Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to adequately monitor and assess weight loss for one of three sampled residents at risk for weight loss. (Resident 5) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, last reviewed January 18, 2024, revealed that any weight change of five pounds (lbs.) or more from the last weight assessment would be retaken for confirmation. If the weight was verified, nursing staff would notify the dietitian. The dietitian or Certified Dietary Manager would review the individual weight records and make recommendations as appropriate. Clinical record review revealed that Resident 5 had diagnoses that included osteoporosis and dementia. Review of the care plan revealed that the resident had a history of weight loss. On March 1, 2024, the resident weighed 127 lbs. On April 5, 2024, the resident weighed 117 lbs. The resident was reweighed on April 7, 2024, and weighed 120 lbs., which verified a weight loss of 7 lbs., (5.5 percent). There was a lack of evidence to support that staff notified the dietitian, or that the dietitian assessed the weight loss or resident's nutritional status until April 30, 2024, during a regularly scheduled quarterly assessment. In an interview on December 5, 2024, the Administrator confirmed that there was no evidence that the dietitian was notified of the verified weight loss and that the dietitian should have assessed the resident prior to April 30, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 had diagnoses that included congestive heart failure, diabetes mellitus, dementia, and peripheral vascular disease. On November 20, 2023, the physician ordered that staff administer a medication (Lasix) if the resident gained more than three pounds in one day to treat the resident's swelling in her legs. Review of Resident 10's weights revealed that on December 7, 2023, Resident 10 weighed 134 pounds (lbs). On December 8, 2023, the resident weighed 145 lbs, indicating a nine pound weight gain. On December 15, 2023, the physician ordered for staff to weigh the resident three times a week and administer Lasix if the resident gained more than three pounds when weighed on Monday, Wednesday, or Friday. On December 25, 2023, the resident weighed 140 lbs and on December 27, 2023, she weighed 145 lbs, indicating a five pound weight gain. A review of the December 2023, Medication Administration Record revealed that there was no evidence that staff administer the Lasix as ordered on December 8, 2023, or December 27, 2023. In an interview on January 5, 2024, at 10:15 a.m., the Director of Nursing confirmed that Resident 10 did not receive the Lasix as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen during a tour on January 3, 2024, at 10:00 a.m. revealed an opened container of thickener that was not labeled or dated, an opened bag of spaghetti that was undated, and a grilled cheese sandwich on the bottom shelf in the dry storage area. There was trash and food debris on the floor in the freezer. In an interview on January 3, 2024, at 10:20 a.m., Employee 1 confirmed that the opened items should have been dated and that the grilled cheese sandwich should have been discarded. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that proper catheter care was provided for one of two sampled residents who used an indwelling urinary catheter (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine). (Resident 8) Findings include: Clinical record review revealed that Resident 8 had a physician's order dated January 7, 2023, for the use of an indwelling catheter for the diagnosis of urinary retention. Observations on January 19, 2023, from 12:15 p.m. through 1:33 p.m., revealed the resident was seated in a wheelchair with the Foley bag and tubing directly on the floor. In addition, Resident 8's care plan directed that staff place the catheter bag in a privacy bag. There was no privacy bag in use during the observation. During an interview on January 20, 2023, at 12:50 p.m., the Director of Nursing confirmed that the bag and tubing should not have been in contact with the floor and that a privacy bag was to be used. 28 Pa. Code 211.12(d)(1)(5) Nursing services.