**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of the nine residents reviewed (Resident R24, R29, R57, R71). Findings Include: A review of the facility policy Advanced Directives last reviewed 1/18/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R24 was admitted to the facility on [DATE], with diagnoses that included type II diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia (difficulty swallowing), muscle weakness, left below knee amputation. A review of the clinical record failed to reveal and advance directive or documentation that Resident R24 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R29 was admitted to the facility on [DATE], with diagnoses that include type II diabetes, dysphagia, high blood pressure, difficulty walking. A review of the clinical record failed to reveal and advance directive or documentation that Resident R29 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R57 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, history of falling, chronic kidney disease, stage III (moderate level of kidney damage where the kidneys have mild to moderate impairment in filtering waste from the blood). A review of the clinical record failed to reveal and advance directive or documentation that Resident R57 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses that include multiple sclerosis (the immune system eats away at the protective covering of nerves , this damage disrupts communication between the brain and the body), dysphagia, chronic kidney disease, stage III. A review of the clinical record failed to reveal and advance directive or documentation that Resident R71 was given the opportunity to formulate an Advanced Directive. During an interview on 12/10/24 at 12:45 p.m. the Social Worker and the Director of Nursing (DON) confirmed that the clinical record did not include documentation that Resident R24, R29, R57, R71, were not afforded the opportunity to formulate Advance Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly secure medication in one of two medication carts on the 300 hall nursing unit (B cart). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed on 1/18/24, indicated the facility stores medications in locked compartments and only authorized have access to the keys. During an observation on 12/8/24, at 12:10 p.m., the 300 hall B medication cart was left unsecured and unattended and accessible to any passerby. During an interview on 12/8/24, at 12:15 p.m., the Director of Nursing confirmed the facility failed to properly secure medications on one of two medication carts on the 300 hall nursing unit accessible to any passerby. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of manufacturer guidelines, observation, and staff interview, it was determined that the facility failed to make certain that medications were properly stored in two of two medication carts (200 B and 200 A). Findings include: Review of the Humalog lispro insulin (injectable medication used to treat high blood sugar) prescribing information revised 02/2020, indicated that for Humalog injection pens Do not use your pen past the expiration date printed on the label or for more than 28 days after you first start using the pen. For Humalog vials of insulin Do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it. During an observation of the 200 B medication cart on 11/17/23, at 11:17 a.m. a partially used flex-pen of Humalog was observed, without an open date. During an interview on 11/17/23, at 11:18 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation. During an observation of the 200 A medication cart on 11/17/23, at 11:21 a.m. two partially used vials of Humalog were observed, without an open date. During an interview on 11/17/23, at 11:22 a.m. LPN Employee E2 confirmed the above observation. During an interview on 11/17/23, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications were properly stored in two of two medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for two of four residents (Residents R35 and R61). Findings include: A review of the facility policy Restorative Nursing Services last reviewed 1/20/22, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. During resident group meeting two out of seven resident's stated the restorative nurse aide gets pulled to the floor and they do not get restorative nursing. A review of the clinical record revealed that resident R61 was admitted to the facility on [DATE], with diagnoses that included, cerebral palsy (condition marked by impaired muscle coordination, caused by damage to the brain), spastic hemiplegic cerebral palsy and fatty liver. A review of the minimum data set (MDS-periodic assessment of care needs) dated 10/11/22, indicated the diagnoses remain current. Review of Resident R61's medical record included Therapy Communication to Nursing, dated 4/08/22, stated that therapy recommends that nursing follow through with the following: RNP (Restorative Nursing Program) for Ambulation with RW(Rolling Walker). Patient will ambulate 50-75 feet with RW and SBA(stand by assist) with wheel chair follow. A review of the Restorative Bed Mobility Tasks documentation indicated Resident R61 did not receive active rehabilitation on 12/1/22-12/13/22, 12/15/22-12/17/22, 12/29-12/31/22 A review of the clinical record revealed that resident R35 was admitted to the facility on [DATE], with diagnoses that included, muscle weakness, heart disease, and hypertension (a condition impacting blood circulation through the heart related to poor pressure). A review of the minimum data set (MDS-periodic assessment of care needs) dated 9/26/22, indicated the diagnoses remain current. Review of Resident R35's medical record included Therapy Communication to Nursing, dated 1/31/22, stated that therapy recommends that nursing follow through with the following: Transfer supine (lying horizontally with the face and torso facing up) to sit max (maximum) assist (providing 51-75 percent of the work required for the task), sit at edge of bed with assist to place legs flexed under him to sit and use of arms on edge of bed assistance can vary from Min (minimum- providing one to 25 percent of the work required for the task) to Mod (moderate- providing 26-50 percent of the work required for the task) Limit to 5 mins (minutes). A review of the Restorative Bed Mobility Tasks documentation indicated Resident R35 did not receive active rehabilitation on 12/8/22, 12/9/22, 12/14/22, 12/15/22, 12/17/22, 12/20/22, 12/21/22, 12/22/22, 12/24/22, 12/27/22, 12/28/22, 12/30/22, 12/31/22, 1/3/23, and 1/4/23. During an interview on 1/6/23, at 11:30 a.m., Nursing Home Administrator confirmed that the Restorative Aide is pulled to work on the floor as a nurse aide and the facility fails to provide the restorative program. During an interview on 1/6/23, at 1:45 p.m., Restorative Aide Employee E1 stated that she is the only Restorative Aide at the facility and that she is often pulled out of restorative to fill other needs in the building. It was also clarified that she works as a Restorative Aide approximately 15 percent of her working hours and confirmed that the facility failed to provide specialized rehabilitative services as needed to help promote optimal safety and independence. 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies.