Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services necessary to maintain adequate personal hygiene and grooming for care-dependent residents for two out of 10 residents reviewed (Residents 1 and 3).Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, leading to difficulty breathing). Review of Resident 1's Kardex (a concise, portable document used to record and organize essential patient information) revealed that it is important for the Resident to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident 1's clinical record revealed a shower task indicating Resident 1's shower days are on Mondays and Thursdays. Further review of the task revealed on August 28, 2025; September 4, 8, and 11, 2025, it was marked not applicable, indicating the Resident did not receive a shower on those days. Review of Resident 3's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hypertensive heart disease (problems with your heart that can develop if you have high blood pressure). Review of Resident 3's comprehensive care plan revealed a focus area where the Resident stated it is important that he has the opportunity to engage in daily routines that are meaningful relative to their preferences; with an intervention to include that it is important to the Resident to choose between a tub bath, shower, bed bath or sponge bath, both created on August 29, 2025. Review of Resident 3's clinical record revealed a shower task indicating Resident 3's shower days are on Mondays and Fridays. Further review of the task revealed on August 29, 2025; September 5, 8, 15, 19, and 22, 2025, it was marked not applicable, indicating the Resident did not receive a shower on those days. During an interview with Nursing Home Administrator on September 24, 2025, at 1:40 PM, she revealed that if a resident refused to get a shower on their shower days, she would expect it to be marked as a refusal instead of not applicable. 28 Pa Code 211.12(d)(1)(3)(5)Nursing services.28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to obtain a physician's order for the use of a restraint following application of an emergency restraint for one of one individuals reviewed for restraint use (Resident 4).Findings include:Review of facility policy, Restraints: Use of, revised June 15, 2022, revealed, Emergency restraints may be used: As a last resort to protect the safety of the patient and others if patient's unanticipated violent or aggressive behavior places self or others in imminent danger. The order for the use of the restraint must be obtained from the physician/advanced practice provider either during the application of the restraint or immediately after the restraint has been applied. Supporting documentation must reflect what the patient was doing and what happened that presented the imminent danger.Review of Resident 4's clinical record revealed diagnoses that included Parkinson's Disease (movement disorder of the nervous system that worsens over time) and dementia, severe with psychotic disturbance (decline in cognitive functioning that affects memory, thinking and social abilities, significantly interfering with everyday life).Review of Resident 4's nursing progress note dated August 11, 2025, revealed, Called toward room, in hallway, by [nurse aide] in hall stating 'the patient is going to hit the girl in this room.' Upon entering room, patient was being asked to sit down in chair at bedside and began striking out at Staff. Patient continued growing more agitated with staff despite quiet verbal redirection and patience offered. This writer intervened to deflect patient's aggressive advances toward staff and protect patient with the assistance of two others. Patient fighting against chair, proceeded to try scratching, gripping, head butting and biting at those in his vicinity. Staff preserved safety to the patient and their peers despite the aggressive and violent outbursts. Patient verbalizing threats towards Staff and demand he be released from position. Educated patient on steps needed to release from position however, patient persistently posturing with flat affect, lacking insight, and judgment while thrashing.Respirations and pulse slightly elevated due to agitation, patient shows no signs or symptoms of distress. Circulation and skin integrity monitored throughout interaction without deviation from baseline.While interaction was taking place, supervisory staff stepped in to call for outside help. EMS [Emergency Medical Services] was contacted via 911. EMS arrived on scene to survey situation and upon seeing patient's aggression, called for assistance from state police. Wife entered room and offered to help facilitate de-escalation, paramedics told her to stay back for safety. When [State Police] arrived on scene, background of the situation was relayed to officers, and intramuscular ketamine [anesthetic] was administered by paramedic to patient's left thigh. Staff was cycled slowly to be replaced by officers and paramedics to facilitate ease of transfer to stretcher. Upon patient's exit from the unit, one on one processing and active listening provided to patient's wife at bedside.Review of Employee 7's (Nurse Aide) witness statement dated August 11, 2025, revealed, in part, I was called to assist fellow CNA [certified nurse aide] with [Resident 4]. When walking [Resident 4] was already irritable and not following commands when I went closer to him he then lunged forward pinning me on to the bed. Fellow CNA called for help [Resident 4] still wasn't following commands and still was very aggressive .no way to console him or de-escalate. Employee 7 was helping to hold his knees down until Employee 2 [Registered Nurse] came in.Review of Employee 9's (Nurse Aide) witness statement dated August 11, 2025, revealed, in part, [Resident 4] was getting up from his bed. I assisted him by bringing his wheelchair, but he wouldn't sit down. The nurse was walking past and I asked her for help but one of the aides came in to help assist as we told [Resident 4] to have a seat in his chair cause we didn't want him to fall. He pushed the other aide down to this bed and held her down. We tried to tell him we were there to help but he kept holding her down to the bed .Nurse and aides came to assist but he became aggressive.Review of Employee 10's (Registered Nurse) witness statement dated August 11, 2025, revealed, in part, I was alerted by CNA screaming down the A hall that they needed help with [Resident 4]. I go in the room and see [Resident 4] pinning one of the CNAs on the bed. As another aide attempts to take him off her, but as she tries to get him off her he tries to throw punches at them. We attempted to get him to sit on the chair, but he continued to throw punches and kick with both legs at all staff members. As he continues his aggression I call [practitioner] and get order to send to ER [Emergency Room]. When Employee 10 entered room [Employee 8 (Nurse Aide)] had Resident's left wrist. [Employee 13 (Licensed Practical Nurse)] had right wrist. They sat him down on chair. He began kicking staff so Employee 2 was holding his right thigh down to keep him from kicking.Review of Employee 11's (Licensed Practical Nurse) witness statement dated August 11, 2025, revealed, in part, I was down C Hall when [Employee 9] came down the hall stating they need help with [Resident 4]. She said he was trying to punch staff. When I entered the room [Employee 8] was holding [Resident 4's] left arm, [Employee 2] was assisting trying to hold his legs down as he was trying to kick staff and [Employee 13] was holding his right arm. He continued to try to kick, bite, and punch staff. I assisted holding his right forearm as he continued to try to punch staff, kick and turn his head to bite Ambulance crew arrived then [State Police] who after [Resident 4] was administered IM [Intramuscular] medication in his left thigh by the ambulance crew directed us one by one out of the room.Review of Resident 4's physician orders failed to reveal an order allowing use of physical restraint either before or immediately following the aforementioned incident.During an interview with the Director of Nursing on August 13, 2025, at 1:33 PM, she confirmed that no order for application of a physical restraint was obtained for Resident 4.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.8 (d) Use of restraints.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, facility documents, and resident and staff interviews, it was determined the facility failed to ensure that residents were free from any significant medication errors for one of four residents reviewed (Resident 1). Findings include:Review of facility policy, Medication Administration last revised January 2025, stated, medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. # 9. The individual administering medications verifies medication is correct three (3) times before administering the medication.When pulling the medication package from med cart.When dose is prepared.Before dose is administered.# 10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: a. Check identification band. b. Check attached to medical record photograph. c. Verify resident identification with other nursing care center personnel.Note: the resident's room number or physical location is not used as an identifier.Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure) and dysphagia (difficulty swallowing).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) completed May 5, 2025, revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition.Review of a select documents revealed Resident 1 reported to her daughter that Employee 1 (Registered Nurse) on July 31, 2025, at 2:00 AM, entered her room, where she resides with her spouse who is hospice status. Resident 1 said she was asleep, and Employee 1 placed a syringe in the corner of her mouth. Resident 1 immediately woke up and said no, no, no that is my husband's medication. Resident 1 reported that she was able to taste some of the medication before the syringe was removed. Resident 1 reported that Employee 1 pulled the syringe out of her mouth, turned around, and inserted the same syringe into her husband's mouth and administered the Morphine (opioid). Resident 1 reported the event to nursing on July 31, 2025, at 7:00 AM. Resident 1 notified her daughter in the evening of the event on July 31, 2025.Resident 1 was interviewed by Employee 2 (Registered Nurse) on July 31, 2025, at 9:30 AM, after Employee 12 (Registered Nurse) informed her that Resident 1 needs to talk with her because the night shift nurse tried to give her husband's liquid medication.Resident 1 was interviewed again on August 1, 2025, after family of Resident 1 came to the nurse's station and questioned Employee 2 why their mother received their dad's medication and what was being done about it. Employee 2 informed the family that she didn't realize the syringe went into her mouth when she interviewed Resident 1 on July 31, 2025. Employee 2 reported to the Director of Nursing (DON) on August 1, 2025, after interviewing Resident 1 for more details about the syringe and it being placed in her mouth. The DON completed an Individual Performance Improvement Plan on August 1, 2025, and had Employee 1 sign it. The form is marked Unsatisfactory Job Performance.This Surveyor interviewed Resident 1 on August 13, 2025, at 11:00 AM, and requested that she review the event that occurred on July 31, 2025. Resident 1 stated that she was awoken on July 31, 2025, at 2:00 AM, by a syringe being placed in the corner of her mouth by Employee 1, a male nurse. She said she yelled no, no, no that's my husband's medication. Resident 1 added that her husband receives liquid Morphine every 4 hours with a syringe for his hospice care. Resident 1 confirmed that she was able to taste some of the medication. Resident 1 said the nurse removed the syringe from her mouth and immediately turned toward her husband in the next bed and administered the medication to her husband with the same syringe. Resident 1 was asked if she reported the event and she said she reported that morning about 7:00 AM, because no one approached her about the event. Resident 1 said she wasn't sure if it was reported by the male nurse. Resident said staff took her blood pressure on July 31, 2025, at 10:30 AM, and it was 100/60, (confirmed in clinical record) which was low per Resident 1. Resident 1 added that she didn't urinate for about 6-8 hours, which she said was unusual for her, but denied any pelvic pressure. (Note: a side effect of morphine is urinary retention and reduced arterial blood pressure). Resident 1 said was able to attend activities and had no complaints of discomfort.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at 11:45 AM, she confirmed that Employee 1 never reported the medication error with Resident 1. A statement written August 1, 2025, by Employee 1 failed to admit syringe entered Resident 1's mouth, but did admit to approaching Resident 1 and that Resident 1 stopped him. The NHA stated that Employee 1 no longer works at the facility. There was no record of the physician being notified of the event.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, as well as resident, resident family member, and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of four residents reviewed (Resident 1).Findings include: A review of the facility policy, titled Infection Control Policies and Procedures, last revised February 24, 2025, stated, Centers will record incidents identified under the Infection Prevention and Control Program (IPCP) and the corrective actions taken. Breaches in Practice are failures in infection control practices, such as non-compliance.Reports from staff, patients, or families on any healthcare associated infection or spread of disease due to possible errors in infection prevention or control Centers for Disease Control states all single-dose syringes should never be used for more than one patient and is a breach in practice.Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure) and dysphagia (difficulty swallowing).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) completed May 5, 2025, revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition.Review of select documents revealed Resident 1 reported to her daughter that Employee 1 (Registered Nurse) on July 31, 2025, at 2:00 AM, entered her room, where she resides with her spouse who is hospice status. Resident 1 said she was asleep, and Employee 1 placed a syringe in the corner of her mouth. Resident 1 immediately woke up and said no, no, no that is my husband's medication. Resident 1 reported that she was able to taste some of the medication before the syringe was removed. Resident 1 reported that Employee 1 pulled the syringe out of her mouth, turned around, and inserted the same syringe into her husband's mouth and administered the Morphine (opioid).Resident 1 reported the event to nursing on July 31, 2025, at 7:00 AM. Resident 1 notified her daughter in the evening of the event on July 31, 2025.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025. Resident 1's daughter was also concerned about the syringe being placed in her dad's mouth due to a current infection Resident 1 was receiving antibiotics to treat.A review of Resident 1's clinical record revealed the Resident was diagnosed with bacterial sinusitis and was currently receiving Cefuroxime Axetil (antibiotic that treats bacterial infections) 500 milligrams twice a day for 7 days, effective July 29, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at approximately 1:00 PM, the NHA agreed that the syringe should have been discarded after being inserted into Resident 1's mouth and the event should have been reported by Employee 1. The NHA added that Employee 1 no longer works at the facility.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Based on facility policy review, clinical record reviews, facility incident report review, hospital records review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 16 residents reviewed (Residents 1 and 5). Findings include: Review of facility policy, titled NSG115 Physician/ Advanced Practice Provider (APP) Notification, with a last revision date of December 16, 2024, revealed, in part, Upon identification of a patient who has a change in condition, abnormal laboratory values, or diagnostic tests, a licensed nurse will: perform appropriate clinical observations, collect pertinent patient information, and report to physician/Advanced Practice Provider (APP); complete the eInteract Change in Condition UDA and determine if the change in condition requires immediate or non-immediate notification, and notify physician/APP as applicable. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure), bradycardia (heart rate lower than 60 beats per minute), and chronic pain syndrome. Review of Resident 1's progress notes revealed a note written by Employee 8 (Registered Nurse [RN]) dated March 1, 2025, at 3:49 PM, that indicated Resident 1's family was at the bedside requesting that Resident 1 be transferred to the hospital right away because of confusion, low blood pressure, and unrelieved pain. Review of Resident 1's Medication Administration Record revealed that she received oxycodone on March 1, 2025, at 1:41 PM, for a pain level of 10; and received Tylenol at 2:30 PM for continued pain level of 8. Review of Resident 1's vital signs documentation for March 1, 2025, at 3:25 PM, revealed a temperature of 96.7 degrees Fahrenheit (normal 98.6 degrees Fahrenheit), a pulse rate of 76 (normal 60-100), a respiratory rate of 22 per minute (normal 16-20 per minute), a blood pressure of 77/50 (normal 120/80), and an oxygen saturation of 93% on room air (normal 95-100%). Review of Resident 1's clinical record progress notes revealed a note written by Employee 6 (RN), who was Resident 1's assigned nurse for that shift, dated March 1, 2025, at 3:50 PM, that noted Resident 1 had increased weakness, pain medicine not effective after administering her as needed oxycodone and Tylenol, her blood pressure was low, Resident 1's son was visiting and requesting her to be sent to the hospital for evaluation and treatment, the nurse practitioner was made aware, and the ambulance arrived at 3:50 PM. Review of Resident 1's progress notes revealed a note written by Employee 8 dated March 1, 2025, at 9:00 PM, that indicated Resident 1 had been admitted to the hospital with diagnoses of septic shock (life threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention), acute kidney injury (an abrupt disruption in kidney function), and a urinary tract infection. Review of facility provided incident report documentation revealed that Resident 1's son contacted the facility and reported concerns regarding Employee 5's (Agency RN Supervisor) actions and Resident 1's care on March 1, 2025. The son notified Employee 5 of Resident 1's change in condition and requested that she be sent to the hospital, Employee 5 rolled her eyes and stated that Resident 1 did not need to go to the hospital. Review of facility provided incident report documentation revealed a statement written by Employee 5 dated March 10, 2025, that indicated she was unaware of any situation or incident involving Resident 1 on March 1, 2025. Further review of Resident 1's progress notes failed to reveal any documentation that Employee 5 completed a nursing assessment of Resident 1 when she was notified of the change in her condition, or that Resident 1's physician was made aware of the changes at time they were initially noted. Review of facility provided incident report documentation revealed a statement written by Employee 6, undated, that Resident 1's son had approached her about his mother's condition as he thought something was off and that she seemed worse than she was 2 weeks ago. Employee 6 indicated that she did tell Resident 1's son that she had administered a narcotic pain medication about an hour prior and that she had also just administered Tylenol right before his arrival. Employee 6 notified Employee 5 of Resident's son's request. Employee 6 indicated that she overheard Employee 5 tell Resident 1's son she had no clinical indications to send her to the hospital. Further review of the incident report revealed a statement written by Employee 8, dated March 7, 2025, that indicated on March 1, 2025, she arrived on the nursing unit at approximately 3:15 PM. Employee 8 said she greeted Employee 5 who was leaving the nursing station. Employee 7 indicated that Employee 5 told her that there was not much going on in the building except a lady wanting to go to the hospital. Employee 8 indicated that she spoke to Employees 6 and 7, and Employee 7 told her that Resident 1's blood pressure was 78/40 and that she was experiencing a change in mental status. Employee 8 indicated that she immediately began calling 911. Review of Resident 1's hospital records revealed that she arrived at the emergency room on March 1, 2025, at 4:20 PM, and that she had a temperature of 86.9 degrees Fahrenheit, a pulse rate of 44, a respiratory rate of 27 per minute (normal 16-20 per minute), a blood pressure of 79/43, and an oxygen saturation of 87% on 10 liters of oxygen. She was noted to be in acute distress, mildly confused, very fatigued and lethargic, and able to move all extremities with generalized weakness noted. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 (RN) on March 20, 2025, at 10:50 AM, the NHA indicated that she was not comfortable stating whether Employee 5 should have sent Resident 1 to the hospital when the Resident and her son requested since she was not present to visualize Resident 1's status. When asked if Employee 6 should have notified Resident 1's physician and sent her to the hospital as requested by Resident 1 and her son, the NHA indicated that Employee 6 had followed the chain of command. Review of Resident 5's clinical record revealed diagnoses that included hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and severe protein-calorie malnutrition (malnutrition caused when not enough proteins and calories are consumed). Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 9, 2025, at 10:05 PM, that indicated Resident 5 had refused her medications and had multiple episodes of nausea and vomiting on evening shift. Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 10, 2025, at 10:50 AM, that indicated Resident 5 had refused her medications and was complaining of feeling nauseous. Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 10, 2025, at 4:59 PM, that indicated Resident 5 had refused her medications and was complaining of general malaise (a general feeling of being ill or having no energy which can be an indefinite feeling of debility or discomfort, or a sign of an illness). Review of Resident 5's physician orders failed to reveal any medication orders to treat her nausea or vomiting. Review of Resident 5's meal intakes revealed that no meal intakes were documented after March 9, 2025, at 4:30 PM. Further review of Resident 5's clinical failed to reveal any documentation that the LPNs had notified a RN of Resident 5's refusal of medications, nausea, vomiting, and malaise; that Resident 5 was assessed by a RN; or that Resident 5's physician was made aware of her nausea, vomiting, malaise, and medication refusals. During a staff interview with the NHA and Employee 1 on March 20, 2025, at 10:50 AM, Employee 1 indicated that the LPNs should have notified a RN of Resident 5's condition, and a RN should have completed an assessment and notified the physician as applicable. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 24 residents reviewed (Resident 4). Findings Include: Review of Resident 4's clinical record revealed diagnoses that included congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs) and anxiety (a group of mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life). Observation of Resident 4 on February 17, 2025, at 11:22 AM, revealed Resident 4 lying in bed and Resident 4 had facial hair. Review of Resident 4's care plan revealed a focus area of, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, with a revision date of August 31, 2024. Review of the interventions of this care plan failed to mention any expectation that Resident 4 refuses care or that Resident 4 would complete their own facial shaving. Interview with the Director of Nursing on February 19, 2025, at 11:56 AM, revealed that Resident 4 often refuses care and completes her own facial shaving when she feels it is necessary, and that it should have and would be added to the care plan. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, staff interviews, clinical record review, and facility's policy review, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice for one of three residents reviewed (Resident 54). Findings include: A review of the facility policy, titled Wound Dressings: Aseptic, last reviewed January 2025, directed staff to do the following: after applying and securing the clean dressing, to apply a label with date and initials. A review of the clinical record for Resident 54 on February 19, 2025, revealed clinical diagnoses that included stage IV sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone of the large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) and bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 54's physician orders dated February 2025, included an order for wound care to the sacrum every evening shift. The physician order stated, cleanse with normal saline solution (salt solution), lightly pack with calcium alginate (absorbs excess wound exudate, creating a moist environment that promotes wound healing), cover with bordered gauze island dressing. Observation of wound care on February 19, 2025, at 2:23 PM, revealed there was no dressing in place to indicate when the last dressing change was completed. Employee 6 (Registered Nurse) had no explanation for the missing dressing and agreed that there should have been a dressing in place from the previous day. During an interview with the Nursing Home Administrator (NHA) on February 20, 2025, at 10:50 AM, the NHA agreed that Resident 54's dressing should have been in place from the previous treatment and dated and initialed as the facility policy stated. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure protection from contamination of a urinary catheter for one of three residents reviewed with indwelling catheters (Resident 17). Findings include: Review of facility policy, Catheter:Indwelling Urinary - Care of, revised February 1, 2023, revealed, Secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off of the floor. Review of Resident 17's clinical record revealed diagnoses that included obstructive uropathy (condition in which urine cannot drain through the urinary tract and causes kidney damage) and hydronephrosis (swelling of the kidneys when urine flow is obstructed in any part of the urinary tract). Review of Resident 17's care plan revealed that he utilized an indwelling foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for obstructive uropathy. Further review of Resident 17's care plan revealed Keep catheter off floor. Observation of Resident 17 on February 18, 2025, at 11:43 AM, revealed him being transported by staff in his wheelchair, and his catheter tubing was dragging on the ground underneath his chair. During an interview with the Nursing Home Administrator on February 20, 2025, at 10:45 AM, she revealed the expectation that Resident 17's catheter tubing should not have been touching the ground. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, facility document review, and staff interviews, it was determined that the facility failed to serve all items on the posted menu, and failed to serve items in the appropriate quantity for one of 12 residents observed (Resident 8). Findings include: Review of Resident 8's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and need for assistance with personal care. Review of Resident 8's physician orders revealed an order for a regular/liberalized diet, dysphagia puree texture (type of diet for those with swallowing difficulties consisting of pureed, homogenous and cohesive foods that are pudding-like), effective September 26, 2024. Review of Resident 8's lunch meal ticket for February 18, 2025, (paper slip provided with tray that indicates diet, items to be received, as well as resident allergies and preferences) revealed she was to receive the following: #8 scoop (1/2 cup/4 oz) pureed dysphagia sweet and sour meatballs, pureed boiled potatoes, pureed white rice, pureed warm bread, pudding, and brown gravy. Observation of meal service on February 18, 2025, at 12:39 PM, revealed Employee 1 (Dietary Aide) plating Resident 8's meal, then nursing staff delivering the meal tray. Employee 1 served the pureed meatballs using a #16 scoop (1/4 cup/2 oz). Additionally, it was observed that Resident 8 did not receive pureed rice. During an interview with Employee 1 on February 18, 2025, at 12:47 PM, he confirmed that he missed serving Resident 8's rice. He also confirmed that he used a #16 scoop to serve the pureed meatballs. Review of Resident 8's lunch meal ticket for February 19, 2025, revealed that she was supposed to receive 2 ounces of brown gravy with her meal. Observation on February 19, 2025, at 12:50 PM, revealed Resident 8 was served her lunch meal in her room. No gravy was present on her tray. During an immediate interview with Employee 2 (Dietary Aide), she confirmed that she had not given Resident 8 her gravy. During an interview with the Nursing Home Administrator on February 20, 2025, at 12:34 PM, she revealed the expectation that Resident 8 should have received all of her food and in the correct portion sizes. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to the resident or their representative upon transfer out of the facility, which included the following information: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for three of three residents reviewed for hospitalizations (Residents 63, 77, and 84). Findings include: Review of the clinical record for Resident 63 on February 19, 2025, revealed clinical diagnoses that included depression disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of Resident 63's clinical record revealed transfers to the hospital on March 28, 2024, to April 1, 2024; July 30, 2024, to August 9, 2024; and January 6, 2025, to January 21, 2025. The surveyor requested copies of the transfer, bed hold, and Ombudsman notification. The Ombudsman notification and bed hold notices were provided, however, the transfer notices provided failed to include a statement of the Resident's appeal rights and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman. During an interview with the Nursing Home Administrator (NHA) on February 20, 2025, at 10:50 AM, the NHA confirmed that the written transfer notice should include information that is required. Review of Resident 77's clinical record revealed diagnoses that included congestive heart failure (decreased ability of heart to pump blood through out the body) and atrial fibrillation (irregular heartbeat). Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute medical change in condition on June 23, 2024. Review of Resident 77's clinical record revealed no evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's Representative. Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute medical change in condition on January 22, 2025. Review of Resident 77's clinical record revealed no evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's representative. During a staff interview on February 20, 2025, at approximately 1:00 PM, the NHA confirmed that the facility did not provide Resident 77 or Resident 77's Representative with a notice of transfer letter for the transfers to the hospital on June 23, 2024, and January 22, 2025. Review of Resident 84's clinical record revealed diagnoses that included dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and history of falling. Further review of Resident 84's clinical record revealed that she was transferred to the hospital on January 13, 2025, following a fall with fracture, and was subsequently admitted . Review of Resident 84's clinical record failed to reveal that written notification was provided to her or her representative regarding her transfer to the hospital, which included the following required contents: reason for transfer, effective date of the transfer, location to which the Resident was transferred, a statement of the Resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. During an interview with the NHA on February 20, 2025, at 12:52 PM, she confirmed that the aforementioned transfer notice was not provided to Resident 84 or her Representative. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to ensure medications were stored in a manner that met professional standards for three of three medication carts observed (North Hall B, North Hall C, and South Hall A medication carts). Findings include: Observations of North B Hall medication cart on February 19, 2025 revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. It was also observed that a blister-pack of medications was lodged behind the lowest drawer, which had been filled by the pharmacy in April 2024, for a Resident that had been discharged from the facility in April 2024. During a staff interview directly after the aforementioned observation, Employee 3 (Licensed Practical Nurse) revealed that she was unaware of the facility's procedure for cleaning the medication carts. Observations of North C Hall medication cart on February 19, 2025, revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. Observations of the South A Hall medication cart on February 19, 2025, revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. During a staff interview on February 19, 2025, directly after the aforementioned observation of South A Hall medication cart, Employee 4 (Licensed Practical Nurse) revealed she was familiar with the facility's procedure regarding cleaning of the medication carts as she was recently hired by the facility. During a staff interview on February 20, 2025, at approximately 1:00 PM, Nursing Home Administrator (NHA) revealed that the facility did not have policy or procedure in place that addressed how often medication carts should be inspected and cleaned. During the interview, the NHA revealed that it was the facility's expectation that medication carts are clean 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Weights and Heights, last revised June 15, 2022, required staff to weigh the resident on admission and on readmission, adding the hospital discharge weight may be used for the admission or readmission weight. The policy also required staff to weigh all new admissions to the facility weekly for 4 weeks, and then weigh monthly after the 4 weeks. A review of the closed clinical record for Resident 1 revealed diagnoses that included a stage 4 sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone), type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of Resident 1's care plan dated July 10, 2024, revealed Resident 1 with a nutritional risk due to decreased oral intake, dementia diagnosis, increased nutrient needs related to wound, and required a mechanical altered diet. A closed clinical record review for Resident 1 revealed a physician's order dated July 7, 2024, that staff were to complete weekly weights on day shift every Saturday for the next four weeks. On July 6, 2024, the day of admission, Resident 1's weight was 118.4 pounds, and on July 15, 2024, Resident 1's weight was 116.2 pounds, revealing a 2.2 pound weight loss. Review of Resident 1's clinical documentation revealed that staff did not complete Resident 1's weights on the following dates: July 13, 20, and 27, 2024. The Resident was discharged from the facility on July 29, 2024. During email communication with the Nursing Home Administrator (NHA) on July 31, 2024, at 3:38 PM, the NHA agreed that Resident 1's weights should have been obtained as ordered by the physician and per the facility policy. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observations, facility document review, and resident and staff interviews, it was determined that the facility failed to provide a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) for the lunch meal on June 5, 2024, for three of three residents on a renal diet (Resident 1, 3, and 12) and two of two residents reviewed for a consistent carbohydrate diet (Residents 2 and 4). Findings include: Review of the facility meal extension sheets for June 5, 2024, revealed that residents on a renal diet (a diet to control potassium, phosphorus, sodium, protein for kidney health) were to be served a half a cup of seasoned beets instead of a half a cup of stewed tomatoes; and a half a cup of fruit sherbet instead of a half a cup of chocolate ice cream. Further review of the facility meal extension sheets for June 5, 2024, revealed that residents on a consistent carbohydrate diet (a diet designed to keep blood sugar levels stable by eating the same amount of carbohydrates every day) were to receive a dinner roll. Review of Resident 1's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 1's physician orders revealed an order for a renal diet, dated May 10, 2024. Observation of Resident 1's meal tray and tray ticket on June 5, 2024, at 12:24 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets. Resident 1 had stewed tomatoes in place of the seasoned beets. Interview with Employee 1 (Dietary Aide) who was serving the food on the unit where Resident 1 resides on June 5, 2024, at 12:28 PM, revealed that they did not have seasoned beets on the tray line to serve. Review of Resident 2's clinical record revealed diagnoses that included diabetes mellitus type II and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure). Review of Resident 2's physician orders revealed an order for a consistent carbohydrate diet, dated May 30, 2024. Observation of Resident 2's meal tray and tray ticket on June 5, 2024, at 12:30 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive a dinner roll. Resident 2 did not have a dinner roll present on their tray at time of delivery. Review of Resident 3's clinical record revealed diagnoses that included CKD and diabetes mellitus type II. Review of Resident 3's physician orders revealed an order for a renal diet, dated January 17, 2024. Review of Resident Council Meeting minutes for February 27, 2024, revealed that Resident 3 questioned why their renal diet was not always being followed. The minutes also indicated that the Dietary Manager said she would educate dietary staff on making sure that the Resident receives what they are supposed to be receiving on their meal trays. Observation of Resident 3's meal tray and tray ticket on June 5, 2024, at 12:35 PM, revealed that the Resident was on a renal diet and was to receive a half cup of seasoned beets and a half cup of fruit sherbet. Resident 3 had stewed tomatoes in place of the seasoned beets and chocolate ice cream instead of the fruit sherbet. During observation, Resident 3 stated, they never follow my renal diet. Review of Resident 4's clinical record revealed diagnoses that included diabetes mellitus type II and CKD. Review of Resident 4's physician orders revealed an order for a consistent carbohydrate diet, dated March 12, 2018. Observation of Resident 4's plate and tray ticket on June 5, 2024, at 12:36 PM, revealed that the Resident was on a consistent carbohydrate diet and was to receive wheat bread only. Resident 4's plate had a dinner roll in place of the wheat bread. Resident 4 stated, I don't always get wheat bread. Review of Resident 12's clinical record revealed diagnoses that included diabetes mellitus type II and CKD. Review of Resident 12's physician orders revealed an order for a renal diet, dated May 22, 2024. Review of facility grievance log for June 2024, revealed that a grievance had been received on June 3, 2024, from Resident 12 and their significant other, which indicated that their renal diet was not being followed as they felt Resident 12 was receiving too many potatoes. Interview with Employee 2 (Dietary Manager in Training) on June 5, 2024, at 12:45 PM, she indicated that no beets were prepared for the lunch meal and confirmed that Residents 1, 3, and 12 were not provided the seasoned beets as their ordered diet indicated. She further indicated that they were available in the kitchen, but offered no information as to why they were not prepared for the lunch meal. She also indicated that fruit sherbet was available and could not answer why Resident 3 did not receive it. During an interview with the Nursing Home Administrator (NHA) on June 5, 2024, at 2:45 PM, the aforementioned observations and interviews were shared. The NHA confirmed that she would expect residents to receive their ordered therapeutic diets. Pa code 211.6(a) Dietary Services Pa code 211.10(c) Resident Care Policies Pa code 211. 12(d)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to inform and assist in making transportation arrangements based on financial conditions for one of three residents reviewed (Resident 1). Findings include: A review of the clinical record for Resident 1 on April 15, 2024, revealed clinical diagnoses that included displaced bimalleolar (two of the three parts of the ankle are fractured) fracture of right lower leg and hypertension (elevated blood pressure). A review of the clinical record for Resident 1 revealed that she required transportation to four medical orthopedic appointments while a Resident at the facility. The appointments occurred on February 6, 8, 13, and 27, 2024. The Resident was never informed on admission that she was responsible financially for the transportation cost, or that she had the option of having family transport her to the appointments. Resident 1 received an unexpected bill for the cost of those transports. During interviews with the Director of Nursing (DON) on April 15, 2024, the DON confirmed that there was no Admissions Director for the facility when Resident 1 was admitted . The DON stated that, because Resident 1 had commercial insurance coverage, the Resident would normally have been informed by the Admissions Director that the Resident was responsible for the cost of transportation if her insurance didn't cover it, as well as would have been informed of other options for transport. 28 Pa. Code 201.14(a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure protection of residents' personal property while in the facility and upon discharge or after death for two of two discharged residents reviewed (Residents 95 and 96). Findings include: Review of facility policy, Center Operations Policies and Procedure, Personal Property: Patient's, revision date August 15, 2023, read, in part, personnel will identify and record the resident's belongings upon admission to a center. All items brought into the Center will be listed on the Inventory Of Personal Effects form and kept in the resident's clinical chart. Any additional items brought into the Center after admission must be added to this list. The resident representative will sign the Inventory Of Personal Effects for again at discharge to acknowledge receipt of personal property. In the event of the resident's discharge or death, return of any personal property remaining in the Center must be made within 30 days after the discharge or death. Review of Resident 95's clinical record revealed diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and chronic kidney disease (CKD - kidneys don't function as they should). Review of Resident 95's clinical record revealed the resident was admitted to the facility January 11, 2023, and was in the process of being transferred to the hospital on January 2, 2024, due to a change in condition and, subsequently passed away. Further clinical record review revealed Resident 95's clinical record failed to contain an inventory of personal effects, or communication with the resident's representative regarding return of personal property remaining at the facility within 30 days after their death. Review of Resident 96's clinical record revealed diagnoses that included dementia and history of falls. Review of Resident 96's clinical record revealed she was admitted to the facility on [DATE], and left against medical advice on December 25, 2023. Additional review of Resident 96's clinical record revealed that it failed to contain an inventory of personal effects, or communication with the resident representative regarding return of personal property remaining at the facility within 30 days after discharge. During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 9:17 AM, it was revealed that the facility could not locate Resident 95's and 96's Inventory Of Personal Effects form. It was further explained that the nursing department initiates the Inventory Of Personal Effects form. It is located in the hard medical record, and could be updated by any staff member. During an interview with the NHA on March 21, 2024, at 10:37 AM, it was revealed that Residents 95 and 96 should have had an inventory of personal effects initiated during admission and signed upon discharge. 28 Pa. code 201.18(b)(2) Management.

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 88). Findings include: Review of Resident 88's clinical record revealed diagnoses that included muscle weakness (weakness of muscle movements) and hemiplegia (a total or nearly complete paralysis on one side of the body). Observation of Resident 88 on March 18, 2024, at 12:14 PM, revealed Resident 88 in her bed in her room, with a bed-side commode sitting in the corner of the room. An interview with Resident 88 at that time revealed that the bed-side commode belonged to her. Review of Resident 88's care plan on March 18, 2024, revealed an active care plan for, Resident requires assistance for ADL (activities of daily living) care related to: recent hospitalization, cardiovascular accident, with a date initiated of February 8, 2024. Review of the care plan failed to reveal any directions for Resident 88's use of a bed-side commode. An interview with the Director of Nursing on March 20, 2024, at 12:20 PM, revealed that Resident 88's care plan should have been updated to include her use of the bed-side commode, and that it would be updated. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide and document post-dialysis assessments for one of one resident reviewed for dialysis (Resident 150). Findings include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation), last revised June 15, 2022, revealed the policy stated, [The facility] staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. Review of the Practice Standards section of the policy revealed it included, 1. Prior to a patient leaving the [Facility] for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit . 3. Upon return of the patient to the [Facility], a licensed nurse will: 3.1 Review the certified dialysis facility communications; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. Review of the facility's Hemodialysis Communication Record form, revealed the section for post-hemodialysis stated facility staff were to document the condition of the access site; a resident's blood pressure, temperature and pulse; presence of bruit or thrill (sound that blood makes when flowing through a shunt); post-hemodialysis complications such as dizziness, nausea, vomiting, fatigue or hypotension (low blood pressure); and any new orders from the dialysis center. Finally, the form had an area for the licensed nurse to sign and date the post-dialysis assessment. Review of Resident 150's clinical record on March 18, 2024, at approximately 11:30 AM, revealed diagnoses that included heart failure (decreased ability of the heart to effectively pump blood to the body) with stage 5 chronic kidney disease (severe decrease ability of the kidneys to filter toxins from the blood), which required hemodialysis (a process which removes toxins from the blood using a machine). Review of Resident 150's physician orders revealed Resident 150 was sent to a dialysis center every Monday, Wednesday, and Friday for dialysis treatments. Review of Resident 150's Hemodialysis Communication Record sheets dated March 8 and 18, 2024, revealed that facility staff did not complete the post-hemodialysis treatment section upon Resident 150's return to the facility. Review of both forms revealed that they had been reviewed and signed by a facility medical practioner. During a staff interview on March 21, 2024, at approximately 10:45 AM, Nursing Home Administrator revealed it was the facility's expectation that staff complete the post-dialysis assessment when a resident returns to the facility from a dialysis treatment. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, staff interviews, and facility policy review, it was determined that the facility failed to ensure medications were stored in a manner that met professional standards for one of three medication carts observed (North 1 Medication cart). Findings include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications, Biologicals, last revised August 7, 2023, revealed subsection 9 of Procedures, stated, Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure that no transfers between containers are performed by non-Pharmacy personnel. Observation of the North 1 Medication cart on March 19, 2024, at approximately 9:30 AM, revealed that there was a medicine cup filled with small, round, red tablets stowed in the top drawer of the medicine cart. Observation of the medicine cup revealed Senna S (over-the-counter medication used to treat constipation) was written on the medicine cup with marker. The medicine cup was stored with multiple manufacturer-provided over-the-counter medicine containers. During a staff interview at the time of the observations, Employee 1 (Licensed Practical Nurse) stated it was her opinion that staff had placed the medicine in the medicine cup with the other small over-the-counter medicine containers because the pharmacy sent a large bottle of the Senna-S medication. At the time of the interview, Employee 1 displayed the large bottle of Senna-S in a lower drawer. During a staff interview on March 21, 2024, at approximately 10:45 AM, the Nursing Home Administrator confirmed that medications should be stored in the original containers received from pharmacy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, facility policy review, and staff interviews, it was determined that the facility failed to provide medications in a manner consistent with infection control practices for one of four residents observed for medication administration (Resident 3). Findings include: Review of facility policy, titled 6.0 General Dose Preparation and Medication Administration, last revised January 1, 2022, revealed the Applicability, section stated, This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. Review of Resident 3's clinical record on March 19, 2024, at approximately 10:00 AM, revealed diagnoses that included breast cancer and congestive heart failure (CHF - condition that results in decreased ability of the heart to pump blood efficiently throughout the body). During medication administration observations conducted on March 19, 2024, at approximately 9:05 AM, Employee 1 (Licensed Practical Nurse) was observed preparing medications for administration to Resident 3. During the preparation of the medication, Employee 1 was observed dispensing nine separate medications from multi-dose containers into her bare hand, then dropping the medication into a medicine cup. Employee 1 was also observed dispensing one medication from a blister-pack (card of medications that have individual pills/doses in small separate pockets) into her bare hand, then dropping the medication into the medicine cup. At approximately 9:20 AM, Employee 1 administered the medications to Resident 3. During a staff interview on March 20, 2024, at approximately 1:25 PM, the Director of Nursing revealed it was her expectation that staff only handle medications with gloved hands. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative of a resident's transfer in writing to include the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman; and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for three of three resident records reviewed for hospitalization (Residents 21, 84, and 297). Findings include: Review of Resident 21's clinical record on March 20, 2024, at 9:13 AM, revealed diagnoses that included type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) and atrial fibrillation (quivering or irregular heartbeat in the upper chamber of the heart). Further review of Resident 21's clinical record revealed that on October 1 and 5, 2023; November 5, 2023; and January 14, 2024, Resident 21 was transferred out of the facility to the hospital and subsequently was admitted to the hospital. During an interview on March 20, 2024, at 1:05 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor requested a copy of the Resident Representative transfer notices and Ombudsman notifications for the aforementioned hospital transfers. During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware that transfer notices needed to be sent, and they had not been done. Review of Resident 84's clinical record on March 19, 2024, at 10:20 AM, revealed diagnoses that included dementia (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and Parkinson's disease (disorder of the brain that causes unintentional and uncontrollable movements of the body, stiffness, and difficulty with balance and coordination). Further review of Resident 84's clinical record revealed that on December 8, 2023, Resident 84 was transferred and admitted to the hospital. Resident 84 subsequently returned to the facility on December 11, 2023. As of March 21, 2024, at 12:15 PM, the facility was unable to provide a hospital transfer form nor evidence that the State Ombudsmans office was notified of Resident 84's transfer to the hospital. During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware transfer notices needed to be sent, and they had not been done. Review of Resident 297's clinical record on March 20, 2024, at 9:19 AM, revealed diagnoses that included protein-calorie malnutrition (not enough protein and calories are consumed to meet the body's needs) and dementia. Further review of Resident 297's clinical record revealed that on February 24, 2024, and on March 18, 2024, Resident 297 was transferred out of the facility to the hospital and subsequently was admitted to the hospital. During an interview on March 20, 2024, at 1:05 PM, with the NHA and DON, the surveyor requested a copy of the Resident Representative transfer notices and Ombudsman notifications for the aforementioned hospital transfers. During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware transfer notices needed to be sent, and they had not been done. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, resident and staff interviews, facility policy review, and record review, the facility failed to ensure pressure ulcer preventative and management interventions were followed for one of three Resident's reviewed (Resident 1). Findings include: A review of the facility policy on January 11, 2024, last revised May 26, 2022, titled Turning and Repositioning Pressure Ulcer Prevention and Management, revealed that the policy states all patients who have limited mobility or have actual pressure ulcers may require a turning and repositioning program while in bed or while sitting. Turning schedules may vary and be more or less that two (2) hours not to extend beyond four (4) hours, depending on patient's individualized risk factors, surfaces, and tissue tolerance. A review of the clinical record for Resident 1 on January 10, 2024, revealed diagnoses that included a stage IV pressure (ulcer involving loss of skin layers, exposing muscle and bone) and malignant neoplasm of the right kidney (cancer of the right kidney). Also, it revealed Resident 1 was bedridden (unable to ambulate, and unable to independently move in bed or get out of bed). A review of Resident 1's Quarterly Minimum Data Set (periodic assessment and care screening) dated January 26, 2024, revealed Resident 1 with a BIMS (brief interview of mental status) of 15, indicating she is cognitively intact. A review of MDS Section GG, Mobility Status, indicated Resident 1 is dependent on staff to roll left or right and requires two-person or more physical assist. A review of Resident 1's current care plan revealed an intervention created October 18, 2023, to turn and reposition the Resident approximately every 2-3 hours for preventive wound measures. A review of the wound care physician notes documented weekly November 3, 2023, through January 12, 2024, stated to reposition the Resident per facility policy. A review of the Nurse Aide task section of the electronic health record revealed the Nurse Aides are to turn Resident 1 every two hours. Documentation on the task section revealed the Resident was repositioned 1-2 times per day, December 14, 2023, to January 12, 2023; with the exception of January 5, 2024, task showed repositioning three times that day. There was no documentation regarding the missed turning and repositioning, or refusals of repositioning in the progress notes during this time. During an interview with family and Resident 1 on January 10, 2023, at approximately 4:00 PM, the family member stated that Resident 1 was last turned from her side to her back at approximately 2:00 PM (documentation stated 2:59 PM). Both the Resident and two family members stated that the Resident is never offered to be turned and repositioned every 2-3 hours. Observation by the surveyor on January 10, 2024, from 4:00 PM until 6:30 PM, revealed staff never attempted repositioning, even though staff entered the room on two separate occasions during that time period. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on January 10, 2024, both agreed that preventative measures should be followed to prevent worsening of pressure ulcers. The NHA and DON also stated that they heard the wound physician tell Resident 1 and her family members that, since Resident 1 has a pressure reducing mattress, less turning is required. Correspondence via telephone with the DON and NHA on January 12, 2024, at 3:50 PM, revealed both believe that, since the Resident is on an off-loading mattress, she only needed to be turned every 4-6 hours. 28 Pa. Code 211.10(a)(d)Resident care policies

Based on observation, resident and staff interviews, record review, and policy review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Catheter: Indwelling Urinary-Care of, last revised February 1, 2023, stated, inspect the catheter tube holder (a securement device to prevent the catheter tube from becoming detached or shifted) daily, change when clinically indicated, and as recommended by the manufacturer. Review of Resident 1's clinical record on January 10, 2024, revealed Resident 1 has diagnoses that included urinary retention (inability to completely empty the bladder) and malignant neoplasm of right kidney (cancer of the right kidney). Review of physician orders dated January 2024, identified that Resident 1 had an indwelling urinary catheter in place with a 14 French catheter and 10 milliliter filled balloon to maintain placement within the bladder. Observation of Resident 1 on January 10, 2024, at 5:00 PM, revealed Resident 1's catheter tubing dangling and without a securement device attaching the catheter to the thigh area. Both Resident 1 and a family member, who was present during the observation, stated they have informed staff many times that the tubing was dangling and not secured. During a discussion with Employee 1 (Licensed Practical Nurse) on January 10, 2024, at approximately 5:00 PM, regarding the dangling catheter tube, Employee 1 confirmed that the catheter tubing should be secured with a catheter tube holder. During an interview with the Nursing Home Administrator (NHA) on January 12, 2024, at 10:15AM, the NHA stated that policy should be followed and the catheter tubing should be secured at all times. 28 Pa. Code 211.10(a)(d)Resident care policies

