi-dose vials opened and accessed are dated and discarded within 28 days unless the manufacturers specify a shorter or longer time for the open vial. A review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Aspart (Novolog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of manufacturers' storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. An observation on the south side medication cart was conducted on April 8, 2025, at 10:00 a.m., in the presence of licensed nurse Employee E6. The observation revealed two Lantus Insulin pens used and undated and one Lispro Insulin pen used and undated. An interview conducted with Employee E6 on April 8, 2025, at 10:05 a.m., confirmed that the Insulin pens should have been dated when opened. An observation on north side medication cart was conducted on April 8, 2025, at 10:12 a.m., in the presence of licensed nurse Employee E8. The observation revealed one Lispro insulin vial used with an open date of February 9, 2025. The same observation revealed a two Lantus insulin pen used and undated, and a Lidocaine vial (A medication that prevents pain by blocking the signals at the nerve ending in the skin) used and undated. An interview conducted with Employee E8 on April 8, 2025, at 10:15 a.m., confirmed that the above medications should have been dated when opened. An observation on the north/south side medication cart was conducted on April 8, 2025, at 12:15 p.m., in the presence of licensed nurse Employee E9. The observation revealed the following insulins were all opened, used, and undated: three Novolog pens, one Lantus pen, one Insulin Aspart pen, and two Insulin Gargline pens. An interview conducted with Employee E9 on April 8, 2025, at 12:28 p.m., confirmed that the above insulin pens should have been dated when opened. An observation conducted on the southeast/northeast side medication cart was conducted on April 8, 2025, at 12:40 p.m., in the presence of licensed nurse Employee E10. The observation revealed the following: Two Insulin Aspart vials and one Insulin Gargline pen were all opened, used, and undated. Further observation revealed 16 white long tablets in a medication cup in the top drawer. An interview conducted with Employee E10 on April 8, 2025, at 12:45 p.m., confirmed that the insulin medications should have been dated when opened. Furthermore, Employee E10 was unable to verify the name of the white medications observed on the top drawer of the medication cart. The above findings were discussed with the Nursing Home Administrator on April 11, 2025, at 11:00 a.m. The facility failed to ensure correct storage and labeling were maintained on the 7th and 8th Floor medication carts. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/22/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/22/24

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide rea...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for one of five residents reviewed (Resident R1). Findings Include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with the following diagnosis: acute respiratory failure with hypoxia (not enough oxygen in the blood due to a failure in oxygen exchange in the lungs), chronic obstructive pulmonary disease (a lung condition caused by damage to the airways that limit airflow in and out of the lungs), anxiety disorder (characterized by excessive, persistent and uncontrollable worry and fear about everyday situations), muscle wasting and atrophy (deterioration of ones muscles), and difficulty in walking. Review of Resident R1's clinical record revealed a progress note dated September 26, 2024, at 10:25 a.m. stating call placed to [power of attorney for care] who stated she requested 2 siderails [power of attorney for care] as informed this is considered a restraint educated on the risks of 2 siderails. [power of attorney for care] was updated on all fall interventions in place. [power of attorney for care] wants to talk to nursing administration stated she will be in. Additional review of Resident R1's clinical record revealed a Bed Side Rail Evaluation dated November 11, 2024, reporting the Resident R1 needed bed rails for positioning and/or rising from [lying down] to sitting. Further review of the evaluating revealed the from was not completed and Resident R1 did not receive bed rails. Subsequent review of Resident R1's clinical record revealed an additional Bed Side Rail Evaluation dated January 10, 2025, revealed the evaluation was entirely completed and Resident R1 received bed rails on January 10, 2025. An interview conducted with the Director of Nursing (DON) on January 27, 2025, at 12:45 p.m. revealed he was not aware of the incomplete Bed Side Rail Evaluation and confirmed that Resident R1 should've had bed rails installed on her bed on November 11, 2024. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that [NAME] Nursing and Rehabilitation Center failed to e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that [NAME] Nursing and Rehabilitation Center failed to ensure a resident was monitored for weight loss and follow physician orders for one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed diagnoses including but not limited to following: unspecified injury of head, Obesity, Depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities of daily living), Chronic pain, and Congenital Malformation of Corpus Callosum (brain defect where there is a complete or partial absence of the corpus callosum, a bundle of nerves connecting the right and left side of the brain). Review of Resident R1's clinical record revealed the resident had a recorded weight of 275.7 pounds on May 1, 2024. Further review of Resident R1's clinical record revealed a weight of 180 pounds on June 6, 2024. Additional review of Resident R1's clinical record revealed that the resident's attending physician or dietician were not informed until June 21, 2024, when dietician noted weight loss and requested weight monitoring weekly times four weeks. Review of Resident R1's physician orders revealed an order initiated on June 24, 2024, with instructions of weekly weights x4 every day shift every Mon (Monday) for 4 week. Review of Resident R1's clinical record including June and July 2024 Medication Administration Record (MARs) failed to reveal weekly weight monitoring. Weight was recorded on June 17, 2024, of 180 pounds. Further review of Resident R1's July 2024 MAR failed to reveal weights for the second and third week of July 2024. Additional review of July 2024 MAR revealed blank (not signed) entries for July 1, July 8, and July 15, 2024. A weight was record in Resident R1's vital section for July 3, 2024, of 186 pounds. Review of Resident R1's meal consumption documentation revealed, Resident R1 refused to eat any meals for July 5, July 6, and July 7, 2024. Interview with Nursing Home Administrator on July 29, 2024, at 1:16 p.m. confirmed the weights of Resident R1 were not monitored and physician orders were not followed. 28 Pa. Code 211.5(f) Clinical Records Previously cited on 5/22/24 and 7/27/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited on 5/22/24 and 7/27/23

May 2024 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**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 assessments accur...

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**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 assessments accurately reflected the resident's status for three of 35 residents reviewed (Residents 165, 250, and 396). Findings include: Review of Resident 165's progress note of November 1, 2023, revealed resident was found on the floor and reported severe pain to the lower back and right hip area. The physician was notified and ordered the resident be sent to the hospital. Review of additional progress note of November 1, 2023, revealed that a CT scan (computed tomography scan - type of x-ray that creates cross-sectional images) showed a comminuted impacted right acetabular (hip) fracture with right iliac (hip) muscle hematoma (bruise) and right inferior pubic ramus (part of the pelvis) fracture. Review of Resident 165's significant change MDS (Minimum Data Set - periodic assessment of resident needs) of November 10, 2023, section J1700A indicated that the resident did not have a fall any time in the last month prior to admission/entry or reentry and section J1700C indicated that the resident did not have a fracture related to a fall in the 6 months prior to admission/entry or reentry. Interview with the RNAC (registered nurse assessment coordinator) Employee E6 on May 22, 2024, at 9:10 a.m. confirmed that Resident 165's significant change MDS was coded incorrectly. Review of Resident 250's quarterly Minimum Data Set (MDS-periodic assessment of resident needs) dated April 18, 2024 revealed the resident had a fall with a major injury. Review of Resident 250's clinical record revealed the resident had not had a fall with a major injury in the past year. Interview with Licensed Nursing Employee E6 on May 22, 2024 at 9:45 a.m. confirmed Resident 25 was incorrectly coded for a fall with major injury on the quarterly MDS dated [DATE]. Review of Resident 396's discharge MDS dated [DATE] revealed the resident was coded as being discharged to an acute care hospital. Review of Resident 396's progress notes revealed a nursing entry dated February 20, 2024 stating, Patient discharged to home. Interview with Licensed Nursing Employee E6 on May 22, 2024 at 9:45 a.m. confirmed Resident 396 was incorrectly coded for a discharge to an acute care hospital on the discharge MDS on February 20, 2024. F641 Accuracy of Assessments Previously cited 7/27/2023 28 Pa. Code 211.5(f) Clinical records Previously cited 7/27/23 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/27/23

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 35 residents reviewed (Resident 73). Findings includ...

