Based on review of clinical records, observations, and staff and family interviews, it was determined that the facility failed to obtain a physician's order for the management of the use of a splint for one of 18 residents reviewed (Resident R64). Findings include: Upon request, no facility policy was provided. Resident's R64's clinical record revealed an admission date of 10/01/19, with diagnoses that included Alzheimer's dementia (a disease of the brain that affects mood and behaviors, safety awareness, and organized decision making), high blood pressure, hypothyroidism (a condition where the thyroid does not make enough thyroid hormone), and hemiplegia affecting left nondominant side (total or partial paralysis of one side of the body affecting arms, legs and face). Resident R64's clinical record revealed Nursing Assistant (NA) Documentation Task: RESTORATIVE - Splint/Brace Assistance Program #1 in AM: Left hand splint/brace APPLIED. At HS: splint/brace assistance, please REMOVE from left hand. Also, may remove for hygiene/skin checks. Written instruction for splint/brace provided to caregivers/nursing, picture or illustration of splint/brace application provided to caregivers/nursing. Skin checks to be performed every 8 hours to monitor for any redness or pressure areas. Notify CN of any redness or change in condition. NA Documentation further indicated on 8/26/25, at 3:17 a.m. as Resident Refused and 8/26/25, at 14:59 p.m. as 1, on 8/27/25, at 3:48 a.m. as Not Applicable for Follow Up Question 1 Amount of minutes spent providing splint or brace assistance. Review of the NA task documentation revealed insufficient documentation that the splint was placed on Resident R64's hand during the daytime hours and removed at HS (hour of sleep) on 8/26/25, and 8/27/25. There was no indication in the clinical progress notes to reflect that Resident R64 refused to wear the left hand splint on 8/26/25, or 8/27/25. During an interview with Resident R64's family member on 8/26/25, at 2:38 p.m. it was indicated the facility does not ensure Resident R64's left hand splint is on. The family member further indicated that if the splint is on, it typically is not on correctly, which increases the risk for the resident to be in pain and/or skin breakdown. Observations on 8/26/25, at 3:35 p.m. and 8/27/25, at 10:38 a.m. revealed Resident R64 without a splint maintained to his/her left hand. During an interview with Licensed Practical Nurse (LPN) Employee E1 on 8/27/25, at 11:20 a.m. he/she was unable to locate a physician's order in the electronic medical record (EMR) for Resident R64's splint and indicated that Resident R64 does not have a splint for his/her hands. During an interview on 8/27/25, at 12:44 p.m. the Director of Nursing (DON) confirmed that Resident R64 should have a splint maintained to his/her left hand during the daytime hours. The DON further revealed that the facility lacked a physician's order for the splint and management of splint for Resident R64's left hand. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R13). Findings include: Review of facility policy dated 1/11/24, entitled Oxygen Therapy under Storage and Cleaning indicated Check humidifier each shift. Change bottle when water level is low or weekly. Date and initial bottle. Policy also indicated to Remove re-usable oxygen concentrator filter weekly and replace with clean, dry filter. Wash removed filter with water, dry and store in specific location. Resident R13's clinical record revealed an admission date of 5/28/23, with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), high blood pressure, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R13's nurse aide (NA) tasks initiated 8/08/24, revealed NA will replace oxygen tubing and canister (humidifier bottle) weekly. Further review of Resident R13's clinical record lacked evidence of instructions or care related to oxygen concentrator filters. Observation on 9/03/24, at approximately 2:20 p.m. and again on 9/04/24, at approximately 11:45 a.m. revealed that Resident R13's oxygen concentrator contained a humidifier bottle attached to the concentrator dated for 8/19/24, and two filters (one on each side of the concentrator) that contained a gray dusty substance. During an interview on 9/04/24, at approximately 11:51 a.m. Licensed Practical Nurse Employee E1 confirmed that the oxygen concentrator humidifier bottle was dated for 8/19/24, but he/she was not sure how often it was to be changed and both filters contained a gray dusty substance and should not have that appearance. During an interview on 9/04/24, at approximately 2:51 p.m. Director of Nursing confirmed that the humidifier bottles are to be changed on a weekly basis. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of six residents reviewed for unnecessary medications (Resident R13). Findings include: Resident R13's clinical record revealed an admission date of 5/28/23 with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), high blood pressure, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R13's clinical record revealed physician's order dated 7/30/24, that identified to administer Lorazepam (anti-anxiety medication) Oral Concentrate 2 milligram (mg) per milliliter (ml). Give 0.25 ml by mouth every two hours as needed (PRN) for anxiety for 14-days. A physician's order dated 8/13/24, identified to administer Lorazepam Oral Concentrate 2mg/ml. Give 0.25 ml by mouth every two hours PRN for anxiety for 14-days. A physician's order dated 8/27/24, identified to administer Lorazepam Oral Concentrate 2mg/ml. Give 0.25 ml by mouth every two hours PRN for anxiety for 14-days. Resident R13's August 2024 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used three times (8/10/24, 8/24/24, and 8/29/24). Review of the August MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam two of the three times it was used. Resident R13's September 2024 MAR revealed that the PRN Lorazepam was used two times (9/02/24 twice). Review of September MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam two of the two times it was used. During an interview on 9/05/24, at 1:45 p.m., the Director of Nursing confirmed that Resident R13's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services