Based on a review of facility policy, observations, clinical records and staff interviews, it was determined that the facility failed to follow physician orders for two of 22 residents reviewed (Resident 86 and 164). Finding include: A review of the facility's policy regarding Enteral Nutrition, dated March 2020, revealed adequate nutritional support through enteral feeding will be provided to residents as ordered. A review of Resident 86's clinical records revealed medical diagnoses that include Dysphagia following other Cerebrovascular Disease (swallowing disorder that occurs after a stroke or other neurological disease), Muscle Wasting and Atrophy (loss of muscle mass), and Severe Protein-Calorie Malnutrition (inadequate protein or calories in diet). Review of Resident 86's clinical records revealed a physician order dated January 9,2025, for Jevity 1.5 at 40ml/ per hour x20 hours via Kangaroo pump (pump that delivers nutrition through a tube inserted in the stomach or intestine that's programmed with desired feed rate and volume), total volume 800ml per day or until infused. Down at 11am, up at 3pm. This provides 1200 kcal, 51g protein and 608ml free water every shift for Peg-Tube. Observations of Resident 86's Kangaroo pump on February 18, 2025, at 9:30 a.m., revealed the pump was already disconnected from the resident and turned off. Observations of Resident 86's Kangaroo pump on February 19, 2025, at 9:40 a.m., revealed the pump was already disconnected from the resident and turned off. A review of Resident 86's February Medication Administration Record (MAR) revealed the resident received the following amounts of Jevity daily: February 1-2, 300ml evening, 0ml night, 160ml day for a total of 460ml February 2-3 320ml evening, 230ml night, 160ml morning for a total of 480 ml February 3-4 320ml evening, 230ml night, 160ml morning for a total of 780ml February 4-5 250ml evening, 0ml night, 160ml morning for a total of 420 ml February 5-6 320ml evening, 40ml night, 160ml morning for a total of 520ml February 6-7 300ml evening, 240ml night, 160ml morning for a total of 700ml February 7-8 240ml evening, 230ml night, 240ml day for a total of 710ml February 8-9 240ml evening, 240ml night, 0ml day for a total of 480ml February 9-10 300ml evening, 300ml night, 160ml day for a total of 760ml February 10-11 0ml evening, 240ml night, 160ml day for a total of 400ml February 11-12 300ml evening, 240ml night, 160ml day for a total of 700ml February 12-13 300ml evening, 240ml night 160ml day for a total of 700ml February 13-14 300ml evening, 230ml night, 0ml day for a total of 530ml February 14-15 0ml evening, 230ml night, 160ml day for a total of 390ml February 15-16 320ml evening, 230ml night, 160ml day for a total of 710ml February 16-17 150ml evening, 90ml night, 0ml day for a total of 240ml February 17-18 280ml evening, 230ml night, 160ml day for a total of 510ml February 18-19 200ml evening, 245ml night, 160ml day for a total of 605ml February 19-20m 300ml evening, 240ml night 160ml day for a total of 700ml Review of Resident 86's February 2025 MAR failed to reveal any day that the resident received the prescribed amount of tube feed. Interview conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on February 20, 2025, at 12:07 p.m., when the above information was presented, the ADON stated that the Kangaroo pump shuts down when the total 800ml is infused. The ADON stated the pump clears itself when it is shut off and there was no way to see a 24-hour look-back of total amounts dispensed for the pump. The DON confirmed that the amounts documented on the resident's MAR should equal the total amount prescribed in the physician orders. The DON confirmed the amounts on the resident's February MAR did not match the physician orders. A review of Resident 164's diagnosis list includes Type II Diabetes Mellitus (A chronic disease where the body does not use insulin properly or does not produce enough of it, causing high blood sugar levels). A review of the physician's order dated February 1, 2025, revealed an order for Insulin Aspart Injection Solution 100 ml/unit (fast-acting insulin) Inject 12 units subcutaneously (Injection is given in the fatty tissues, just under the skin) every six hours-injection to be given at 12:00 a.m. midnight, 6:00 a.m., 12 noon, and 6:00 p.m. A review of Resident 164's February 2025, Medication Administration Record revealed that from February 1, 2025, until February 18, 2025, Insulin Aspart was not administered to the resident seven times on the following dates: February 4, 2025, at 6:00 p.m.; February 5, 2025, at noon; February 7, 2025, at midnight; February 11, 2025, at 6:00 p.m.; February 14, 2025, at 6:00 p.m.; February 15, 2025, at 12:00 a.m., and 6:00 a.m. MAR review revealed Aspart Insulin 12 units were not administered on February 4, at 6:00 p.m., and February 5, at 12 noon. The MAR was coded with 9 which indicated BS (blood sugar) within limit coverage. MAR review revealed Aspart Insulin 12 units were not administered on February 7, 11, 14, and 15, at the times listed above. The