Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for dressing changes were followed for one of three residents reviewed (Resident 2).Findings include:A facility policy regarding physician orders, dated January 1, 2025, revealed that the licensed nurse would complete the physician order how it was written regarding timing and frequency.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 4, 2025, indicated that the resident was severely cognitively impaired, could sometimes understand, was sometimes understood, required assistance from staff for all care needs, and had diagnoses that included dementia.A nursing note dated August 19, 2025, indicated that staff found a large skin tear. Resident 2 was assessed by a registered nurse and identified a seven centimeter (cm) by nine cm skin tear with bruising noted on the right forearm.Physician's orders for Resident 2, dated August 20, 2025, included an order for the resident to have wound care to the right forearm skin tear. The skin tear was to be cleansed with wound cleanser, patted dry, xeroform (gauze dressing with petroleum) applied, and covered with a foam dressing daily and as needed.Review of the Treatment Administration Record (TAR) for Resident 2, dated August and September 2025, revealed that on August 20, 23, 24, 27, 28, and 29, 2025, and September 2, 3, 6, and 7, 2025, the dressing was not administered as ordered. Interview with the Director of Nursing on September 9, 2025, at 2:09 p.m. confirmed that Resident 2's dressing changes were not completed as ordered for the dates listed above. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to develop an individualized care plan for three of 49 residents reviewed (Residents 26, 48, 110). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated March 24, 2025, indicated that the resident was alert and oriented, had diagnoses that included diabetes, and was on a mechanically altered, therapeutic diet. Resident 26's care plan, dated March 24, 2025, revealed that it did not include any information or interventions related to the resident's nutritional needs. An interview with Resident 26 on May 12, 2025, at 9:31 a.m. revealed that she was not happy with the food choices she received and that she was not offered a snack at night, even though she was a diabetic. An interview with the Dietician on May 15, 2025, at 8:30 a.m. confirmed that Resident 26's care plan did not include anything regarding the resident's nutritional status and that it should have. A comprehensive MDS assessment for Resident 48, dated April 6, 2025, indicated that the resident was alert and oriented and was frequently incontinent of urine and bowel. According to the resident's task record, dated April 2025, the resident was incontinent of urine 41 times in the month and incontinent of bowel 11 times in the month. Resident 48's care plan, dated April 6, 2025, did not include any information or interventions related to the resident's incontinence. An interview with the Nursing Home Administrator on May 15, 2025, at 8:30 a.m. confirmed that Resident 48's care plan did not include anything regarding the resident's incontinence and that it should have. A comprehensive MDS assessment for Resident 110, dated April 15, 2025, indicated that the resident was alert and oriented. A nurse's note, dated April 23, 2025, revealed that the resident's daughter could not tolerate orange juice because of a hiatal hernia (protrusion of an organ, usually the stomach, through the esophageal opening in the diaphragm). A nursing note, dated May 8, 2025, revealed that the resident's daughter requested Tums for the resident and that she not have tomato soup because of her hiatal hernia and the acid causing heartburn. She asked that dietary not send her tomatoes in the future. Resident 110's care plan, dated April 23, 2025, revealed that it did not include any information or interventions related to the resident's hiatal hernia. An interview with the Director of Nursing on May 15, 2025, at 11:21 a.m. confirmed that Resident 110's care plan did not include anything regarding the resident's hiatal hernia and that it should have. 28 Pa. Code 201.24(e)(4) admission Policy.

Based on clinical record review, as well as staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 49 residents reviewed (Residents 62, 126). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was taking an antipsychotic medication (medications used to treat mental health disorders), and had diagnoses that included dementia. A nursing note for Resident 62, dated April 30, 2025, at 8:51 p.m., indicated that there was an order to gradually decrease the resident's Abilify (an antipsychotic medication) from 5 milligrams (mg) to 2.5 mg at bedtime per vital health care recommendations. Physician's orders for Resident 62, dated April 30, 2025, included orders for the resident to receive 2.5 mg of Abilify via her peg tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth) at bedtime. Review of Resident 62's Medication Administration Record (MAR) for May 2025 revealed that the resident received 2.5 mg and 5 mg of Abilify at bedtime on May 1, 2025, for a total of 7.5 mg. Interview with the Director of Nursing on May 14, 2025, at 1:57 p.m. confirmed that Resident 62 did receive both the 5 mg tablet and the 2.5 mg tablet of Abilify on May 1, 2025, for a total of 7.5 mg. She confirmed that the new dose was ordered, but the old dose was not discontinued, resulting in an extra dose. An admission (MDS) for Resident 126, dated May 5, 2025, revealed that the resident was moderately cognitively impaired, required assistance for care needs, had an indwelling urinary catheter, and a right upper arm PICC (peripherally inserted central line catheter, a flexible tube placed in the arm for intravenous medications), and had diagnoses that included, right hip fracture and obstructive uropathy (decreased urine flow). Nursing notes for Resident 126, dated April 29, 2025, indicted that the resident was admitted to the facility post hospitalization for a left hip fracture sustained after a syncopal (dizzy) episode and fall on on April 20, 2025. Discharge notes from the hospital, dated April 29, 2025, indicated that the resident was discharged with a urinary catheter and a PICC line in place. Notes further indicated that the catheter remained in place after discharge because the resident was not able to void on her own. The PICC line was utilized for blood draws and medications; however, upon discharge no orders were obtained to use the PICC line. During the initial tour of the facility on May 12, 2025, at 1030 a.m. the surveyor was speaking with Resident 126 and her family. The resident's family member indicated that they were concerned that the catheter and PICC line were still in place and that both were a source of possible infection. The family member stated that at one point in the hospital the catheter was out, but they had to reinsert it because she was unable to control her urine. The family member further indicated that she has addressed her concerns with several staff and did not get any resolution. Later that day the surveyor saw the family member in the hall and she was visibly upset/angry and crying. She indicated that she was unhappy about not getting answers about her concerns. She indicated that staff had previously told her the urology appointment was not until May 28th because the doctor was full. She felt this was too long to wait to see about getting the catheter out, and she has been wanting someone to look into it for her. Then again, she commented that she has had the same concern for the PICC line. She stated that she has been telling staff to address the need for it, that it is not being used and that she wants it out. Interview with Registered Nurse 1 on May 15, 2025, at 8:53 a.m. indicated that she spoke with Resident 126's family member regarding her concerns. Registered Nurse 1 informed the family member that the doctor makes rounds on Friday and that her concerns could be discussed with him at that time. She further indicated that in retrospect it would have been better for the resident and family if she would have contacted the physician at that time regarding the families concerns. Interview with the Director of Nursing on May 15, 2025, at 2:12 p.m. confirmed that staff should have contacted the physician in a more timely manner in order to provide clarification regarding the continued need for Resident 126's urinary catheter and PICC line. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for one of 49 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and had diagnoses that included hypertension. Physician's orders for Resident 62, dated April 30, 2024, included an order for the resident to receive 12.5 milligrams (mg) of metoprolol tartrate (treats hypertension) twice daily for hypertension. The medication was to be held if the resident's systolic blood pressure (the top number of a blood pressure reading) was 110 millimeters of mercury (mmHg) or less, or if the heart rate was less than 60 beats per minute. Physician's orders for Resident 62, dated April 8, 2025, included an order for the resident to receive 6.25 mg of metoprolol tartrate twice daily for hypertension. The medication was to be held if the resident's systolic blood pressure was 110 mmHg or less, or if the heart rate was less than 60 beats per minute. Review of Resident 62's Medication Administration Record (MAR) for February, March and April 2025 revealed that the resident's systolic blood pressure was less than 110 mmHg during the morning on March 2 and April 15, 2025, and during the evening on February 27 and April 11, 2025. There was no documented evidence that the metoprolol tartrate was held as ordered by the physician on the above-mentioned dates and times. Review of Resident 62's MAR for February, March and April 2025, as well as review of the clinical record, revealed no documented evidence that the resident's blood pressure or heart rate was obtained prior to administering the metoprolol tartrate during the morning on February 21 and during the evening on March 27 and April 22, 2025. Interview with the Director of Nursing on May 14, 2025, at 11:39 a.m. confirmed that Resident 62's metoprolol tartrate was not held as ordered by the physician on the above-mentioned dates and times and confirmed that the resident's blood pressure and heart rate were not obtained prior to administering the metoprolol tartrate on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for three of 49 residents reviewed who had an indwelling urinary catheter (Residents 55, 59, 106). Findings include: The facility's policy regarding indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag) management, dated January 31, 2025, indicated to properly position the drainage bag below the level of the bladder to facilitate urine flow and avoid allowing the drainage bag or tubing to touch the floor. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55, dated April 17, 2025, revealed that the resident was understood, could usually understand others, and had an indwelling urinary catheter. A care plan for the resident, dated January 10, 2025, revealed that the resident had an indwelling urinary catheter, and staff was to position the indwelling urinary catheter bag and tubing below the level of the bladder. Observations of Resident 55 on May 12, 2025, at 10:59 a.m. revealed that the resident was sitting in his wheelchair in the hallway outside nurses' station on the fourth floor. His indwelling urinary catheter drainage bag was connected underneath his wheelchair in a privacy bag; however, the indwelling urinary catheter tubing was lying on the floor. The resident then began to self-propel in his wheelchair in the hallway with his indwelling urinary catheter tubing on the floor. Interview with Licensed Practical Nurse 3 on May 12, 2025, at 11:18 a.m. confirmed that Resident 55's indwelling urinary catheter tubing should not be on the floor. Interview with the Director of Nursing on May 13, 2025, at 1:05 p.m. confirmed that Resident 55's indwelling catheter tubing should not be on the floor. An admission MDS assessment for Resident 59, dated March 31, 2025, revealed that the resident was understood, could usually understand others, had an indwelling urinary catheter, and had diagnoses that included benign prostatic hyperplasia (enlarged prostate resulting in urinary problems). A care plan for the resident, dated March 26, 2025, revealed that the resident had an indwelling urinary catheter, and staff was to position the indwelling urinary catheter bag and tubing below the level of the bladder and away from the entrance room door. Observations of Resident 59, on May 14, 2025, at 9:21 a.m. revealed that the resident was lying in his bed watching television. His indwelling urinary catheter drainage bag was lying directly on the floor on the right side of the bed, visible upon entrance to the room. Interview with Nurse Aide 4 on May 14, 2025, at 9:47 a.m. confirmed that Resident 59's indwelling urinary catheter bag should not be on the floor. Interview with the Director of Nursing on May 14, 2025, at 3:54 p.m. confirmed that Resident 59's indwelling catheter should not be on the floor. A quarterly MDS assessment for Resident 106, dated April 24, 2025, revealed that the resident was cognitively intact and had an indwelling urinary catheter. A care plan for the resident, dated February 24, 2025, revealed that the resident had an indwelling urinary catheter, and staff were to position the indwelling urinary catheter bag and tubing below the level of the bladder. Observations of Resident 106 on May 12, 2025, at 10:56 a.m. revealed that the resident was sitting in her wheelchair in her room. Her indwelling urinary catheter drainage bag was connected underneath her wheelchair with half of the drainage bag hanging out of the dignity bag. The exposed part of the drainage bag and the indwelling urinary catheter tubing were lying in direct contact with the floor. Interview with Nurse Aide 5 on May 12, 2025, at 11:18 a.m. confirmed that Resident 106's indwelling urinary catheter drainage bag and the indwelling urinary catheter tubing should not have been in direct contact with the floor. She indicated that she hooked the bag under her wheelchair, but it slides off. Interview with the Director of Nursing on May 12, 2025, at 3:47 p.m. confirmed that Resident 106's indwelling urinary catheter drainage bag and the indwelling urinary catheter tubing should not have been in direct contact with the floor. The facility's policy regarding intake and output documentation, dated January 31, 2025, indicated that the purpose of the procedure was to accurately determine the amount of urine that a resident excretes in a 24-hour period. Current physician's orders for Resident 106, included an order for staff to measure the resident's urinary output every shift. A care plan for the resident, dated February 24, 2025, revealed that the resident had an indwelling urinary catheter, and staff were to monitor and document intake and output as per facility policy. Review of Resident 106's clinical record, for February, March, April and May 2025 revealed that there was no documented evidence that the resident's urinary output was measured on the following dates and shifts: February 23 and 25 on the night shift; March 1 and 12 on the night shift; March 3 on the day shift; March 22 and 30 on the evening shift; April 19 and 24 on the night shift; April 27 on the evening shift; and May 12 and 13 on the day shift. Interview with the Director of Nursing on May 14, 2025, at 12:53 p.m. confirmed that there was no documented evidence that Resident 106's urinary output was measured as per facility policy, per physician's orders, and per the care plan on the above-mentioned dates and shifts. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush a peripherally-inserted central catheter (PICC, a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart), and a midline (a thin soft tube that's inserted through a vein in the arm and passed through to where the tip is at or near armpit level) as ordered by the physician for one of 49 residents reviewed (Resident 96). Findings include: The facility's policy regarding flushing central venous and midline catheters, dated January 31, 2025, indicated to flush catheters at regular intervals to maintain patency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 96, dated March 31, 2025, indicated that the resident was cognitively intact, required assistance with care needs, received intravenous medications (medications delivered through a tube placed in a vein) while a resident, and had a diagnosis of anemia. Physician's orders for Resident 96, dated February 16, 2025, included an order for staff to flush the resident's midline with 10 milliliters (ml) of Normal Saline (NSS) every shift for preventative measures, midline maintenance. Review of Resident 96's Medication Administration Record (MARs), dated February and March 2025, revealed that there was no documented evidence that staff flushed the resident's midline with 10 ml of NSS during the day shift on March 7, during the evening shift on February 27 and March 17, and during the night shift on February 20 and 25, and March 5, 9, 10, 13, 14, 16, 17, 19 and 20. Physician's orders for Resident 96, dated March 22, 2025, included an order for staff to flush the resident's PICC with 10 ml of NSS every shift for PICC maintenance. Review of Resident 96's MARs, dated March, April and May 2025, revealed that there was no documented evidence that staff flushed the resident's PICC with the 10 ml of NSS during the day shift on April 22 and May 1; during the evening shift on March 22, 25 and 27; and during the night shift on April 8, 9, and 24, and May 8 and 13. Interview with the Director of Nursing on May 15, 2025, at 11:15 a.m. confirmed that there was no documented evidence that Resident 96's midline and PICC was flushed with the 10 ml of NSS every shift as per facility policy and as per the physician's orders on the above-mentioned dates and shifts. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of nurse aides' dates of hire and their most recent performance review dates, it was determined that the facility failed to complete annual nurse aide performance evaluations for two of three nurse aides reviewed (Nurse Aides 6, 7). Findings include: A list of nurse aides provided by the facility revealed that based on their months and days of hire, an annual performance evaluation was due in November 2024 for Nurse Aide 6 and in January 2025 for Nurse Aide 7. However, there was no documented evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. Interview with the Nursing Home Administrator on May 14, 2025, at 12:51 confirmed that she could provide no evidence that annual performance evaluations were completed as required for Nurse Aides 6 and 7. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of facility policies and information provided by the facility, as well as observations and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding temperatures for safe food handling, dated January 31, 2024, revealed that the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). All cold food items must be stored and served at a temperature of 41 degrees F or below. An interview with Resident 51 on May 12, 2025, at 1:10 p.m. indicated that his meals are often cold when his tray arrives. His room was toward the end of the hall and he indicated that it is often one of the last trays delivered. Observations of the lunch meal service in the main kitchen on May 13, 2024, revealed that the second north unit cart containing a test tray left the main kitchen at 12:30 p.m. and arrived on north unit at 12:31 p.m. Trays were passed to the residents that were in their rooms beginning at 12:41 p.m. and the last resident was served at 12:57 p.m. The test tray was removed from the cart at 12:59 p.m. and the temperature of the soda was 51.5 degrees F, the chicken was 131.5 degrees F, the carrots were 125.4 degrees F, and the potatoes were 133.8 degrees F. The soda was warm and the chicken, carrots and potatoes were cold and not at a palatable or appetizing temperature. A council meeting with approximately ten residents was held on May 14, 2025. They indicated that it took too long to get their food, and when it did arrive it was often cold. Interview with the Dietary Director at the time of observation confirmed that the soda, chicken, carrots and potatoes on the test tray, were not at an appetizing temperature. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary Services.

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending June 27, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 15, 2025, identified repeated deficiencies related to failure to develop and implement comprehensive care plans, failure to provide quality of care, failure to provide a safe environment that is free of accident hazards, failure to provide appropriate treatment and services for residents with dementia, and failure to maintain compliance with the regulation regarding infection control. The facility's plans of correction for deficiencies regarding developing and implementing comprehensive care plans, cited during the survey ending June 27, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 27, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care. The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending June 27, 2024, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. The facility's plan of correction for a deficiency regarding appropriate treatment and services for residents with dementia, cited during the survey ending June 27, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F744, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding appropriate treatment and services for residents with dementia. The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending June 27, 2024, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding infection control. Refer to F656, F684, F689, F744, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain their infection prevention and control program for hand hygiene during wound care for one of 49 residents reviewed (Resident 59). Findings include: The facility's policy regarding hand hygiene, dated January 31, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated March 31, 2025, indicated that the resident was understood and able to understand others. Physician's orders for Resident 59, dated May 7, 2025, included an order to cleanse the right heel surgical wound thoroughly with Vashe (a wound cleanser) and gauze. Apply silver calcium alginate (a type of silver infused wound dressing) on the wound bed, then cover with an ABD and wrap with kerlix and tape; perform daily and as needed. A care plan for the resident, dated April 26, 2025, revealed that the resident had impaired skin integrity related to multiple surgical wounds. Observations on May 15, 2025, at 8:36 a.m. revealed that Licensed Practical Nurse 8 donned a gown and gloves and with scissors she removed Resident 59's right heel dressing; then without removing her gloves and performing hand hygiene, she cleansed the area with Vashe and gauze. She then applied silver calcium alginate to the wound bed, covered the area with an ABD and wrapped kerlix (gauze) around the resident's heel, and taped the dressing closed. She then gathered her garbage, removed her gloves, and washed her hands. Interview with Licensed Practical Nurse 8 on May 15, 2025, at 8:36 a.m. confirmed that while performing wound care on Resident 59, she removed the soiled dressing and without changing her gloves and hand sanitizing, she went on to perform clean wound care. Interview with the Director of Nursing on May 15, 2025, at 10:25 a.m. confirmed that Licensed Practical Nurse 8 should have removed her gloves, sanitized her hands, and donned new gloves after removing the old dressing and before placing the new one. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and cleaning schedules/documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that essential kitchen equipment was maintained in a safe operating condition. Findings include: The facility's policy regarding routine stovetop cleaning, dated January 31, 2025, indicated that in order to keep all equipment at optimal levels of functioning and cleanliness, a routine cleaning schedule would be followed. Observations of the kitchen stove top on May 12, 2025, at 9:46 a.m. and May 13, 2025, at 8:38 a.m. and 1:37 p.m., revealed that there was a thick accumulation of black grease on and around four out of six stove top burners. These burners were located next to the grill area on the stovetop. Review of the kitchen cleaning schedule for April and May 2025 indicated that the stovetop was to be cleaned monthly. Interview with the Dietary Manager on May 14, 2025, at 11:08 a.m. confirmed that there was a large accumulation of heavy grease on and around four of the stovetop burners. She indicated that on April 1, 2025, the stovetop was cleaned and that it should have been cleaned again on May 1, 2025 and it was not. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code 211.6(c) Dietary Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for one of 49 residents reviewed (Resident 17) who were at risk for falls, and failed to ensure that other residents' environment remained free of accident hazards from a resident with aggressive behaviors for one of 49 residents reviewed (Resident 93). Findings include: The facility's policy regarding fall prevention and management, dated January 31, 2025, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors. The [NAME], point of care and point of care tasks will reflect all safety devices utilized as ordered. The care plan will be updated to reflect resident-specific safety needs and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated March 13, 2025, revealed that the resident was cognitively impaired, required substantial assistance for bed mobility, was dependent with transfers, had a fall with a major injury since the prior assessment, and had diagnoses that included Alzheimer's dementia. Physician's orders for Resident 17, dated November 14, 2024, included an order for staff to keep the resident's bed in the lowest position with landing strips beside the bed when the resident was in bed. The current fall risk care plan for Resident 17 included an intervention to keep the resident's bed in the lowest position with landing strips beside the bed when the resident was in bed. Observations of Resident 17 on May 12, 2025, at 12:20 p.m. revealed that the resident was in bed with a fall mat on the floor to the left of her bed. Her bedside table was to the right of her bed, and a fall mat was observed on the floor on the other side of bedside table, not on the floor beside her bed. Interview with Licensed Practical Nurse 2 on May 12, 2025, 12:32 p.m. confirmed that Resident 17's fall mat was not on the floor beside the right side of her bed. She stated that the fall mat was probably not at bedside because sometimes the bedside table is not easy to move on the fall mat. Interview with the Director of Nursing on May 12, 2025, at 3:47 p.m. confirmed that Resident 17's fall mat should have been next to the resident's bed