Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and in accordance with physician's orders for five of 23 residents reviewed (Residents R4, R40, R75, R95 and R205). Findings include: A facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen to breathe) dated 10/28/24, revealed to not run concentrator with a dusty filter. A facility policy entitled, Oxygen Therapy dated 10/28/24, revealed that humidification (process that adds moisture to oxygen therapy to prevent a dry, irritated respiratory tract) for patient comfort may be provided at any flow rate and whenever specifically ordered by the physician. A facility policy entitled, Oxygen Therapy via Nasal Cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) dated 10/28/24, revealed to verify physician's order, attach the humidifying device, if liter flow is 4 or greater or upon resident request, and change the prefilled bottle humidifier when low or at least weekly. Resident R4's clinical record revealed an admission date of 10/24/17, with diagnoses that included Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), heart disease, heart failure, myopathy (disease that affects the muscles that control voluntary movement). Resident R4's clinical record lacked evidence of a physician's order/treatment to provide humidification to his/her supplemental oxygen and clean the concentrator filter. Observation on 1/11/25, at 2:25 p.m. revealed Resident R4's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance and the prefilled humidifier bottle attached to the oxygen tubing and secured to the external surface of the concentrator was empty. Observation on 1/12/25, at 11:53 a.m. revealed Resident R4's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface and a full prefilled humidifier bottle was sitting on the floor. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around, and that the humidification bottle should not have been resting on the floor. During an interview on 1/12/25, at 1:56 p.m. the Regional Director of Nursing confirmed Resident R4's clinical record lacked evidence of a physician's order to provide humidification and an order on the Treatment Administration Record (TAR) for cleaning the oxygen concentrator filter was not identified. Resident R40's clinical record revealed an admission date of 5/09/24, with diagnoses that included blood clots in the legs, dependence on supplemental oxygen, stroke with paralysis, pleural effusion (condition where too much fluid builds up in the area between the lungs and chest wall). Resident R40's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:00 p.m. revealed Resident R40's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:50 a.m. revealed Resident R40's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observtion on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R75's clinical record revealed an admission date of 4/06/22, with diagnoses that included respiratory failure, dependence on supplemental oxygen, blood clots in the legs, disorders of diaphragm (trauma, tumors, or other conditions that affect the diaphragm muscle and make it difficult to breathe). Resident R75's January 2025 TAR indicated that the oxygen concentrator was scheduled to be cleaned on 1/12/25, at 7:00 p.m. Observation on 1/11/25, at 3:10 p.m. revealed Resident R75's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:55 a.m. revealed Resident R75's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R95's clinical record revealed an admission date of 10/16/24, with diagnoses that included respiratory failure, dependence on supplemental oxygen, alcoholic cirrhosis of liver (severe form of liver disease that occurs when the liver is permanently scarred from excessive alcohol consumption), myopathy. Resident R95's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:20 p.m. revealed Resident R95's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:53 a.m. revealed Resident R95's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R205's clinical record revealed an admission date of 1/06/25, with diagnoses that included respiratory failure, heart disease, chronic obstructive pulmonary disease (COPD- ongoing lung disease limits airflow into and out of the lungs). Resident R205's TAR lacked evidence of a treatment to clean the concentrator filter. Observation on 1/11/25, at 2:30 p.m. revealed Resident R205's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:58 a.m. revealed Resident R205's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(i)(viii) Medical records

Based on observations, review of facility policy, and staff interview it was determined that the facility failed to maintain a clean, homelike environment for two of 12 residents reviewed (Residents R1 and R2). Findings include: Review of a facility policy entitled Daily Resident Room and Bathroom Cleaning dated 10/10/23, indicated, Check privacy curtains and spot clean as needed. Observations of Resident R1's room on 8/8/24, at approximately 12:50 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. Observations of Resident R2's room on 8/8/24, at approximately 12:55 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. During an interview on 8/8/24, at 1:25 p.m. the Assistant Director of Nursing confirmed that the privacy curtains in Resident R1's and R2's rooms were heavily soiled with a brown colored substance and that the privacy curtains should have been cleaned or replaced. 