Based on facility policy review, clinical record review, observation, and staff interview it was determined that the facility failed to provide appropriate care for respiratory equipment for one of 18 sampled residents. (Resident 60) Findings include: Review of facility policy entitled, Oxygen Usage and Storage on Nursing Units, last reviewed on November 6, 2024, revealed that all respiratory therapy equipment was to be changed on a weekly basis. Clinical record review revealed that Resident 60 had diagnoses that included chronic respiratory failure with hypoxia (low oxygen level). On May 17, 2025 the physician ordered oxygen via nasal cannula at bedtime and as needed for labored breathing, dyspnea, and for comfort. On April 5, 2025, the physician ordered for staff to wipe down the concentrator, clean filters, replace humidification bottle, oxygen mask, nasal cannula, and plastic bags weekly on night shift and items should be marked with date of replacement. Observations on June 11, 2025, at 9:59 a.m. and on June 12, 2025, at 12:15 p.m., revealed that the oxygen tubing was dated May 25, 2025. In an interview on June 11, 2025, at 2:09 p.m., the Assistant Director of Nursing confirmed that the oxygen tubing should be changed weekly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide behavioral health services for one of three sampled residents with mood and behavior concerns. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included anxiety. Review of the care plan revealed the resident had a history of suicidal ideation and alterations to psychosocial well-being with behaviors and delusions. The interventions were for staff to monitor the resident for anxiety, distress, and changed mood or behavior. Staff were to notify the resident's physician, provide social services case assistance, and interventions as needed. On July 26, 2024, staff noted that the resident had refused to go to bed or allow staff to provide incontinence care and stated that she just wanted to die. There was no evidence that staff notified social services or the resident's physician of the alteration in the resident's mood. In an interview on August 1, 2024, at 9: 49 a.m., the Director of Nursing confirmed that staff were to notify social services or the physician for changes in mood and there was no evidence that the resident's care team was made aware of the alteration in mood or that interventions were implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's physician and responsible party of a change in condition/injury for one of 19 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease, chronic kidney disease, and hypertension (high blood pressure). Review of a nurse's note dated July 17, 2023, revealed that a bruise was observed on the resident's right forearm. There was no documentation to support that the resident's physician or responsible party were notified of the bruise. In an interview on July 28, 2023, at 12:54 p.m., the Director of Nursing confirmed that there was no documented evidence that the resident's physician or responsible party were notified of the change in condition/injury. 28 Pa. Code 211.12(d)(1)(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 19 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Alzheimer's disease, hypertension, and orthostatic hypotension. On November 13, 2022, a physician ordered that staff administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure of 140 mm/Hg (millimeters of mercury) or more. A review of the May, June, and July 2023, Medication Administration Records revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter one time in May, four times in June, and two times in July. In an interview on July 28, 2023, at 12:50 p.m., the Director of Nursing confirmed the documentation indicated that Resident 5 received the midodrine hydrochloride when his systolic blood pressure was above 140 mm/Hg. 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 ensure pain management was consistent with professional standards and 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 19 sampled residents. (Resident 65) Findings include: Review of the facility policy entitled, Pain Assessment and Management Policy, reviewed November 9, 2022, revealed that the interdisciplinary care plan team would ensure that pain management and interventions were in place to address pain and the use of as needed pain medications would be based upon person-centered needs. Additional documentation provided by the facility indicated that a standardized 10-point numeric pain rating scale for cognitively impaired residents (0-3 mild pain, 4-6 moderate pain, and 7-10 severe pain) was to be used to determine level of pain. Clinical record review revealed that Resident 65 had diagnoses that included dementia, rheumatoid arthritis, osteoporosis, history of left femur fracture, and presence of artificial left hip joint. There were physician's orders dated February 11, 2023, for the resident to receive the narcotic pain medication morphine sulfate every