Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that physician orders were followed for one of two residents observed during medication administration. (Resident R111) Findings include: On February 24, 2025, 8:20 a.m., observed that Employee E5, a Registered Nurse, administered to Resident R111, the medicine, Bicalutamide Oral Tablet 50 MG (Bicalutamide), give 50 milligrams by mouth one time a day for prostate cancer related to Malignant Neoplasm of Prostate; but, E5 administered the medicine, Bicalutamide Oral Tablet without wearing gloves when handling Bicalutamide medication and E5 did not wash her hands after. Review of physician order for Resident R111, revealed an order, dated December 11, 2024, to administer 'Bicalutamide Oral Tablet 50 mg., give 50 mg., by mouth one time a day for prostate cancer related to Malignant Neoplasm of Prostate, wear gloves when handling this medication and wash your hands after use, warning: requires special handling by those who are pregnant or suspect or anticipate pregnancy. It could potentially have an adverse effect on a male fetus'. The Registered Nurse, E5 did not follow the physician order to administer Bicalutamide Oral Tablet. On February 24, 2025, 8:21 a.m., observed that Employee E5, was going to administer to Resident R111, the medicine Torsemide Oral Tablet 10 mg., two tablets by mouth. After safely preventing Employee E5 the administration of Torsemide Oral Tablet 10 mg. two tablets; Registered Nurse was asked to double check the medicine; the nurse stated it was Torsemide Oral Tablet 10 mg., two tablets. When asked the Registered Nurse to double check the physician order; Employee E5 checked the physician order, and sated that the physician order was as follows: Torsemide Oral Tablet 20 mg., give two tablets to equal 40 mg, by mouth, in the morning, every other day; then, E5 did administer the physician ordered Torsemide Oral Tablet 40 mg, to R111. Review of physician order for Resident R111, revealed an order, dated January 14, 2025, to administer Torsemide Oral Tablet 20 mg., give two tablets to equal 40 mg, by mouth. At the time of the finding, during an interview with the Director of Nursing, confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise one of seventeen residents reviewed (Resident R110) resulting in Resident R110 eloping from the facility. Findings include: Review of the facility policy title Clinical Guideline; Elopement revised [DATE], stated that the facility was, to strive to identify residents in Willowbrooke Court (WBC) who are at risk for wandering and potential elopement and provide a safe environment while maintaining their highest practicable level of physical, mental, and psychosocial well-being. Review of Resident R110's clinical record revealed the resident was admitted on [DATE], with diagnosis including dementia with psychotic disturbance (the mental state where someone is not sure what's real or not, which can include paranoid or delusional thoughts as well as hallucinations. Psychosis can be a complication of dementia, which is the greatest risk factor for development of psychotic symptoms in the geriatric population). Review of Resident R110's clinical record revealed a Wandering Risk Assessment (Scale) completed on [DATE], which indicated the resident was at high risk to wander. Review of Resident R110's Minimum Data Set (MDS-assessment of resident care needs) dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 12 which indicated that the resident's cognitive status was moderately impaired. Review of Resident R110's clinical record revealed a care plan dated [DATE], for being at risk for wandering which included placement of a Wander Alert device which will be checked for function and expiration weekly. Review of Resident R110's nursing note dated [DATE], at 2:25 p.m. revealed that at 11:20 a.m. the charge nurse, Employee E5, observed Resident R110 to be walking unattended in the parking lot using her walker. The resident refused to come back in. That security was notified and that after approximately 5 minutes the resident agreed to come back into the facility. A review of the facility incident investigation for the [DATE], revealed statements from the Charge Nurse which indicated that Resident R110's Wander Alert that was on her left wrist had an expiration date of [DATE], and that it had been recorded as [DATE]. Interview with Resident R110 on [DATE], at 1:15 p.m., revealed that the resident admitted that she went outside on [DATE]. That she was watching people going in and out the front door, and that there was no staff in the area so she decided that she would go outside since she was not setting off the alarm when she approached the door. She said that she knew that the nurses did not want her to go outside by herself, but that she was not a prisoner and she wanted to enjoy the fresh air. Interview with Employee E5, RN Charge Nurse, on [DATE], at 12:30 p.m. confirmed that Resident R110 was at risk for wandering, and that she had left the building through the front door and was walking unattended in the parking lot when the nurse saw her. The Charge Nurse also confirmed that the Wander Alert bracelet had been expired, and the wrong date had been written on the log. Interview with the Nursing Home Administrator, on [DATE], at 1:00 p.m. confirmed that Resident R110 had left the facility without permission on [DATE]. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 PA. Code 211.12(d)(1) Nursing services

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: An initial tour of the Food Service Department was conducted on July 17, 2023, at 10:30 a.m. with Employee E3, Nutrition Services Manager (NSM), which revealed the following: Observations in the receiving area revealed a dumpster/trash compactor which was designed with an open trash collection bin when the ram is in the open or resting position, which exposes the trash to the open air. There were several white/translucent bags of trash visible and exposed to the elements. Observations in the satellite kitchen in the dish washing area revealed a grey brute trash can with the lid off exposing the trash inside the can. Interview with the NSM on July 17, 2023, at 10:45 a.m. confirmed the above findings. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee