**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, incident report review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 12 sampled residents. (Resident 14) Findings include: Review of the facility policy entitled, Abuse Prevention, dated June 15, 2022, revealed that procedures were in place to assure adequate review of all incidents, accidents, and suspicious bruising or injuries of unknown origin. Occurrences were reviewed for trends or patterns that might constitute abuse. An investigation was to begin immediately by interviewing the resident who was suspected of being abused and any witnesses. Clinical record review revealed that Resident 14 had diagnoses that included arthritis, dementia, anxiety, and depression. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assistance from staff for activities of daily living. On August 13, 2022, a nurse noted that staff observed an abrasion to the resident's ribs on the right side of her body, as well as petechiae (small red or purple spots caused by bleeding into the skin) to the resident's right hip. It was noted that the resident was unable to describe how this injury occurred due to her diagnosis of dementia. On August 13, 2022, the physician ordered duoderm dressing bandage to be applied to the mid-lateral right rib area for five days. Review of the incident report dated August 13, 2022, confirmed that the resident had an abrasion to the right lateral ribs and petechiae to her right hip and that the resident was unable to give a description of how the injury happened. There was no evidence that the facility conducted a thorough investigation that included interviews with all witnesses of the injury identified on August 13, 2022, to rule out abuse. In an interview on August 25, 2022, at 10:14 a.m., the Director of Nursing confirmed that there was no evidence that the facility conducted a thorough investigation of the injury of unknown origin identified on August 13, 2022. 28 Pa. Code 201.29(i) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of consultant pharmacist reports, and staff interview, it was determined that the facility failed to document the rationale for the continued use of an as needed (PRN) anti-anxiety medication for one of 12 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety. The physician ordered an anti-anxiety medication (Alprazolam) every 12 hours PRN for anxiety January 19, 2022, through June 15, 2022, and June 15, 2022, through July 19, 2022. Review of Resident 1's medication administration record revealed that staff adminstered the PRN anti-anxiety medication on April 2 and 10, May 6 and 25, and June 29, 2022. On April 14, 2022, a consultant pharmacist completed a review and requested documentation of the rationale for the continued use of the PRN anti-anxiety medication beyond 14 days and that a specific duration be documented in the physician order. On May 10, 2022, the physician signed the pharmacist's recommendation and indicated he was in agreement with the request. On May 10, 2022, the consultant pharmacist again requested justification for the continued use of the PRN anti-anxiety medication. On June 20, 2022, the physician again acknowledged the pharmacist's recommendation and indicated he was in agreement however no further action was taken. There was no evidence that the order for the PRN anti-anxiety medication was adjusted with a specific duration or that the physician provided rationale for the ongoing use of the PRN anti-anxiety medication beyond 14 days, following the pharmacist's recommendations on April 14, 2022, and May 10, 2022. In an interview on August 25, 2022, at 11:40 a.m., the Director of Nursing confirmed that the order for the PRN anti-anxiety medication was not revised and that there was no evidence that the physician provided rationale for its continued use past 14 days from the original order dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to serve and store food items in a safe and sanitary manner in the main dining room and nursing unit pantry. Findings include: During the lunch observation on August 23, 2022, at 12:01 p.m., in the main resident dining room, Resident 10 was seated at a table and the nurse aide (NA 2) was setting up her lunch. After touching multiple items, including a soda can, and not performing hand hygiene, NA 2 used her ungloved fingers to hold back ice while pouring water from a glass into another container. She then opened the can of gingerale, poured it into the glass of ice, placed a straw, and presented it to Resident 10. Resident 10 was observed drinking the beverage. Observation on August 23, 2022, at 1:11 pm., in the East corridor pantry revealed an open container of applesauce in the resident refrigerator. The date on the facility label indicated that it was opened February 20, 2022, and the manufacturer's expiration date on the container was May 28, 2022. 28 Pa. Code 211.6(c)(f) Dietary services.