Based on a review of clinical records, facility policies, professional guidelines, staff interviews, and wound care documentation, it was determined that the facility failed to implement appropriate interventions consistent with professional standards of practice to prevent the development of a pressure injury for one resident (Resident 47) out of 25 residents reviewed.Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of facility policy titled Pressure Injury Prevention and Management, last reviewed by the facility on February 18, 2025, revealed the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. A review of Resident 47's clinical record revealed admission to the facility on July 31, 2025, as a transfer resident from a sister facility that was closing, with diagnosis which included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients), cerebral infarction (stroke), osteoporosis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), and kyphosis of the thoracic spine (excessive forward curvature of the upper back, causing a hunchback appearance). The resident's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2025, documented severe cognitive impairment, total dependence on staff for activities of daily living (ADLs), bed mobility, and transfers, and identified the resident as at high risk for pressure injury development. The initial plan of care dated August 1, 2025, identified skin integrity risks due to ecchymotic (bruising) areas and fragile skin. Interventions included the use of an alternating air mattress (mattress with air chambers that inflate and deflate to reduce pressure), incontinence care, pressure redistribution gel cushions when out of bed, weekly skin evaluations during bathing, and Braden Scale risk assessments (a tool used to measure pressure ulcer risk). The goal was to maintain intact skin.On August 13, 2025, after a pressure injury developed on the mid-back, the plan of care was revised to include wound cleansing with Vashe solution (a wound cleanser), application of Santyl ointment (a topical agent to remove dead tissue), calcium alginate dressings (a gel-forming dressing derived from seaweed), covered with foam dressing, changed daily or as needed use of an EHOB cushion (a specialized pressure relief cushion) on the Broda chair (a specialty wheelchair with positioning supports), repositioning side to side in bed, limiting time out of bed to meals only, and use of a P500 pressure redistribution mattress. The resident's care goal remained unchanged.A Braden Scale for Predicting Pressure Sore Risk form on admission dated July 31, 2025, identified Resident 47 as high risk for pressure injury development. A review of physician orders transferred from the previous facility of July 31, 2025, included an order dated May 30, 2025, to cleanse the thoracic spine area with soap and water and apply bordered foam dressing every three days and as needed, ensuring dressing placement every shift and replacement if soiled. Additional transferred orders specified out-of-bed use with a pressure redistribution wedge cushion to the Broda chair (specialty chair) and gel cushion to the back of the Broda chair, with repositioning every 1-2 hours while seated out of bed. However, the facility's admission physician orders dated July 31, 2025, failed to include these wound care orders, representing a transcription error. A review of an admission facility skin assessment titled Skin Observation Tool on admission dated July 31, 2025, documented a reddened area on the upper-mid thoracic vertebrae. Cavilon (barrier cream to prevent skin breakdown) and foam dressing were applied to the mid-back for prevention. There was no physician order documented for these treatments. A review of a facility skin assessment titled Skin Observation Tool on admission dated August 6, 2025, documented persistent redness to the same area without documented treatment orders.A review of a facility skin assessment titled Skin Observation Tool on admission dated August 13, 2025, documented an unstageable pressure injury (pressure injury where the full depth of tissue damage is obscured by slough, layer of dead, yellow or gray tissue that separates from the underlying healthy skin, or eschar, thick, dry crust of dead tissue that forms over a wound, making it impossible to determine the underlying stage) on the mid-back measuring 2.5 cm x 2.0 cm x 0.2 cm. No treatment was noted in the record. A review of an outside wound consultant's report dated August 13, 2025, revealed a mid-back unstageable wound measuring 2.5 cm x 2.0 cm x 0.3 cm, 90% slough and 10% pink on the edges with moderate serosanguinous drainage (fluid discharged from wound, characterized by a mix of serum and blood). Recommendations included cleanse with Vashe, pat dry, apply Santyl to the wound bed then apply calcium alginate plain then cover with silicone foam. Change daily and as needed for soilage or lifting, P500 low air loss mattress, EHOB cushion under the Broda chair back cushion, turn and reposition every 2 hours to offload the wound using wedges away from the back area. Limiting out-of-bed for meals only and Nutritional supplementation with Magic Cup, ProSource, and Mighty Shakes.A review of a statement provided by Employee 1 (Registered Nurse) dated August 14, 2025, (no time indicated) stated that Employee 1 took care of Resident 47 on August 5 and 6, 2025. Employee 1 did not see any treatment ordered for the resident's mid-upper back. A review of a statement provided by Employee 2 (Registered Nurse) dated August 13, 2025, (no time indicated) stated that Employee 2 was notified of any dressings or