MAR was coded with a 5 which indicated Hold/see nurses' notes A review of the progress notes dated February 7, 2025, at 3:23 a.m., revealed BS was 97 mg/dl. A review of the progress notes dated February 11, 2025, at 6:25 p.m., revealed Aspart Insulin 12 units was held for BS of 127 mg/dl. A review of the progress notes dated February 14, 2025, at 5:41 p.m., revealed Aspart Insulin 12 units was held for BS of 97 mg/dl. A review of the progress notes dated February 15, 2025, at 12:18 a.m., revealed BS was 102 mg/dl. A review of the progress notes dated February 15, 2025, at 5:20 a.m., revealed BS was 110 mg/dl. Clinical records review failed to reveal that the physician was notified that Aspart Insulin 12 units was not administered to Resident 164 on the above dates/time. The above was confirmed with the Director of Nursing on February 21, 2025, at 1:00 p.m. The facility failed to ensure Resident 164's physician order for Insulin was followed by holding insulin despite there being no paramters for the administration of insulin. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 1/12/24

Based on clinical records review and staff interview, it was determined that the facility failed to ensure appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two of five residents reviewed (Residents 3 and 22). Findings include: A review of Resident 3's physician's order dated May 24, 2024, revealed an order for Ativan (anti-anxiety medication) gel 1mg/ml applied to the base of the neck topically two times a day for Anxiety. On September 24, 2024, an order for Ativan gel 1mg/ml applied to the neck every eight hours as needed for anxiety was ordered aside from the routine Ativan gel. A review of the November 2024, Medication Administration Record revealed that from November 1, 2024, until November 30, 2024, as needed Ativan gel was administered to Resident 3 seven times with no appropriate indication and was administered five times without attempting a non-pharmacological intervention. A review of Resident 22's physician's order dated January 16, 2025, revealed an order for Clonazepam 0.5 mg (anti-anxiety medication) every 12 hours as needed for Anxiety. A review of the January 2025, MAR revealed that from January 17, 2025, until January 31, 2025, Resident 22 was administered with as-needed Clonazepam nine times without appropriate indication. The MAR also revealed that non-pharmacological interventions were not attempted before administering the as-needed Clonazepam nine times. The above was confirmed with the Director of Nursing on February 21, 2025, at 12:07 p.m. The facility failed to ensure Resident 3 and 22 were administered with as-needed anti-anxiety medication with appropriate indication and attempted non-pharmacological interventions prior to the adminstration of the as needed psycotropic medication. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 1/12/24

Based on clinical records review, resident and staff interview, it was determined that the facility failed to implement a comprehensive care plan intervention to prevent alteration in nutrition and hydration for one of eight residents reviewed (Resident R14). Findings include: Review of R14's records revealed a care plan dated May 12, 2020, documenting the resident has potential for self-care deficit. Interventions included resident requires eating assist x one person. Further review of R14's records revealed a care plan dated May 12, 2020, with a revision date of November 17, 2023, documenting R14 has the potential for alteration in nutrition and hydration. Intervention dated March 29, 2022, documented the need for staff to assess R14's ability to prepare food/fluids and feed self. Interventions also included the need to offer the resident assistance as needed. An intervention dated September 6, 2023, documented the need for adaptive equipment: lipped plate with meals. Observation of R14 on January 10, 2024, at 09:02 AM, revealed the resident having difficulty eating. The resident had food on her clothes and face. The resident was observed trying to grab a pastry from the table. The pastry was sitting on a tissue, no plate was observed on the table. The resident was able to grab the pastry, but not able to remove the tissue. The resident became frustrated, put the pastry back on the table and didn't attempt to eat it again. Observation of R14 on January 11, 2024, at 09:15 AM, revealed resident in the dining room with a plate on her lap attempting to eat breakfast. The resident was observed with food on her clothing and face. The resident did not have a lipped plate, or a staff person to assist with eating as documented in her care plan. Interview on January 11, 2024, at 09:33 AM with E#3, confirmed that R14 was care planned for a lipped plate and one person assist with eating. Interview on January 12, 2024, at 11:32 AM with DON, confirmed that R14 was care planned for a lipped plate and one person assist with eating. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/18/21 28 Pa Code 211.11(d) Resident care plan 3/26/18, 8/4/21, 9/29/21 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for a planned discharge for one of one residents reviewed. (Resident 112) Findings Include: Review of Resident 112's Physician Orders revealed an order dated January 8, 2024 for the resident to be discharged to a group home on January 8, 2024. Review of Resident 112's entire clinical record revealed there was no discharge summary completed upon discharge. Interview with the Director of Nursing on January 12, 2023 at 11:30 a.m. confirmed there was no discharge summary completed upon the discharge of Resident 112. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure physician orders regarding medications were followed for two of the 24 residents reviewed (Residents 26 and 97). Findings include: Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral Vascular Accident (CVA- An interruption in the flow of blood to cells in the brain). Review of Resident 26's clinical records revealed Resident 26 had a Gastrostomy Tube (GT- A tube inserted through the belly that brings nutrition directly to the stomach) due to Dysphagia (Difficulty swallowing). Review of Resident 26's physician order (POS) revealed an order initiated on December 20, 2023, for Insulin Gargline (Long-acting insulin) Subcutaneous Pen-Injector 100 unit/ml Inject 24 units subcutaneously at bedtime. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed resident was not administered with the ordered Insulin Gargline on December 20, 21, 22, 26, and 29, 2023. Interview with the Director of Nursing (DON) was conducted on January 12. 2024. The DON indicated the nurse did not administer Resident 26's ordered Insulin Gargline on the above dates because the resident's tube feeding was held due to abdominal discomfort, thus the nurse held the ordered insulin as per nursing judgment. The Director of Nursing confirmed the physician was not notified of the missed Insulin Gargline on the above-mentioned dates. The facility failed to ensure Resident 26 was administered the ordered Insulin Gargline daily at bedtime. Review of Resident 97's POS dated December 7, 2023, revealed an order for Midodrine HCL (medication used to treat low blood pressure) oral tablet 2.5 mg given one tablet by mouth three times a day. Hold for systolic >140. Review of Resident 97's December 2023 MAR (Medication Administration Record) revealed from December 7, 2023, until December 31, 2023, Resident 97 was administered the Midodrine medication outside of the ordered blood pressure parameter, a total of six times. Review of Resident 97's January 2024 MAR revealed that from January 1, 2024, until January 11, 2024, Resident 97 was administered seven times with Midodrine medication outside of the ordered blood pressure parameter. The above information was conveyed to the Director of Nursing on January 12, 2024, at 11:00 a.m. The facility failed to ensure Resident 102's physician's order for blood pressure parameters before administering Midodrine medication was followed. 28 Pa. Code 211.12(d)(1)(2)(3)(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 ensure the pharmacy services provided medications timely for two of the 24 residents reviewed. (Resident 26 and 102) Finding include: Review of Resident 26's clinical record revealed Resident 26 was readmitted to the facility on [DATE]. Review of Resident 26's physician order (POS) dated December 20, 2023, revealed an order for Onfi Oral Suspension (A medication used to treat seizures) 2.5 mg/ml given 3 ml every 12 hours for Seizures. The medication was scheduled for 9:00 a.m. and 9:00 p.m. Review of Resident 26's December 2023 Medication Administration Record (MAR) revealed that the Onfi medication was not administered to the resident until the morning of December 25, 2023, five days after the medication was ordered. MAR review revealed that the resident had missed a total of nine doses of the Onfi medication. Interview with the Director of Nursing was conducted on January 12, 2024. The DON reported that the medication was not administered because of the unavailability of the medication from the pharmacy. Review of Resident 102's clinical records revealed resident was readmitted to the facility on [DATE], with a diagnosis of Osteomyelitis (bone infection) of the Vertebra. Review of the POS dated November 23, 2023, revealed an order for Cefepime HCL (medication used to treat bacterial infection) injection solution, using two grams intravenously every 8 hours for infection for 39 days. Review of Resident 102's November 2023 MAR revealed that Cefepime medication was not administered to the resident until the morning of November 27, 2023, four days after the medication was ordered. Interview with the Director of Nursing was conducted on January 12, 2024. The DON reported that the medication was not administered because of the unavailability of the medication from the pharmacy. The facility failed to ensure Resident 26, and Resident 102 ordered medications were administered due to unavailable from the pharmacy. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 Pa. Code: 211.9 (a)(1) Pharmacy services.

Based on clinical records review and staff interview, it was determined that the facility failed to ensure that laboratory test was obtained as ordered by the physician for one of the 24 residents reviewed (Resident 35). Findings include: Review of Resident 35's diagnosis list includes Heart Failure and Atrial Fibrillation (A-fib- An irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 35's clinical records review revealed resident was receiving Jantoven (Warfarin) for blood clot prevention. Review of the Physicians order dated October 23, 2023, revealed an order for PT (Prothrombin Time- a test that measures how long it takes for a clot to form in a blood sample) and INR (International Normalized Ratio- a type of calculation based on PT test results) every other day, call the physician for INR >3, INR<1.5. Review of Resident 35's clinical records revealed that INR was done on October 25, 2023, but failed to reveal that the INR test was done on October 27, 2023. Clinical records review failed to reveal that the physician was notified that the October 27, 2023, PT/ INR blood test was not done. Review of Resident 35's clinical record revealed the laboratory results reported on October 30, 2023, revealed an H (high) result of 44.1 (normal range 9.7 - 12.5 sec) and a CH (critical high) INR result was 4.2 (normal range 0.8-1.1) Review of Resident 35's clinical records, physician order dated October 30, 2023, revealed an order of Phytonadione Solution (Vitamin K- A medication used to prevent bleeding in people with blood clotting problems) 10mg/ml, Inject 5 milligram one time only for critical INR for one day. Review of Resident 35's clinical record the Medication Administration Record (MAR) revealed Resident 35 was administered with Vitamin K injection on October 30, 2023, at 5:37 p.m. due to a critical high INR result. Interview was conducted with the Director of Nursing on January 12, 2023, at 11:00 a.m., who confirmed that the PT/INR test on October 27, 2023, was not done. The DON was unable to provide a reason as to why Resident 35's PT/INR test was not done on October 27, 2023, a test that could indicate if an adjustment on the resident's medication dosage is needed. The facility failed to ensure Resident 35's PT/INR blood test was done on October 27, 2023. 42 CFR 483.50(a)(1)(i) Laboratory Services. 28 Pa. Code 211.5(f) Clinical record. 28 Pa. Code 211.12(d)(3) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to obtain weights to maintain residents' nutritional status for four of 14 residents reviewed. (Residents 26, 74, 109, and 113) Findings Include: Review of facility policy and procedure titled Resident Weights, revised May 2022, revealed the nursing staff will measure residents' weights during the admission process which can take up to 24 to 48 hours from admission date. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each resident electronic medical record. Any weight change of 5% or more since the last weight assessment will be retaken. If the weight is verified, nursing will notify the Dietitian. Review of Resident 26's diagnosis list revealed a diagnosis of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Cerebrovascular Accident (CVA- Stroke), Cerebral Vascular Accident (CVA- interruption in the flow of blood to cells in the brain). Clinical records review revealed Resident 26 was receiving feeding through a Gastrostomy Tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) due to Dysphagia (Difficulty swallowing). Review of Resident 26's clinical records revealed resident's admission weight was taken on November 23, 2023, which was 156 pounds. Records revealed resident was sent to the hospital on the same day for respiratory failure. Review of Resident 26's clinical records review revealed resident was readmitted to the facility on [DATE]. The records failed to reveal that a readmission weight was obtained within the first 24-48 hours after readmission. Review of Resident 26's hospital records dated December 18, 2023, revealed resident's weight was 154 pounds. Review of Resident 26's weight and vitals revealed a weight of 145.4 pounds taken on December 27, 2023, seven days after the resident was readmitted from the hospital. The resident had a 5.52% weight loss from December 18, 2023, until December 27, 2023. Review of Resident 26's clinical record revealed dietitian's progress notes dated December 28, 2023, at 9:48 a.m., revealed resident was triggered for unplanned/unfavorable weight loss, re-weight requested. Review of Resident 26's clinical record