on the right side. The facility's policy regarding dementia care, dated January 31, 2025, indicated that managing safety in residents living with dementia can be challenging secondary to cognitive impairment. Implementing interventions for safety are instituted on a case-by-case basis. A quarterly MDS assessment for Resident 93, dated December 18, 2024, revealed that the resident was severely cognitively impaired, displayed physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred one to three days during the review period, wandered which occurred daily, and had a diagnosis of dementia. A quarterly MDS assessment for Resident 93, dated March 19, 2025, revealed that the resident was severely cognitively impaired and wandered daily. A care plan for Resident 93, dated August 15, 2024, revealed that the resident was not able to make leisure choices. The resident's daughter stated that he does like listening to music, being outdoors, and conversing/being around others. She stated he does like to keep busy as he always thinks he is working. She stated that him doing things with groups of people was very important as he does like to be around others. Activities department will offer supportive visits, encourage independent leisure pursuits, and invite/assist in transporting to/from recreational programs of potential interest while respecting his right to decline. Staff was to offer diversional therapeutic tasks when the resident displays increased behaviors. Have different tasks available after 30 minutes if behaviors increase or do not change. Offer recreational programs and leisure activities that correlate to resident's interests such as music/Catholic programs, therapeutic tasks, outdoor activities, socials, some active games. A care plan, dated November 11, 2024, revealed that the resident has the potential for behaviors such as agitation with other residents causing confrontation episodes, as well as pacing and using the restroom in public places within the unit. Staff was to offer activities that will grab his attention, such as a movie. When the resident begins to pace it is usually an indication that he is getting increasingly agitated. Remove the resident from the area that might be causing the increased agitation; however, keep within eyesight of staff to allow to monitor behaviors. The resident was a mechanic and enjoys working with his hands, attempt to redirect with tasks that involve hand movement when able. A nursing note for Resident 93, dated August 20, 2024, revealed that the resident wandered all shift and has not sat down anywhere, yet. The resident was often seen pushing other residents in their wheelchairs and turning tray tables upside down and trying to disassemble them, etc. Tried to distract and redirect the resident and has not been successful as the resident has no interest in what staff was saying and no interest in food or drinks, as well as no interest in sitting, television, etc. Nursing notes for Resident 93, dated September 10, 2024, at 9:43 p.m. and September 11, 2024, at 8:59 p.m. revealed that the resident grabbed another resident's wrist and grabbed another resident's forearm. Nursing notes for Resident 93, dated October 12, through 22, 2024, revealed that the resident had been wandering into other residents' rooms and rummaging through their belongings, as well as pushing other residents in their wheelchairs. A nursing note for Resident 93, dated October 28, 2024, revealed that the resident was attempting to push a female resident in her wheelchair to the dining table. The female resident requested him to stop. The resident got agitated and wrapped his hands around her head and poked her right eye. Nursing notes for Resident 93, dated November 4 through 7, 2024, revealed that the resident had been wandering into other residents' rooms and rummaging through their belongings. A nursing note for Resident 93, dated November 9, 2024, revealed that the resident was in another female resident's room, and it was believed that resident may have hit the female resident in the face. This was unwitnessed, but staff believes that they heard a pop as if from a punch and then saw female resident holding her face. Attempted to interview resident about the incident; however, the resident was cognitively unable to recall an event. An assessment was completed on both of resident's hands, as there was no way to know which hand was used. There were no visible injuries to either of resident's hands. A nursing note for Resident 93, dated November 14, 2024, revealed that the resident was found in another resident's room punching the other resident in their arm. A nursing note for Resident 93, dated December 14, 2024, revealed that the resident had episodes of wandering. The resident went up to a female resident and locked his hand with her and would not let go. Nursing notes for Resident 93, dated December 17, 2024, through March 24, 2025, revealed that the resident was wandering in and out of other residents' rooms, at times pushing other residents in their wheelchairs or urinating in other residents' rooms, as well as tinkering with stuff as if he was repairing the item. A nursing note for Resident 93, dated March 25, 2025, revealed that the resident attempted to take another resident's walker and attempted to push another resident in their wheelchair. A nursing note for Resident 93, dated April 1, 2025, revealed that the resident had punched another male resident in the face. The resident is not oriented and according to staff looked to be attempting to repair the other resident's wheelchair. Nursing notes for Resident 93, dated April 2, through 10, 2025, revealed that the resident had been wandering in and out of other residents' rooms. A nursing note for Resident 93, dated April 11, 2025, revealed that the resident was wandering the unit as usual. At one point he grabbed onto another resident's wheelchair on the wheel. The other resident told him to leave her wheelchair alone, but he would not let go. As the other resident tried to move away, the resident complained that this was hurting his hand. The resident's hand was removed from the wheelchair by staff, and the resident was reminded that the other resident does not want him touching her chair. The resident continued to grip the wheelchair and the nurse's wrist and became angry, saying You never let me do anything! A nursing note for Resident 93, dated May 4, 2025, revealed that the resident was pushing another resident in her wheelchair. The other resident had asked the Resident 93 to stop, but he continued to push. The other resident pushed back with her legs and Resident 93 pushed forward harder. The other resident had reached both of her hands back to slap Resident 93 in the face and did make contact. After the other resident slapped Resident 93, he drew his fist back like he was going to hit the other resident. A nursing note for Resident 93, dated May 5, 2025, revealed that the resident was trying to push another female resident's wheelchair with her in it. She asked him not to, but he kept trying to push her. She reached back and slapped the resident in the face with both hands on both sides of his face. He did stop and the female resident hurried and went into her bedroom to get away from male resident. There was no documented evidence that any new interventions were attempted to address Resident 93's wandering and increased resident-to-resident altercations except to have his medications adjusted, and a hospital admission from November 14, 2024, through December 15, 2024, for his increased behaviors. Interview with the Director of Nursing on May 14, 2025, at 2:05 p.m. confirmed that there was no documented evidence that any new interventions were attempted to address Resident 93's wandering and increased resident-to-resident altercations except to have his medications adjusted, and a hospital admission from November 14, 2024, through December 15, 2024, for his increased behaviors. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical record, as well as and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for two of 49 residents reviewed (Residents 38, 93) who had dementia. Findings include: The facility's policy regarding dementia care, dated January 31, 2025, indicated that residents living with dementia may experience agitation, aggression, distress or psychosis. Consideration should be given to non-pharmacological interventions prior to instituting a pharmacological treatment. It is the intent to use the lowest effective dose and utilize for the shortest time possible. A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated February 21, 2025, revealed that the resident was severely cognitively impaired, exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred one to three days, and had a diagnosis which included Alzheimer's disease and adjustment disorder with mixed anxiety and depressed mood. A care plan for the resident, dated February 21, 2025, revealed that the resident chooses to spend most of his leisure time watching some television and listening to music on the lane. He will partake in some group activities as desired such as music programs, outdoor activities when it is nice outside, and some socials at times. Activities department will offer supportive visits, encourage independent leisure pursuits, and invite/assist in transporting to/from recreational programs of potential interest while respecting his right to decline. A care plan, dated June 27, 2023, revealed that the resident displays behaviors of wandering, being agitated with staff/in general, refusing care, rummaging through other residents' items, peeing on the floor, and calling 911 related to Alzheimer's disease, mood disorder, and insomnia. His behaviors may be triggered by disorientation to place. A nursing note for Resident 38, dated September 27, 2024, revealed that the resident was anxious and restless. He was pacing the unit and upset with other residents because he believes they were his employees, and they are not listening to him. He told some of the residents that they were fired and they needed to leave. A nursing note for Resident 38, dated October 12, 2024, revealed that the resident was agitated at the beginning of the shift due to the bar still being open and people were passed out at the bar. The resident was restless and wandering into other residents' rooms. The resident got irritated with staff and other residents that did not help him try to find a car. A nursing note for Resident 38, dated October 16, 2024, revealed that the resident was agitated and anxious. He was wandering the hall, in and out of other residents' rooms. He was taking other residents' cloths and putting them on. He went into another resident's room and emptied the closet and dresser onto the floor and beds. A nursing note for Resident 38, dated October 17, 2024, revealed that the resident was pleasant throughout shift until bedtime. He got into a female resident's bed and would not get out of her bed. He was vulgar with staff, and he then spent the next hour pacing the hallways attempting to go into other residents' rooms. Nursing notes for Resident 38, dated October 31, 2024, through November 30, 2024, revealed that the resident was agitated and anxious at times wandering into other residents' rooms and messing with their belongings. Nursing notes for Resident 38, dated December 8, 2024, through December 27, 2024, revealed that the resident was agitated and anxious at times wandering into other residents' rooms and messing with their belongings. He was even caught wearing other residents' clothing. Nursing notes for Resident 38, dated January 1, through 21, 2025, revealed that the resident had been wandering in and out of other residents' rooms looking for something to do. There was no documented evidence that any new interventions were attempted to address Resident 38's wandering except to have his medications adjusted. Interview with the Director of Nursing on May 15, 2025, at 10:25 a.m. confirmed that there was no documented evidence that any new interventions were attempted to address Resident 38's wandering except to have his medications adjusted. A quarterly MDS assessment for Resident 93, dated December 18, 2024, revealed that the resident was severely cognitively impaired, displayed physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred one to three days during the review period, wandered which occurred daily, and had a diagnosis which included dementia. A quarterly MDS assessment for Resident 93, dated March 19, 2025, revealed that the resident was severely cognitively impaired and wandered daily. A care plan for the resident, dated August 15, 2024, revealed that the resident was not able to make leisure choices. The resident's daughter stated that he does like listening to music, being outdoors, and conversing/being around others. She stated he does like to keep busy as he always thinks he is working. She stated that him doing things with groups of people was very important as he does like to be around others. Activities department will offer supportive visits, encourage independent leisure pursuits, and invite/assist in transporting to/from recreational programs of potential interest while respecting his right to decline. Staff was to offer diversional therapeutic tasks when resident displays increased behaviors. Have different tasks available after 30 minutes if behaviors increase or do not change. Offer recreational programs and leisure activities that correlate to resident's interests such as music/Catholic programs, therapeutic tasks, outdoor activities, socials, some active games. A care plan, dated