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Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 35 residents reviewed (Resident 73). Findings include: Review of Resident 73's physician's orders included an order dated September 22, 2023, for Eliquis (anticoagulation - medication used to prevent blood clots) 2.5 milligrams one tablet twice a day for paroxysmal atrial fibrillation (type of irregular heartbeat). Review of quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of March 20, 2024, revealed that resident was receiving an anticoagulant. Review of Resident 73's current care plan revealed no care plan or interventions for anticoagulant medication. Interview with the Nursing Home Administrator on May 21, 2024, at 1:30 confirmed that Resident 73 did not have a care plan to address the anticoagulant. 483.21 Comprehensive Resident Centered Care Plan Previously cited 7/27/23 28 Pa. Code 211.5(f) Clinical records Previously cited 7/27/23 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/27/23

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of 35 residents reviewed for nutrition (Resident...

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Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for two of 35 residents reviewed for nutrition (Residents 259 and 348). Findings include: Review of facility policy Weight Assessment and Intervention revised September 2008 indicated that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will notify nursing witin 48-72 hours after weight is reviewed for needed re-weights. Review of Resident 259's clinical records revealed Resident 259 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS- nervous system disease that weakens muscles and impacts physical function). The resident had a Tracheostomy (An opening surgically created through the neck into the trachea to allow air to fill the lungs) and a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Review of the weight and vitals revealed a weight of 192.5 pounds on April 19, 2024, and a weight of 181.4 pounds on May 13, 2024, an 11.1 pounds (5.77 %) weight loss in less than a month. A review of the same report revealed resident ' s weight was not rechecked until May 21, 2024. (181.3 pounds) eight days after significant weight change was identified. Interview with the Dietitian was conducted on May 22, 2024, who reported that she/he was not notified of the significant weight loss identified on May 13, 2024. The employee learned about the weight loss on May 21, 2024, when the reweight was done. The dietitian confirmed that the resident should have been re-weighed within 24-48 hours when a significant weight change is identified. Review of Resident 348's clinical record revealed a weight of 118.4 pounds on April 4, 2024. Weight was recorded on May 7, 2024 at 105.8 pounds (loss of 12.6 pounds or 10.6%) with no reweight obtained. Further review of Resident 348's clinical record revealed a weight of 93.2 pounds on May 12, 2024 (loss of 12.6 pounds or 11.9% over five days) with no reweigh obtained. Further review of Resident 348's clinical record revealed no evidence that the Registered Dietitian reviewed the record due to the significant weight loss. Interview with the Registered Dietitian, Employee E9, on May 22, 2024, at 9:15 a.m. revealed that reweights should be done within 24-48 hours for a significant weight loss of 5% or more. Employee E9 also confirmed that reweights should have been completed for Resident 348. 28 Pa. Code 211.5(f) Clinical Records Previously cited 7/27/23 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 7/27/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 7/27/23

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of ten residents reviewed for unnecessary medication...

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Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of ten residents reviewed for unnecessary medications (Resident 97). Findings include: Review of Resident 97's physician's orders revealed an order dated January 30, 2024, for Oxycodone (narcotic pain reliever) 5 milligrams (mg) every 8 hours as needed for moderate to severe pain. Review of Resident 97's May 2024 Medication Administration Report (MAR) revealed the resident received Oxycodone on May 8, 2024, and May 10, 2024, for pain rated 1 on a scale of 1-10. Review of resident 97's April 2024 MAR revealed the resident received Oxycodone 5mg on April 3, 2024, and April 4, 2024, for pain rated 0, April 19, 2024, for pain rated 1, and April 21, 2024, for pain rate 3 on a scale of 1-10. Review of resident 97's March 2024 MAR revealed the resident received Oxycodone 5mg on March 1, 2024, March 2, 2024, and March 3, 2024, for pain rated 1 on a scale of 1-10. Interview with Director of Nursing (DON) on May 22, 2024, at 12:43 pm., confirmed that Resident 97 should not have received as needed pain medication for a pain rating of 0-3. Interview with DON confirmed moderate to severe pain should be rated 4-6. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on resident interview and clinical record review, it was determined that the facility failed to ensure one of three residents reviewed for dialysis was free of significant medication errors (Res...

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Based on resident interview and clinical record review, it was determined that the facility failed to ensure one of three residents reviewed for dialysis was free of significant medication errors (Resident 220). Findings include: Interview with Resident 220 on May 20, 2024, at approximately 1:10 p.m. revealed the resident received insulin (medication given to lower blood sugar) but was not receiving it correctly. Further interview with Resident 220 at this time revealed the resident did not receive certain medications on the days the resident attended dialysis. Review of Resident 220's physician's orders revealed an order dated May 2, 2024, for insulin lispro (fast acting insulin), inject per sliding scale: If blood sugar is 0-199 - give 0 units of insulin If blood sugar is 200-250 - give 4 units of insulin If blood sugar is 251-300 - give 6 units of insulin If blood sugar is 301-350 - give 8 units of insulin If blood sugar is 351-400 - give 10 units of insulin; and if blood sugar is greater than 400, give 10 units of insulin and call the physician. The order further read to hold the morning insulin dose on Monday, Wednesdays, and Fridays (the resident ' s dialysis days.) Review of Resident 220's May 2024 Medication Administration Record revealed the resident received insulin on Monday, Wednesday, and Friday mornings on the following dates: Friday, May 3, 2024, at 6:00 a.m. the resident was given 10 units of insulin for a blood sugar of 377 Monday, May 6, 2024, at 6:00 a.m. the resident was given 4 units of insulin for a blood sugar of 208 Wednesday, May 8, 2024, at 6:00 a.m. the resident was given 10 units of insulin for a blood sugar of 385 Monday, May 13, 2024, at 6:00 a.m. the resident was given 8 units of insulin for a blood sugar of 339 Friday, May 17, 2024, at 6:00 a.m. the resident was given 4 units of insulin for a blood sugar of 221 Monday, May 20, 2024, at 6:00 a.m. the resident was given 8 units of insulin for a blood sugar of 305 Further review of Resident 220's physician's orders revealed an order dated May 15, 2024, that the facility May adjust medication times on dialysis days as needed. Further review of Resident 220's physician's orders revealed orders dated May 1, 2024 for Bisacodyl (laxative) 5 milligrams (mg) one time a day at 8:00 a.m., Bumetanide (diuretic) 2mg one time daily at 8:00 a.m., Docusate Sodium (stool softener) 100mg once daily at 8:00 a.m., probiotic one capsule one time daily at 8:00 a.m., umeclidinium-vilanterol (inhaler used to treat wheezing and shortness of breath) one puff daily at 8:00 a.m., calcium acetate 667mg two capsules three times daily, lactulose (used to treat cirrhosis) oral solution 20 grams/30 milliliters give 30 mls three times daily, Sevelamer Carbonate (a medication used to treat an increased level of phosphate in the blood) 800 mg two tablets three times daily, and albuterol sulfate (inhaler that relaxes muscles in the airways and increases air flow to the lungs) two puffs every four hours. Review of Resident 220's May 2024 MAR revealed the resident did not receive the abovementioned medications 8:00 a.m. doses on Mondays, Wednesdays, and Fridays, due to the resident being out of the facility at dialysis. There was no documentation to show the medications were offered when the resident returned from dialysis. Interview with the Nursing Home Administrator on May 22, 2024, at approximately 1:30 p.m. confirmed the above findings. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

