Based on review of facility documents, policy and clinical records, and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis (a medical procedure that filters blood when the kidneys are not functioning properly) communication and failed to ensure medications were administered according to physician's orders for residents receiving dialysis for one of one residents reviewed for dialysis (Resident R18) Findings include: Review of a Memorandum of Agreement signed 2/22/21, between the facility and Dialysis Clinic, Inc. (DCI) revealed the facility shall provide all relevant information to DCI regarding the condition and needs of each resident during his/her dialysis treatment and that DCI shall provide to the facility relevant information regarding each treatment, which may require follow-up care or observation by the facility staff. A facility policy dated 6/2/25, entitled Dialysis Care revealed residents ordered dialysis therapy will be monitored and documentation will be maintained in the medical record and should such information not be received from the Dialysis Provider upon the residents return, the facility shall contact the Dialysis Provider to obtain such medical information. The policy further stated that medication administration times are adjusted to accommodate the schedule for dialysis as well as to achieve maximum therapeutic effect. Resident R18's clinical record revealed an admission date of 5/16/25, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), End Stage Renal Disease (ESRD - when the kidneys have permanently lost their ability to function effectively. A person typically requires regular dialysis or a kidney transplant to survive), and respiratory failure (a condition where you don't get enough oxygen, or you get too much carbon dioxide in your body). Resident R18's clinical record revealed a physician's order dated 5/16/15, for Dialysis every Monday, Wednesday, and Friday. Resident R18's clinical record lacked evidence of Nursing Facility Dialysis Clinic Communication form being completed for scheduled dialysis treatments completed on 5/21/25, 5/30/25, 6/2/25, and 6/4/25. During an interview on 6/5/25, at 12:39 p.m. the Nursing Home Administrator (NHA) confirmed that Resident R18's clinical record lacked evidence of dialysis communication for 5/21/25, 5/30/25, 6/2/25, and 6/4/25, and that the facility should have evidence of dialysis communication for each dialysis treatment rendered. Resident R18's clinical record revealed a care plan for dialysis with an intervention to Assure residents medication times does not conflict with dialysis schedule. Review of physician's orders dated 5/16/15, indicated that Resident R18 was to have Amlodipine Besylate (medication for high blood pressure) 10 milligrams (mg) daily, Lidocaine External Patch (medication for pain) 4% to lower back applied every morning and removed every evening, Clonidine HCL (medication for high blood pressure) 0.2 mg twice daily, Coreg (medication for high blood pressure) 25 mg twice daily, Pregabalin (medication for nerve pain) 75 mg twice daily, Protonix (medication for acid reflux) 40 mg twice daily, Sevelamer Carbonate Oral Packet (medication used to lower blood phosphate levels) 0.8 grams three times a day with meals, Novolog FlexPen (medication for diabetes) inject 5 units four times a day, and Novolog FlexPen sliding scale (used to determine how much insulin to administer based on your blood glucose levels) four times a day. Further review revealed Physician orders dated 5/20/25, for Creon Delayed Release (medication to treat pancreatitis) 14000-76000 unit three times a day before meals Review of the May and June 2025 Medication Administration Records (MARs) for 5/17/25, through 6/5/25, revealed that Resident R18 did not receive the following medications as ordered with reason give as Leave of Absence (LOA). Amlodipine Besylate 9:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25. Lidocaine External applied at 9:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25. Clonidine HCL 8:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25. Coreg 8:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25. Pregabalin 9:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, and 6/2/25. Protonix 9:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, and 6/2/25. Sevelamer Carbonate Oral Packet 9:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25, and 1:00 p.m. dose on 5/24/25, and 6/4/25. Novolog FlexPen routinely 8:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/29/25, 5/30/25, 6/2/25, and 6/4/25, and 12:00 p.m. dose on 5/24/25, 5/26/25, and 6/4/25. Novolog FlexPen based on sliding scale 8:00 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/29/25, 5/30/25, 6/2/25, and 6/4/25, and 12:00 p.m. dose on 5/24/25, 5/28/25, and 6/4/25. Creon Delayed Release 10:00 a.m. dose on 5/21/25, 7:30 a.m. dose on 5/21/25, 5/23/25, 5/26/25, 5/28/25, 5/30/25, 6/2/25, and 6/4/25, and 11:30 a.m. dose on 5/24/25, and 6/4/25. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R18 on dialysis days. During an interview on 6/5/25, at 2:14 p.m. the Assistant Director of Nursing confirmed that the above medications for Resident R18 were not administered on dialysis days as ordered by the physician and the clinical record lacked any evidence of physician notification that medications were not administered as ordered. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(f)(viii) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to label one multi-dose vial medication with the resident name, date it was opened, and date it should be used by in one of two medication storage rooms observed (Unit One medication room). Findings include: Review of facility policy entitled Storage of Medications, with a policy review date of 6/2/25, revealed that Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are relabeled before storing. Observations of the Unit One medication storage room on 6/6/25, at approximately 11:45 a.m. revealed that one multi-dose vial of Tirzepatide (a prescription medication used to manage type two diabetes and for weight loss in adults) was opened and was currently in use, but not labeled with the any resident name, opened date or the use by date. At the time of the observation, Registered Nurse Employee R1 confirmed that the one undated multi-dose vial of Tirzepatide was opened, in use, and should have been labeled with the resident's name, date opened, and use by date. During an interview on 6/6/25, at approximately 12:00 p.m. on 6/6/25, the Director of Nursing and Assistant Director of Nursing confirmed that the vial was unlabeled and undated and should have that information identified on the vial. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to monitor resident's personal refrigerators for temperatures for one of one residents reviewed with personal refrigerators (Resident R12). Findings include: A facility policy dated 6/2/25, entitled Personal Refrigerators revealed personal refrigerators are permitted after thorough inspection and will be subject to the same monitoring as other facility refrigerators. The policy further stated that the refrigerator must include a thermometer and will be monitored regularly for temperature compliance. Observation on 6/4/25, at 11:30 a.m. revealed Resident R12 had a personal refrigerator in their room. There was no evidence in the room of a temperature log sheet being present. Observation of the inside of the refrigerator revealed that there was no thermometer to monitor the temperature of the refrigerator. During an interview on 6/4/25, at 11:45 a.m. the Assistant Director of Nursing stated that temperatures for resident's personal refrigerators are documented on each resident's electronic medication administration record (EMAR). During an interview on 6/5/25, at 12:30 p.m. Licensed Practical Nurse Employee E2 stated that any resident with a personal refrigerator was to have a thermometer in it and the nurse was to check and document the temperature on the EMAR every shift. Review of Resident R12's EMAR lacked evidence of any temperatures being monitored and recorded for their personal refrigerator. During an interview on 6/5/25, at 12:40 p.m. the Nursing Home Administrator confirmed that Resident R12's personal refrigerator did not contain a thermometer and the facility lacked evidence that the facility was monitoring their refrigerator temperature. 28 Pa. Code 201.14 (a) Responsibility of Licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and clinical records, and staff interview, it was determined that the facility failed to report an incident of serious bodily injury of unknown source for one of one residents reviewed (Resident R1). Findings include: A facility policy entitled Abuse Reporting, dated 11/24, revealed that The Facility shall notify the Department of Health, Department of Aging, and Area Agency on Aging, Adult Protective Services, local law enforcement and licensing agencies depending on the circumstances of the allegation or actual event in compliance with Federal and State regulations, including Act 13. Title 42 Code of Federal Regulations (CFR) §483.12(c) states in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The clinical record for Resident R1 documented that the resident was admitted to the facility on [DATE], with diagnoses that included dementia (disorganized thinking and confusion) and age related disability. An x-ray report dated March 8, 2025, revealed that Resident R1 had an acute fracture of the left proximal femur bone, (a hip fracture). A facility investigation completed on March 8, 2025, identified that the cause of Resident R1's left hip fracture injury was of unknown origin. Review of information submitted by the facility dated March 10, 2025, to the State Survey Agency disclosed that on March 7, 2025, at 6:20 a.m. Resident R1 complained of leg pain. The physician was notified, an x-ray was ordered and completed that revealed a left hip fracture and required surgical repair which was completed on March 9, 2025. The resident was to return to the facility on March 10, 2025. The report indicated that the resident had not experienced any recent falls at the facility. During interview on March 15, 2025, at approximately 11:15 a.m. the Director of Nursing confirmed that Resident R1's injury of unknown origin was not reported to the State Survey Agency until March 10, 2025. 28 Pa. Code 201.14 (a)(c) Responsibility of licensee

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications and medication information on one of four medication carts observed (Unit 1). Findings include: Review of a facility policy entitled, Storage of Medications dated 1/24/2023, indicated that compartments containing medications are locked when not in use and carts used to transport such items are not left unattended. Observation on 8/15/23, at approximately 3:50 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 prepared medications for a resident from the Unit 1 medication cart parked in the hall in front of the resident room. LPN Employee E1 then proceeded into resident room to administer medications to a resident in the room behind a privacy curtain. LPN Employee E1 did not securely lock the Unit 1 medication cart or cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E1 was unable to view medication cart and drawers of the medication cart or the computer on top of the cart from behind the privacy curtain while unattended. During an interview on 8/15/2023, at the time of the observation, LPN Employee E1 confirmed that he/she left the medication cart unlocked and resident information in view while it was parked in the resident room doorway, which was out of view during administration of medications to a resident behind a privacy curtain. LPN Employee E1 also confirmed that the medication cart was to be locked and resident information covered when out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of facility policy and resident and staff interviews, it was determined the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable mental and psychosocial well-being by not serving all meals in the dining room daily. Findings include: Review of a facility policy, Serving of Food, dated 1/24/23, stated All residents are encouraged to eat in the dining room/s. During resident interviews on 8/16/23, at approximately 9:00 a.m. and 10:00 a.m. Residents R6, R10, R22, R25, R29, R37, and R49 indicated they enjoy eating their meals in the dining room with other residents, however, the dining room was not open for dinner on the weekdays and all meals on the weekends. During an interview on 8/16/23, at approximately 2:45 p.m. Dietary Staff Employee E8 indicated the residents do not eat in the dining room for certain meals, such as dinner on the weekdays and all meals on the weekends, due to a lack of nursing staff. During an interview on 8/18/23, at approximately 9:50 a.m. the Director of Nursing confirmed that the residents were served meals in the dining room for breakfast and lunch on week days but not on weekends or for the evening meals due to staffing concerns. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 201.18(b)(3) Management