November 11, 2024, revealed that the resident has the potential for behaviors such as agitation with other residents causing confrontation episodes, as well as pacing and using the restroom in public places within the unit. Staff was to offer activities that will grab his attention, such as a movie. When the resident begins to pace that is usually an indication that he is getting increasingly agitated, remove the resident from the area that might be causing the increased agitation; however, keep within eyesight of staff to allow to monitor behaviors. The resident was a mechanic and enjoys working with his hands, attempt to redirect with tasks that involve hand movement when able. A nursing note for Resident 93, dated August 20, 2024, revealed that the resident wandered all shift. That he has not sat down anywhere, yet. The resident was often seen pushing other residents in their wheelchairs, turning tray tables upside down and trying to disassemble them, etc. Tried to distract and redirect the resident and has not been successful as the resident has no interest in what staff was saying, and no interest in food or drinks, as well as no interest in sitting, T.V., etc. Nursing notes for Resident 93, dated September 10, 2024, at 9:43 p.m. and September 11, 2024, at 8:59 p.m. revealed that the resident grabbed another resident's wrist and grabbed another resident's forearm. Nursing notes for Resident 93, dated October 12 through 22, 2024, revealed that the resident had been wandering into other residents' rooms and rummaging through their belongings, as well as pushing other residents in their wheelchairs. Nursing notes for Resident 93, dated November 4 through 7, 2024, revealed that the resident had been wandering into other residents' rooms and rummaging through their belongings. A nursing note for Resident 93, dated December 14, 2024, revealed that the resident had episodes of wandering. The resident went up to a female resident and locked his hand with her and would not let go. Nursing notes for Resident 93, dated December 17, 2024, through March 24, 2025, revealed that the resident was wandering in and out of other residents' rooms, at times pushing other residents in their wheelchairs or urinating in other residents' rooms, as well as tinkering with stuff as if he was repairing the item. A nursing note for Resident 93, dated March 25, 2025, revealed that the resident attempted to take another resident's walker and attempted to push another resident in their wheelchair. Nursing notes for Resident 93, dated April 2 through 10, 2025, revealed that the resident had been wandering in and out of other residents' rooms. A nursing note for Resident 93, dated April 11, 2025, revealed that the resident was wandering the unit as usual. At one point he grabbed onto another resident's wheelchair on the wheel. The other resident told him to leave her wheelchair alone, but he would not let go. As the other resident tried to move away, the resident complained that this was hurting his hand. The resident's hand was removed from the wheelchair by staff, and the resident was reminded that the other resident does not want him touching her chair. The resident continued to grip the wheelchair, and the nurse's wrist and became angry, saying You never let me do anything! There was no documented evidence that any new interventions were attempted to address Resident 93's wandering except to have his medications adjusted, and a hospital admission from November 14, 2024, through December 15, 2024, for his increased behaviors. Interview with the Director of Nursing on May 14, 2025, at 2:05 p.m. confirmed that there was no documented evidence that any new interventions were attempted to address Resident 93's wandering except to have his medications adjusted, and a hospital admission from November 14, 2024, through December 15, 2024, for his increased behaviors. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 49 residents reviewed (Resident 62). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 11, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and was taking an opioid medication (medications with the potential to be abused used to treat pain). Physician's orders for Resident 62, dated January 27, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (a narcotic pain medication) every six hours as needed for moderate to severe pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 62, dated February, March and April, 2025, revealed that a 50 mg tablet of Tramadol was signed out on February 22 at 7:00 p.m.; March 1 at 7:22 p.m.; March 7 at 7:30 p.m.; March 9 at 7:45 p.m.; April 5 at 7:30 p.m. and April 7 at 7:15 p.m. However, there was no documented evidence in Resident 62's clinical record, including the Medication Administration Record (MAR), that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on May 15, 2025, at 11:15 a.m. confirmed that there was no documented evidence in Resident 62's clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about a resident requiring oxygen for one of five residents reviewed (Resident 2). Findings include: The facility's policy regarding notification, dated January 25, 2024, revealed that staff will inform the resident's responsible party when there is a significant change in the resident's care or condition timely. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 8, 2024, revealed that the resident was cognitively impaired and required assistance from staff for daily care needs. A nursing note for Resident 2, dated August 11, 2024, revealed that the resident was having a hard time breathing and was coughing harshly. Staff applied oxygen for his comfort. A nursing note for Resident 2, dated August 12, 2024, revealed that the resident's family arrived and were concerned that he was wearing oxygen, and they had not been notified that he required oxygen. There was no documented evidence that Resident 2's responsible party was notified about the coughing episode or that he required oxygen at that time. Interview with the Director of Nursing on August 27, 2024, at 11:51 a.m. confirmed that Resident 2's responsible party was not notified about the coughing episode and the application of oxygen. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to enhance each resident's dignity by failing to provide clean durable medical equipment for one of 40 residents reviewed (Resident 105). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 105, dated May 23, 2024, revealed that the resident was somewhat understood and could somewhat understand others, and was dependent on staff for care care needs, including feeding assistance. A care plan for Resident 105 regarding an alteration in neurological status related to a cervical 4/cervical 5 surgical repair with discectomy (surgical removal of abnormal disc in the spine) indicated that the resident had a hard cervical collar (neck brace). Physician's orders for Resident 105, dated May 17, 2024, included an order for the resident to have a hard cervical collar in place at all time until further instructions were obtained from neurosurgery. Observations on June 24, 2024, at 12:17 p.m.; June 26, 2024, at 3:17 p.m.; and June 27, 2024, at 2:20 p.m. revealed that Resident 105's hard cervical collar had discoloration and a brown, red, removable substance on the padded areas around the chin, neck, and mouth areas. Interview with Nurse Aide 2 on June 27, 2024, at 2:20 p.m. confirmed that the neck brace was not clean. She explained that Resident 105 required feeding assistance following her surgery and that she tends to drool and food will fall out of her mouth. Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that Resident 105's neck brace was soiled and not clean. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to accommodate the residents' needs by failing to ensure the proper positioning needed for eating for one of 40 residents reviewed (Resident 10) who had nutritional and self-care concerns. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated June 7, 2024, revealed that the resident was usually understood, could usually understand others, had a diagnosis which included dementia, had a weight loss of 5 percent or more in the last month and/or a weight loss of 10 percent or more in last six months, was not on a prescribed weight-loss regimen, and received a therapeutic diet (e.g., low salt, diabetic, low cholesterol). A care plan for the resident, dated November 16, 2020, revealed that the resident had a potential for weight fluctuations related to variable PO (by mouth) intake. The resident was to be up in a Broda chair (an adaptive wheelchair) for breakfast then laid back down after lunch, then back up for supper. Physician's orders for Resident 10, dated February 27, 2024, included an order for the resident to be up in Broda chair for breakfast then laid back down after lunch then back up for supper, and the resident was to always have a Broda chair for mobility with leg rests. Observations in the third floor dining room during the lunch meals on June 24, 2024, at 12:12 p.m. and June 25, 2024, at 12:08 p.m. revealed that Resident 10 was sitting in a Broda chair at a table across from a male resident at the same table. The resident's Broda chair was in a slightly reclined position with the leg rests in place, which would not allow the resident's Broda chair to be placed close to the edge of the table. The table was raised to allow the resident's Broda chair and the male resident's specialized wheelchair to fit under the table. The resident had to fully extend her arm to obtain her food from the plate. The resident was observed placing her fork into the handle of a flow cup (a cup with a spouted lid that regulates the flow for controlled release of liquids) to pull the flow cup to the edge of the table, so she could grab the handle of the flow cup to take a drink. The resident also had small bowls of food beyond her plate that she was not able to reach. Interview with Licensed Practical Nurse 1 on June 25, 2024, at 12:41 p.m. confirmed that Resident 10's Broda chair would not sit up any straighter and that the table was raised in a higher position. Interview with the Dietitian on June 25, 2024, at 1:27 p.m. revealed that Resident 10's table needs to be in a higher position as to allow her Broda chair and the male resident's specialized wheelchair to be placed under the table. She indicated that they could have therapy re-evaluate the resident to see if there could be anything else done with her positioning during the meals. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for a maintenance nursing program were followed for one of 40 residents reviewed (Resident 22) and failed to complete wound treatments as ordered for one of 40 residents reviewed (Resident 48). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated May 17, 2024, revealed that the resident was sometimes understood and sometimes able to understand others and required assistance with care needs. A care plan for Resident 22, dated April 19, 2011, indicated that the resident was to receive a maintenance nursing program consisting of active range of motion (person can actively range a part of the body) to her right lower extremity and passive range of motion (person needs assistance from someone else to range a part of the body) to her left lower extremity twice daily with a.m. and p.m. care. Physician's orders for Resident 22, dated September 16, 2021, included an order for the resident to receive a maintenance nursing program consisting of active range of motion to her right lower extremity and passive range of motion to her left lower extremity twice daily with a.m. and p.m. care. Documentation in Resident 22's clinical record for May 2024 revealed that the maintenance nursing program consisting of active range of motion to her right lower extremity and passive range of motion to her left lower extremity was not documented as completed on the evening shift for April 3 and April 5, 2024, and documented as not applicable (NA) on the evening shift for May 4, 14, 20, 24, 28, 29 and 30. Documentation in Resident 22's clinical record for June 2024 revealed that the maintenance nursing program consisting of active range of motion to her right lower extremity and passive range of motion to her left lower extremity was not documented as completed on the day shift for June 3 and was documented as not applicable (NA) on the evening shifts for June 1, 2, 5, 6, 8, 10, 11, 12, 13, 15, 23, 24, 25 and 26. There was no documented evidence that the maintenance nursing program consisting of active range of motion to her right lower extremity and passive range of motion to her left lower extremity was completed as ordered on the above mentioned dates and shifts. Interview with the Director of Nursing on June 27, 2024, at 2:59 p.m. confirmed that the nursing maintenance program for Resident 22 was not completed as ordered and it should have been. She indicated she was not sure why the staff would be charting not applicable (NA) as they have been educated on this. The facility's policy for on Medication Administration Documentation, dated January 25, 2024, indicated that topical medications used in treatments are listed on the Electronic Treatment Administration Record (ETAR) and the licensed nurse will record the treatment was administered per the physician's order on the ETAR directly after the treatment has been completed. A quarterly MDS assessment for Resident 48, dated May 24, 2024, revealed that the resident was cognitively intact, was understood and understands others, required assistance for care needs, had a surgical wound, and was receiving an antibiotic. Physician's orders for Resident 48, dated April 18, 2024, indicated that the resident's right great toe amputation incision was to be cleaned with Vashe (wound cleanser) and gauze and pat dry, apply silver calcium alginate (dressing used to aid in wound healing) to incision, cover with abdominal dressing (dressing used to absorb drainage), and wrap with kling (used to secure dressings in place) daily every day shift and as needed for soilage. There was no documented evidence on Resident 48's ETARs for April 2024 that the treatment to his right great toe amputation incision was completed as ordered on April 18, 2024. Physician's orders for Resident 48, dated May 23, 2024, indicated that the resident's right great toe amputation incision was to be cleaned well with Vashe and gauze, apply a piece of silver calcium alginate to open areas of the incision, and cover with a 5.0 inch x 5.0 inch foam dressing daily every day shift. There was no documented evidence on Resident 48's ETARs for May 2024 that the treatment to his right great toe amputation incision was completed as ordered on May 24, 2024. Interview with the Director of Nursing on June 27, 2024, at 1:41 p.m. confirmed there was no documented evidence that the treatments were done as ordered on the above mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 40 residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 28, 2024, revealed that the resident was understood, able to understand others, required assistance with care needs, and had two Stage 4 pressure ulcers (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle). Physician's orders for Resident 2, dated January 25, 2024, included an order for the staff to clean the wound to the left ischium with Vashe wound cleanser (used to cleanse and debride wounds) and pat dry, pack wound with a piece of silver calcium alginate (dressing used to aid in wound healing), and cover with a foam dressing daily every day shift. A review of the resident's Treatment Administration Record (TAR) for April 2024 revealed that the resident did not receive the treatment on April 18, 2024, as ordered. Physician's orders for Resident 2, dated March 7, 2024, included an order for the staff to apply no-sting barrier film (used to protect broken or intact skin from irritation) to scar to left posterior thigh and cover with a foam dressing every other day on day shift and as needed for dislodgement. A review of the resident's TAR for April 2024 revealed that the resident did not receive the treatment on April 18, 2024, as ordered. Physician's orders for Resident 2, dated April 11, 2024, included an order for the staff to apply no-sting barrier film to a healed scar to left gluteal, allow to dry, and cover with a foam dressing daily every day shift to prevent the wound from reopening. A review of the resident's TAR for April 2024 revealed that the resident did not receive the treatment on April 18, 2024, as ordered. Physician's orders for Resident 2, dated May 16, 2024, included an order for the staff to clean the wound to the left ischium with Vashe wound cleanser, pat dry, apply skin prep (forms a barrier between skin and adhesives) to peri wound redness, pack with a piece of silver calcium alginate, cover with a Zetuvit foam dressing (absorbent dressing for wounds with drainage) daily every day shift, and peel back the foam to left posterior thigh to make sure wound remained healed daily. A review of the resident's TAR for May 2024 revealed that the resident did not receive the treatment on May 24, 2024, as ordered. Physician's orders for Resident 2, dated May 18, 2024, included an order for the staff to apply no-sting barrier film to the wound and peri area to left posterior thigh and cover with a foam dressing every three days on day shift and as needed for dislodgement. A review of the resident's TAR for May 2024 revealed that the resident did not receive the treatment on May 24, 2024, as ordered. Physician's orders for Resident 2, dated May 23, 2024, included an order for the staff to clean the left gluteal with Vashe and gauze, pat dry, apply skin prep to the wound and peri-wound, apply Xeroform (non-adherent gauze dressing that prevents air and moisture loss to promote wound healing) with collagen powder (stimulates wound healing) to the wound bed, and cover with a foam dressing daily every day shift to prevent that wound from reopening. A review of the resident's TAR for May 2024 revealed that the resident did not receive the treatment on May 24, 2024, as ordered. Physician's orders for Resident 2, dated May 30, 2024, included an order for the staff to clean the wound to the left ischium with Vashe wound cleanser, apply skin prep to peri wound, pack wound with a piece of silver calcium alginate, and cover with a Zetuvit foam dressing daily every day shift. A review of the resident's TAR for June 2024 revealed that the resident did not receive the treatment on June 16, 2024 as ordered. Physician's orders for Resident 2, dated June 1, 2024, included an order for the staff to apply skin prep to left posterior thigh and cover with a foam dressing every three days on day shift for preventative care. A review of the resident's TAR for June 2024 revealed that the resident did not receive the treatment on June 16, 2024, as ordered. Physician's orders for Resident 2, dated June 1, 2024, included an order for the staff to clean left gluteal with Vashe and gauze, pat dry, apply skin prep to wound and peri-wound, apply foam dressing over the scar, and change every three days on day shift and as needed for dislodgement/soilage. A review of the resident's TAR for June 2024 revealed that the resident did not receive the treatment on June 16, 2024, as ordered. Interview with the Director of Nursing on June 27, 2024, at 2:23 p.m. confirmed there was no documented evidence that Resident 2 received wound treatments as ordered to the areas listed above on dates listed above. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 40 residents reviewed (Resident 50). Findings include: The facility's policy regarding Trauma Informed Care, dated January 25, 2024, revealed that upon admission the facility will assess each resident to ensure they receive appropriate treatment and services. A questionnaire will be utilized for each resident by the social services department to identify any trauma and/or post-traumatic stress disorder and to gather trigger information, so that our understanding of their traumatic events can be detailed and specific. Additional information may be obtained from the medical record, physical and emotional assessments, from the resident, from family members who have shared this information. Resident input will be solicited, and the resident will be involved in the care planning process, if able. An evaluation of the information received will be done to identify those risk factors/areas that we would want to include in our approaches with the resident. Social services personnel, in coordination with our interdisciplinary care team, will review the information given and work to develop methodologies and approaches to mitigate/eliminate those triggers. However, the facility's policy did not address current residents that had a diagnosis of PTSD. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated April 2, 2024, revealed that the resident was usually understood, could usually understand others, and had diagnoses that included dementia, and PTSD. A care plan for the resident, dated January 19, 2024, revealed that the resident was a high risk for falls due Parkinson's disease, a history of falls, and cognitive status fluctuations, with a past occupation of being a Navy Seal who dismantled bombs during war time. Alarms (historically) discontinued due to the resident constantly dismantling and causing him anxiety/triggers PTSD. A nursing note for Resident 50, dated March 3, 2024, revealed that after a quick nap, the resident had an episode of PTSD starting with aggressive/physical swinging of his fist. Staff tried to calmly redirect the resident, check and change him, as well as offering him soda. The resident was not responding to staff and the PTSD was increasing. He was in the process of trying to self-transfer from bed to a standing position. Medication was applied and with a calm wait period the resident deescalated, became more at ease, and staff quickly finished dressing and use a lift and sling to safely place resident into his chair, and he was wheeled into the hall for staff to observe his actions. However, there was no documented evidence that the facility completed a questionnaire for a history of trauma for Resident 50 to identify specific triggers that could re-traumatize the resident. Interview with the Nursing Home Administrator on June 26, 2024, at 12:40 p.m. confirmed that there was no documented evidence of the questionnaire for a history of trauma being completed for Resident 50. He indicated that they only do the questionnaire for a history of trauma when a resident is a new admission to the facility. He indicated that they have not performed the questionnaire for a history of trauma on current residents. 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for one of 40 residents reviewed (Resident 30) who had dementia. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated [DATE], revealed that the resident was sometimes understood, could sometimes understand others, and had diagnosis that included dementia and Parkinson's disease. A care plan for the resident, dated [DATE], revealed that the resident has an impaired cognitive function or impaired thought processes related to Parkinson's disease. Staff were to provide the resident with a homelike environment: visible clocks, a calendar, low-glare light, consistent care routines, familiar objects, and reduced sensory noise. Physician's orders for Resident 30, dated [DATE], and discontinued on [DATE], included an order for the resident to receive one 25 milligram (mg) tablet of Sertraline (a medication used for depression, panic disorders, obsessive-compulsive disorder, and social anxiety disorder) one time a day for depression. Physician's orders for Resident 30, dated [DATE], included an order for the resident to receive one 50 mg tablet of Trazodone (used to treat depression) at bedtime for restlessness. Physician's orders for Resident 30, dated [DATE], included an order for the resident to receive one 25 mg tablet of Trazodone three times a day as needed for restlessness. Physician's orders for Resident 30, dated [DATE], included an order for the resident to receive one 50 mg tablet of Sertraline one time a day for major depressive disorder (a mood disorder that interferes with daily life). A nursing note for Resident 30, dated [DATE], revealed that the writer received a call from the resident's niece. She stated that the resident calls her every morning at 5:30 a.m. and asks her to call the police as there are things going on here. He has told her that staff put people in the basement for being bad, and that the man across the hall wants to beat him up. The resident's urine was recently tested and was negative. She feels that his dementia has progressed. The writer advised her that they would reach out to the physician. A nursing note for Resident 30, dated [DATE], revealed that his as-needed Trazodone was given. The resident voiced that the resident across the hall was screaming all day and into the night, and that it reminds him of his dead daughter. The resident said that his daughter is across the hall screaming for help and that she took too much dope. The resident said he is getting out of bed to go across the hall to let his daughter sleep in his bed tonight. A nursing note for Resident 30, dated [DATE], revealed that the resident's niece phoned in regard to the resident's paranoid behaviors. It was explained to her that the resident was ordered Trazadone 50 mg three times per day, and she stated that this medication was for sleep. She also wanted him moved to a different unit. Advised her that she would have to speak with social services regarding any room changes. A nursing note for Resident 30, dated [DATE], at 10:30 a.m. revealed that the writer instructed the resident to continue to self-propel down the hallway, as he is sitting outside of Resident 18's room, staring at her. I do believe that this is upsetting to Resident 18. A nursing note at 11:44 a.m. revealed that the resident thinks his deceased daughter is in the room across the hall from him and he yells across the hall for most of shift. Medication for given for restlessness/behaviors was not effective. The resident was yelling to get his lawyer because he is not permitted to see his daughter and she needs attention. When Resident 18 yells out or turns up her television, the resident becomes confused and agitated. A nursing note for Resident 30, dated [DATE], revealed that the resident began yelling at 5:20 a.m. that morning. The resident was yelling toward the hallway stating, Come in here and I'll tell you everything I know, multiple times. The resident was unable to be redirected at this time. The resident appeared to be confused at that time. A social service note for Resident 30, dated [DATE], at 3:43 p.m. revealed that they spoke with the resident about moving rooms, due to his niece's request, who is also his power of attorney. The resident stated that he does not really want to move, but that he would think about it. He states that if it's quieter up there maybe I'll go. He informed the writer that he cannot sleep with a bunch of noise. The writer advised him that they understand and that they would let the staff up there know. The writer