revealed resident's re-weight was not conducted until January 1, 2024, (145.4 lbs.) five days after a significant weight loss was identified. Interview was conducted with the DON on January 12, 2024. The DON reported that re-weights are done within 24 hours. The DON reported that Resident 26's readmission weight was not done until seven days later due to the weight lift not working. Review of Resident 74's weights revealed a weight on September 1, 2023 of 105.2 pounds and a weight on December 1, 2023 of 89.4 pounds, a decrease of 15.02% over three months. Further review of Resident 74's weights revealed there was no weight obtained after December 1, 2023. Review of Resident 74's Progress Notes revealed a nursing entry dated December 28, 2023 at 2:01 p.m. revealed the resident had returned from the hospital and now had a feeding tube. Review of resident 74's weights revealed there was no documented weight for Resident 74 when readmitted to the facility on [DATE] and resident 74 had not been weighed since December 1, 2023. Review of Resident 74's Nutritional readmission assessment dated [DATE] revealed Resident 74 was re-admitted from the hospital on December 28, 2023 with a new PEG tube (feeding tube) placement on December 26, 2023. Resident 74's weight was documented as 89 pounds and it was noted that the re-admission weight was pending. Interview with Licensed Dietitian E3 on January 11, 2023 at 1:00 p.m. confirmed there was no readmission weight completed for Resident 74 on December 28, 2024 and there had been no weights completed for that resident at the time of the interview since December 1, 2023. Review of Resident 109 weights revealed a weight on December 1, 2023 of 138 pound. There were no weights after this date documented in resident 109 clinical record. Review of Resident 109 Progress notes revealed a Dietary Weight Change Note on October 6, 2023 noting Resident 109 had a weight on September 11, 2023 of 159.2 pounds and a weight on October 3, 2023 of 150 pounds an unplanned and unfavorable weight loss of 9.2 pound or 5.8%. Weekly weights for four weeks were recommended related to the resident's weight loss. Review of Resident 109 weights revealed a weight on October 11, 2023 of 149.4 pounds and a weight on November 3, 2023 of 134 pounds. Interview with Licensed Dietitian E3 on January 11, 2023 at 1:00 p.m. confirmed the weekly weights that were recommended on October 3, 2023 were not completed and the resident had no documented weight since December 1, 2023. Review of Resident 113's weights and vitals revealed a weight of 149.3 pounds on December 20, 2023. On January 1, 2024, the resident's weight was 124 pounds, a 16.95% weight loss in 12 days. Review of Resident 113's clinical record revealed dietitian progress notes dated January 3, 2024, at 11:06 a.m., revealed resident was triggered for significant unplanned/unfavorable weight loss. Re-weight requested and will follow up upon re-weight obtainment. Interview conducted with the dietitian on January 11, 2024, revealed Resident 113's re-weight requested on January 3, 2024, was not done until January 11, 2024, after the surveyor had asked for it. The above information was conveyed with the DON on January 12, 2024. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on resident and staff interviews, observations, and facility documentation review it was determined the facility failed to have adequate number of dietary staff to meet the needs of the residents. Findings Include: Interviews conducted with Resident R1, R2, R3, R4, and R5 on August 29, 2023 between 9:15 and 9:50 a.m. revealed the breakfast trays are always late for the residents and arrive between 9:15 a.m. and 10:15 a.m. Observations of the breakfast tray delivery on August 29, 2023 revealed the last tray was delivered to a resident on the 600 hall at 10:10 a.m. Observation of the dining room during the breakfast meal revealed the dining room was not being used and a sign was posted to the door that it opens at 8:15 a.m. Interview with Dietary Director Employee E3 on August 29, 2023 at 10:35 a.m. revealed the kitchen was short staffed the day of the survey. The kitchen should be staffed with three staff on tray line, on staff member to pushed the completed carts to the units and one cook and one dishwasher, today the kitchen was staffed with one staff on tray line, on to push the carts and one dishwasher with another staff who came in to put the order that delivered away and the dietary director helping in the kitchen with production. The dietary