**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, clinical records, and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure resident safety during transportation in a wheelchair for one of 40 residents reviewed (Resident 216). Findings include: A facility policy regarding safe mobility, dated March 15, 2024, indicated that the facility would promote safe mobility for all residents in their care. Yellow code was caution, the resident needs assistance with mobility. A review of the clinical record for Resident 216 indicated that the resident was admitted to the facility on [DATE], with a diagnosis of a closed non-displaced intertrochanteric fracture of the right femur. Resident 216 was coded yellow. A mobility care plan for Resident 216, dated February 12, 2025, indicated that the resident was to have therapeutic exercise, bed mobility gait training, and transfer and ambulation devices as ordered. The resident was weight bearing as tolerated to the right lower extremity. A certified physician's assistant note for Resident 216, dated February 12, 2025, revealed that the resident had active problems that included a distal radius fracture of the right upper extremity with splint and a right femur fracture. The resident had an open reduction and internal fixation (surgical procedure used to treat broken bones) on February 8, 2025. Observations on February 20, 2025, at 1:15 p.m. in the therapy room revealed that Occupational Therapist 2 pushed Resident 216 into the therapy room. Resident 216's wheelchair did not have foot rests in place and her feet were approximately one inch off the ground. Resident 216 was pushed to the table to work on a hand coordination activity with a board and plastic pins. Interview with the Occupational Therapist 2 at the time of the observation revealed that Resident 216 had foot rests and they should be in use. Interview with Director of Nursing on February 20, 2025, at 12:44 p.m. confirmed that the staff should always use leg/footrests on wheelchairs when residents are being transported in their wheelchairs but indicated that therapy staff have their own procedure. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of medications for one of 15 residents reviewed (Resident 116). Findings include: The facility's policy regarding medication administration, dated March 15, 2024, indicated that medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff will follow all infection control practices for hand hygiene and application of personal protective equipment as indicated. Physician's orders for Resident 116 included an order for the resident to receive 8.6 milligrams of Sennosides glycoside two tablets daily for constipation. Observations on February 19, 2025, at 8:45 a.m. revealed that Registered Nurse 1 dropped a tablet of Sennosides glycoside onto the medication cart. She picked the medication up off the cart with her bare hands and placed it into the medication cup and administered the medications to the resident. Interview with Registered Nurse 1 at that time confirmed that she should have wasted the medication. Interview with the Nursing Home Administrator on February 19, 2025, at 3:15 p.m. confirmed that medications that were dropped should have been wasted and were not to be touched with bare hands. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a safety assessment was completed for side rail use for one of 12 residents reviewed (Resident 163). Findings include: The facility's policy regarding side rails, dated March 15, 2024, indicated that the facility would promote a person-centered approach when determining the need and/or use of grab bars and side rails, which would include an assessment of the resident, medical condition, decision-making ability, and a review for possible entrapment and/or injury from use of a bed rail. Observations of Resident 163 on March 25, 2024, at 9:58 a.m. and March 26, 2024, at 8:20 a.m. revealed that the resident's bed was equipped with bilateral side rails. There was no documented evidence that Resident 163 was assessed for potential safety hazards prior to the side rails being applied to the resident's bed. Interview with the Director of Nursing on March 26, 2024, at 11:25 a.m. confirmed that there was no safety assessment completed for the use of side rails for Resident 163. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly stored in the medication cart. Findings include: A policy for Pharmacy Services, dated March 16, 2023, indicated that medications should be secured in the proper medication cart for administration. Observations during medication administration on April 5, 2023, at 7:50 a.m. revealed that Registered Nurse 1 prepared Atenolol 50 milligrams (mg), Bupropion 300 mg, Lexapro 10 mg, Metformin 1000 mg, and Potassium Chloride 10 milliequivalents (mEq) for Resident 9 and left the blister packs of medications unsecured and unattended on top of the medication cart while he entered the resident's room to administer the medications to the resident. When Registered Nurse 1 entered the resident's room, the medication cart was out of his line of sight and was left unlocked with the keys to the medication cart hanging in the lock. An interview with Registered Nurse 1 at that time revealed that he should have put all medication in the cart, locked the cart, and removed the keys prior to entering the resident's room. Interview with the Director of Nursing on April 5, 2023, at 12:10 p.m. confirmed that medications should not have been left unattended and unsecured on the medication cart and the medication cart should have been locked and the keys removed. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain weights as ordered by the physician for eight of 11 residents reviewed (Residents 2, 6, 7, 9, 10, 12, 13, 14). Findings include: The facility's policy for weights, dated March 16, 2023, indicated that upon admission, residents would have an admission weight done to record baseline weight. Residents will then be set up on a biweekly weight schedule unless otherwise ordered by physician or deemed necessary by registered nurse. All weights would be documented in the electronic record and on the report sheet. Physician's orders for Resident 2, dated March 22, 2023, included and order for the resident to be weighed every Wednesday and Saturday. A review of Resident 2's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 6, dated March 29, 2023, included an order for the resident to be weighed daily. A review of Resident 6's weight records from admission on [DATE], until April 5, 2023, revealed that the resident was not weighed seven out of seven days. Physician's orders for Resident 7, dated March 28, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 7's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed two out of two days. Physician's orders for Resident 9, dated March 25, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 9's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 10, dated March 18, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 10's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed five out of five days. Physician's orders for Resident 12, dated March 30, 2023, included an order for the resident to be weighed every Monday and Thursday. A review of Resident 12's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed two out of two days. Physician's orders for Resident 13, dated March 21, 2023, included an order for the resident to be weighed every Tuesday and Friday. A review of Resident 13's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed four out of four days. Physician's orders for Resident 14, dated March 24, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 14's weight records from March 24, 2023, to April 5, 2023, revealed that the resident was not weighed four out of four days. Interview with the Director of Nursing on April 5, 2023, at 9:20 a.m. confirmed that Residents 2, 6, 7, 9, 10, 12, 13 and 14 should have been weighed per their physician's orders and they were not. 28 Pa. Code 211.12(d)(3)(5) Nursing services.