Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of three residents reviewed for nutrition (Resident 20). Findings include: Review of facility policy, Weight Management/Weight Loss, revised July 12, 2022, revealed that monthly weights will be taken by qualified staff during the first 5 days of each month and documented in the electronic medical record after being verified by licensed staff. If a +/- 5 lb [pound] discrepancy exists, the resident should be reweighed immediately with nurse verifying weight. If unable to verify immediately reweight will be obtained on the following day. Additionally, if a weight loss/gain of 5 or more pounds is noted, dietitian is to be notified in a timely manner for follow up and recommendations. Review of Resident 20's clinical record revealed recorded weights of 121.4 pounds on January 4, 2025; 121.4 pounds on January 5, 2025; 108.4 pounds on February 5, 2025, with a reweight on February 6, 2025, of 107.6 pounds. (loss of 13.8pounds or11.37% in one month) Further review of Resident 20's clinical record revealed a dietary note dated February 10, 2025, indicating the resident's weight. Further review of the same dietary note failed to reveal recommendations to address the weight loss. Interview with Employee E3 on February 21, 2025 at 11:30 a.m. confirmed that further dietary interventions should have been implemented to address Resident 20's weight loss. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review, it was determined the facility failed to ensure monitoring for effectiveness and side effect monitoring for psychotropic medications was completed for one of five residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed Resident 6 had been receiving Trazodone (anti-depressant medication) for insomnia since March 2024. Further review of Resident 6's clinical record failed to reveal evidence of monitoring for side effects and/or effectiveness of Trazodone since the medication was initiated in March 2024. Interview with the Director of Nursing on February 21, 2025, at 10:00 a.m. confirmed that no monitoring for side effects or effectiveness was documented since March 2024 to present when Resident 6 was receiving Trazodone. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 3/1/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review and interview, it was determined the facility failed to accurately complete a discharge Minimum Data Set Assessment upon discharge for one of three records reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed Resident 51 was admitted to the facility on [DATE], and was discharged to home on January 19, 2024. Review of Resident 51's discharge Minimum Data Set (MDS - periodic assessment of resident needs) dated January 19, 2024, revealed Resident 51 was discharged to an acute care facility. Interview with the Director of Nursing on March 1, 2024, at 10:00 a.m. confirmed Resident 51's discharge MDS was inaccurate and should have reflected Resident 51 was discharged to home. 28 Pa. Code 211.5(f) Clinical Records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely identify a pressure ulcer for one of six residents reviewed (Resident 43). Findings include: Review of facility policy, Altered skin integrity: Assessment, prevention, and treatment, last revised February 2023 revealed that the Braden Scale for Predicting Pressure Ulcer Risk should be completed quarterly. The policy also revealed that weekly skin checks will be completed in the resident's record. Review of Resident 43's clinical record revealed Resident 43 was admitted to the facility on [DATE] Review of Resident 43's clinical record revealed the resident had a diagnosis of spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), Low back pain, Radiculopathy (pinched nerve due to increased pressure causing numbness, weakness, and pain), (lumbar region), Spondylosis of lumbar region (degeneration of the vertebra of lumbar region), Other Intervertebral Disc Degeneration of lumbar region (occur when cushioning in spine weakens causing weakness and numbness in back, neck, and legs) and Osteoporosis (weakening of the bones). Review of Resident 43's clinical record revealed Resident 43's Braden Scale Assessment (tool used to evaluate a resident's risk of developing pressure ulcers) dated January 19, 2024 indicated Resident 43 was At Risk of developing pressure ulcer/wound. Review of Resident 43's Minimum Data Set (MDS - periodic assessment of resident care needs) dated January 25, 2024, revealed the resident experiences pain daily and prevents the resident from sleeping and participating in therapy. The MDS assessment further revealed the resident was at risk for skin breakdown. The MDS assessment also indicated that the resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of Resident 43's clinical record including weekly Skin assessment dated [DATE], and January 31, 2024, revealed the resident's skin was intact at the time of the assessment. Review of Resident 43's clinical record revealed a progress note dated February 2, 2024 (17:23) indicating, Message left at Pain management office due to resident's reports of increased pain in LE (lower extremity) and numbness/tingling in right leg and left leg, more in right per resident following spinal injection. Injection site on low back bruised, no warmth, no redness, no drainage. Awaiting call back. [Provider] CRNP (Certified Registered Nurse Practitioner) updated on call to pain management. Review of Resident 43's clinical record including nursing note dated February 4, 2024, which revealed, [Resident] has reported increased low back pain since [his/her] spinal steroid injection (anti-inflammatory medicine) on January 29, 2024. Nursing contacted office for recommendations February 2, 2024: Cannot assess effectiveness of epidural as it is too early. Two weeks out date is February 12, 2024. Previous shift reported to oncoming nurse that an open area was observed this a.m. to sacrum [triangular bone at the base of the spine] measuring 4.2 cm (centimeters) x 1.5 cm with 100% slough [yellow, tan, gray, green or brown] to wound bed. Staff reports resident slept in recliner past x 2 nights per resident request as it helps with the discomfort. Review of Resident 43's clinical record revealed a nursing progress note dated February 14, 2024, indicating the unstageable pressure ulcer has been classified as a stage 3 pressure ulcer (full thickness skin loss exposing subcutaneous tissue). Further review of the same progress note revealed Resident 43 experiencing pain during wound treatment. Review of Resident 43's initial wound consult dated February 20, 2024, revealed the wound was reclassified to Stage 3 pressure ulcer with new measurements of 4.0 x 1.5 x 0.2 cm by the wound doctor on February 20, 2024. Review of Resident 43's care plans revealed a care plan for skin integrity was initiated and developed on February 4, 2024, with interventions of Encourage resident to nap in bed to offload sacral area; Do incontinence care to prevent skin breakdown; House stock barrier cream to be applied to prevent skin breakdown; and Keep skin clean and dry. Resident 43 was discharged home on February 29, 2024, and therefore unavailable for an interview or observation of wound conducted. The facility's failure to notify the physician of Resident 43's increased pain, resulted in a delay in identifying an unstageable pressure ulcer to the resident's sacrum. This facility deficient practice was discussed with the Nursing Home Administrator and Director of Nursing on March 1, 2024, at 11:50. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a rationale for not making a change in the medication was documented by the physician for a medication regime review (MRR) for one of five residents reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed that a MRR was completed on November 14, 2023. The MRR included a recommendation to consider a gradual dose reduction of Quetiapine (antipsychotic medication) due to questionable need with stable behaviors. The physician responded no change with no rationale documented. Interview with the Nursing Home Administrator on March 1, 2024, at 12:11 a.m. confirmed the physician did not provide a rationale. 483.45 Pharmacy Services 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation and clinical record review, it was determined the facility failed to adequately investigate a missing extended-release opioid medication patch and failed to provide lock free doors to resident bathrooms for one of 18 residents reviewed (Resident 35) and three of three nursing units. Findings include: Review of Resident 35's physician orders revealed an order for Buprenorphine 5 mcg/hr [micrograms per hour] apply one patch transdermally every day shift every 7 days. Apply 1 patch topically every 7 days; remove old before applying new. Review of Resident 35's February 2024 Medication Administration Record (MAR) revealed a Butrans patch was applied on February 8, 2024, and another patch was due to be applied on February 15, 2024. Review of Resident 35's clinical progress notes dated February 13, 2024, revealed Staff unable to locate Butrans [Buprenorphine - Schedule III opioid pain medication] patch. Caregivers reported patch was on back in am, when nurse went to confirm placement of patch, patch was missing. Full body check completed and room searched, but unable to locate patch. [physician] updated and gave order to wait on next schedule day to apply new patch. Interview with the Director of Nursing on March 1, 2024, at 11:00 a.m. failed to reveal evidence that any further investigation was conducted to locate the missing Butrans opioid patch. The facility failed to conduct a thorough investigation to determine the location or cause of the missing Butrans opioid patch. Review of Resident 35's clinical progress notes dated October 4, 2023, revealed Resident is often locking herself in the bathroom and is not safe. Work order placed into Worxhub for maintenance to replace with doorknob so that resident is not able to lock for safety concerns. Observation of Resident 35's bathroom door and all bathroom doors on all three nursing units revealed bathroom doors had door locks in place. Resident 35's doorknob was not replaced with a non-locking doorknob. Interview with nursing personnel on the [NAME] nursing unit on February 29, 2024, at 11:00 a.m. revealed nursing personnel identified a key ring with an item to unlock the bathroom doors. Upon attempting to unlock the door, the item on the key ring failed to unlock the door. Interview with the Director of Nursing on February 29, 2024, at 11:30 a.m. revealed a second item on the key ring that opened the locked bathroom doors and also revealed all key rings have an item to unlock the doors and extra keys are located the Director of Nursing's office. Nursing personnel were unaware of the correct item to use to unlock the bathroom doors on the nursing units. The above information was conveyed to the Nursing Home Administrator on March 1, 2024, at 11:00 a.m. 28 Pa. Code 201.18(a)(b)(1) Management

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of four residents reviewed for nutrition (Residents 12, 36, and 45). Findings include: Review of facility policy, Weight Management/Weight Loss, revised July 12, 2022, revealed that monthly weights will be taken by qualified staff during the first 5 days of each month and documented in the electronic medical record after being verified by licensed staff. If a +/- 3 lb [pound] discrepancy exists, the resident should be reweighed immediately with nurse verifying weight. If unable to verify immediately reweight will be obtained on the following day. Additionally, if a weight loss/gain of 3 or more pounds is noted, dietitian is to be notified in a timely manner for follow up and recommendations. Review of Resident 12's clinical record revealed an admission weight of 147.0 pounds on August 28, 2023. Resident's weight was recorded as 135.8 pounds on January 4, 2024 and 129.4 pounds on February 1, 2024, with a reweight on February 2, 2024 of 127.4 pounds (loss of 8.4 pounds or 6.2% in one month). Further review of the clinical record revealed that a nutrition/dietary progress note on February 26, 2024, (24 days after the reweight was obtained) indicated that the resident triggered on the monthly weight report for significant weight loss. No further recommendations were initiated. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. revealed that potentially would expect some intervention to be put into place due to significant weight loss over one month and progressive weight loss since admission. Review of Resident 36's clinical record revealed a weight of 99.0 pounds on January 1, 2024, and a weight of 83.8 pounds on February 1, 2024 (loss of 15.2 pounds or 15.4% in one month). Further review revealed that a reweight was not obtained. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. confirmed that a reweight should have been completed. Review of Resident 45's clinical record revealed a weight of 204.8 pounds on January 2, 2024, and 188.4 pounds on February 1, 2024( loss of 16.4 pounds or 8.00% in one month). Further review revealed that a reweight was not obtained. Review of nutrition assessment of February 4, 2024, noted significant weight loss. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. confirmed that a reweight should have been obtained so an accurate assessment could be completed. Employee E3 indicated that a reweight should be obtained for a 5 pound change for a resident over 100 pounds and a 3 pound change for a resident under 100 pounds. A reweight should have been completed within 24 hours. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services