director confirmed the kitchen was short of two staff members for the breakfast meal. Review of the facility assessment, last assessed on July 25, 2023 revealed the facility needs on average 5-7 staff members per meal. Further interview with the Dietary Director Employee E3 on August 29, 2023 confirmed the meal trays were late and that the dinning room was not open because there was not enough dietary staff to have breakfast served both in the dinning room and on the units. Interview with the Nursing Home Administrator and the Director of Nursing on August 29, 2023 at 11:00 a.m. confirmed there was not a sufficient number of staff in the kitchen to meet the needs of the residents resulting in breakfast being delivered late and the residents not being able to eat in the dining room if preferred. 28 Pa Code 211.6(c) Dietary services. 28 Pa. Code 201.18(b)(6) Management

Based on a review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agencies for three of nine residents reviewed (Residents R1, R2, and Resident R3). Findings include: Review of facility policy Abuse Prevention/ Reporting revised April 2022, revealed that the facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13. Review of Resident R1's progress note of March 9, 2023, revealed that Resident R1 was admitted to the hospital. Review of Resident R1's Individual Patient Controlled Substance Administration Record revealed that one tablet of Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 milligrams (mg) was signed out on March 10, 2023, by licensed staff Employee E3. Review of Resident R2's physician's orders included an order for Tramadol (opioid used to help relieve moderate to severe pain) 50 mg one tablet twice a day. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. and 6 p.m. Review of Resident R2's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 12, 2023 at 3:00 a.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Tramadol at 3:00 a.m. on March 12, 2023. Review of Resident R3's physician's orders included an order for Oxycodone/APAP 5/325 mg (Percocet - used to help relieve moderate to severe pain) two tablets once daily. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. Review of Resident R3's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 10, 2023 at 1:15 a.m. and two tablets on March 11, 2023, at 11:30 p.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Oxycodone/APAP at those times. Interview with the Director of Nursing (DON) on April 27, 2023, at 10:45 a.m. revealed that the DON was notified that Employee E3 had signed out medication for Resident R1 while Resident R1 was hospitalized and that Employee E3 was not always documenting on the resident MARs. Employee E3's agency was made aware of the issues and was asked to not return to the facility. The DON confirmed that the allegation of misappropriation was not reported to the Department of Health. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 3/10/23 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa Code 211.10(a)(d) Resident Care Policies Previously cited 3/10/23

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for three of nine residents reviewed (Residents R4, R5, and R6). Findings include: Review of Resident R4's physician's orders included an order for Oxycodone/APAP5/325 milligrams(mg) (Percocet - used to help relieve moderate to severe pain) one tablet every eight hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 11, 2023, at 6:45 p.m. and March 12, 2023, at 2:50 a.m.; however, the administration was not documented on the electronic Medication Administration Record (MAR). Review of Resident R5's physician's orders included an order for Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 mg one tablet every four hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 11:15 p.m., March 10, 2023, at 4:40 a.m., and March 11, 2023, at 11:45 p.m.; however, the administration was not documented on the electronic MAR. Review of Resident R6's physician's orders included an order for Oxycodone IR 5 mg one tablet every six hours as needed for severe pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 4:10 p.m. and 10:30 p.m.; however, the administration was not documented on the electronic MAR. Interview with the Director of Nursing on , April 27, 2023, at 10:45 a.m. confirmed that the medications should be documented on both the controlled substance record and the MARs, but were not documented on the MARs. 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/10/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 3/10/23