wounds on the resident's back until August 13, 2025. A review of a statement provided by Employee 3 (Registered Nurse) dated August 19, 2025, (no time indicated) stated the resident typically sleeps at night and is changed and repositioned during the shift. Employee 3 denied having any knowledge of a pressure area to her mid-back. A review of a statement provided by Employee 4 (nurse aide) dated August 13, 2025, (no time indicated) stated Employee 4 observed drainage seeping from the dressing on the resident's back during morning care.A review of a statement provided by Employee 5 (nurse aide) dated August 13, 2025, (no time indicated) reported during transfer to the shower sling, drainage was noticed under a patch and wound care was promptly notified. Staff interviews revealed gaps in communication and treatment initiation. Two registered nurses reported no knowledge of wound treatment orders before August 13, 2025. A nurse aide reported observing drainage on August 13, 2025, while transferring the resident, prompting wound care notification the same day. During an interview with the Director of Nursing (DON) on August 21, 2025, at 12:00 PM, the DON acknowledged a transcription error occurred during admission, resulting in failure to transcribe and implement the physician's wound care orders from the transferring facility. The DON was unable to provide documented evidence that nursing staff notified the physician or initiated a preventive treatment plan after identifying the reddened area on the resident's thoracic spine on admission to the facility on July 31, 2025. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, observations, and staff interview, it was determined the facility failed to follow physician orders for oxygen therapy for one out of 15 residents sampled (Resident 2).Findings include: A review of the facility's policy titled Oxygen Administration, last reviewed on February 18, 2025, indicated that oxygen is to be administered in accordance with professional standards of practice, the comprehensive person-centered care plans, and resident goals and preferences. The policy further states that oxygen must be administered per a physician's order. Review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include respiratory failure (not enough oxygen passes from the lungs to the blood, making it difficult to breath), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). A physician's order dated March 14, 2025, directed continuous oxygen therapy via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at three (3) liters per minute. Review of Resident 2's care plan initiated on March 15, 2025, identified altered respiratory status/difficulty breathing due to acute or chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and hypercapnia (carbon dioxide retention). Interventions included oxygen therapy at 3 liters per minute via nasal cannula, consistent with the physician's order. However, observation conducted on August 19, 2025, at 11:30 AM revealed that Resident 2 was seated in a wheelchair with supplemental oxygen delivered via nasal cannula from an oxygen tank (oxygen cylinders which contain oxygen under pressure) with the flow rate set at 2 liters per minute. Additional observations on August 20, 2025, at 10:00 AM and 1:10 PM again showed the resident receiving oxygen at 2 liters per minute, despite the physician order specifying 3 liters per minute. During an interview conducted on August 20, 2025, at 1:10 PM, the Director of Nursing confirmed that Resident 2 had a current physician order for continuous oxygen at 3 liters per minute and acknowledged that the resident was receiving only 2 liters per minute at the time of observation.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident Care Policies.

Based on review of clinical records, select facility policy and controlled drug records, and staff interview, it was determined the facility failed to implement procedures to promote accurate accounting and administration of controlled medications for one out of 15 residents sampled (Resident 47). Finding include: Review of the facility policy titled Controlled Substance Administration & Accountability last reviewed by the facility on February 18, 2025, indicated that the facility is to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances (medications with the potential for abuse or harm). The policy states the facility shall implement safeguards to prevent loss, diversion, or accidental exposure to controlled substances. Per facility policy, all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. The policy further specifies that the dosage recorded on the usage form must match the dosage documented in the Medication Administration Record (MAR), Controlled Drug Record, or other facility-specified form, which must be retained in the resident's medical record. A review of Resident 47's clinical record revealed admission to the facility on July 31, 2025, with diagnosis which included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), osteoporosis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down), and cerebral infarction (stroke). A physician order dated July 31, 2025, indicated that Resident 47 was to receive Level 4 Comfort Care, defined as the provision of comfort measures only for residents with terminal medical conditions who decline or are not candidates for aggressive therapy. The order also advised consideration of a hospice referral and to allow natural death. Further review of physician orders revealed an order dated July 31, 2025, for Morphine Sulfate Solution 20 mg/mL (an opioid pain medication used to treat moderate to severe pain. Morphine Sulfate is a Schedule II controlled substance, classified as having a high potential for abuse), with instructions to administer 0.25 mL by mouth every two hours as needed for pain. A review of the controlled substance record for Resident 47's Morphine Sulfate Solution 20 mL showed that nursing staff documented signed-out doses of the medication on the following dates and times:August 15, 2025, at 5:00 AMAugust 15, 2025, at 9:30 AMAugust 17, 2025, at 2:40 PM However, a review of Resident 47's Medication Administration Record (MAR) revealed there was no documentation indicating that the medication was administered to the resident on these dates and times. This discrepancy between the controlled substance record and the MAR constitutes a failure to ensure accurate documentation of medication administration and to reconcile narcotic records, as required under the facility's policy. During an interview on August 21, 2025, at 10:50 AM, the Director of Nursing confirmed the discrepancies in the accounting and administration of opioid pain medication for Resident 47.28 Pa Code 211.5 (f)(xi) Medical records28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services28 Pa Code 211.9(a)(1)(k) Pharmacy services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 12 residents reviewed (Resident 25) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated August 30, 2024, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 9 indicating moderate cognitive impairment. A review of the resident's comprehensive care plan, reviewed during the survey ending November 7, 2024, revealed that a discharge plan was developed upon admission February 22, 2024 with no revisions noted, indicating the residents desire to be discharged to the community. A review of the clinical record revealed a social service progress note dated August 30, 2024, indicating the resident was a long term placement in the facility. There were no further notes or revisions to Resident 25's care plan to reflect this change in his discharge planning. During an interview with the Director of Nursing on November 6, 2024, at 12:00 PM confirmed there was no documented evidence that an individualized discharge care plan to reflect discharge planning for Resident 25 was developed and updated to reflect Resident 25's goal to return to the community. 28 Pa. Code 201.29 (a) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, observations, staff, and resident interviews, it was determined the facility failed to ensure that residents receive care consistent with professional standards of practice to prevent pressure sore development for one of 13 residents sampled (Resident 28). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. A clinical record review revealed Resident 28 was admitted to the facility on [DATE], with diagnoses that include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). He was admitted to the facility with necrotic diabetic ulcers and multiple pressure injuries, including a Stage IV sacrum injury (a severe wound that involves full-thickness tissue loss and exposure of underlying bone, muscle, tendon, ligament, or cartilage). A wound observation tool dated April 13, 2023, revealed Resident 28's stage IV sacrum pressure injury healed. The tool indicated the special equipment and prevention measures in place included a P 500 bed mattress (a therapy bed surface instrument designed to help prevent and treat shear, friction, and pressure injuries through microclimate adjustments, repositioning, and automatic weight redistribution). On October 12, 2023, a physician issued an order for Resident 28 to utilize a P-500 mattress for wound care, which was subsequently discontinued on February 9, 2024. A care plan revealed Resident 28 has a history and problem with diabetic ulcer areas related to immobility and history of poor intake and a stage IV sacral area that resolved on April 13, 2023. The goal indicated is for Resident 28 to have intact skin free of redness, blisters, or discoloration through the next review date. Interventions included a flat sheet applied to the resident's P-500 mattress as ordered, initiated on October 14, 2023, and discontinued on February 9, 2024. An alternating air mattress for pressure reduction was implemented for Resident 28 on February 8, 2024. Other interventions in place to help Resident 28's skin remain intact included turning and repositioning the resident every two hours, cleansing his buttocks and sacrum with soap and water, patting dry, and applying border foam. A clinical record review of tasks and interventions from February 8, 2024, through February 24, 2024, revealed the tasks and interventions were documented as completed. A Braden Scale for Predicting Pressure Sore Risk dated February 10, 2024, revealed Resident 28 is at risk for developing pressure injuries. A wound observation tool dated February 24, 2024, revealed Resident 28 developed a new open pressure injury on his sacrum measuring 4.0 cm x 2.5 cm x 0.5 cm with macerated(skin that looks light wrinkly and wet can be a result of contact with moisture) edges. A wound care note dated February 29, 2024, indicated Resident 28 has a Stage IV pressure injury to his sacrum measuring 3.2 cm x 3.2 cm x 1.0 cm with undermining 9-12 cm of 1.0 cm (when the wound's edges erode, creating a pocket beneath the skin). The wound had moderate tan drainage, macerated and thick edges, and a 100% granular wound bed. The note also indicated recommendations for Resident 28 to utilize a P-500 low-air-loss mattress. A review of Resident 28's physician's order revealed the P 500 low air loss mattress was initiated on February 24, 2024, following Resident 28 developing a stage IV pressure injury to his sacrum. A wound observation tool dated November 7, 2024, revealed Resident 28's Stage IV sacral wound measured 2.5 cm x 1.5 cm x 0.7 cm with undermining of 0.7 cm with rolled macerated edges and a wound bed of 50% fibrotic tissue and 50% granular tissue. During an interview on November 7, 2024, at 9:30 AM, Resident 28 declined to allow surveyors to observe his wound. During an interview on November 7, 2024, at 10:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure residents do not develop pressure injuries unless clinically unavoidable. The NHA confirmed the facility discontinued the use of the P-500 low-loss air mattress on February 9, 2024, which contributed to the development of Resident 28's Stage IV sacrum pressure injury on February 24, 2024. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, information submitted by the facility, select facility reports, and resident and staff interview it was determined the facility failed to implement effective safety measures to prevent a fall for one out of the 13 sampled residents (Resident 9). Findings include: A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a condition that occurs when the heart can't pump enough blood to the body) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 17, 2024, revealed that Resident 9 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A facility investigation report dated April 22, 2024, revealed Resident 9 fell from a transport van while out of the facility for an appointment. The report indicated that while the transport van was parked outside the facility, Employee 1, Vehicle Operator, pushed the resident out of the vehicle without realizing the lift chair was on the ground, resulting in the resident falling out of the vehicle to the ground. Review of the resident's clinical record revealed a progress note dated April 22, 2024, at 2:53 PM, indicated Resident 9 had an incident at the hospital entrance upon returning from a podiatry appointment. She was sent directly to the emergency department for assessment. The physician and resident representatives were notified. A progress note dated April 22, 2024, at 7:45 PM, indicated Resident 9 returned from the emergency department in stable condition. She is alert and oriented; neurological checks and assessments have been completed. The note indicated Resident 9 is in her room and denying discomfort. A progress note dated April 23, 2024, at 1:17 AM indicated neurological checks were completed for Resident 9 with no deficits noted. She is alert, oriented, and able to make needs known. Resident 9 reports mild generalized aches. She is able to move in bed without difficulty. No bruising or swelling to the head. A new bruise was noted on her left upper buttock measuring 1.0 cm x 1.0 cm and her left lateral thigh that measures 0.7 cm x 0.7 cm. A practitioner progress note dated April 24, 2024, at 10:21 PM indicated Resident 9 fell from the wheelchair van and suffered some bruising. No fractures were noted, and she denies any significant pain at this point. A progress note dated April 26, 2024, at 10:44 AM revealed Resident 9 received a psychiatric evaluation following her fall with a head strike. The note indicated Resident 9 was screened and evaluated and determined as not exhibiting any symptoms of depression, anxiety, mania, or paranoia. A physician's order for Acetaminophen Oral Tablet 325 mg with instruction to give three tablets by mouth every eight hours as needed for mild pain initiated on April 13, 2024. A review of Resident 9 Medication Administration Record dated April 2024, revealed she received Acetaminophen Oral Capsule on the following dates: April 22, 2024, at 9:41 PM for a pain level 4 out of 10 April 23, 2024, at 5:37 AM for a pain level 3 out of 10 April 23, 2024, at 9:14 PM for a pain level 5 out of 10 April 24, 2024, at 9:19 PM for a pain level 4 out of 10 April 25, 2024, at 9:01 PM for a pain level 4 out of 10 April 26, 2024, at 11:47 PM for a pain level 3 out of 10 April 28, 2024, at 2:00 AM for a pain level 3 out of 10 April 30, 2024, at 12:20 AM for a pain level 3 out of 10 April 30, 2024, at 10:16 AM for a pain level 2 out of 10 During an interview on November 5, 2024, at 11:15 AM, Resident 9 indicated that she fell a few months ago (approx 6 months) from a transport vehicle when a lift operator failed to secure the lift locking mechanism. She explained that she rolled back and fell out of the vehicle and hit her head. Resident 9 indicated the experience was very unpleasant and frightening. During an interview on November 7, 2024, at 10:30 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure effective safety measures are implemented to prevent residents from falling. The NHA confirmed that Employee 1, Vehicle Operator from contracted transportation company, failed to follow the appropriate safety measures (i.e. securing the lock and lift positioning), resulting in Resident 9 falling out of the vehicle, striking her head, and sustaining pain and bruising with no major injury. The vehicle operator resigned from the transportation company. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for two out of 13 residents reviewed (Resident 12 and 25). Findings include: A review of Resident 12's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life). A review of a behavior note dated August 23, 2024, at 8:00 PM revealed the resident was verbally aggressive and argumentative with staff. The resident was noted to be yelling, cursing, slamming items on the bedside table, and throwing things on the floor. Further it was documented the resident would become more agitated when staff tried to talk to her. The resident's current care plan for impaired cognitive function related to dementia, did not identify the resident's specific behaviors the resident exhibits and specific person centered interventions to address each of these behaviors. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms. A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of a behavior notes between August 12, 2024, and end of survey November 7, 2024 revealed the resident was having increasing behaviors. The resident was noted to be yelling, crying, agitation, accusatory to staff, refusing care and hitting out at staff. Further it was documented the resident was often difficult to redirect The resident's current care plan for impaired cognitive function related to dementia, did not identify the resident's specific behaviors the resident exhibits and specific person centered interventions to address each of these behaviors. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms. An interview with Nursing Home Administrator on November 7, 2024, at approximately 1:00 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical records and staff interviews, it was determined the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed psychotropic medication for one of 13 residents reviewed (Resident 12). Findings include: A review of Resident 12's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life). A review of Resident 12's clinical record revealed a physician's order dated June 29, 2024, for Lorazepam (antianxiety medication) tablet 0.5 MG, give 0.5 MG by mouth every 8 hours as needed for Anxiety or shortness of breath for 60 days. A review of the resident's June 2024 Medication Administration Records (MAR commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional. The MAR is a part of a resident's permanent record on their medical chart. The health care professional signs off on the record at the time that the drug or device is administered) revealed the as needed Lorazepam was administered on June 29, 2024. A review of the resident's July 2024 MAR revealed the as needed Lorazepam was administered just once on July 9, 2024. A review of the resident's August 2024 MAR revealed the as needed Lorazepam was administered just once on August 30, 2024. A review of the resident's clinical record revealed the physician failed to document the clinical rationale for the extended use of an as needed antianxiety medication at the time it was ordered. An interview was conducted with the Director of Nursing on November 7, 2024, at approximately 1:00 PM confirmed there was no physician documentation of the clinical rationale for the as needed medication to be used more than 14 days. 28 Pa. Code 211.2(d)(3) Medical Director

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview it was determined that the facility failed to develop an individualized comprehensive care plan to address a resident's (Resident 27) refusal of care and services to promote the resident's mental, medical, nursing, and psychosocial needs to the extent possible for one out 12 sampled residents. Findings include: Clinical record review revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses which included diabetes and depression. Review of a Neuropsychology Consult dated February 12, 2022, to assess the resident's cognitive functioning and comment on capacity to make informed medical decisions revealed that the resident had unacceptable home conditions prior to admission to the facility. The results of a Neuropsychological exam revealed that the resident had diffuse cognitive dysfunction and on a measure assessing awareness of personal health status and ability to evaluate health problems, handle medical emergencies, and take safety precautions, the resident performed in the impaired range of functioning. At the time of the consult, the resident did not appear to have capacity to make fully informed medical decisions. The impression of the consult noted a diagnosis of an unspecified neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (the Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and physical behaviors occurred one to three days. A social service noted dated September 27, 2023, indicated that the resident displayed behaviors one to three days a week. The entry indicated that the resident got real upset when his guardian (court appointed) told him his house was sold. Review of a nurses note dated October 9, 2023, indicated that the resident's gastroccult test (detects gastric blood) returned positive and the results were reviewed by the physician with a new order for the resident to go to the emergency department for evaluation. Nursing noted that the resident was refusing to go to the ER. Risks versus benefits were discussed with resident but the resident continued to refuse transfer and the physician was notified. A nurses note dated October 9, 2023, indicated that the resident's guardian was contacted and made aware of resident's current medical condition. Review of a Rehabilitation Screen dated October 12, 2023, indicated that the resident was dependent for transfers with a Hoyer lift and refuses out of bed positioning. The resident was not appropriate for physical therapy due to poor motivation and refusals to transfer out of bed. A review of the resident's care plan in effect at the time of the survey ending December 1, 2023, revealed no documented evidence that Resident 27's neurocognitive disorder, his limited ability to make informed medical and financial decisions, refusal of medical care, refusals to get out of bed, and behaviors related to having a guardian and the need for his home to be sold were addressed on the plan of care with corresponding interventions to promote the resident's physican and mental health and psychosocial well-being . An interview with the director of social services on November 30, 2023, at approximately 1:00 PM failed to provide documented evidence the facility developed an individualized person-centered care plan to promote the resident's mental, medical, nursing, and psychosocial needs to the extent possible. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a prescribed bowel protocol for one resident out of 12 sampled (Resident 21) to promote normal bowel activity to the extent practicable. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). Clinical record revealed that Resident 21 was readmitted to the facility on [DATE] with diagnosis to include dementia. A significant change Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 4, 2023 revealed that Resident 21 was severely, cognitively impaired, required staff assistance for activities of daily living and was frequently incontinent of bowel. Physicians orders dated October 13, 2022, were noted to give 8 oz of prune juice on day 2 with no bowel movement (BM); an order dated July 11, 2023, to give 30 ccs of Milk of Magnesia (MOM) on day 3 with no BM and an order dated July 11, 2023, to insert Biscolox suppository, 10 mg rectally on day 4 with no BM. A review of bowel records revealed that Resident 21 did not have a bowel movement on: -November 5, 2023- day one without a bowel movement -November 6, 2023- day two without bowel movement, Prune juice, 8 oz was ordered but no evidence that it was given to the resident. -November 7, 2023- day three, Prune juice, 8 oz was administered to the resident, 30 ccs of MOM was ordered, but no documented that it was administered to the resident -November 8, 2023- day four, there was no documented evidence of intervention to promote a BM; Biscolox suppository was ordered but there was no evidence that it was administered. -November 9, 2023- day five - no bowel movement or intervention to promote a bowel movement -November 10, 2023- day six, a biscolox suppository was administered and the resident had a bowel movement. November 11, 2023 - day one without a bowel movement -November 12, 2023 - day two, no BM, no intervention; prune juice was ordered but no evidence that it was administered -November 13, 2023 -day three without a bowel movement; 30 ccs MOM was administered as ordered; however, the resident spit out the medication -November 14, 2023 - on day 4 without a bowel movement - 30 ccs of MOM was administered and not the Biscolox suppository as ordered. During an interview December 1, 2023 at 1 PM, the Director of nursing confirmed that staff failed to consistently carry out physician orders for the bowel regimen prescribed for Resident 21 to prevent constipation and promote normal bowel activity. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records

**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 pharmacist identified irregularities in the drug regimen prescribed for one of 12 residents sampled (Resident 4). Findings include: Clinical record revealed that Resident 4 was readmitted to the facility on [DATE] with diagnosis to include rheumatoid arthritis, chronic pain and was opioid dependent. An annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that Resident 4 was cognitively intact, required staff assistance for activities of daily living and had occasional pain relieved by medication. The resident had physician orders dated June 5, 2023, oxycodone HCL Oral Tablet 5 MG ( a narcotic, opiod pain medication) Give 1 tablet by mouth every 4 hours as needed for severe pain (rated from 7-9). A review of medication administration records (MAR) revealed that Resident 4 received the prn Oxycodone 5 mg narcotic pain medication as follows: August 2023 - 24 doses September 2023 - 21 doses October 2023 - 0 doses November 2023 - 17 doses Facility documentation revealed that the contracted Pharmacist completed a monthly medication/pharmacy review for Resident 4 during each of the preceeding 12 months. There was no evidence at the time of the survey ending December 1, 2023, that the pharmacist identified any irregularities regarding the resident's use of oxycodone during those months. The pharmacist did not identify the opioid dependent resident's use of multiple doses of Oxycodone during August 2023 and September 2023, and zero usage in October 2023, and the multiple doses again November 2023. There was no documented evidence that the pharmacist had recommended that the physician evaluate the continued necessity of the opioid medication when the resident received no doses of the prn medication during the month of October 2023. During an interview December 1, 2023 at 1 P.M., the Director of Nursing confirmed that the pharmacist did not identify any irregularities related to Resident 4's prn Oxycodone 5 mg usage. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.9 (k) Pharmacy services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to document medication and treatment administration as prescribed for one of 12 sampled residents (Resident 37). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of the clinical record of Resident 37 revealed that the resident was cognitively intact and admitted to the facility on [DATE], with diagnoses to include infection and inflammation reaction due to internal left prosthesis (infection of the left hip replacement) and pyogenic arthritis (an infection in the joint fluid and joint tissues). Further review of the clinical record revealed that Resident 37 had physician's orders dated November 8, 2023, for Vancomycin HCL Intravenous Solution (IV antibiotic used for treatment of potentially life-threatening infections) 1000 mg intravenously every 12 hours for 200 ml/hr over 60 minutes, and PICC line catheter (a long, thin tube that is inserted through a vein in the arm and passed through to a larger vein near the heart) flush with 10 cc NSS (normal saline solution) before and after medications. A review of the November 2023 medication administration record (MAR) for Resident 37 revealed that there was no documented evidence that the medication Vancomycin was administered to the resident as ordered on November 14, 2023, at 10:00 PM. Further review of the November 2023 MAR revealed no documented evidence that the PICC line catheter flush was performed as ordered on November 14, 2023, at 10:00 PM. Interview with the Director of Nursing on December 1, 2023, at 8:35 AM confirmed that the facility's nursing staff failed to consistently and accurately document the administration of prescribed medications, treatments and services to Resident 37 and as a result, the resident's clinical record was inaccurate and incomplete. 28 Pa. Code 211.5 (f) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) care and services consistent with professional standards of practice for one of one resident reviewed with a colostomy (Resident 27). Findings include: Review of the facility Ostomy Care Policy last reviewed February 21, 2023, indicated that it is the policy of the facility to ensure that residents who require colostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Colostomy care will be provided by licensed nurses under the orders of the attending physician. The frequency of pouch changes and the products required will be noted on the resident's person-centered care plan. The surrounding skin of the colostomy will be monitored for excoriation, abrasion, and breakdown. Changes in the pouching system or frequency of pouch changes will be made, as appropriate. The comprehensive care plan will reflect any special products or pouching techniques needed to prevent or manage any skin breakdown surrounding the colostomy. Clinical record review revealed that Resident 27 was admitted to the facility on [DATE] with diagnoses, which included diabetes and depression. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (the Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and a colostomy was present. Interview with Resident 27 on November 29, 2023, at approximately 10:00 AM confirmed that he had a colostomy. Resident 27 stated that on occasion the colostomy bag leaks and that the bag does not always seem to seal properly. Review of current physician orders revealed a current order for colostomy care every shift and as needed. Change appliance as needed. Review of Resident 27's care plan initially dated January 12, 2022, revealed that the resident had a colostomy. The care plan failed to include the type of appliance, size of the appliance or wafer, type of collection bag required for colostomy maintenance. The care plan indicated that the nurse aide would provide colostomy care every shift and change the appliance as needed. Licensed nursing staff will notify the physician if the colostomy is not functioning properly. Interview with employee 1 (nurse aide) on December 1, 2023, at 8:50 AM confirmed that she provides care to Resident 27's colostomy, which includes changing the wafer and the colostomy bag. Employee 1 (nurse aide) confirmed that at times the colostomy bag does leak. Interview with the director of nursing on December 1, 2023, at approximately 9:30 AM confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice and facility policy for Resident 27. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code:211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview it was determined that the facility failed to consistently monitor a resident's fluid intake for maintenance of the physician prescribed fluid restriction and to ensure adequate hydration for one resident out of 12 sampled (Resident 4). Findings included: A review of the clinical record revealed that Resident 4 had diagnoses, which included acute and chronic respiratory failure and congestive heart failure. A physician order dated September 6, 2023, was noted for a Fluid Restriction 1800 ml per day distributed per shift: day - 360 cc, evening-360 cc, night-180 cc to equal 900 ccs. The order did not delineate the remaining distribution of 900 ccs of free fluid for this resident to include the amount allotted for medication administration, activites, and hydration at the bedside or as desired by the resident. The resident's care plan, dated March 31, 2023 and revised on September 6, 2023, revealed that the resident had the potential for nutritional problems and included an intervention of 1800 fluid restriction in 24 hours. The breakdown of distribution of the allotted fluids per shift and free fluids with medications and hydration throughout the day was not included on the resident's care plan. A review of a readmission nutrition assessment dated [DATE] revealed Resident 4's estimated 24 hour fluid intake ranged from 1610 ccs to 2013 ccs. A review of the resident's 24 hour fluid intakes dated November 1, 2023 through November 30, 2023 revealed the following noted intakes: November 1, 2023--1530 mls November 2, 2023--1230 mls November 3, 2023--1320 mls November 4, 2023--900 mls November 5, 2023--730 mls November 6, 2023--900 mls November 7, 2023--1200 mls