Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a manner that prevented unauthorized access on one of two nursing units. (Second floor) Findings include: Review of the facility policy entitled, Storage and Expiration Dating of Medications and Biologicals, last reviewed August 1, 2024, revealed that medications and biologicals, including treatment items, were to be securely stored in a locked cabinet/cart or locked medication room that is unaccessible by residents and visitors. Observation on June 2, 2025, at 10:20 a.m., on the second floor nursing unit, revealed that the treatment cart in the hallway was unlocked and unattended and contained several tubes of medicated creams for pain, bottles of saline solution for nose and eyes, and boxes of alcohol pads that were accessible. In an interview on June 2, 2025, at 10:30 a.m., the RN Supervisor confirmed that the treatment cart should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 22 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included rheumatoid arthritis, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and had limitations on both sides of his upper extremities. The care plan identified that the resident had a self-care deficit related to muscle weakness and contractures. There was an intervention for staff to provide total assistance with eating. Observation of the lunch meal on the 2nd floor nursing unit on February 26, 2025, at 12:08 p.m., revealed Resident 39 and Resident 79 seated in their room awaiting lunch. At 12:12 p.m., Resident 39 was served and eating their meal. Resident 79 was observed without a meal and making comments, including, When do I get my food? At 12:35 p.m., Resident 79 used the call bell, State Trained Nursing Assistant (STNA) 1 entered the room, and Resident 79 stated, I didn't get my food. Resident 79 was not assisted with his lunch tray until 12:38 p.m. In an interview on February 27, 2025, the Director of Nursing stated that Residents 39 and 79 should have had their meals provided at the same time. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 22 sampled residents. (Resident 85) Findings include: Clinical record review revealed that Resident 85 had diagnoses that included congestive heart failure, pulmonary hypertension, and chronic kidney disease. A physician's order dated January 30, 2025, directed staff to weigh the resident daily. A review of the Medication Administration Record (MAR) for February 2025, revealed that there was no evidence that staff weighed Resident 85 as ordered on February 9, 11, 15, 16, and 25, 2025. In an interview on February 27, 2025, at 10:58 a.m., the Director of Nursing confirmed that there was no documented evidence that the resident was weighed as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of an incident for two of 23 sampled residents. (Residents 75, 109) Findings include: Review of the facility policy entitled, Resident Change in Condition, last reviewed March 16, 2023, revealed that the physician would be notified as soon as the nurse identified a change in condition, accident, or incident. The nurse would record the notification in the resident's health record. Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, senile degeneration of the brain, and repeated falls. Review of a nurse's noted dated November 30, 2023, revealed that Resident 75 had a fall. There was no documented evidence that the resident's physician was notified of the fall. In an interview on February 2, 2024, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified of the fall. Clinical record review revealed that Resident 109 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (weakness or paralysis after a stroke), low back pain, anxiety, and depression. Review of a nurse's noted dated January 31, 2024, revealed that Resident 109 was found in possession of unmarked pills, empty medication bottles, medication bottles containing pills, and empty medication cards. There was no documented evidence that the resident's physician was notified of the incident per facility policy. In an interview on February 2, 2024, at 9:30 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified at the time of the incident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**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 develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 23 sampled residents. (Resident 67) Findings include: Clinical record review revealed that Resident 67 was admitted to the facility on [DATE], with diagnoses that included hallucinations and dementia with mood disturbances, anxiety, and behavior disturbances. The Minimum Data Set assessment Care Area Assessment (CAA) summary dated December 30, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 67's psychotropic drug use were included in the care plan. In an interview on February 2, 2024, at 9:40 a.m., the Regional Nurse confirmed that there was no documented evidence that the identified care area (psychotropic drug use) was addressed in Resident 67's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 23 sampled residents. (Resident 3) Findings include: Review of the facility policy entitled, Pain Management, last reviewed March 16, 2023, revealed that non-pharmacological interventions would be attempted prior to the administration of an as needed pain medication. Interventions for pain would be monitored for effectiveness in the electronic medication record. Clinical record review revealed that Resident 3 had diagnoses that included rheumatoid arthritis and muscle weakness. A physician's order dated January 15, 2024, directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for pain rated at four through seven of ten. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation techniques to assist with pain control. Review of the January 2024, Medication Administration Record revealed that the resident received the as needed oxycodone 37 times without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication. In an interview on February 3, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence staff offered non-pharmacological interventions prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Use-By Guide-Quick Reference, last reviewed March 16, 2023, revealed that the use-by date marked on a container should be followed and that time/temperature control for safety directed that foods (milk and meat items) would not be held more than seven days. Review of the facility's policy entitled, Storage of Dry Food Policy, last reviewed March 16, 2023, revealed that containers holding food removed from the original packaging were to be labeled and dated. Observation during the kitchen tour on January 30, 2024, at 9:40 a.m., revealed the following: In the dessert cooler, there was a pitcher of water with lemon slices in it and six small dishes of various salad dressings that were not dated. There was a container of frosting that was dated January 18, 2024. In the cook's cooler, there was an open container of cottage cheese with a use-by date of January 12, 2024. There was a package of sliced cheese and a bag of bread with illegible dates noted. There was a container of mozzarella cheese that was dated January 3, 2024. There was a large pan of chocolate mousse that was not labeled or dated. There were three packages of angel food cake and four bags of bread slices that were not dated. In the trayline cooler #1, there was a small cup of milk that was not dated. In trayline cooler #2, there was a pitcher of honey thick milk that was dated January 19, 2024, and 14 cups of milk that were not dated. In the walk-in cooler, there were 24 cartons of chocolate milk with a use-by date of January 28, 2024. In dry storage, there were two bins of white substances that were not labeled or dated. One bin had white food debris covering the top of the lid. The dish machine required a chemical solution to sanitize the dishware and when measured, the sanitizing solution did not meet the required parts per million to sanitize dishes. In an interview on January 30, 2024, at 11:00 a.m., the Registered Dietitian confirmed that the food items should have been labelled and dated and were not, the expired items should have been removed, and that during observation the dish machine was not properly sanitizing dishes. 28 Pa. Code 201.14(a) Responsibility of licensee.