Based on observation, resident, and staff interviews, it was determined that the facility failed to ensure assistive devices for eating were made available for one of the 18 residents reviewed (Reside...

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Based on observation, resident, and staff interviews, it was determined that the facility failed to ensure assistive devices for eating were made available for one of the 18 residents reviewed (Resident 189). Findings include: Review of resident 189's diagnosis list includes Diabetes with Mononeuropathy (nerve damage caused by high blood sugar levels), legal blindness, and Brachial plexus disorder (An injury in the network of nerve fibers that innervates the skin and musculature of the upper extremity. It causes a burning sensation, numbness or weakness of the arm, severe pain, and inability to move or feel the affected arm). Review of Resident 189's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 3, 2024, revealed Resident 189 was cognitively intact. The same MDS revealed resident had one side impairment of the upper extremity. Interview was conducted with Resident 189 on May 21, 2024, at 12:10 p.m. The resident reported that due to limitations on his/her hands/fingers, he was provided with a special kind of spoon and fork, and plate to use during meals but has not been provided to him/her during meals for more than a month now. Observation in the presence of licensed nurse Employee E3 was conducted on May 22, 2024, at 8:40 a.m., and revealed resident's meal was served on a regular plate and was provided with a regular spoon and fork. Review of the resident breakfast meal ticket dated May 22, 2024, revealed adaptive equipment: scoop plate; large, handled fork; left-handed spoon. Interview with Licensed nurse, Employee E3 was conducted on May 22, 2024, at 8:45 a.m., and confirmed Resident 189 uses an adaptive utensil and a scoop plate during mealtime. Employee E3 does not know the reason why Resident was not provided with his/her adaptive spoon and plate. Interview with non licensed, Employee E4 was conducted on May 22, 2024, at 8:48 a.m. Employee E4 reported being the regular nurse aide of Resident 189. Non licensed, Employee E4 reported that she/he was informed that the resident's adaptive utensils and plate comes from the kitchen. Employee E4 reported that the kitchen had not sent the resident's adaptive equipment for eating for almost a month now. Review of the Occupational Therapy notes dated October 24, 2023, revealed Resident will use built-up utensils and scoop plates with supervision during mealtime to increase participation and independence with successful mealtimes for self-feeding. Interview with the Rehabilitation Director, Employee E5 was conducted on May 22, 2024, at 11:00 a.m., who confirmed that OT recommended that the resident use an adaptive equipment device for eating on October 24, 2023. The facility failed to ensure Resident 189 was provided with the recommended adaptive equipment device during mealtime. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Based on clinical record review and staff interview it was determined the facility failed to follow physician orders for three of 40 residents reviewed. (Residents 67, 222, and Resident 223) Findings ...

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Based on clinical record review and staff interview it was determined the facility failed to follow physician orders for three of 40 residents reviewed. (Residents 67, 222, and Resident 223) Findings include: Review of Resident 67's physician's orders included an order dated July 5, 2022, for a 24-hour fluid restriction of 1800 milliliters (ml) with 660 mL from nursing and 1140 mL from dining. Review of Resident 67's clinical record including April 2024 Medication Administration Record (MAR) revealed the resident exceeded the amount of fluids provided by nursing on 29 of 30 occasions. Review of Resident 67's clinical record including May 2024 MAR revealed that the resident exceeded the amount of fluids provided by nursing on 12 of 20 occasions. Further review of the clinical record revealed no documentation of the amount of fluids consumed with meals for May 2024. The above information was presented to the Nursing Home Administrator (NHA) on May 21, 2024, at 1:45 p.m. Review of Resident 222's physician order dated April 6, 2024, revealed an order for a Milk of Magnesia Suspension 400 mg/5ml given 30 cc by mouth every 24 hours as needed for constipation if no bowel movement in three days, give at HS (hours of sleep) Review of Resident 222' s bowel records revealed that the resident did not have recorded bowel movements from May 5, 2024, until May 9, 2024. Review of Resident 222' s May 2024 Medication Administration Record failed to reveal that the resident was administered with as-needed Milk of Magnesia on May 8, 2024. The above information was discussed with the Nursing Home Administrator on May 22, 2024, at 10:00 a.m. Review of Resident 223's physician orders revealed an order dated August 7, 2023 for a 24-hour fluid restriction of 1500 milliliters (ml). Review of Resident 223's clinical record including MAR for March, and April 2024 revealed there was no documentation as to how much fluid the resident had in a 24-hour period and the MAR for May 2024 revealed the resident was coded as having 1500 ml per shift each day which is the total fluid restriction. Interview conducted with Nursing Home Administrator on May 22, 2024 at 10:30 a.m. confirmed there was no documentation of Resident 223's intake for March and April 2023 and the documentation on the MAR for May 2024 was inaccurate prohibiting the facility from ensuring the fluid restriction was being followed as ordered. 483.25 Quality of Care Previously cited 7/23/23 28 Pa. Code 201.18(b)(1) Management Previously cited 11/1/23 28 Pa. Code 211.5(f) Clinical records Previously cited 7/23/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 1/9/24, 7/23/23

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

Based on clinical record review and staff interviews, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with physician's o...