Based on review of facility policy, test tray, observation, and staff and resident interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the 200 unit. Findings include: Interviews with multiple resident during the initial pool process on April 10, 2023, revealed concerns with the quality and the temperature of food during mealtime. Review of facility form Tray Assessment and Delivery info, no date, read, in part, fully acceptable point of service temperatures: hot beverage 145 to 149 degrees; hot entrée, starch, and vegetable 125 to 129 degrees; cold food and beverages 48 to 50 degrees. A test tray was completed on April 12, 2023, in the 200 unit Dining Room, and food was served off the steam table in the Dining Room. Test tray temperatures were taken by Employee 2 (Dining Services Director), at 12:32 PM, and revealed the following: Country Fried Steak 121 degrees Fahrenheit, not acceptable for temperature Potato Wedges 125 degrees Fahrenheit, acceptable Green Beans 97 degrees Fahrenheit, not acceptable for temperature Pineapple 60 degrees Fahrenheit, not acceptable for temperature Cranberry Juice 41 degrees Fahrenheit, acceptable Coffee 143 degrees Fahrenheit, acceptable During an interview with the Employee 2 on April 12, 2023, at 12:35 PM, it was revealed that the temperature of the entree, and vegetable should be warmer, and the temperature of the pineapple should be cooler. It was also revealed that the pineapple was to be served cold, and was refrigerated and then in the freezer for a short period prior to service. Interview with Nursing Home Administrator on April 12, 2023, at 11:45 AM, no further information was provided regarding the test tray. 28 Pa code 211.6(b)(d) - Dietary Services

Based on observation, review of facility policy, manufacturer product label, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of three dining rooms (200 unit dining room). Findings include: Review of facility policy, titled Food Storage: Cold Foods, revised April 2018, read, in part, all perishable foods will be maintained at a temperature of 41 degrees or below, except during necessary periods of preparation and service. Observation in the 200 unit dining room on April 12, 2023, at 9:30 AM, there was one half case of butter portion controlled packets on the counter, not refrigerated. Observation in the 200 unit dining room on April 12, 2023, at 12:25 PM, there was one half case of butter portion controlled packets on the counter, not refrigerated. Review of the product label, read, in part, hold between 43 to 40 degrees Fahrenheit. Observation on April 12, 2023, at 12:35 PM, Employee 2 took the temperature of several butter packets and they were 77 degrees Fahrenheit. Interview with Employee 2, on April 12, 2023, at 12:45 PM, revealed that portion controlled butter packets must have been left on the counter since breakfast, and would be discarded. Interview with Nursing Home Administrator on April 12, 2023, at 11:45 AM, no further information was provided regarding the storage of the portion controlled butter packets. 28 Pa code 211.6(b)(d) - Dietary Services

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure the medical records were maintained in accordance with professional standards and practice for one of 21 residents reviewed (Resident 57). Findings include: Review of Resident 57's clinical record on April 10, 2023, at approximately 11:00 AM, revealed diagnoses of diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells) and vascular dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living). Review of Resident 57's clinical record revealed that on March 22, 2023, staff observed an unstable pressure ulcer to Resident 57's sacrum. Review of Resident 57's interdisciplinary progress notes revealed that on March 29, 2023, the sacral pressure ulcer was assessed, A deteriorating pressure wound Stage 3 . Review of Resident 57's physician orders revealed that Resident 57 had an order for, Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to sacral wound topically every day shift every Mon[day], Wed[nesday], Fri[day] for Wound, which was dated March 15, 2023. Resident 57 also had an order for, Sacrum Cleanse with wound cleanser, pat dry[.] Apply AG Alginate to open areas Cover with sacral or bordered foam every day shift ever Mon[day], Wed[nesday], Fri[day] for MASD, which was dated April 5, 2023. During wound dressing observation on April 12, 2023, Employee 10 was observed changing the dressing to Resident 57's sacrum. Employee 10 was observed cleansing the wound and applying an AG Alginate dressing to a pressure wound on Resident 57's sacrum. Employee 10 was not observed to apply the ordered Medihoney dressing paste. During a staff interview, directly after the observed dressing change, Employee 10 revealed that the Medihoney dressing paste should have been discontinued when the AG Alginate dressing was initiated on April 5, 2023. Review of Resident 57's progress notes revealed that on April 5, 2023, at 1:10 PM, Employee 10 documented, Medihoney Wound/Burn Dressing External Paste[.] Apply to sacral wound topically every day shift .Dressing changed to alginate[.] During a staff interview on April 13, 2023, at approximately 1:00 PM, Director of Nursing confirmed that the Medihoney dressing paste should have been discontinued on April 5, 2023, and should not have continued as an active order. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on interviews, employee training documents, and regulations, it was determined that the facility failed to have an Infection Preventionist (IP) that completed an approved program for specialized training in infection prevention and control. Findings include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(4) states, The facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's IPCP (Infection Prevention Control Program) that have completed specialized training in infection prevention and control. The individual must work a minimum of part-time within the facility. Employee 1 (Registered Nurse) assumed role as IP at the facility on November 1, 2021. During an interview with The Nursing Home Administrator (NHA) on April 10, 2023, at 1:50 PM, Employee 1's credentials were requested. Employee 1 is currently designated IP that requires completion of an approved specialized training in infection prevention and control. The facility provided a manual that was developed by their corporate company. Employee 1 was unable to provide supporting documentation of the completion of the 10 modules in the manual, unable to provide approval of the program by Centers for Medicare and Medicaid (CMS), and unable to provide a certificate of completion. The training manual does not reference Centers for Disease Control (CDC) or Association for Professionals in Infection Control and Epidemiology (APIC) for approval status. No CE credits are listed. The manual states, upon completion of the training, you will be able to print the certificate. There are six classes enrolled and completed per a print out provided but no certificate. During an interview with the NHA on April 13, 2023, at 12:30 PM, stated the current IP is unable to provide a certificate of completion of the program for specialized training in infection prevention and control as specified in the manual. 28 Pa. Code 201.18(b)(2) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for five of 22 residents reviewed (Residents 4, 50, 52, 71, and 92). Findings include: Review of Resident 4's clinical record revealed diagnoses including chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body) and end stage renal disease. Further review of Resident 4's clinical record revealed that Resident 4 was transferred out of the facility to the hospital on March 25, 2023, and was subsequently admitted to the hospital. Review of facility provided documents failed to reveal that the facility bed hold notice was provided to the Resident or their Representative at time of transfer. During an interview with the Nursing Home Administrator (NHA) on April 12, 2023, at 12:09 PM, the NHA revealed that the previous NHA had instructed staff to not use the bed-hold notice anymore because of the plan of correction for the survey findings from April 2022. NHA indicated that she was not aware the facility was not issuing a bed-hold notice and confirmed that they should be providing this information to the Resident or their Responsible Party. She further indicated that she had instructed staff to start doing so. Review of Resident 50's clinical record revealed diagnoses including chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body). Further review of Resident 50's clinical record revealed that on March 12, 2023, they were transferred out of the facility to the hospital and were subsequently admitted to the hospital. Review of facility provided documents failed to reveal that the facility bed hold notice was provided to the Resident or their Representative at time of transfer. Review of Resident 52's clinical record revealed diagnoses that include multiple sclerosis ( MS- slow progressive disease of the central nervous system) and neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord, or nerve problem). Review of nursing progress revealed that Resident 52 was transferred and admitted to the hospital March 16, 2023, and returned to the facility on March 23, 2023. Review of facility provided documents failed to reveal that the facility bed hold notice was provided to the Resident or their Representative at time of transfer. Interview with the Director of Nursing (DON) on April 12, 2023, at 12:09 PM, revealed that the facility has not been completing a bed-hold notice. Review of Resident 71's clinical record revealed diagnoses that include chronic diastolic congestive heart failure (excessive body/lung fluid caused by a weakened heart) and atherosclerotic heart disease (a disease in which plaque builds up inside your arteries, plaque is made up of fat, cholesterol, and calcium). Review of nursing progress revealed that Resident 71 was transferred and admitted to the hospital March 17, 2023, and returned to the facility on March 20, 2023. Review of facility provided documents failed to reveal that the facility bed-hold notice was provided to the Resident or their Representative at time of transfer. Interview with the DON on April 12, 2023, at 12:09 PM, revealed that the facility has not been completing a bed-hold notice. Review of Resident 92's clinical record revealed diagnoses that included hypertension (high blood pressure) and spinal cord injury. Further review of Resident 92's clinical record revealed that on December 4, 2022, and on January 19, 2023, they were transferred out of the facility to the hospital and were subsequently admitted to the hospital. Review of facility provided documents failed to reveal that the facility bed hold notice was provided to the Resident or their Representative at time of transfer. During an interview with the NHA on April 12, 2023, at 12:09 PM, the NHA revealed that the previous NHA had instructed staff to not use the bed hold notice anymore because of the plan of correction for the survey findings from April 2022. NHA indicated that she was not aware the facility was not issuing a bed-hold notice and confirmed that they should be providing this information to the Resident or their responsible party. She further indicated that she had instructed staff to start doing so. 28 Pa. Code 201.14(a) Responsibility of Licensee

