Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during each of his/her visits for four of 12 residents reviewed (Residents R26, R36, R37, and R42). Findings include: A facility policy entitled Physician Services dated 11/14/24, indicated that physician orders and progress notes are maintained with current regulations. Resident R26's clinical record revealed an admission date of 2/25/21, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and endocarditis (inflammation of the inner lining of the heart chambers and valves usually caused by bacterial infection). Resident R26's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R36's clinical record revealed an admission date of 2/09/24, with diagnoses that included high blood pressure, stroke resulting in paralysis of left side, and hypothyroidism (a condition resulting from decreased production of thyroid hormones). Resident R36's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R37's clinical record revealed an admission date of 10/10/23, with diagnoses that included congestive heart failure (CHF-progressive heart disease that affects the pumping action of the heart resulting in difficulty breathing and tiredness), and multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), and neurogenic bladder (when the nerves or the brain cannot communicate effectively to the muscles in the bladder). Resident R37's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R42's clinical record revealed an admission date of 11/14/24, with diagnoses that included diabetes, high blood pressure, and CHF. Resident R42's physician's orders revealed that his/her physician orders had not been reviewed, signed, and dated by his/her physician. During an interview on 2/12/25, at 11:02 a.m. Registered Nurse Assessment Coordinator confirmed that the physician orders for Residents R26, R36, R37, and R42 were past due for being reviewed and signed by the physician During an interview on 2/13/25, at 8:50 a.m. the Director of Nursing (DON) confirmed that physician orders for Residents R26, R36, and R37 should have been signed every sixty days and were not signed in September 2024, November 2024, or January 2025 as required. The DON also confirmed that Resident R42's physician orders should have been signed in November 2024 at the time of admission and every thirty days thereafter for the first ninety days, which included December 2024 and January 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least every 30 days for the first 90 days after admission for one of eight new admissions reviewed (Resident R42). Findings include: A facility policy entitled Physician Services dated 11/14/24, indicated that physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current regulations. Resident R42's clinical record revealed an admission date of 11/14/24, with diagnoses that included diabetes, high blood pressure, and congestive heart failure. Resident R42's clinical record progress notes revealed he/she was seen by the Certified Registered Nurse Practitioner on 11/18/24, and 12/16/24. The clinical record lacked evidence that he/she was seen in January 2025 as required by the physician. During an interview on 2/13/25, at 9:24 a.m. the Director of Nursing confirmed that Resident R42 was not seen by the physician as required in January 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two resident refrigerators ([NAME] Unit and [NAME] Lane); failed to label food brought into the facility with the resident's name and use by date; and failed to maintain sanitary conditions in one of two resident refrigerators ([NAME] Unit). Findings include: Review of facility policy entitled, Food Brought by Family/Visitors, dated 11/14/24, revealed that perishable foods are to be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date and that nursing staff will discard perishable food on or before the use by date. Review of facility policy entitled, Food Receiving and Storage, dated 11/14/24, revealed that food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Review of facility policy entitled Foods and Snacks kept on Nursing Units, dated 11/14/24, revealed that all foods belonging to residents are labeled with the resident's name, the item and the use by date. Observations on 2/10/25, at 2:48 p.m. revealed a refrigerator on [NAME] Unit used for residents contained a sandwich in a sealed container with a resident name but no use by date; a sandwich in a sealed container with a resident name and use by date of 2/07/25; and six sealed Activia yogurts labeled with a resident name and expiration date of 1/23/24. Inside the refrigerator, the bottom door shelf contained a pink/sticky liquid substance. The freezer contained a blue/sticky substance coating the bottom of the base of the freezer under the freezer drawer and multiple old, discolored ice cubes. During an interview on 2/10/25, at 2:55 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the refrigerator contained a sandwich lacking a use by date, a sandwich that was past the use by date, and six Activia yogurts that expired on 1/23/24, and stated they should be discarded. LPN Employee E2 also confirmed the refrigerator contained a pink sticky liquid substance and the freezer contained blue sticky substance and old discolored ice cubes and needed cleaned. Observations on 2/12/25, at 9:45 a.m. revealed a refrigerator on [NAME] Unit used for residents that contained five sealed cottage cheese cups with a use by date of 2/11/25. During an interview on 2/12/25, at 9:48 a.m. LPN Employee E1 confirmed that the five sealed cottage cheese cups were expired and should be discarded. Observation on 2/12/25, at 10:11 a.m. revealed a refrigerator on [NAME] Lane used for residents that contained a sealed plastic container with blueberry cobbler with a resident's name on it and a use by date of 1/28/25, and also contained an eleven ounce bottle of Ensure nutritional drink with an expiration date of 8/2024. During an interview on 2/12/25, at 9:48 a.m. Registered Nurse Employee E3 confirmed that the resident who the blueberry cobbler was for, discharged from the facility and also that it was past the use by date, the Ensure drink was expired, and both should have been discarded. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and infection control records, and staff interviews, it was determined that the facility failed to ensure measures were in place to monitor and prevent legionella in the facility water. Findings include: A facility policy, Infection Prevention and Control Plan FY2024, dated 11/14/24, revealed the infection control plan describes the process for the detection, prevention, and control of healthcare-associated infections (HAI), and disease transmission among residents, visitors, and healthcare personnel (HCP) (i.e., staff, providers, contractors/vendors, volunteers, and students). Water is tested at least quarterly for waterborne pathogens including Legionella. Response to positive test results is prescribed in the WMP (Water Management Plan). Facility policy, Legionella Water Management Program, dated 11/14/24, revealed the facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation further indicated the facility will have a system to monitor limits and the effectiveness of control measures, a plan for when control limits are not met and/or control measures are not effective, and documentation of the program. Review of facility water management records, Special Pathogens Laboratory - The Legionella Experts dated 10/10/24, revealed positive results for Legionella rubrilucens in [NAME] Lane room [ROOM NUMBER], and positive results for L. pneumophila, not serogroups in the Skilled Hall Med Room. The facility lacked evidence of further testing for Legionella of the facility water system after 10/10/24. An interview with the Maintenance/Environmental Services Director on 2/13/25, at 9:25 a.m. revealed the facility received the positive findings for Legionella in the above noted areas on 10/10/24; Flushing of the facility water system with 160-degree water was completed, but no further testing of the water system for Legionella was completed after 10/10/24. He/she further confirmed that testing for Legionella should have been completed after the 10/10/24, positive results of Legionella, to ensure the usage of facility water was safe for all persons. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 13 residents reviewed (Resident R27). Findings include: A facility policy dated 3/20/24, entitled Care Plans indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives, and timetables to meet residents medical, nursing, and mental / psychosocial needs of the resident. Resident R27's clinical record revealed an admission date of 7/1/21, with diagnoses that included diabetes, transient ischemic attack (TIA - minor stroke or mini-stroke with noticeable symptoms going away) and obstructive sleep apnea (a disorder that makes you stop breathing repeatedly during sleep). Resident R27's clinical record revealed a physician's order 1/15/24, for Seroquel (psychotropic medication - affects the mind) 25 milligram (mg) by mouth at bedtime for depression and anxiety. Another physician's order dated 3/6/24, indicated the Seroquel dosage was increased to 50 mg at bedtime for delusions. The clinical record lacked evidence that a care plan had been developed to address Resident R27's behaviors and use of Seroquel. During an interview on 3/28/24, at 11:14 a.m. confirmed that a care plan had not been developed to address Resident R27's behaviors and use of Seroquel. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and 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 five residents reviewed for unnecessary medications (Resident R158). Findings include: A facility policy dated 3/20/24, entitled Unnecessary Drugs indicated that non-pharmacological interventions are considered and used when indicated. Review of Resident R158's clinical record revealed an admission date of 3/19/24, with diagnoses that included anxiety, depression, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Review of Resident R158's clinical record revealed a physician's order dated 3/19/24, that identified to administer Clonazepam (medication to treat anxiety) 1 milligram (mg) by mouth every 8 hours as needed for anxiety until 4/2/24. Review of Resident R158's Medication Administration Record (MAR) for March 2024 revealed that the PRN Clonazepam was used 18 times between 3/19/24, and 3/28/24. Review of the March 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions were attempted prior to the administration of the PRN Clonazepam 18 of the 18 times the Clonazepam was utilized in March 2024. During an interview on 3/28/24, at approximately 2:22 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Clonazepam 18 of the 18 times it was administered to Resident R158 between 3/19/24, and 3/28/24. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3) Management