Based on clinical record review and staff interviews it was determined that the facility did not update or revise the care plan in a timely manner for one of 32 residents reviewed (Resident 363). Findings include: Review of the clinical record of Resident 363 revealed, an admission date of December 13, 2016, with the following (but not limited to) diagnosis; Cerebral infarction (Stroke), muscle weakness, history of falls, and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of Resident 363's clinical record revealed nursing notes for September 17, 2022, the resident was transferring to the wheelchair, without assistance, and fell sideways, landing on their bottom. September 19, 2022, a nursing note stating that the resident was standing up from the wheelchair and then fell back on the floor and an adjacent chair fell on top of the resident. September 20, 2022, a nursing note states that the resident fell on the floor in the lounge striking his head and reporting pain in the left groin or hip with movement and some pain to right leg. A skin tear was noted to the left hand next to the 5th digit and was sent to the emergency room. Review of nursing note from December 26, 2022, observed resident lying on his left side on the floor matt. Resident unable to explain what happened due to cognitive disorder. A nursing note dated December 31, 2022, revealed observed resident lying next to his bed on his right side with both legs extended. A nursing note dated January 8, 2023, revealed the resident was on the floor matt located on the right side of the bed. Review of Resident 363's care plan revealed that a care plan was developed for falls on September 19, 2020. Further review of the care plan revealed that new interventions were not put into place to prevent further falls until September 26, 2022, six days after the resident returned from the emergency room and again on January 17, 2023. Interview with the Director of Nursing on March 10, 2023, at 12:45 p.m. confirmed that no interventions were added to the resident's care plan timely to prevent further falls. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician, and/or clarify physician orders regarding daily weights for edema for one resident and for insulin administration for one resident (Resident 48 and Resident 78). Findings include: Review of Resident 48's diagnosis list revealed a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to remove sugar from the blood stream). Review of Resident 48's physician orders revealed an order for Novolog Solution (medication used for diabetes management) 100 units/milliliter (ml) inject as per sliding scale 0-150 - 1 unit; 151-200 - 2 units; 201-250 - 3 units; 251-300 - 4 units; 351-400 - 5 units; 401-450 - 6 units subcutaneously (below skin) before meals and at bedtime. Review of Resident 48's December 2022 Medication Administration Record (MAR) revealed that insulin was not administered according to physician orders on the following dates: December 2 at 4:30 p.m.; December 4 at 11:00 a.m.; December 5 at 6:30 a.m.; December 6 at 6:30 a.m.; December 7 at 6:30 a.m.; December 8 at 11:00 a.m.; December 9 at 11:00 a.m.; December 10 at 8:00 p.m.; December 13 at 4:30 p.m.; December 14 at 11:00 a.m.; December 19 at 11:00 a.m.; December 20 at 6:30 a.m.; December 22 at 11:30 a.m.; December 24 at 11:00 a.m. December 26 at 8:00 p.m.; December 27 at 4:30 p.m. and December 30 at 6:30 a.m. Review of Resident 48's January 2023 MAR revealed that Resident 48's insulin was not administered according to physician orders on the following dates: January 1 at 6:30 and 11:00 a.m.; January 2 at 6:30 a.m.; January 4 at 6:30 a.m. and 11:00 a.m.; January 6 at 11:30 a.m.; January 7 at 11:00 a.m., 4:30 p.m. and 8:00 p.m.; January 10 at 6:30 a.m.; January 11 at 6:30 a.m. and 11:00 a.m.; January 12 at 11:00 a.m.; January 14 at 4:30 p.m.; January 15 at 4:30 p.m.and 8:00 p.m.; January 16 at 6:30 a.m. 11:00 a.m. and 8:00 p.m.; January 17 at 6:30 a.m.; January 29 at 4:30 p.m. and 8:00 p.m.; January 30 at 4:30 p.m.; January 31 at 6:30 a.m. and 4:30 p.m. Interview with the Director of Nursing and Nursing Home Administrator on March 9, 2023, at 1:00 p.m. confirmed that Resident 48 did not receive insulin according to Resident 48's physician orders. The facility failed to ensure Resident 48's physician's orders were followed and failed to ensure medication was administered as ordered by attending physician. Review of Resident 78's electronic clinical record revealed the following physician order Daily weights, every dayshift for edema (swelling caused by too much fluid trapped in the body's tissues) with an order date of December 28, 2022, at 9: 48 A.M. Further review of Resident 78's clinical record revealed the following dates that weights were taken, January 5, 2023, February 2, 2023, February 4, 2023. And March 7, 20233. Additional review of Resident 78's clinical record revealed that the facility failed to weigh resident R78; 69 times between December 28, 2022, and March 10, 2023. Interviews conducted with RD1 and RD2 on March 9, 2023, at approximately 11:59 A.M. confirmed the facility failed to follow resident R78's physician order for daily weights. Interview conducted with the Nursing Home Administrator on March 9, 2023, at approximately 1:15 P.M. confirmed the facility failed to follow resident R78's physician order of daily weight. The facility failed to follow physician and or clarify physician orders regarding Medication Administration. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 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 rationale from attending physician was provided for disagreed recommendations provided by the pharmacy consultant for one of 24 residents reviewed (Resident 54). Findings include: Review of Resident 54's diagnosis list revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Psychosis- A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality. Review of the May 2022 Medication Administration Record (MAR) revealed an order of Quetiapine Fumarate tablet (Antipsychotic medication) 25mg given 0.5 tablets by mouth related to Psychotic Disorder with Delusions. The medication was ordered on May 13, 2021. Review of the Pharmacy Consultant report dated May 30, 2022, revealed a recommendation to consider a GDR (Gradual Dose Reduction) for Quetiapine 12.5 mg, especially with a psychotic disorder. The Pharmacist also indicated in the consult the currently accepted diagnosis for antipsychotics. Further review of the report revealed that the physician responded to the pharmacy recommendation on June 14, 2022, with a note of no change. The physician did not provide a rationale for his/her response. Review of the Pharmacy Consultant report dated August 25, 2022, revealed a recommendation as follows Quetiapine with the psychotic disorder will trigger MDS (Minimum Data Set- standardized assessment tool that measures health status in long-term care residents) inappropriate use on the quality indicator report. Please review the diagnosis. The physician responded Disagree with no rationale provided. Review of the Pharmacy Consultant report dated November 13, 2022, revealed a recommendation as follows Quetiapine with the psychotic disorder will trigger MDS inappropriate use on the quality indicator report. Please review the diagnosis and usage in considering a GDR. The physician responded Disagree with no rationale provided. Interview with the Director of Nursing on March 10, 2023, at 1:00 p.m., confirmed that there was no documentation of the physician's reasons/rationale for the disagreed recommendations from the pharmacy consultant regarding a GDR and appropriate antipsychotic diagnosis. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on a review of facility documentation, observation, and staff interview it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of two units (Garden). Findings include: Review of the facility's policy titled Meal assessments, dated November 28, 2017, revealed that foods are served at temperatures appropriate for food safety and palatability. Review of the facility's documentation, Tray Assessments revealed that the standard temperature at the point of service is 140 F min.(minimum) for starch, vegetables, and entrée. Observation of the lunch meal on March 8, 2023, in the presence of the Dining Director, Employee E3 revealed that the food cart was ready at 12:04 p.m., and staff started to deliver the resident's meal to the rooms. The last resident was assisted with their meal at 12:12 p.m. A test tray was evaluated at 12:14 p.m., with Employee E3. The test tray revealed the following temperatures: Ham was 112 degrees F, cabbage was 123 F, and sweet potato is 126 F. An interview with Employee E3 on March 8, 2023, at 12:20 p.m., revealed that the expectation as per the facility's policy temperature at the point of service for hot food should not be less than 145 F. The above was conveyed to the Director of nursing on March 10, 2023, at 1:00 p.m. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services