28 Pa. Code 201.18 5(e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (North medication room) and one of five medication carts (South medication cart). Findings include: Observation on 2/14/2024, at 9:45 a.m. in the North medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded. At the time of the observation, the Registered Nurse Supervisor Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing (DON) confirmed on 2/15/2024, at 9:45 a.m. the PPD vial should have been identified with an open date to indicate after 30 days of use, the vial would be discarded. Observation on 2/14/2024, at 3:10 p.m. of the South medication cart, revealed an opened Humalog insulin pen without an open date marked on the pen. A review of the drug manufacturer leaflet indicated a Humalog insulin pen which has been entered and in use for 28 days should be discarded. At the time of the observation, the Licensed Practical Nurse Employee E2 confirmed the insulin pen was opened, undated and not dated to indicate when the medication should be discarded. The DON confirmed on 2/15/2024, at 9:45 a.m. the insulin pen should have been identified with an open date to indicate after 28 days of use, the insulin pen would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and facility documents, and staff and resident interviews, it was determined that the facility failed to ensure that the residents were offered snacks at bedtime daily for four of four nursing units. Findings include: Review of facility policy entitled Resident Nourishments, with a policy review date of 10/30/2023, revealed Nourishments will be provided in addition to regular meals in order to promote high levels of nutritional intake. These items are located in the pantries. At any time, residents can request food from the kitchen or direct care staff. When kitchen staff are not available, the direct care staff can access food if it is not in the pantry. Review of meal times revealed that breakfast is delivered to the first hallway at 7:35 a.m. and dinner delivered to the first hallway at 4:35 p.m., which is fifteen hours between meals. The facility must provide meals within 14 hours unless a nourishing snack is served. During a resident council meeting held on 2/14/2024, at 1:00 p.m. there were seven cognitively intact residents that regularly attend resident council meetings. The residents were asked if the facility offers them snacks in the evening. The residents responded that the kitchen area is stocked with snacks after dinner, you have to get what you want right away or else they are out of snacks. If you try to request a snack, staff are either too busy or you have to wait long periods of time to get what you want. Sometimes they forget and you don't get anything. Residents who can't request a snack do not get one. Observation of the snack cabinets on 2/15/24, at 9:30 a.m. in the dining area revealed snacks were available for resident consumption. It was observed that the pantry doors were unlocked, and snacks were available for residents to take when they wanted. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), on 2/15/2024, at 8:45 a.m. they confirmed that the facility does supply and stock snacks to residents in the kitchen area. Residents have to obtain them themselves if they are able to go to the kitchen area, or wait for staff assistance to request a snack from staff members. It was confirmed that snacks are not offered or delivered to all residents by staff members routinely. Residents unable to request or obtain a snack themselves do not get snacks. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide medication administration in a manner that enhanced resident dignity for one of eight residents observed (Resident R61). Findings include: Review of the facility policy entitled, Resident Privacy dated as last reviewed 1/2/23, indicated that all residents will be examined and treated in the privacy of their own room or a private examination room. No residents will be assessed in a public space. Observation of medication pass on 3/14/23, at 4:20 p.m. revealed that Resident R61 received medications from Licensed Practical Nurse (LPN) Employee E1, in the hallway while sitting in a wheelchair by the nurses station. While Resident R61 was trying to take the medications he/she was having trouble swallowing them and needed multiple sips of water. Another resident passing by assisted Resident R61 with a drink to help with swallowing the medications. After the medications were administered, an interview was conducted on 3/14/23, at 4:28 p.m. with LPN Employee E1 who confirmed that it would have been more appropriate to administer the medications for Resident R61 in his/her room or a private area to ensure resident dignity. During an interview on 3/16/23, at 1:00 p.m. the Director of Nursing confirmed that Resident R61 should not have had his/her medications administered in the middle of a busy hallway with other residents and passers by present to observe and that residents should receive medications and care in a private area to maintain dignity and respect. 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.10 (c) (d) Resident care policies 28 Pa. Code 2121.12 (d) (3) (5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interviews, it was determined that the facility failed to reorder medications in a timely manner for one of three residents reviewed for medication administration (Resident R61). Findings include: Review of Resident R61's clinical record revealed an admission date of [DATE], with diagnoses that included acute respiratory failure, cognitive communication deficit, Alzheimer's disease, dementia, major depressive disorder, anxiety disorder, undue concern and preoccupation with stressful events, and age related physical debility. Review of Resident R61's clinical record revealed a physician's order with a start date of [DATE], for Lorazepam tablet 0.5 milligrams (mg) give 1 tablet by mouth three times a day for anxiety disorder for 180 days. This order expired on Monday [DATE], and was not reordered until [DATE], at 8:00 p.m. for Ativan tablet 0.5 mg (Lorazepam) give 1 tablet by mouth three times a day for related anxiety for 180 days. Resident R61 missed six doses of the medication. The facility could not produce a policy regarding timeliness of reordering expired medication orders. During an interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed that Resident R61 missed six doses of the medication Ativan for anxiety between [DATE] and [DATE]. The medications were not reordered in a timely manner after the order expired. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 201.18 (d)(3) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services