**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 ensure the resident assessment accurately reflected the resident status for two of 21 residents reviewed (Residents 41 and 57). Findings include: Review of Resident 41's clinical record revealed diagnoses that included: chronic kidney disease stage 5 (kidneys are severely damaged and have stopped doing their job, to filter waste from your blood). Further review of Resident 41's clinical record documented physician orders that included dialysis on Tuesdays, Thursdays, and Saturdays, with a start date of September 23, 2022. Review of Resident 41's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated August 3, 2022, failed to document dialysis. Interview on April 12, 2023, at 11:05 AM, with Employee 4 (Clinical Reimbursement Coordinator) revealed that Resident 41's quarterly MDS dated [DATE], was marked in error, dialysis should have been documented. Interview with Director of Nursing (DON) on April 12, 2023, at 11:45AM, no further information was provided regarding Resident 41's quarterly MDS dated [DATE]. Review of Resident 57's clinical record on April 10, 2023, at approximately 11:00 AM, revealed diagnoses of diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells) and vascular dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living). Review of Resident 57's physician orders revealed an order that stated, Admit into Hospice Care with Compassus Hospice effective 11/11/2022 with diagnosis of PCM [Protein Calorie Malnutrition], Vascular Dementia, which was dated November 11, 2022. Review of Resident 57's Significant Change Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental and psychosocial needs), with an assessment reference date of November 17, 2022, revealed that Section I: Active Diagnoses, subsection I5600. Malnutrition (protein or calorie) or at risk for malnutrition, was not assessed to indicate that Resident 57 had a diagnosis of protein calorie malnutrition. Review of Resident 57's Quarterly MDS, with an assessment reference date of February 17, 2023, revealed that Section I: Active Diagnoses, subsection I5600. Malnutrition (protein or calorie) or at risk for malnutrition, was not assessed to indicate that Resident 57 had a diagnosis of protein calorie malnutrition. Further review of Resident 57's Quarterly MDS, revealed that section G0100. Activities of Daily Living (ADL) Assistance, subsection, B. Transfer - how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . revealed that Resident 57 was coded as, 1 = Supervision - oversight, encouragement or cueing. Review of Resident 57's clinical record revealed that Resident 57 required extensive assistance to transfer between surfaces. During a staff interview on April 12, 2023, at approximately 9:42 AM, Facility Registered Nurse Assessment Coordinator confirmed that Resident 57's MDS assessments should have included the diagnosis of protein calorie malnutrition and that section G0100B - 1, on the February 17, 2023 Quarterly MDS was coded incorrectly. During a staff interview on April 13, 2023, at approximately 11:50 AM, DON revealed it was the facility's expectation that the Resident MDS would be coded accurately. 28 Pa. Code 211.5(f) Clinical records

Based on observation, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident comprehensive plan of care was reviewed and revised for two of 21 residents reviewed (Residents 11 and 57). Findings include: Review of facility policy, titled OPS416 Person-Centered Care Plan, last revised October 24, 2022, revealed that section 6 stated, The PointClicCare (PCC) care plan library is used to develop the patient's care plan. 6.1 The care plan must be customized to each individual patient's preferences and needs. 6.2 If there is not a care plan available to meet a patient's needs, staff may develop one using the custom care plan in PCC. Review of Resident 11's clinical record, revealed diagnoses including depression (prolonged feelings of sadness that affect mood, energy level, and sleep patterns) and hypertensive heart disease with heart failure (disease in which changes within the heart cause chronic blood pressure elevation, resulting in the decreased ability of the heart to pump blood to the rest of the body). Review of Resident 11's comprehensive plan of care revealed an activities care plan for Resident 11 was created and initiated on August 8, 2022. Review of the care plan interventions revealed 11 interventions that were not completed as evidenced by blank spaces which had instructions such as specify type .specify leisure options .delete all that do not apply, etc. During an interview on April 13, 2023, at approximately 1:10 PM, facility Activity Director confirmed that Resident 11's activity care plan was not completed. Review of Resident 57's clinical record on April 10, 2023, at approximately 11:00 AM, revealed diagnoses of diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells) and vascular dementia (irreversible, progressive degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living). Review of Resident 57's clinical record revealed that on March 22, 2023, staff observed an unstable pressure ulcer to Resident 57's sacrum. Review of Resident 57's interdisciplinary progress notes revealed that on March 29, 2023, the sacral pressure ulcer was assessed, A deteriorating pressure wound Stage 3 . Review of Resident 57's clinical record revealed that as of April 10, 2023, Resident 57 continued to have the pressure ulcer to the sacrum. Observations on April 12, 2023, at approximately 10:40 AM, confirmed that Resident 57 had a pressure ulcer to the sacrum. Review of the care plan revealed that the pressure ulcer on Resident 57's sacrum was not identified in the plan of care. During a staff interview on April 12, 2023, at approximately 1:05 PM, Director of Nursing confirmed that Resident 57's care plan did not include the sacral pressure ulcer and should have been updated to reflect that Resident 57 suffered a pressure ulcer to the sacrum. Pa code 211.11(d) Resident Care Plans

Based on review of facility policy review, record review, observations, and resident and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for three of 22 residents reviewed (Residents 4, 74, and 87). Findings include: Review of facility policy, titled NSG230 Respiratory Equipment/Supply Cleaning/Disinfection with a last revision date of June 1, 2021, revealed Cleaning and disinfection of respiratory equipment is performed by a respiratory therapist, licensed nurse, or equipment technician. All respiratory equipment which cannot be immersed in water is cleaned with a disinfecting solution and allowed to dry. Disinfection is performed on all equipment on a scheduled basis and upon discontinuation from service and between patients. Review of Resident 4's clinical record revealed diagnoses including chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body) and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident 4's clinical record revealed the following orders: 1) Humidified Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while one sleeps) with oxygen at 2 Liters inline. Pressure Settings: 10cmH2O (water). Hours of Usage HS (hours of sleep) and as needed daily for rest period every evening and night shift, dated January 9, 2023; 2) CPAP: clean Nasal mask and empty Reservoir per manufacturer's instructions daily every day shift, dated January 9, 2023; and 3) RT (Respiratory Therapy) services for optimal oxygenation/ventilation to include increased Cardiopulmonary endurance. Interventions, education, incentive spirometer (a handheld device used to help patients improve the function of their lungs by training people to take slow deep breaths), deep breath and cough, oxygen management and/or weaning, and assessment, dated March 29, 2023. Observations of Resident 4 on April 10, 2023, at 10:50 AM; April 11, 2023, at 10:29 AM; and April 12, 2023, at 10:05 AM, all revealed that the Resident's CPAP mask was still attached to the tubing. The mask was tucked inside the drawer of their nightstand with other personal belongings of Resident 4, and the tubing was not dated. Interview with Employee 7 on April 12, 2023, at 11:56 AM, revealed that the mask should be bagged, but that there were CPAP Mask Wipes at bedside and staff clean the mask prior to applying the mask at night. Employee 7 further indicated that they were not sure about the policy regarding changing the tubing, but that they would look into it and get back to me. A follow-up interview with Employee 7 on April 12, 2023, at 12:30 PM, revealed that they had spoken to the Director of Nursing (DON) and that the facility does not have a policy regarding CPAP tubing changes. Employee 7 further indicated that they had contacted respiratory therapy, they would be changing the tubing, and they had cleaned Resident 4's mask with the CPAP wipes and placed it in a bag. Concerns with dating and mask being unbagged and placed in drawer with miscellaneous other personal items was shared with Nursing Home Administrator (NHA) and DON on April 12, 2023, at 2:30 PM. DON indicated that their policy does not indicate when tubing is to be changed. She indicated that Respiratory Therapy follows the manufacturer guidelines. As for the concern of the masks being unbagged, she indicated that this could be a Resident preference because some of the residents are involved in managing their CPAP or Bi-PAP (bi-level positive airway pressure machine that provides two different levels of air pressure-one for breathing in and one for breathing out). DON indicated that she would seek out information regarding manufacturer guidelines. During a follow-up interview with the DON on April 13, 2023, at 9:15 AM, revealed that they rent the C-PAP's/BiPAP's from Lincare. She indicated that they did not send her the manufacturer guidelines, but they indicated that the corrugated tubing should be changed every three months. She said that she would have expected the tubing to have been changed per these guidelines. She further indicated that she could not find in any facility policy that the mask needed to be bagged for infection control purposes. Review of Resident 74's clinical record revealed diagnoses that included morbid (severe) obesity with alveolar hypoventilation ( a disorder in which poor breathing lowers oxygen and raises carbon dioxide levels) and chronic systolic congestive heart failure (heart failure that occurs when the left ventricle in the heart cannot pump enough blood). Review of Resident 74's clinical record revealed the following orders: 1) humidified BiPAP (bi-level positive airway pressure machine that provides two different levels of air pressure-one for breathing in and one for breathing out) at HS (bedtime) and remove in AM (morning). Pressure setting inspiratory 20cm (centimeters) H2O (water) and expiratory 10cmH2O. Fill humidifier with sterile or distilled water every day and evening shift for on at HS and remove in AM/ per family request, dated June 13, 2022; 2) Respiratory Therapy (RT)- Evaluation and treatment as recommended, dated June 12, 2022; 3) RT services for improved lung function. Interventions to include education, Acapella (a device used as part of a treatment to help people who have difficulty clearing sputum [phlegm] from their lungs), incentive spirometer (a handheld device used to help patients improve the function of their lungs by training people to take slow deep breaths), BiPAP, monitoring respiratory status as needed, dated June 13, 2022; and 4) RT services for improved Pulmonary status/prevention of respiratory distress. Interventions: incentive spirometry, Acapella, daily assessments, BiPAP compliance, dated July 6, 2022. Observations of Resident 74 on April 10, 2023, at 11:08 AM, and April 11, 2023, at 10:53 AM, revealed Resident 74 was in bed and their Bi-Pap mask was lying on top of the nightstand unbagged. The filter was dated February 13, 2023, the tubing was dated January 30, 2023, at the filter connection and the same continuous tubing was dated July 13, 2022, at the other end of the tubing that connects to the mask. The nightstand was not within reach of Resident 74 when in bed. Observation of Resident 74 on April 12, 2023, at 10:10 AM, revealed Resident 74 was in bed and their Bi-Pap mask was lying on top of the nightstand unbagged. The filter was dated April 11, 2023, the tubing was dated January 30, 2023, at the filter connection and the same continuous tubing was dated July 13, 2022, at the other end of the tubing that connects to the mask. Interview with Employee 7 on April 12, 2023, at 11:53 AM, revealed that the mask should be bagged, but that there were Bi-Pap Mask Wipes at bedside and staff clean the mask prior to applying the mask at night. Employee 7 further indicated that they were not sure about the policy regarding changing the tubing, but that they would look into it and get back to me. A follow-up interview with Employee 7 on April 12, 2023, at 12:30 PM, revealed that they had spoken to the DON and that the facility does not have a policy regarding Bi-PAP tubing changes. Employee 7 further indicated that they had contacted respiratory therapy and they would be changing the tubing and that they had cleaned Resident 74's mask with the Bi-Pap wipes and placed it in a bag. Concerns with dating and mask being unbagged and laying on top of nightstand was shared with NHA and DON on April 12, 2023, at 2:30 PM. DON indicated that their policy does not indicate when tubing is to be changed. She indicated that Respiratory Therapy follows the manufacturer guidelines. As for the concern of the masks being unbagged, she indicated that this could be a Resident preference because some of the residents are involved in managing their CPAP or Bi-PAP. DON indicated that she would seek out information regarding manufacturer