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Based on clinical record review and staff interviews, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with physician's order for four of 11 residents receiving enteral feeding (Residents 72, 244, 259, and 364). Findings include: A review of the facility's policy titled Enteral Nutrition, revised in November 2018, revealed facility will provide adequate nutritional support through enteral nutrition to the residents as ordered. Review of Resident 72's physician's order of October 18. 2023 included an order for enteral feeding Jevity 1.5 via peg tube continuous at a rate of 55 milliliter(mL)/hour for a total volume of 1210 mL/24 hours. Review of Resident 72's April 2024 Medication Administration Record (MAR) revealed that the resident exceeded 1210 mL/24 hours for six of 30 days. Documentation on four of 90 shifts revealed staff were documenting the rate of 55 mL/hour instead of the volume received. Review of the May 2024 MAR revealed that the resident exceeded 1210 mL/24 hours for three of 20 days and two of 60 shifts documented the rate of 55 mL/hour. This information was presented to the NHA on May 21, 2024, at 1:45 p.m. Clinical records review revealed Resident 244 had a diagnosis of Anoxic brain damage (Which occurs when the brain is deprived of oxygen). The resident had a Tracheostomy (An opening surgically created through the neck into the trachea to allow air to fill the lungs), and a Gastrotomy Tube (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth). A review of Resident 244's Physician's order dated January 9, 2024, revealed Enteral Feed Order: Osmolyte 1.5 Cal @ 55 ml/hr. Total volume per hour 1210 ml. A review of the May 2024, Medication Administration Record dated May 1, 2024, until May 22, 2024, revealed that Resident 244 was not provided with a total volume of 1210 ml of Osmolyte on the following days: May 3, 4, 5, 10, 11, 12, 16, 17, 18, and 19 2024. The total GT feeding provided on those days ranged only from 550 ml to 1035 ml which was less than the total feeding volume ordered by the physician. Clinical records review revealed Resident 259 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS- A nervous system disease that weakens muscles and impacts physical function). The resident had a Tracheostomy and a GT. A review of Resident 259's Physician's order dated April 19, 2024, revealed an Enteral Feed order every shift: Nutren 1.5 via peg tube continuous at rate 45 ml for 22/24 hours, documenting total shift intake. A review of the May 2024 MAR failed to reveal a documented feeding tube total shift intake from May 1, 2024, until May 15, 2024. A review of the same MAR revealed a total intake of 450 ml on May 17, 2024, 765 ml on May 18, 2024, and 765 ml on May 19, 2024, which was less than the 990 ml /22/24 hours total feeding intake ordered by the physician. Clinical records review revealed Resident 364 had a diagnosis of Cerebral Infarction (stroke). The resident had a Tracheostomy and GT. A review of Resident 364's Physician's order dated May 6, 2024, revealed an Enteral Feed order every shift: Jevity 1.5 continuous at 60 ml/hr for 22/24 hours administration (Total 1320 ml). A review of the May 2024 MAR from May 6, 2024, until May 22, 2024, revealed that Resident 365 was not provided with a total volume of 1320 ml of Jevity 1.5 on the following days: May 11, 12, 16, 17, and 20, 2024. The total GT feeding provided on hose days ranges only from 600 ml - 960 ml which was less than the total feeding volume (1320 ml) ordered by the physician. The above was conveyed to the Nursing Home Administrator on May 22, 2024, at 11:00 a.m. The facility failed to ensure residents on tube feeding were provided with adequate and ordered tube feeding. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce ...

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Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for nine of nine residents reviewed (Residents 59, 67, 72, 106, 130, 152, 220, 343, and 364). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated April 2024, revealed EBP employees targeted gown and glove use during high-contact resident care activities in which there is an opportunity for transfer of MDRO (Multiple Drug Resistant Organisms) to staff hands and clothing. EBP is indicated for residents with the following: Wounds and/or indwelling medical devices regardless of MDRO infections or colonization status; Indwelling medical devices: urinary catheters, feeding tubes, tracheostomies, and ventilators. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instruction for PPE use. Clinical records review revealed Resident 59 had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) pressure ulcer to the left medial malleolus (inner side of the ankle) Observation conducted of Resident 59's room failed to reveal evidence of EBP signage/communication. Observation on May 21, 2024, at 1:05 p.m., revealed Resident 67 had an indwelling Foley catheter. Observation conducted of Resident 67's room failed to reveal evidence of EBP signage/communication. Observation on May 20, 2024, at 12:05 p.m. revealed Resident 72 had a Gastrostomy Tube Observation conducted of Resident 72's room failed to reveal evidence of EBP signage/communication. Observation conducted on March 19, 2024, at 9:30 a.m., revealed Resident 106 had a Tracheostomy tube (curved tube that is inserted into the opening made in the neck and trachea) and Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted of Resident 106's room on the first three days of the survey failed to reveal evidence of EBP (Enhanced Barrier Precautions) signage/communication. Observation on May 20, 2024, at 9:30 a.m., revealed Resident 130 had a GT and indwelling Foley catheter (A medical device that helps drain urine from your bladder) Observation conducted of Resident 130's room failed to reveal evidence of EBP signage/communication. Observation conducted on March 19, 2024, at 10:40 a.m., revealed Resident 152 had a Tracheostomy tube and Gastrostomy Tube. Observation conducted of Resident 152's room on the first three days of the survey failed to reveal evidence of EBP signage/communication. Clinical records review revealed Resident 220 had a left heel wound on a Negative pressure wound therapy (A therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudates and promote wound healing). Observation conducted of Resident 220's room failed to reveal evidence of EBP signage/communication. Observation conducted on March 19, 2024, at 10:00 a.m., revealed Resident 343 had a Tracheostomy tube and Gastrostomy Tube. Observation conducted of Resident 343's room on the first three days of the survey failed to reveal evidence of EBP signage/communication. Observation conducted on March 19, 2024, at 9:40 a.m., revealed Resident 364 had a Tracheostomy tube and Gastrostomy Tube. Observation conducted of Resident 364's room on the first three days of the survey failed to reveal evidence of EBP signage/communication. Interview was conducted with licensed nurse Employee E3 on May 21, 2024, at 11:30 a.m. Employee E3 was unable to provide information regarding the EBP process/procedures. An interview with the Director of Nursing was conducted on May 22, 204, at 11:00 a.m. The DON confirmed that the EBP process was not fully implemented due to waiting for more supplies. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Jan 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on review of the medication manufacturer's guidelines, observation, and staff interviews, it was determined that the facility failed to ensure medications were properly labeled and stored on one...

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Based on review of the medication manufacturer's guidelines, observation, and staff interviews, it was determined that the facility failed to ensure medications were properly labeled and stored on one of the medication carts observed (8th SW Floor Medication Cart). Findings include: Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of manufacturer's storage guidelines for Insulin Gargline (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Insulin Aspart (Novolog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Levemir FlexTouch (long-acting insulin), revealed in-use Levemir insulin must be discarded 42 days after opening. Observation of the 8th Floor SW medication cart was conducted in the presence of licensed employee E3 on January 4, 2024, at 12:30 p.m. The observation revealed the following: Three vials of Insulin Lispro, opened and undated; One Insulin Aspart pen, opened and undated; Three Insulin Aspart vials, opened and undated; One Levemir Insulin vial, opened and undated; One Insulin Gargline vial, opened and undated; One Insulin Gargline vial with an open dated of November 30, 2023, and One Novolog insulin vial with an open date of November 25, 2023, Interview conducted with Employee E3 on January 4, 2024, at 12:40 p.m. confirmed the above medications should have been dated once opened and discarded after the 28th day it was opened. The facility failed to ensure medications were properly stored and labeled for the 8th floor SW medication cart. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Nov 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined that [NAME] Nursing and Rehabilitation Center failed to ensure a clean, sa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined that [NAME] Nursing and Rehabilitation Center failed to ensure a clean, sanitary environment in the kitchen and/or food storage area. Findings include: Observation conducted on November 1, 2023 at approximately 9:10 a.m. in the company of the assistant food/beverage director, Employee E3, of the dry storage room revealed one wall, approximately one yard in length, was noted to have splattered areas of black-like substance on it. The floor was visibly soiled in areas with food particles. Further observation revealed open packets of crackers on a shelving unit. Interview with Employee E3 on November 1, 2023 at approximately 9:12 a.m. confirmed the dry storage area was not sanitary/clean area. Employee E3 indicated the areas should be clean and free of any food debris or substances. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.6(d) Dietary Services

Jul 2023 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Employment Screening (Tag F0606)

Could have caused harm · This affected 1 resident

Based on review of facility policy, employee personnel files and staff interview, it was determined that the facility failed to obtain a FBI background check for one out of five employees (Employee E5...

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Based on review of facility policy, employee personnel files and staff interview, it was determined that the facility failed to obtain a FBI background check for one out of five employees (Employee E5). Findings include: Review of the facility policy and procedure, titled Background Screening Investigation undated , revealed Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks (including fingerprinting as may be required by state law) on all applicants for purposes of the national background check program. Review of personnel file for Dietician, Employee E5, revealed the date of hire was April 10, 2023, and the employee did not live in Pennsylvania for the past two years. The facility did not perform the FBI background check as required for out-of-state employees. 28 Pa. Code 201.14 (c) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.10 (d) Resident care policies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for 4 out of 4 (Resident 27,154, 1...

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Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for 4 out of 4 (Resident 27,154, 189, 370). Findings include: Review of quarterly Assessment MDS (Minimum Data Set -periodic assessment of resident needs) for Resident 27 indicated a completion date of June 19, 2023 (Section Z0500B), the assessment has not been completed and is listed as in progress as of July 25, 2023. The assessment does not accurately reflect the status of resident 27 due to missing information. Review of quarterly MDS assessment for Resident 154 indicated a completion date of June 16, and June 20, 2023, (Section Z0500B); the assessment is not completed and is listed as in progress as of July 25, 2023. The assessment does not accurately reflect the status of resident154 due to missing information. Review of quarterly MDS assessmentfor Resident 189 indicated a completion date of June 15, 2023, (Section Z0500B); the assessment is not completed and is listed as in progress as of July25, 2023. The assessment does not accurately reflect the status of resident 189 due to missing information. Review of quarterly MDS assessment for Resident 370 indicated a completion date of March 16, 2023, (Section Z0500B); the assessment is not completed and is listed as in progress as of July 25, 2023. The assessment does not accurately reflect the status of resident 370 due to missing information. Interview with the Registered Nurse, Employee E4 on July 26, 2023, approximately 11:00 a.m. confirmed MDS assessments did not accurately reflect the resident status, as the MDS assessments are incomplete and missing information on the assessment regarding each resident's status. F641 Accuracy of Assessments Previously cited 7/15/2022 28 Pa. Code 211.5(f) Clinical records Previously cited 07/15/2022,3/7/2023 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/7/2023, 06/27/2023

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of clinical records, it was determined the facility failed to ensure a baseline care plan was initiated upon a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of clinical records, it was determined the facility failed to ensure a baseline care plan was initiated upon admission for a foley catheter for one of 35 residents reviewed (Resident 324). Findings include: Resident 324 was admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy requiring a foley catheter for urination. Review of Resident 324's clinical record failed to reveal evidence that a baseline care plan was created for the use of a foley catheter. Interview with the Nursing Home Administrator on July 27, 2023 at 11:15 a.m. confirmed a baseline care plan was not created for Resident 324 for the use of a foley catheter. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 7/15/2022

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based upon clinical record review, it was determined the facility failed to ensure a comprehensive care plan was initiated for a resident on a fluid restriction for one of 35 residents reviewed (Resid...

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Based upon clinical record review, it was determined the facility failed to ensure a comprehensive care plan was initiated for a resident on a fluid restriction for one of 35 residents reviewed (Resident 140). Findings include: Review of Resident 140's clinical record revealed Resident 140 receives dialysis three times per week. Further review of Resident 140's clinical record revealed a physician's order dated June 8, 2023 requiring a fluid restriction. Review of Resident 140's care plan failed to reveal evidence of a care plan for fluid restriction. Interview with the Nursing Home Administrator on July 27, 2023 at 11:20 a.m. confirmed that no care plan for fluid restriction exists for Resident 140. The facility failed to provide a comprehensive care plan for fluid restriction for Resident 140. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based upon clinical record review and staff interview, it was determined that the facility failed to update or revise active care plans for one of six residents reviewed (Resident 138) Findings includ...

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Based upon clinical record review and staff interview, it was determined that the facility failed to update or revise active care plans for one of six residents reviewed (Resident 138) Findings include: Review of Resident 138's diagnosis list revealed diagnoses including Major Depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine), Anxiety (mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension). Review of Resident 138's medical record revealed, Resident is actively taking: Ativan (benzodiazepine that is used to treat anxiety), Seroquel (antipsychotic that is used to treat depression), Depakote (anticonvulsant used to treat manic phase of bipolar disorder), Zoloft (antidepressant used to treat depression), and Duloxetine (antidepressant used to treat depression and anxiety). Review of Resident 138's clinical record revealed, Resident 138 was sent to the hospital on June 14, 2023, due to active Suicidal Ideations. Resident returned to the facility on June 14, 2023, at 12:02 pm. Further review of Resident 138's active plan of care failed to reveal, facility staff had updated and/or revised the resident's care plan to reflect Resident 138's recent development of suicidal ideations. The above-mentioned information was relayed to the Director of Nursing on July 27, 2023 at approximately 2:50 p.m. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on clinical record review, it was determined that the facility failed to ensure physician's orders were followed related to fluid restrictions and blood pressure medication parameters for three ...

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Based on clinical record review, it was determined that the facility failed to ensure physician's orders were followed related to fluid restrictions and blood pressure medication parameters for three of 35 residents reviewed (Residents 37, 140, and 202). Findings include: Review of Resident 37's clinical record revealed the resident receives hemodialysis and diagnosed with End Stage Renal Disease, Edema, and dependence on renal dialysis. Review of Resident 37's physician's orders revealed an order dated May 11, 2023, for a 1500 milliliter (ml) fluid restriction, with nursing allotted 600 ml total daily. Review of Resident 37's May 2023 Medication Administration Record (MAR) revealed that the resident was documented as receiving more than physician ordered 600 ml a total of 12 times. Review of Resident 37's June 2023 MAR revealed that the resident was documented as receiving over 600 ml 14 times. Further review of Resident 37's physician's orders revealed on June 29, 2023, the resident's fluid restriction was increased to 2000ml, with nursing allotted 860ml total daily. Review of Resident 37's June 2023 MAR revealed the resident was documented as receiving over 2000ml one time. Review of Resident 37's July 2023 MAR revealed the resident was documented as receiving over 2000ml 14 times. Interview with the Nursing Home Administrator and Director of Nursing on July 27, 2023, at 12:55 p.m. confirmed that the facility was not following Resident 37's physician's orders for fluid restriction. Review of Resident 140's clinical record revealed a physician's order dated June 8, 2023, for a fluid restriction of 1.5 Liters/day. Further review of Resident 140's clinical record failed to reveal documentation of the amount of fluid administered to Resident 140 per shift to ensure Resident 140 received fluids within the parameters ordered by the physician. Interview with the Nursing Home Administrator on July 27, 2023, at 11:20 a.m. confirmed that no documentation existed to determine the amount of fluid administered to Resident 140 per shift or the daily total of fluids administered as was ordered by resident's physician. Review of Resident 202's clinical record revealed an order for Fludrocortisone Acetate Tablet 0.1 MG Give 0.1 mg by mouth one time a day for ortho hypotension (Hold for SBP >128) (used to raise blood pressure). Review of Resident 202's MAR revealed the resident was documented to have a blood pressure above 128 and received the medication on April 2,17,28,29; June 2,3,4,5,20; and July 3 and July 4, 2023, when it should have been held. An interview with the Nursing Home Administrator on July 27, 2023 at 11:00 a.m. confirmed that the medication was given outside of the parameters on the dates as mentioned above. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview, it was determined that the facility failed to timely provide the ne...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview, it was determined that the facility failed to timely provide the necessary psychological services to attain or maintain the highest practicable mental and psychosocial well-being for one of 35 residents reviewed (Resident 255). Findings include: Observation of Resident 255 on July 24, 2023, at approximately 12:00 p.m. revealed the resident was on a ventilator and had mitt restraints on both hands. Clinical record review revealed Resident 255 had a plan of care for using physical restraints due to being at risk of self-harm and pulling at the ventilator/tracheostomy site. Further review of the resident's clinical record revealed diagnoses including Anxiety and Depression. Review of Resident 255's progress notes revealed a nursing progress note dated June 30, 2023, which stated: Resident continues with increased behaviors, pulling vent tubing off, resident expressed he wanted to die and go to heaven, he made motions with his hands. resident is not able to be redirected at this time. Further review of Resident 255's progress notes revealed a social services progress note dated June 30, 2023, which stated: Today he used hand gestures pointing at the ceiling and waving hands across his neck. He shook his head yes when asked if he wanted to be with God .[Social worker] emailed for psych consult. Further review of Resident 255's clinical record revealed the resident was sent to the hospital from [DATE], to July 13, 2023, due to seizure-like activity. Review of Resident 255's clinical record failed to reveal evidence that the resident had a psychology consult or that any psychology consults were attempted upon returning from the hospital. Interview with the Nursing Home Administrator on July 27, 2023, at approximately 1:00 p.m. revealed Resident 255 was supposed to be seen by psych on July 21, 2023. Further interview with the Nursing Home Administrator revealed that the resident was not seen on this date, due to psychology indicating the resident was not present in his/her room at the time of the consult. Clinical record review failed to reveal evidence that Resident 255 had any outside appointments during the time on July 21, 2023. Further interview with the Nursing Home Administrator on July 27, 2023, at approximately 2:00 p.m. confirmed there was no documented evidence that Resident 255 had been seen by psychology or that a psychology consult had been attempted. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services 28 Pa Code 211.16(a) Social services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of five residents reviewed for unnecessary medicatio...

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Based on clinical record review, it was determined the facility failed to administer as needed pain medications for appropriate pain levels for one of five residents reviewed for unnecessary medications (Resident 286). Findings include: Review of Resident 286's physician's orders revealed an order dated April 17, 2023, for Oxycodone (narcotic pain reliever) 5 milligrams (mg) every 8 hours as needed for moderate to severe pain. Review of Resident 286's June 2023 Medication Administration Record (MAR) revealed the resident received Oxycodone 5 mg four time for pain rated '0' on a scale of 1-10. Review of Resident 286's July 2023 MAR revealed the resident received Oxycodone 5 mg six times for pain rated '0' on a scale of 1-10. Interview with the Nursing Home Administrator and Director of Nursing on July 27, 2023, at 12:40 p.m. confirmed that Resident 286 should not have received as needed pain medication for a pain rating of '0.' 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and interviews with staff it was determined that the facility failed to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and interviews with staff it was determined that the facility failed to to ensure new psychotropic medications were given including proper diagnosis and documentation for one out of 32 residents (202). Findings include: Review of the facility policy labeled, Antipsychotic Medication Use, revealed Antipsychotic medications (class of drugs commonly used to treat serious psychiatric disorders) may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Review of Resident 202 clincial record revealed Residetn 202 was admitted to the facility on [DATE]; with the following diagnosis; Cerebral infarct (stroke), Heart Disease, Vascular Dementia without behavioral disturbance, Mood Disturbance, and Anxiety. Review of Resident 202's clinical record revealed nursing note dated June 22, 2023, indicating the (physician) in to facility today. New order for hospice. New order for Seroquel (antipsychotic medication used to treat mental/mood disorders)12.5 mg (miligram) PO BID (by mouth twice a day). The physician ordered hospice due to Resident 202's health declining (hospice is a service to individuals that have less than 6 months to live). Further review of the Resident 202's Medication Administration Record (MAR) revealed the physician ordered the medication for indications of personal history of other mental and behavioral disorders. Additional review of Resident 202's clinical record did not reveal behavior monitoring or consult notations from a psychologist in the months prior to the prescirption. Interview conducted with the Nursing Home Administrator (NHA) on July 27, 2023, at 9:27 a.m. revealed there was no documentation of behavior monitoring prior to June 22, 2023, and confirmed that the resident's behavior was frequent falls. The facility failed to ensure that psychotropic medications were not given to Resident 202, unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 28 PA Code 211.5(f) Clinical records Previously cited 07/15/2022, 3/7/2023 28 PA Code 211.10(a) Resident care policies Previously cited 07/15/22, 06/27/2023 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 03/7/2023, 06/27/2023

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Based upon clinical record review and review of staffing documentation, it was determined the facility failed to ensure adequate staffing levels on April 30, 2023, causing significant medication error...

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Based upon clinical record review and review of staffing documentation, it was determined the facility failed to ensure adequate staffing levels on April 30, 2023, causing significant medication errors for 31 residents on the 6th floor nursing unit and 16 residents on the 8th floor nursing unit. Findings include: Review of staffing documentation provided by the facility revealed the facility staffing level on April 30, 2023, was 2.60 hours per person per day (ppd) which was below the State minimum staffing level of 2.70 ppd. Review of clinical records revealed 31 residents on the 6th floor nursing unit missed 8:00 a.m. medications on April 30, 2023, that were ordered by the residents' physician. Further review of clinical records revealed 16 residents on the 8th floor nursing unit missed 8:00 a.m. medications on April 30, 2023, that were ordered by the residents' physician. Interview with the Nursing Home Administrator on July 27, 2023, at 11:00 a.m. confirmed that the above residents missed their 8:00 a.m. medications on April 30, 2023, due to lack of adequate staffing. The facility failed to provide adequate staffing levels to provide the necessary care and services for residents. 28 Pa. Code 201.18 Management

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Based upon clinical record review and resident representative interview, it was determined the facility failed to administer medications as ordered by the physician causing significant medication erro...

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Based upon clinical record review and resident representative interview, it was determined the facility failed to administer medications as ordered by the physician causing significant medication errors for seven out of 35 residents (Resident 55, Resident 72, Resident 76, Resident 220, Resident 291, Resident 365, and Resident 369). Findings include: Review of Resident 55's, physician orders dated April 30, 2023 revealed Resident 55 was to receive the following medications at 8:00 a.m.: Effexor XR (anti-depressant medication) 150 mg (milligrams); Folic Acid (for anemia) 1 mg; Lamictal (medication to treat bipolar disorder) 100 mg; Loratadine (allergy medication) 10 mg; Paliperidone ER (used to treat Bipolar Disorder) 6 mg and Topiramate (medication used to treat Bipolar Disorder) 50 mg. Review of Resident 55's clinical progress notes dated May 1, 2023, revealed Resident 55 did not receive medications on April 30, 2023, as ordered by resident's attending physician. Review of Resident 72's April 30, 2023 physician orders revealed Resident 72 was to receive the following medications at 8:00 a.m.; Bumex (medication used for fluid overload) 0.5 mg; Ellipta Inhaler; Spironolactone (medication used for fluid overload) 50 mg; Wixela Inhaler; Xifaxan (enhances brain function due to liver disease) 550 mg; Insulin Aspart injection (used to treat high blood sugar) 10 units and Midodrine (medication used to treat low blood pressure) 5 mg. Review of Resident 72's clinical progress notes dated May 1, 2023, revealed Resident 72 did not receive medications on April 30, 2023, as ordered by Resident 72's physician. Interview with Resident 76's family representative on July 25, 2023, at 2:00 p.m. revealed Resident 76 did not consistently receive medications as ordered. Review of Resident 76's April 30, 2023, physician orders revealed Resident 76 was to receive the following medications at 8:00 a.m.: Aspirin 81 mg; Atorvastatin (medication used to treat high cholesterol levels) 40 mg and Olanzapine (used to treat bipolar disorder) 5 mg. The above-mentioned medications were not administered as ordered by Resident 76's attending physician. Review of Resident 220's April 30, 2023, physician orders revealed Resident 220 was to receive the following medications at 8:00 a.m.: Aspirin 81 mg; Atenolol (used to treat high blood pressure) 25 mg; Baclofen (used for muscle spasms) 5 mg; Celexa (anti-depressant) 10 mg; Lamictal (anti-seizure medication) 75 mg and Perphenazine (used to treat psychosis) 2 mg. The above-mentioned medications were not administered as ordered by Resident 220's attending physician. Review of Resident 291's April 30, 2023, physician orders revealed Resident 291 was to receive the following medications at 8:00 a.m.: Cyanocobalamin (vitamin) 1000 micrograms; Ferrous Sulfate (iron tablet) 325 mg; Flonase Nasal Spray; Lasix (diuretic) 40 mg;Novolin Insulin (used to treat high blood sugar levels) 16 units; Potassium Chloride 10 meq (milliequivalents); Rosuvastatin (used to treat high cholesterol levels) 40 mg; Eliquis (blood thinner medication) 2.5 mg and Isosorbide (high blood pressure medication) 10 mg. The above-mentioned medications were not administered as ordered by Resident 291's attending physician. Review of Resident 365's April 30, 2023, physician orders revealed Resident 365 was to receive the following medications at 8:00 a.m.: Abilify (anti-depressant) 2 mg; Celexa (anti-depressant) 30 mg; Protonix (used for treatment of reflux) 30 mg and Midodrine (used to treat low blood pressure) 2.5 mg. The above-mentioned medications were not administered as ordered by Resident 365's attending physician. Review of Resident 369's April 30, 2023, physician orders revealed Resident 369 was to receive the following medications at 8:00 a.m.: Amlodipine (medication used to treat high blood pressure) 10 mg; Zoloft (anti-depressant) 125 mg; Baclofen (neurologic medication) 10 mg; Keppra (anti-seizure medication) 1000 mg and Metoprolol (medication used to treat high blood pressure) 25 mg. The above- mentioned medications were not administered as ordered by Resident 369's attending physician. Interview with the Nursing Home Administrator on July 27, 2023, at 11:00 a.m. confirmed that the above-mentioned residents did not receive medications as ordered by their physician on April 30, 2023. The interview further revealed that nursing staff did not show up for work on that day and staff in attendance did not perform their job duties as assigned which contributed to multiple residents not receiving their 8:00 a.m. physician ordered medications on April 30, 2023. The facility failed to ensure medications were administered according to physician orders. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 7/15/2022

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on review of the facility's policy, facility documentation, and clinical records, as well as an interview with staff, it was determined that the facility failed to ensure that allegations of phy...

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Based on review of the facility's policy, facility documentation, and clinical records, as well as an interview with staff, it was determined that the facility failed to ensure that allegations of physical abuse were reported to the state agency for one of four residents reviewed (Resident 1). Findings include: A review of the facility's policy titled Abuse Investigation and Reporting, revised in July 2017, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of the unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. A review of Resident 1's diagnosis list revealed dementia, anxiety disorder, and depressive disorder. A review of Resident R1's current care plan revealed that the resident has impaired behaviors due to psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality). The behaviors include punching staff, yelling, cursing, making racial slurs towards staff, threatening others, refusal of care/treatment, and making false accusations. A review of the nursing progress notes, dated January 10, 2023, at 9:17 p.m., revealed that Resident 1 was heard yelling in the room, the resident sat on the bed and immediately said I'm sorry. The resident further stated, really ugly to the girls. When asked what she told the girls, the resident stated, I called them ni***ers. The resident reported that she apologized to the aides but reported that the aides called her names as well and smacked her with a brief. The supervisor was made aware and the resident was on 15-minute checks for aggressive behaviors towards staff and peers. Review of the facility documentation and state agency's Event Report System failed to reveal that Resident 1's physical abuse allegation was reported to the state agency. An interview with the Nursing Home Administrator and Director of Nursing conducted on June 27, 2023, at 1:00 p.m. confirmed that Resident 1's report of alleged physical abuse was not reported to the state agency. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on review of the facility's policy, facility documentation, and clinical records, as well as an interview with staff, it was determined that the facility failed to ensure that an allegation of p...