also advised him that it may be better up there for him due to the resident across the hall yelling and getting the resident all worked up. The resident said, Yeah, they are always fighting over there. Currently the resident across the hall's television is up too loud, and the resident voiced, See, don't you hear them yelling over there and fighting. The writer attempted to redirect the resident and let him know it was the television, but he did not think it was and insisted he hears them yelling. The writer advised the resident that they could move his rooms tonight if he is willing, and he stated that he would think about it. The writer informed the nurse aides of this. A social service note at 6:32 p.m. revealed that the writer called and updated the resident's niece with the status of the room change, as she requested a room change for the resident. The writer advised her that he was prompted about a room change, in which he stated that he is not sure he wants to do. He informed the writer that he would think about it and decide. He stated that if it is quiet up there, he would go up there, but he was not sure yet. The writer advised him to think about it and encouraged him to try it out, and if he truly did not like it, they could look at an alternative room placement. The resident's niece stated that she was not happy with that, that the resident is stating that he does not want to move because he calls her daily at 6:00 a.m. telling her he wants out of here because the television is too loud and the lady across the hallway is yelling and fighting. She stated that she wants him moved and she would like to speak with him if he does not move. She also asked what could be done if he does not want to move, and the writer advised the resident's niece that they were not sure that they could physically make him move if he does not want to, but that the writer would have to speak with administration and let her know. A nursing note for Resident 30, dated [DATE], revealed that the writer spoke with the resident, who was resting in bed. The writer asked him if he was ready to move upstairs today. He replied, No, I'm not going. Every time I have to pee, I have to S-H-I-T (spelling out the word) and I don't know how things will work up there. The writer assured him that upstairs is run the same, he would ring his bell for assistance from the staff. Again, he said No, maybe another day. A message was left with social services. A nursing note for Resident 30, dated [DATE], revealed that the resident was yelling out about his father being across the hall with his daughter (who is deceased ) saying tuck, which is an old slogan/joke he used to say to her when she would stay over at her grandfather's house. The writer noted that his roommate's television was on, and the volume was turned up fairly loud, as well as the television across the hall. The resident was provided with support by the writer and social services. The writer advised the resident that his daughter or father were not across the hall. The resident was shown that there was no one in the room across the hall aside from another resident. The writer spoke with the resident about his family and let the resident reminisce about his family who have passed away. The resident was offered a drink/snack, which was declined. The writer advised the resident to come out into the hallway and look out the window, as he enjoys looking outside. A nursing note for Resident 30, dated [DATE], revealed that the resident was seen by the Certified Registered Nurse Practitioner (CRNP - a registered nurse (RN) who has advanced education and clinical training in a health care specialty area) from Med Management today and orders were received to increase the resident's Sertraline to 50 mg daily and to administer Trazadone 25 mg three times a day as needed for restlessness for 30 days. A nursing note for Resident 30, dated [DATE], revealed that the resident was having increased confusion that shift. The resident cannot sleep due to another resident across the hall from his bedroom yelling repeatedly, whom he believed is his deceased daughter. The resident was unable to be reoriented or redirected via any attempted interventions. A nursing note for Resident 30, dated [DATE], revealed that the resident was yelling into room [ROOM NUMBER] looking to fight his son-in-law. He thinks that he is in the room. Tried to redirect; however, was not successful. A nursing note for Resident 30, dated [DATE], revealed that the resident's niece called today. She was concerned that the resident's dementia is getting worse and that the issue with the resident across the hall is getting worse. She was going to try to come up in a month or so to visit and maybe talk to her uncle and someone about him moving. He called her and was telling her about it. He believes at times the other resident is his daughter and has some confusion about it. A nursing note for Resident 30, dated [DATE], revealed that the resident was in his wheelchair sitting in front of Resident 18's room yelling in to stop talking about him. The resident yelled in and called Resident 18 a cocksucker. Resident 18 is sleeping, her television is on, and the volume is at an acceptable level. When attempting to redirect the resident he becomes aggressive and agitated, stating not to move him away from the room. He states that his niece pays for him to be there, and he can do what he wants to do. A nursing note for Resident 30, dated [DATE], revealed that the resident was having increased anxiety and anxiousness. The resident stated that someone in room [ROOM NUMBER] kept calling him a cocksucker all night long and he wants to confront the person. The behaviors from room [ROOM NUMBER] have caused a ripple effect with the resident. He was observed emotionally upset and agitated upon awakening this morning. Staff tried to redirect him, without any positive results, and the resident was verbally abusive and uncooperative with his care. A nursing note for Resident 30, dated [DATE], revealed that the resident's niece called to say she was on the phone with the resident for an hour. She was concerned about the bizarre conversation she had with him. He spoke a lot about his dead daughter, who he says was yelling in the bed across from his room. He also spoke of staff trying to take him out in a car with the motive to kill him. The resident's niece was assured that the resident sometimes does talk this way and is safe there. There was no documented evidence that any new interventions were attempted to address Resident 30's increased anxiety, anxiousness, and confusion toward Resident 18 when he refused to be moved to a different room except to have his Sertraline dose increased and added Trazodone three times a day as needed. Interview with the Director of Nursing on [DATE], at 11:33 a.m. confirmed that Resident 30 has had an increase in his behaviors due to Resident 18, that the resident had to have an increase in his Sertraline dose, as well as add Trazodone three times a day as needed, and that there were no other new interventions attempted to address the resident's increased anxiety, anxiousness, and confusion toward Resident 18 when he refused to be moved to a different room. She indicated that Resident 18 knows that the resident thinks she is his deceased daughter and will call out daddy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) surveys ending July 27, 2023, and April 10, 2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending June 27, 2024, identified repeated deficiencies related to a failure to accommodate a resident's needs, to develop comprehensive care plans, to update residents' care plans, and to ensure that the residents' environment remained free from accident hazards. The facility's plan of correction for a deficiency regarding a failure to accommodate a resident's needs, cited during the survey ending July 27, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F558, revealed that the QAPI committee was ineffective in correcting deficient practices related to accommodating a resident's needs. The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending April 10, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans. The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending April 10, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans. The facility's plans of correction for deficiencies regarding ensuring that the residents' environment remained free from accident hazards, cited during surveys ending July 27, 2023, and April 10, 2024, revealed that audits would be completed. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in correcting deficient practices related to ensuring that the residents' environment remained free from accident hazards. Cross refer to F558, F656, F657, F689. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 40 residents reviewed (Residents 17). Findings include: CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated May 13, 2024, revealed that the resident was clearly understood and could understand others, required assistance with care needs, and had a catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder). A care plan for Resident 17 regarding enhanced barrier precautions, dated April 30, 2024, revealed that the resident had EPB in place due to MDRO history and foley placement. Physician's orders for Resident 17, dated May 1, 2024, included an order for resident to receive enhanced barrier precautions due to foley catheter placement and history of MDRO every shift. Physician's orders for Resident 17, dated November 17, 2023, included orders to provide irrigation with 250 milliliters (ml) of normal saline as needed for leakage and blockage of the catheter. Observations of Resident 17 on June 24, 2024, at 12:47 p.m. revealed that the resident had signage at the entrance to her room to indicate that infection control measures for EBP were in place related to her catheter. Nurse Aide 7 was wearing gloves while draining the tea-colored catheter bag into a cylinder, then entered the bathroom. Nurse Aide 7 was not wearing a gown during the task of emptying the catheter bag. Interview with Nurse Aide 7 at the time of observations revealed that she only needed to wear a gown when providing care; however, Resident 17 was on enhanced precautions because she had a catheter. Interview with the Director of Nursing on June 27, 2024, at 1:18 p.m. confirmed that Resident 17 had EBP, and staff should have been wearing a gown to empty the catheter bag. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs for three of 40 residents reviewed (Residents 50, 62, 101). Findings include: The facility's policy for care planning, dated January 25, 2024, indicated that all residents will have an interim, comprehensive, and ongoing plan of care, which will be developed and reviewed by the interdisciplinary team and resident. The plan of care is a working tool and requires changes as needed to meet the residents needs. The resident is to be viewed as a whole to develop a blueprint for care. Unique characteristics and needs are to drive the process. It must be individualized, realistic, functional, and measurable at time frame for completion. All goals are to be related directly to the problem. It is to outline and provide directions to provide care for the resident to meet the goal. The facility's policy regarding Trauma Informed Care, dated January 25, 2024, revealed that the resident's input will be solicited, and the resident will be involved in the care planning process, if able. Trauma-specific interventions for a resident will be placed in their individualized, person-centered care plan upon admission and assessment. Care plans and interventions will be reviewed quarterly and more often, if necessary, based on any change in the resident's physical and psychosocial well-being. The facility's policy regarding Resident Smokeless Tobacco, dated January 25, 2024, revealed that the facility will provide a safe and healthy enviornment for residents, visitors, and employees, including safety as it is related to smokeless tobacco. Any resident who is deemed safe to utilize smokeless tobacco, with or without supervision, will be allowed to in accordance with his/her care plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated April 2, 2024, revealed that the resident was usually understood, could usually understand others, and had diagnoses that included dementia and PTSD. A care plan for the resident, dated January 19, 2024, revealed that the resident was a high risk for falls due Parkinson's disease, a history of falls, and cognitive status fluctuations, with a past occupation of being a Navy Seal who dismantled bombs during war time. Alarms (historically) discontinued due to resident constantly dismantling and causing him anxiety/triggers PTSD. A nursing note for Resident 50, dated March 3, 2024, revealed that after a quick nap, the resident had an episode of PTSD starting with aggressive/physical swinging of his fist. Staff tried to calmly redirect the resident, check, and change him, as well as offering him soda. The resident was not responding to staff and the PTSD was increasing. He was in the process of trying to self-transfer from bed to a standing position. Medication was applied and with a calm wait period the resident deescalated and became more at ease, and staff quickly finished dressing [NAME] and used a lift and sling to safely place him into his chair, and he was wheeled into the hall for staff to observe his actions. However, there was no documented evidence that Resident 50's care plan included specific and individualized interventions to address the care needs for his PTSD. Interview with the Nursing Home Administrator on June 26, 2024, at 12:40 p.m. confirmed that Resident 50's care plan did not include any specific and individualized interventions to address the care needs for his PTSD. A quarterly MDS assessment for Resident 62, dated April 1, 2024, revealed that the resident was clearly understood and could understand others, required assistance with care needs, received antipsychotic medication, and had diagnoses that included dementia. A care plan for Resident 62 regarding psychotropic medications, dated February 15, 2022, revealed that the resident had these medications related to depression, anxiety, and hallucinations with Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Physician's orders for Resident 62, dated October 17, 2023, included an order for resident to receive 5 milligrams (mg) of Abilify (antipsychotic medication) at bedtime for delusions and tearfulness. However, there was no documented evidence that Resident 62's care plan included specific and individualized interventions to address the care needs for her delusions and tearfulness and the use of antipsychotic medication with dementia. Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that Resident 62's care plan did not include any specific and individualized interventions to address the care needs for her delusions and tearfulness and the use of antipsychotic medication with a dementia diagnosis. An admission MDS assessment for Resident 101, dated May 22, 2024, revealed that the resident was cognitively intact and required assistance with care needs, had diagnoses that included chronic kidney disease and heart failure, and received hospice services. Observations on June 24, 2024, at 2:51 p.m. revealed that Resident 101 had a container of smokeless tobacco (chewing tobacco) on his bed side table, and an interview with Resident 101 revealed that he has continued to use the smokeless tobacco since his admission to the facility. However, there was no documented evidence that Resident 101's care plan included specific and individualized interventions to address the use of smokeless tobacco. Interview with the Director of Nursing on June 26, 2024, at 1:24 p.m. confirmed that Resident 101's care plan did not include any specific and individualized interventions to address the use of smokeless tobacco. 28 Pa. Code 211.12(d)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise residents' care plans for five of 40 residents reviewed (Residents 2, 10, 22, 48, 105). Findings include: The facility's policy for care planning, dated January 25, 2024, indicated that the plan of care is a working tool and requires changes as needed to meet the residents' needs. The plan of care will also be reviewed and updated as needed during the change of status meeting. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 28, 2024, revealed that the resident was understood, able to understand others, required assistance with care needs, had two Stage 4 pressure ulcers (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle), had complaints of pain rated a 5 of 10 on a pain scale of 0-10, and took routine and as-needed pain medication. A care plan for Resident 2, dated July 1, 2020, revealed that the resident had pain related to skin impairments. Physician's orders for Resident 2, dated March 3, 2024, included an order for the resident to receive a heat pack to his right hip as needed for right hip pain for 20 minutes on, then off at least 20 minutes with a washcloth placed between the heat pack and his skin. There was no documented evidence that Resident 2's care plan was revised to include the intervention for the heat pack to the right hip. Interview with the Nursing Home Administrator on June 27, 2024, at 10:56 a.m. confirmed that Resident 2's care plan was not revised to include the intervention for the heat pack to the right hip and it should have been. A quarterly MDS assessment for Resident 10, dated June 7, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 16, 2020, revealed that the resident had a potential for weight fluctuations related to variable PO intake (by mouth). The resident was to have flow cups (a cup with a spouted lid that regulates the flow for controlled release of liquids), scoop plate (a non-skid rubber padded bottom designed to help users scoop food onto an eating utensil) and built-up fork and spoon at meals. Physician's orders for Resident 10, dated February 27, 2024, included an order for the resident to receive a consistent carbohydrate, regular texture, regular consistency, no salt packets, and flow cups for all beverages at meals. Observations during the lunch meals on June 24, 2024, at 12:12 p.m. and June 25, 2024, 12:08 p.m. revealed that Resident 10 was sitting in a Broda chair (an adaptive wheelchair) at a table in the 3rd floor dining room. The resident had two flow cups; however, the resident did not have a scoop plate or a built-up fork and spoon. Interview with Licensed Practical Nurse 3 on June 25, 2024, at 12:45 p.m. confirmed that Resident 10 did not have a scoop plate or a built-up fork and spoon. However, there was no documented evidence that Resident 10's care plan was updated/revised to include that the resident does not use a scoop plate or a built-up fork and spoon. Interview with the Dietitian on June 25, 2024, at 1:27 p.m. confirmed that Resident 10's care plan was not updated/revised to include that the resident does not use a scoop plate or a built-up fork and spoon. A quarterly MDS assessment for Resident 22, dated May 17, 2024, revealed that the resident was sometimes understood, was able to sometimes understand others, required assistance with care needs, and had a history of falls. A care plan for Resident 22, dated November 30, 2018, indicated that the resident was at risk for abnormal bleeding related to taking an anticoagulant (medication that prevents or reduces risks of blood clots). However, there was no documented evidence that the resident was ordered an anticoagulant. Physician's orders for Resident 22, dated May 30, 2024, revealed that the resident was ordered transmission-based precautions for COVID infection through June 7, 2024. A care plan for Resident 22, dated September 8, 2020, indicated that the resident was on transmission-based precautions (precautions used to help prevent the spread of infections) related to COVID-19 infection. There was no documented evidence that Resident 22's care plan was revised to reflect that the resident was no longer on transmission-based precautions and that the resident no longer had COVID infection. Interview with the Director of Nursing on June 27, 2024, at 2:59 p.m. confirmed that Resident 22's care plan was not revised to reflect that she was not ordered an anticoagulant and confirmed that the resident was no longer on transmission-based precautions and no longer had COVID infection. A quarterly MDS assessment for Resident 48, dated May 24, 2024, revealed that the resident was cognitively intact, was understood and understands others, required assistance for care needs, had a surgical wound, and was receiving an antibiotic. A care plan for Resident 48, dated September 6, 2023, indicated that the resident had a Methicillin-resistant Staphylococcus aureus (MRSA) (type of staph bacteria resistant to many antibiotics making treatment difficult) infection to right bunion area and was on contact precautions (precautions used to prevent the spread of infection through direct or indirect contact). A care plan for Resident 48, dated May 1, 2024, indicated that the resident was on enhanced barrier precautions (an infection control intervention to reduce multidrug resistant organism (MDRO) transmission in nursing homes) related to surgical wound/amputation of right great toe and a history of MDRO (a germ that is resistant to many antibiotics making treatment difficult). A care plan or Resident 48, dated August 11, 2021, indicated that the resident was receiving an antibiotic for an infection to his right bunion wound and osteomyelitis (infection of the bone) of right foot. Physician's orders for Resident 48, dated May 1, 2024, indicated that the resident was on enhanced barrier precautions due to surgical wound/amputation of great right toe and a history of a MDRO. Physician's orders for Resident 48, dated June 18, 2024, indicated that the resident was ordered 800-160 milligrams of Bactrim DS (an antibiotic) twice daily for a wound infection for 14 days. A skin and wound note for Resident 48, dated June 18, 2024, at 3:41 p.m. revealed that the wound Certified Registered Nurse Practitioner (CRNP) saw the resident related to his right great toe amputation and ordered the Bactrim for infection prevention indicating that the bone culture done by [NAME] Care at the office visit the week prior showed no growth of any infection. There was no documented evidence that Resident 48's care plan was revised to reflect that the MRSA infection to right bunion area was resolved and he was no longer on contact precautions. There was no documented evidence that Resident 48's care plan was revised to reflect that the infection to his right bunion area and osteomyelitis of the right foot were resolved, and that the antibiotic was ordered for infection prevention related to his right great toe amputation. Interview with the Nursing Home Administrator on June 26, 2024, 2:00 p.m. confirmed that Resident 48's care plans were not revised to reflect that the MRSA infection to right bunion area and contact precautions were resolved and confirmed that the care plan for the antibiotic was not revised to reflect the resident's need for the antibiotic related to infection prevention to his right great toe amputation. An admission MDS assessment for Resident 105, dated May 23, 2024, revealed that the resident was somewhat understood and could somewhat understand others, was dependent on staff for care care needs, was at risk for pressure ulcers (wounds caused by pressure), and had a deep tissue injury (DTI) not present on admission. A care plan for Resident 105, regarding impaired skin integrity, dated May 17, 2024, revealed that the resident should not have complications related to the DTI to the right buttocks. Physician's orders for Resident 105, dated June 7, 2024, included an order for wound care to the coccyx/buttock area for a Stage II pressure ulcer (partial thickness loss of skin as a shallow open ulcer). The area was to be cleansed with wound cleanser, pat dry, apply Xeroform (occlusive dressing), and cover with large foam dressing daily and as needed. A skin wound note for Resident 105, dated June 7, 2024, revealed that the pressure area to the right buttock was acquired in-house, and that the DTI was healed, but the resident had a cluster of new open areas to the coccyx and buttocks. Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that Resident 105's care plan was not updated to reflect the care and treatment of the in-house aquired pressure areas and should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls, by failing to follow physician-ordered and care-planned interventions for one of 40 residents reviewed (Resident 50), resulting in a fall; failed to ensure resident safety during transportation in a wheelchair for two of 40 residents reviewed (Residents 60, 80); and failed to ensure that air mattresses were assessed for potential safety hazards for one of 40 residents reviewed (Resident 61). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated April 2, 2024, revealed that the resident was usually understood, could usually understand others, and had diagnoses that included dementia and Parkinson's disease. A care plan for the resident, dated April 2, 2024, revealed that the resident was a high risk for falls due to Parkinson's disease, a history of falls, and cognitive status fluctuations. The resident was to have a large change in position alerting device to his side mattress when in bed to alert staff if he rolls onto the side of the mattress. Physician's orders for Resident 50, dated March 19, 2024, included an order for the resident to have an alarming fall matt to be placed on top of the floor mattress when in bed. A nursing note for Resident 50, dated April 8, 2024, revealed that the writer was called to the resident's room by the nurse aide. The resident was currently kneeling on the floor in front of his bathroom. He has been incontinent of a large amount of stool. Upon assessment the resident was found to have abrasions (an injury where your skin rubs off) to both of his knees and to the top of both of his feet. The resident also had bruising to both of his knees. No other injuries were noted. It was reported that the resident was having an electrocardiogram (EKG - a test to record the electrical signals in the heart), and at the time of the EKG the technician disabled the alarms to do the testing. No alarms were on at the time of fall. An investigation report for Resident 50, dated April 8, 2024, revealed that the technician had just done an EKG on the resident and commented about his alarms. The technician did not inform them that she had shut them off. A witness statement completed by Nurse Aide 4, dated April 8, 2024, revealed that no alarms were sounding because after the technician was done with the EKG the technician left without telling them or turning the alarms back on. An interdisciplinary note for Resident 50, dated April 9, 2024, revealed that the resident got up unassisted, likely due to bathroom needs as he had an incontinent episode of bowel at the time of the fall. The alarm did not sound as the EKG technician who was in to perform the EKG shut the alarm off while in there and forgot to turn them back on. The EKG technician was educated. Interview with the Director of Nursing on June 27, 2024, at 11:21 a.m. confirmed that Resident 50's alarms were not turned on prior to the fall on April 8, 2024, as ordered by the physician and as care planned. She indicated that the EKG technician should have turned the alarms back on or have told staff that the alarms were off, so that they could turn them back on. An admission MDS assessment for Resident 60, dated March 22, 2024, and April 10, 2024, indicated that the resident was cognitively impaired and required assistance from staff with her daily care needs. Observations on June 25, 2024, at 12:08 p.m. revealed that Nurse Aide 5 was transporting Resident 60 to the dining room in a wheelchair without leg rests. Interview with Nurse Aide 5 on June 25, 2024, at 12:14 p.m. revealed that he was aware that leg rests were to be used when transporting Resident 60 in her wheelchair. Interview with Nursing Home Administrator on June 25, 2024, at 12:44 p.m. confirmed that staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs. A significant change MDS assessment for Resident 61, dated April 10, 2024, indicated that the resident was cognitively intact, required assistance from staff with her daily care needs, and was on hospice. Physician's orders, dated May 6, 2024, included an order to check the function of the low air loss mattress. A skin wound note for Resident 61, dated May 7, 2024, revealed that she had a new in-house aquired Stage II pressure ulcer (a shallow open wound) and that hospice provided the resident with an air mattress yesterday due to complaints of soreness on her buttock and coccyx area. Observations on June 24, 2024, at 11:45 a.m. and June 26, 2024, at 3:19 p.m. revealed that Resident 61 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed. Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that there was no assessment for potential safety hazards prior to the air mattress being placed on the Resident 61's bed and there should have been. An annual MDS assessment for Resident 80, dated March 14, 2024, revealed that the resident was cognitively impaired and required extensive assistance for her daily care needs. Observations on June 25, 2024, at 12:25 p.m. revealed that Registered Nurse 6 transported Resident 80 in the hall way in a wheelchair without leg rests. Interview with Registered Nurse 6 on June 25, 2024, at 12:30 p.m. confirmed that she was aware that leg rests were to be used when transporting Resident 80 in her wheelchair. Interview with Nursing Home Administrator on June 25, 2024, at 12:44 p.m. confirmed that staff should be using leg/footrests on wheelchairs when residents are being transported in their wheelchairs. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to accommodate the family's preference for a shower or tub bath for one of 35 residents reviewed (Resident 80). Findings include: A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 80, dated July 12, 2023, indicated that the resident was confused, was totally dependent on staff for bathing, and had diagnosis that included Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior). A bathing schedule, dated July 2023, revealed that the resident was to be bathed on Mondays. Review of Resident 80's bathing records for July 2023 revealed that the resident was showered one time since her admission on [DATE]. A nursing note for Resident 80, dated July 10, 2023, revealed that the resident's daughter would like her showered or offered a shower at least twice per week. Interview with the Nursing Home Administrator on July 27, 2023, at 3:29 p.m. confirmed that there was no documented evidence that Resident 80 received or was offered a second shower or tub bath each week in accordance with her family's preference. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 35 residents reviewed (Resident 54). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated May 8, 2023, revealed that the resident was cognitively intact and required minimal assistance with daily care needs. A fall investigation report for Resident 54, dated January 26, 2023, revealed that the resident had used her over-bed table as a walker while ambulating and then fell. The intervention was to keep the over-bed table in front of her bed while she is sitting in her recliner chair. Resident 54's care plan, most recently updated May 8, 2023, revealed that the resident was at risk for falling; however, the resident's care plan was not revised to indicate that the over-bed table was placed in front of her bed while she was in her recliner. An interview with the Director of Nursing on July 27, 2023, at 8:58 a.m. confirmed that Resident 54's care plan was not revised after her fall to alert staff to place her over-bed table in front of her bed while she was in her recliner and it should have been. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of clinical records, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate hearing for one of 35 residents reviewed (Resident 54). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated May 8, 2023, revealed that the resident was cognitively intact, required minimal assistance with daily care needs, and had moderate difficulty with hearing. Resident 54's care plan, dated August 16, 2022, revealed that she had a hearing deficit. An audiology consult, dated April 5, 2023 recommended that the resident have her ears treated with Debrox (medication that loosens and removes built-up wax) and that the facility provide the resident with a pocket talker (device used to amplify voices when speaking to the resident). Interview with Resident 54 and her son on July 25, 2023, at 10:38 a.m. revealed that the resident had an ear evaluation to get hearing aides over a month ago, but she has not heard anything since then. She was very hard of hearing and her son had to answer for her. Interview with the Director of Nursing on July 26, 2023, at 10:08 a.m. revealed that the facility missed the audiology order for the Debrox treatment in April 2023 and thought the audiology group was going to supply the pocket talker. As a result, the resident did not get one. 28 Pa. Code 201.29(j) Residents rights. 28 Pa. Code 211.12(d)(3)Nursing services 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that care-planned interventions to prevent falls and/or injury were followed for one of 35 residents reviewed (Resident 61). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment to determine a resident's abilities and care needs) for Resident 61, dated June 23, 2023, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had a history of falling. The resident's care plan, dated March 17, 2022, indicated that the resident was at risk for falls and that he should have non-skid socks or shoes on at all times. Observations of Resident 61 on July 25, 2023, at 9:40 a.m. revealed that he was sitting in the dining room with white socks on. He did not have non-skid socks or shoes on at the time. Interview with Licensed Practical Nurse 1 on July 25, 2023, at 9:45 a.m. confirmed that Resident 61 was to have non-skid socks or shoes on at all times when out of bed and he did not. Interview with the Director of Nursing on July 25, 2023, at 3:02 p.m. confirmed that Resident 61 should have had non-skid socks or shoes on when out of bed. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending August 18, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 27, 2023, identified repeated deficiencies related to providing a safe environment, and storage and labeling of medications. The facility's plan of correction for a deficiency regarding a failure to provide a safe environment, cited during the survey ending August 18, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing a safe environment. The facility's plan of correction for a deficiency regarding proper storage and labeling of medications, cited during the survey ending August 18, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding proper storage and labeling of medications. Refer to F689 and F761. 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 review of policies, clinical records, and manufacturer's directions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications remained properly secured in one of four medication carts reviewed (300 Hall Medication Cart), failed to discard expired multi-dose insulin vials for one of four medication carts reviewed (3rd Floor Medication Cart), failed to ensure that medications were properly labeled for one of 35 residents reviewed (Resident 85), failed to label multi-dose containers of insulin with the date they were opened in one of four medication carts reviewed (2nd Floor Medication Cart), and failed to discard expired multi-dose Tuberculin vials for one of two medication refrigerators reviewed (4th Floor Medication Room Refrigerator). Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that medication carts should be locked when not in immediate view of staff. Observations of the 300 hall medication cart on [DATE], at 12:33 p.m. revealed that the cart was unlocked and there were no staff within eye sight of the cart. Licensed Practical Nurse 2 was sitting at the nurse's station on the other side of the wall from where the medication cart was parked and it was not in her direct line of sight. Interview with Licensed Practical Nurse 2 on [DATE], at 12:39 p.m. revealed that the medication cart should have been locked. An interview with the Director of Nursing on [DATE], at 3:02 p.m. revealed that the medication cart should have been locked when out of sight. Manufacturer's directions for Novolog aspart insulin (fast acting insulin that starts to work in about 15 minutes to lower blood sugar), dated February 2015, revealed that once a 10 milliliter (ml) vial is opened, it should be stored at room temperature, below 86 degrees Fahrenheit, and used within 28 days or be discarded. Manufacturer's directions for Lantus glargine insulin (a long acting insulin that works for 24 hours to lower blood sugar), dated May, 2019, revealed that once a 10 ml vial is opened, it should be stored at room temperature, below 86 degrees Farenheit, and used within 28 days or be discarded. Observations in the third floor south medication cart on [DATE], at 10:27 a.m. revealed that there was one 10 ml vial of Novolog insulin and one 10 ml vial of Lantus insulin that were opened and dated [DATE]. Interview with Licenced Practical Nurse 3 at that time confirmed that the vials were expired and should have been discarded. The facility's policy regarding medication labels, dated [DATE], indicated that when a physician's directions change or the label was inaccurate, the nurse may place a change in order - check chart label on the container indicating there was a change in directions for use. Physician's orders for Resident 85, dated [DATE], included an order for the resident to receive 6 units of Lantus glargine insulin subcutaneously once a day. Observations of the third floor south medication cart during the medication pass on [DATE], at 8:40 a.m. revealed a vial of Lantus insulin for Resident 85 with written directions on the label to inject 7 units subcutaneously twice a day. Interview with Licenced Practical Nurse 3 at the time confirmed that the written label did not match the current order, and that per policy, a sticker should be placed on the container to have staff check the current order. Interview with the Director of Nursing on [DATE], at 2:19 p.m. confirmed that the vials of Novolog and Lantus expired after 28 days and should have been discarded and also confirmed that the written label for Resident 85's insulin should match the current physician's order. Manufacturer's directions for Insulin Lispro (a rapid acting Insulin to treat diabetes), dated February 2020, indicated that opened and in-use vials of Insulin Lispro should be stored at room temperature, below 86 degrees Fahrenheit, and used within 28 days or be discarded, even if they still contain Insulin Lispro. Physician's orders for Resident 101, dated [DATE], included an order for the resident to receive 10 units of Insulin Lispro three times per day. Observation of the second floor medication cart on [DATE], at 2:32 p.m. revealed that the 10 ml vial of Insulin Lispro for Resident 101 was opened and was not labeled with the date that it was opened. Interview with Licensed Practical Nurse 4 at that time confirmed that the 10 ml vial of Insulin Lispro should have been labeled with the date it was opened. Manufacturer's directions for the use of Tubersol (an injectable solution used to aid in the diagnosis of tuberculosis infection), dated November, 2013, revealed that a multi-dose vial of Tubersol that has been opened and in use for 30 days should be discarded. Observations in the fourth floor medication room refrigerator on [DATE], at 2:52 p.m. revealed that there was one multi-dose vial of Tubersol solution on the top shelf of the door in the refrigerator. The Tubersol multi-dose vial was dated as being opened on [DATE] (35 days after opening). Interview with Licensed Practical Nurse 5 at the time of observation confirmed that the Tubersol multi-dose vial was opened and dated [DATE], and that it should have been discarded after 30 days. Interview with the Director of Nursing on [DATE], at 3:10 p.m. confirmed that Resident 101's multi-dose vial of Insulin Lispro should have been labeled with the date it was opened and also confirmed that staff should have discarded the Tubersol multi-dose vial after 30 days of being opened. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services.