guidelines. During a follow-up interview with the DON on April 13, 2023, at 9:15 AM, revealed that they rent the C-PAP's/BiPAP's from Lincare. She indicated that they did not send her the manufacturer guidelines, but they indicated that the corrugated tubing should be changed every three months. She said that she would have expected the tubing to have been changed per these guidelines. She further indicated that she could not find in any facility policy that the mask needed to be bagged for infection control purposes. Review of Resident 87's clinical record revealed diagnoses that included: chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), morbid obesity (disorder involving excessive body fat that increases the risk of health problems), anxiety ( feeling of worry, nervousness, or unease), and atherosclerotic heart disease (build-up pf fats, cholesterol, and other substances in and on the artery walls). Further review of Resident 87's clinical record documented physician orders that included: oxygen at 2 liters/minute (L - unit of measure) via nasal cannula continuously, with a start date of May 31, 2022, and revised January 7, 2023; oxygen tubing change weekly label each component with date and initials, with a start date of June 7, 2022; bilevel positive airway pressure (BiPAP- non-invasive ventilation breathing support administered through a face mask, or nasal mask where added oxygen is given under positive pressure), BiPAP oxygen setting: 2 liters/minute, with a start date May 28, 2022; BiPAP humidification (if applicable): fill with sterile water, with a start date May 28, 2022; BiPAP- clean reservoir per manufactures instructions, with a start date May 28, 2022. Observation in Resident 87's room on April 10, 2023, at 11:13 AM, the BiPAP mask was on the floor between the bed and the dresser, and the oxygen tubing/nasal cannula was on the floor near the oxygen concentrator. Resident 87 wasn't in the room at that time. Observation in Resident 87's room on April 11, 2023, at 12:10 PM, Resident 87's BiPAP mask was on the night stand next to the bed on top of a clear plastic bag. Observation in Resident 87's room on April 12, 2023, at 10:15 AM, Resident 87 was dressed for the day and in her wheelchair; the oxygen concentrator running 2L, tubing is on the floor; BiPAP mask on night stand next to a plastic bag. Interview with Resident 87 April 12, 2023, at 10:15 AM, revealed that she can manage her oxygen, and she took off the nasal cannula because staff was coming in to assist her. It was also revealed that the facility helps her manage the BiPAP, however, she can put mask on and off herself. Observation in Resident 87's room on April 12, 2023, at 10:32 AM, after Resident received assistance by a nursing staff member, the BiPAP mask remained on the night stand next to the plastic bag. Observation with Employee 5 (Registered Nurse), on April 12, 2023 at 11:09 AM, in Resident 87's room revealed: oxygen tubing/nasal cannula were on the floor behind the concentrator, and the BiPAP mask on night stand next to a clear plastic bag. Interview with Employee 5 on April 12, 2023 at 11:09 AM, it was revealed that the oxygen tubing shouldn't be on the floor, it should be stored in the bag hanging from the concentrator; and the BiPAP mask should be stored in the bag on the night stand. It was also revealed that Resident 87 most likely removed her nasal cannula and put it on the floor when she was hooked up to the her oxygen portable tank. Interview with the DON on April 12, 2023, at 2:45 PM, it was revealed that the oxygen tubing/nasal cannula and BiPAP mask should not be on the floor. It was also revealed that Resident 87 has separate tubing/nasal cannula for the portable oxygen tank on her wheelchair; and that Resident 87 would require staff to turn on the portable oxygen. 28 Pa code 211.12(d)(1)(2)-Nursing Services

Based on review of facility policy, clinical record review, and interviews with residents and staff, it was determined that the facility failed to provide routine drugs to Residents in a timely manner for one of 31 residents reviewed (Residents 41). Findings include: Review of facility policy, titled Facility Receiving Pharmacy Products and Services from Pharmacy, revision date January 1, 2023, read, in part, upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility should immediately initiate action to obtain the medication from Pharmacy. Facility nurse should call Pharmacy to determine status of order; and if not ordered, an order should be places or reordered for the next scheduled delivery. If the medication is not available in the emergency medication supply, facility staff should notify pharmacy and arrange an emergency delivery if medically necessary. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders of directions. Review of Resident 41's clinical record revealed diagnoses that included: chronic kidney disease stage 5 (kidneys are severely damaged and have stopped doing their job, to filter waste from your blood), dependence on renal dialysis, congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), disorder of phosphorus metabolism, and glaucoma (eye condition that can cause blindness, the nerve connecting the eye to the brain is damaged). Interview with Resident 41 on April 10, 2023, at 11:40 AM, revealed that her eye drops for glaucoma, bladder pill, and potassium binder are not administered to her at times because the facility is awaiting delivery from pharmacy. Review of Resident 41's physician orders included: Renvela Oral Tablet 800 MG (milligrams- unit of measure, Sevelamer- a phosphate binder that helps prevent low levels of calcium in the body caused by elevated phosphorus) give two tablets by mouth with meals every Monday, Wednesday, Friday, and Sunday for elevated phosphorous, start date October 21, 2022; Renvela 800 mg give two tablets three times a day every Tuesday, Thursday, Saturday for elevated phosphorous, start date October 21, 2022; Lokelma Packet 10 GM (Sodium Zirconium Cyclosilicate- for the treatment of high levels of potassium in the blood) Give 10 gram by mouth one time a day every Monday, Wednesday, Friday, Sunday for elevated Potassium, start date February 24, 2023; Torsemide (used to treat high blood pressure and fluid retention) 400 MG by mouth one time a day every Monday, Wednesday, Friday, Sunday for edema, start September 25, 2022; Torsemide 400 mg one time a day for edema Tuesday, Thursdays, Saturday, start date September 24, 2022; and Latanoprost Solution 0.005 % Instill one drop in both eyes at bedtime for glaucoma, start date March 12, 2018. Review of Resident 41's April 2023 medication administration record (MAR- documentation of medications that were administration) revealed that Renvela was not administered on the 12th at 8:00 AM, 12:00 PM, and 5:00 PM; and Torsemide was not administered on the 7th, 9th, and 10th. Review of Resident 41's March 2023 MAR documented Lokelma was not administered on the 10th, 12th, 15th, 22nd, and 24th. Review of Resident 41's March 2023 MAR documented Renvela was not administered on the 17th at 5:00 PM; 18th and 25th at 8:00AM, 2:00 PM, and 5:00 PM; on the 19th and 26th at 8:00 AM ,12:00 PM, and 5:00 PM; and on the 1st and 27th at 8:00 AM, and 12:00 PM; and there was no documentation on the 2nd and 28th at 2:00 PM. Further review of Resident 41's March 2023 MAR documented Latanoprost was not administered on the 18th and 19th. Progress note dated March 19, 2023, at 4:10 PM, read, in part, awaiting from pharmacy, called pharmacy, pharmacy stated that it would be delivered on the next run. Progress note dated April 12, 2023, at 2:36 PM, read, in part, Registered Nurse aware Resident was out of Renvela, medication was reordered April 9th, 2023, pharmacy notified and medication to be delivered on April 12th, 2023, in the evening. Further review of progress notes revealed Lokelma Packet 10 GM was not administered due to medication not on hand, awaiting pharmacy to deliver on March 10, 2023, at 9:19 AM. Further review of progress notes revealed Latanoprost Solution wasn't available to be administered - awaiting from pharmacy on March 18, 2023, at 8:56 PM; and March 19, 2023, at 9:04 PM. Interview on April 12, 2023, at 11:05 AM, with Employee 5 (Registered Nurse), it was revealed that at times there have been medications on back order. If the needed medication is not in the emergency supply a resident may miss dose(s), and if this occurs the physician should be notified. Interview with Director Of Nursing on April 12, 2023, at 11:45 AM, revealed that the facility will order medications when they are getting low; however, the pharmacy doesn't always communicate if an item is on back order. If that happens the staff may not realize it until the medication is finished. It was revealed that the facility has an emergency supply, but the aforementioned items aren't in that stock. It was also revealed that their contract pharmacy is a subsidiary of a local retail pharmacy; however, she wasn't aware if the facility would be able to utilize the local retail pharmacy to obtain needed medications. It was also revealed that the Physician should be notified when ordered medications are not administered. 28 Pa. Code 201.14(a) Responsibility of Licensee 211.9(a)(1)(k) Pharmacy services 211.10(c) Resident Care Policies 211.12(d)(5) Nursing Services

Based on facility policy review, clinical record review, staff interview, and review of facility investigation documentation, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of four residents reviewed (Resident 1). Findings Include: Review of facility's current policy, titled Medication Administration: Oral, last revised June 1, 2021, states Verify medication order on medication administration record (MAR) with medication label for correct: patient; drug; dose; route; and time. Review of Resident 1's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear), personal history of malignant neoplasm of breast (breast cancer), and secondary malignant neoplasm of bone (bone cancer). Review of Resident 1's admission MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated January 17, 2023, revealed a BIMS (brief interview for mental status) score of 10; indicating Resident 1's cognitive status is moderately impaired. Review of Resident 1's physician medication orders dated January 24, 2023, at 12:00 PM, revealed Resident 1 was ordered Ativan (antianxiety) 2 milligrams/milliliter, with a dose of 0.5 milligrams equivalent to 0.25 milliliters, to be administered every six hours sublingual (under the tongue). On January 28, 2023, it was determined that Resident 1 received five doses of Ativan 1 milligram, equivalent to 0.5 milliliters instead of 0.25 milliliters. The dosages of Ativan in error were administered January 25, 2023, at 4:00 PM and 8:00 PM; January 26, 2023, at 3:50 PM and 8:10 PM; and on January 27, 2023 at 12:00 PM. A review of the clinical record revealed that Resident 1 received five incorrect doses of Ativan from January 25, 2023, to January 27, 2023. Resident 1 did not recieve three of the scheduled doses because she was sleeping, one dose was refused by the Resident, and one dose was held due to Resident appearing sedated. Resident had no adverse outcome from the five incorrect doses of Ativan per physician and nursing assessment on January 27, 2023, at 6:57 PM. On January 28, 2023, at 10:35 AM, after a correct dose was administered, and 18 hours after the previous correct dose of Ativan, Resident 1 appeared to be lethargic. The physician was notified again, and there was a new order to decrease the Ativan to every six hours and to hold if Resident 1 appeared sedated. During an interview with the Director of Nursing and Nursing Home Administrator on February 17, 2023, at 10:35 AM, they both agreed that Employees 1, 2, and 3 (Licensed Practical Nurses) did not follow the facility's medication administration policy to verify the correct dose prior to administering the Ativan. Employees 1, 2, and 3 were re-educated January 30, 2023, through February 3, 2023, on the rights of medication administration, that includes verifying the correct dose prior to administration of the medication. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services