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Based on review of the facility's policy, facility documentation, and clinical records, as well as an interview with staff, it was determined that the facility failed to ensure that an allegation of physical abuse was thoroughly investigated and an allegation of sexual abuse was investigated timely for one of four residents reviewed (Resident 1). Findings include: A review of the facility's policy titled Abuse Investigation and Reporting, revised in July 2017, revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of an unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. A review of the facility's policy titled Abuse Prevention Program, revised in October 2022, revealed that as part of the resident abuse prevention, the following protocols, which include investigating and reporting any allegations of abuse within timeframes as required by federal requirement, should be implemented. A review of Resident 1's diagnosis list revealed dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), anxiety disorder, and depressive disorder. A review of Resident R1's current care plan revealed that the resident has impaired behaviors due to psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality). The behaviors include punching staff, yelling, cursing, making racial slurs towards staff, threatening others, refusal of care/treatment, and making false accusations. A review of the nursing progress notes, dated January 10, 2023, at 9:17 p.m., revealed that Resident 1 was heard yelling in the room, the resident sat on the bed and immediately said I'm sorry. The resident further stated, really ugly to the girls. When asked what she told the girls, the resident stated I called them ni***ers. The resident reported that she apologized to the aides, but reported that the aides had called her names as well and smacked her with a brief. he supervisor was made aware and resident was placed on 15-minute checks for aggressive behaviors towards staff and peers. An interview with the Director of Nursing (DON) on June 27, 2023, at 1:00 p.m., was conducted. The DON reported that she/he was not the DON at the time of the incident but recalled receiving the report two days after the incident (January 12, 2023). At that time she/he was the Assistant DON. The current DON reported that on January 10, 2023, the resident was on 15-minute behavior monitoring checks for increased behaviors and was also diagnosed with a urinary tract infection (UTI). Review of the clinical records failed to reveal that the above allegations of physical abuse were thoroughly investigated by the facility. The facility was unable to provide staff statements and other documentation indicating that the above incident was thoroughly investigated. A review of the facility documentation and an incident report, dated June 5, 2023, at 6:15 p.m., revealed that on June 2, 2023, at 8:00 p.m. licensed nurse Employee E3 notified the nursing supervisor of Resident 1's accusations towards another male resident. An interview with the resident revealed that on Saturday night (May 27, 2023) a naked male resident, with his gown open in the front, walked into the room, fell on top of the resident, and inserted a finger into the resident's private part. The resident reported rolling over the bed which resulted in the male resident in question falling to the floor. Resident 1 continued yelling but the door was shut. A female nurse eventually came in and escorted the male resident out of the room. An investigation was conducted on June 2, 2023, a full head-to-toe assessment with two registered nurses was completed, and the Nursing Home Administrator, DON, physician, responsible party, and police were notified. The resident declined to go to the Emergency Room. Emotional support was provided, and psychiatric consults were placed for both residents. The alleged perpetrator was placed on 1:1 observation. A review of Resident 1's psychiatric evaluation and consultation, conducted on June 15, 2023, revealed that after speaking to Resident 1 and the alleged perpetrator, the provider feels that the accusations of being sexually assaulted by the male resident are unfounded. The male resident has severe cognitive impairment and does not have the mental and physical capacity to complete the act he is being accused of. The facility investigation concluded that the above sexual abuse allegation was unsubstantiated. However, upon reviewing the incident report, the resident statement, dated June 2, 2023, revealed that the incident was initially reported to non-licensed Employee E4 on the morning of May 28, 2023. A review of the facility investigation, Employee E4's statement revealed that upon hearing the resident yelling in the room, the resident was checked. The resident reported being hit and choked by a male resident. Employee E4 reported that licensed nurse Employee E5 was notified of Resident 1's report of the alleged abuse. A review of the facility investigation and Employee E5's statement revealed not getting any report from Employee E4 regarding an allegation of abuse from Resident 1 on May 27, 2023, or on May 28, 2023. A review of the facility investigation, Employee E6's statement revealed witnessing Employee E4 report to Employee E5 and saying, I'm reporting this to you, I'm doing my part here, but Employee E5 did not respond when Employee E4 was talking. An interview with the Nursing Home Administrator and DON, conducted on June 27, 2023, at 1:00 p.m., confirmed that Resident 1's report of alleged sexual abuse was reported to the staff on May 28, 2023, but was not thoroughly investigated until June 2, 2023. The facility failed to ensure Resident 1's report of alleged sexual abuse was investigated timely. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies.

Mar 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**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 follow physician's orders for...

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**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 follow physician's orders for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted [DATE], with diagnoses of but not limited to urinary retention, type 2 Diabetes (condition resulting from insufficient production of insulin, causing high blood sugar), and Schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Review of physician's admission orders included an order for Humalog (fast acting insulin) 8 units subcutaneously (under the skin) three times a day related to type 2 diabetes. Review of the February 2023 Medication Administration Record revealed that the Humalog was not administered at 8:00 a.m. because the resident was hospitalized . However, review of the progress note of February 17, 2023, revealed that EMS (EmergencyMedical Services) arrived at 10:48 a.m. and left with the resident at 10:55 a.m. Interview with the Nursing Home Administrator and Director of Nursing on March 7, 2023, at 2:45 p.m. confirmed that the Humalog was not administered to Resident R1 as ordered. F684 Quality of Care Previously cited 7/15/22 28 Pa. Code 211.5(f) Clinical records Previously cited 7/15/22

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**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 the pharmacy provi...

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**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 the pharmacy provided medications timely for two of three residents reviewed (Resident R1 and R2). Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted [DATE], with diagnoses of but not limited to urinary retention, type II Diabetes (condition resulting from insufficient production of insulin, causing high blood sugar), and Schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Review of Resident R1's physician's admission orders included an order for Oxybutynin Chloride 5 mg every six hours for bladder spasms and Quetiapine Fumarate 50 milligrams (mg) two times a day for Schizophrenia Review of the February 2023 Medication Administration Record (MAR) for February 18, 2023, revealed that Oxybutynin was not administered at 6 a.m. and Quetiapine Fumarate was not administered at 8 a.m. Review of progress notes of February 18, 2023 revealed Oxybutynin med not available and Quetiapine Fumarate on order. Review of Resident R2's clinical record revealed Resident R2 was admitted [DATE], with a diagnosis of but not limited to Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Review of physician admission orders included an order for Entacapone Oral 200 mg three times a day for Parkinson's disease. Review of Resident R2's February 2023 MAR revealed the medication was not administered at 2 p.m. on February 9, 2023. Review of progress notes of February 9, 2023 revealed Entacapone on order from pharmacy. Interview with the Nursing Home Administrator and Director of Nursing on March 7, 2023, at 2:45 p.m. confirmed that the residents did not receive their medications as ordered because they were not available from the pharmacy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 7/15/22 28 Pa. Code: 211.9 (a)(1) Pharmacy services.

Nov 2022 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of clinical records, it was determined the facility failed to provide education to residents and/or their repr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of clinical records, it was determined the facility failed to provide education to residents and/or their representatives regarding the COVID-19 vaccination for three of three residents reviewed (Residents R1, R2 and R3). Findings include: Review of Resident R1's clinical progress notes revealed Resident R1 was admitted to the facility on [DATE] and was diagnosed with COVID. Review of Resident R1's clinical record revealed Resident R1 is unvaccinated. Further review of Resident R1's clinical record failed to reveal documented evidence that Resident R1 and/or resident's representative were provided education regarding the COVID-19 vaccination. Further review of Resident R2's clinical record revealed Resident R2 was diagnosed with COVID-19 on November 7, 2022. Review of Resident R2's clinical record revealed Resident R2 is unvaccinated. Further review of Resident R2's clinical record failed to reveal documented evidence that Resident R2 and/or resident's representative were provided education regarding the COVID-19 vaccination. Review of Resident R3's clinical record revealed Resident R3 was diagnosed with COVID-19 on November 7, 2022. Further review of Resident R3's clinical record revealed Resident R3 is unvaccinated. Further review of Resident R3's clinical record failed to reveal documented evidence that Resident R3 and/or resident's representative were provided education regarding the COVID-19 vaccination. Interview with the Nursing Home Administrator and the Director of Nursing on November 8, 2022 at 2:00 p.m. confirmed that Resident R1, Resident R2 and Resident R3 were not provided education regarding the COVID-19 vaccination. 28 Pa Code 201.14(a) Responsiblity of Licensee 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.12(c) Nursing Services

LANCASTER NURSING AND REHABILITATION CENTER

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LANCASTER NURSING AND REHABILITATION CENTER

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