November 8, 2023--2340 mls November 9, 2023--900 mls November 10, 2023--1340 mls November 11, 2023--1000 mls November 12, 2023--1020 mls November 13, 2023--1080 mls November 14, 2023--1520 mls November 15, 2023--1160 mls November 16, 2023--1020 mls November 17, 2023--984 mls November 18, 2023--1240 mls November 19, 2023--1470 mls November 20, 2023--860 mls November 21, 2023--960 mls November 22, 2023--900 mls November 23, 2023--1160 mls November 24, 2023--1000 mls November 25, 2023--1140 mls November 26, 2023--1320 mls November 27, 2023--840 mls November 28, 2023--1220 mls November 29, 2023--1290 mls November 30, 2023--1230 mls Review of Resident 4's November 2023 Medication Administration Records, reflecting the amount of fluid consumed by resident with medications, and Task Documentation Reports, noting the fluid consumed by resident with meals, revealed was no documented evidence that staff were consistently monitoring and calculating the resident's daily fluid with medications and meals, to ensure adherence to the physician ordered fluid restriction and also to assess if the resident was consuming sufficient fluid to maintain adequate hydration. Interview with the director of nursing on December 1, 2023 at 1 P.M., confirmed the lack of documented evidence that the facility had consistently monitored and calculated daily total fluid intake to evaluate adherence to the fluid restriction and evaluating the resident's hydration status while fluids are restricted. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12 (d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one resident out of 12 sampled (Resident 4). The findings include: A review of the facility's current Pain Management policy, last reviewed by the facility on October, 2023, revealed that the facility must ensure that pain management is provided to residents who require such services, consistanet with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Clinical record revealed that Resident 4 was readmitted to the facility on [DATE], with diagnoses to include rheumatoid arthritis, chronic pain and opioid dependence. An annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that Resident 4 was cognitively intact, required staff assistance for activities of daily living and occasional pain relieved by medication. The resident had physician orders dated September 15, 2023, for Acetaminophen Tablet 325 mg 2 tablets by mouth every 6 hours as needed for mild pain (pain scale 1-3, on a 1, least pain to 10, most pain scale) and June 5, 2023, oxycodone HCL Oral Tablet 5 MG ( a narcotic, opiod pain medication) Give 1 tablet by mouth every 4 hours as needed for severe pain (7-9) and Gabapentin (an antiseizure medication sometimes used for chronic pain) Oral Capsule 300 MG, Give 1 capsule by mouth four times a day related to CHRONIC PAIN SYNDROME dated September 11, 2023. A review of medication administration records (MAR) revealed that Resident 4 received the Oxycodone 5 mg narcotic opioid pain medication as follows: August 2023 - 24 doses September 2023 - 21 doses October 2023 - 0 doses November 2023 - 17 doses A review of medication administration records (MAR) revealed that Resident 4 received the non-narcotic pain medication, Acetaminophen 325 mg, 2 tablets as follows: August 2023 - 2 doses September 2023 - 19 doses October 2023 - 9 doses November 2023- 2 doses Further review of the resident's October 2023 medication administration record (MAR) revealed that staff administered Acetaminophen 325 mg, 2 tablets on November 26, 2023 at 9:48 A.M. for a pain rating of 5 November 27, 2023 at 9 A.M for a pain rating of 4, October 15, 2023 at 10:23 A.M. for a pain rating of 5, October 24, 2023 at 10:18 A.M for a pain rating of 4, September 5, 2023 at 8:45 A.M. for a pain rating of 5, September 7, 2023 at 12:47 P.M. for a pain rating of 5 September 7, 2023 at 5:19 P.M. a pain rating of 7 September 12, 2023 at 9:08 A.M. for a pain rating of 5, September 13, 2023 at 12:19 P.M. a pain rating of 5 September 14, 2023 at 1:22 P.M. a pain rating of 6 September 17, 2023 at 5:26 P.M. a pain rating of 4 September 19, 2023 at 10:19 A.M. for a pain rating of 4 September 27, 2023 at 12:13 P.M. a pain rating of 4 August 26, 2023 at 09:48 A.M. for a pain rating of 5 August 27, 2023 at 09:00 A.M. for a pain rating of 5 Staff administered Tylenol for pain rated outside the physician prescribed parameters of pain rated from 1-3 A review of the resident's comprehensive pain assessment dated [DATE] revealed, Resident 4 had frequent pain, rated at 8 and it was relieved by pain medication. A review of a comprehensive pain assessment dated [DATE] revealed, Resident 4, 2023 rarely had any pain and his pain rating was 0. There was no documented evidence that the facility had evaluated the resident's pain and prescribed regimen for the continued necessity of use of the opioid pain medication after no usage by the resident during 31 days in the month of October 2023, to deter potentially problematic patterns of opioid medication use. There was no documented evidence of additional pain relieving modalities developed and implemented to address Resident 4's pain and the development and attempts of non- pharmacological interventions to manage the resident's pain prior to the administration of the prn pain medications. During an interview on December 1, 2023, at approximately 12:00 p.m., the Director of Nursing (DON) was unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to administering prn pain medications or evidence of a reassessment of the resident's pain management needs. Refer F756 28 Pa. Code 211.12 (d)(3)(5) Nursing Services