four hours as needed for pain (failed to identify pain parameters) and acetaminophen every four hours as needed for mild pain. Review of Medication Administration Records revealed that the resident received the as needed narcotic (morphine sulfate) for mild pain on two occasions in June 2023, and once in July 2023. The resident did not receive any doses of as needed acetaminophen for mild pain in June and July, 2023. In addition, Resident 65's care plan directed that probable causes of pain were to be monitored, documented, and removed/limited where possible. There was a lack of documentation to support that non-pharmacological interventions were attempted to remove/limit pain prior to the administration of as needed pain medication on eight occasions in June 2023, and 10 occasions in July 2023. During an interview on July 28, 2023, the Director of Nursing confirmed that parameters had not been ordered for the administration of the narcotic pain medication and that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for two of 19 sampled residents. (Residents 16, 73) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included anxiety and post-traumatic stress disorder. On May 12, 2023, a physician ordered that staff administer a psychoactive medication (lorazepam) every six hours as needed for anxiety. The order for the lorazepam failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on July 28, 2023, the Director of Nursing confirmed that there was no evidence the physician documented a rationale for continuing the medication beyond 14 days. Clinical record review revealed that Resident 73 had diagnoses that included Alzheimer's dementia, aphasia (communication disorder), and anxiety. On July 10, 2023, a physician ordered that staff administer a psychoactive medication (lorazepam) four times a day as needed for anxiety. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on July 28, 2023, at 10:33 a.m., the Director of Nursing confirmed that there was no evidence the physician documented a rationale for continuing the medication beyond 14 days. 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 adequately supervise residents who were at risk for wandering, elopement, and/or other behavioral symptoms for two of 19 sampled residents. (Residents 16, 73) Findings include: Review of the facility policy entitled, Elopement Assessment, Prevention, and Response, last reviewed November 9, 2022, revealed that an elopement is defined as when a resident leaves the premises without authorization. Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia, anxiety, and adjustment disorder. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment and exhibited wandering behavior. Review of the care plan revealed the resident was at risk for elopement and walked independently without any assistive devices. Review of nursing documentation revealed that Resident 73 was attempting to leave the unit on May 19, 2023. On May 31, 2023, and June 6, 2023, a nurse noted that Resident 73 left the unit and was redirected back in by staff. On June 17, 2023, the resident was attempting to leave the unit. On June 18, 2023, a nurse noted that Resident 73 left the unit and was redirected back by staff. On June 27, 29, and 30, 2023, and July 4, 8, and 10, 2023, Resident 73 was attempting to leave the unit. On July 10, 2023, a nurse noted the resident left the unit and was redirected back by staff. On July 11, 12, 14, 17, and 22, 2023, the resident was again attempting to leave the unit. Review of an incident report dated July 22, 2023, revealed that at 3:50 p.m., Resident 73 was observed outside the main entrance of the building by the receptionist. Further review of facility documention, revealed that the resident had exited through the main unit doors, taken the elevator down to the first floor, and then exited the building. She then walked up the sidewalk around the side of the building to the main entrance where she was observed by the receptionist. The facility failed to provide adequate supervision in order to prevent an elopement. Clinical record review revealed that Resident 16 was admitted to the facility with diagnoses that included Alzheimer's disease and depression. Review of Resident 16's current care plan revealed that the resident wandered into other residents' rooms and had the potential to be physically aggressive towards other residents. Review of the nursing notes revealed that on April 28, 2023, June 22, 23, 24, 25, 26, and 29, 2023, and July 1, 5, and 8, 2023, Resident 16 was found in multiple residents' rooms. On May 2, 2023, a social services note indicated that the resident often wandered into other residents' rooms. Review of a facility incident report and nursing notes revealed that on July 3, 2023, the resident was found outside the unit patio outside the fence. Staff was unaware of the resident's location at that time. The facility failed to provide adequate supervision for Resident 16's elopement and wandering behavior. 28 Pa. Code 211.12(d)(1)(5) Nursing services.