**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and facility investigative reports, resident and staff interview it was determined the facility failed to consistently provide care and services consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of 10 sampled residents. (Resident 1) Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia, respiratory failure, and a history of falling at home. Resident 1 was discharged home on March 13, 2025. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 5, 2025, indicated the resident was moderately impaired with a BIMS score of 3(brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment). The MDS further identified the resident as requiring staff assistance for activities of daily living (ADLs) and at risk for pressure ulcer development. A review of Resident 1's care plan-initiated January 29, 2025, identified the resident as being at risk for impaired skin integrity related to aspirin therapy (a medication with anticoagulant, bleeding, properties), which made the resident prone to bruising with slight pressure, decreased mobility, history of falls, and incontinence. Interventions included assessing skin integrity for changes (noting color, texture, temperature, redness,) keeping the skin clean and dry, applying protective creams or lotions, preventing friction, and toileting the resident after meals. An additional care plan problem identified on January 29, 2025, indicated the resident experienced decreased ADL performance due to muscle wasting and atrophy (breakdown of body tissue). Interventions included the use of a mechanical lift for all transfers and assistance of two staff for toileting. A review of facility investigative documentation dated February 16, 2025, at 3:00 AM, revealed that Employee 3 (RN) was called to Resident 1's room by nurse aide staff to assess a new open area on Resident 1's left inner gluteal fold. Upon assessment the area measured 1.5 cm x 0.5 cm x 0.1 cm, with red granulation tissue and minimal serosanguinous drainage (combination or blood and fluid). The physician was called, and a treatment was ordered. The report noted that the resident was resistive when staff tries to reposition him on his side. Documentation indicated the resident was resistant to repositioning, utilized a mechanical lift for transfers, was confused, and was incontinent of urine at the time of discovery. Witness statements dated February 16, 2025, at 3:00 AM from Employees 1 and 2 (Nurse Aides) confirmed they observed the area during care on February 16, 2025, and reported it to the nurse. A subsequent facility investigative report dated February 16, 2025, at 9:30 AM, revealed that Employee 4 (Nurse Aide) observed additional open and discolored areas on the resident's buttocks and sacrum during care. Employee 6 (RN) assessed the areas, which included: Sacrum: open area measuring 1 cm x 1 cm, no drainage. Left buttock: open area measuring 1.5 cm x 1.5 cm with surrounding dark purple, non-blanchable skin measuring 7 cm x 3.5 cm. Left outer buttock: open area measuring 3 cm x 1 cm with surrounding dark purple, non-blanchable skin. Left upper outer buttock: intact, non-blanchable purple area measuring 1 cm x 0.5 cm. The physician was notified of these additional areas. Witness statements from Employee 5 indicated that the resident was last observed at 8:00 AM on February 16, 2025, lying in bed. A physician's order dated February 17, 2025, directed the use of an alternating air mattress and Juven nutritional supplement (used to promote wound healing). Weekly wound assessments documented the progression of wound status as follows: February 21, 2025 Sacrum: 1 cm x 1 cm x 0.1 cm, deep tissue injury (DTI) (damage beneath intact skin, typically presenting as a dark purple area). clean the area with normal saline and apply silver alginate (protect the wound from external contaminants, maintain a moist environment conducive to healing, and help manage exudate, drainage) and cover with a foam dressing every shift and as needed. Left buttock: 4 cm x 3 cm x 0.1 cm, DTI. with scant serosanguinous drainage Right buttock: 5 cm x 3 cm x 0.1 cm, DTI. the peri wound noted as deep purple in color with scant serosanguinous drainage. Treatments included cleansing with normal saline and applying silver alginate dressings (used to manage exudate and support healing), covered with foam dressings. February 28, 2025 Sacral wound resolved. Left and right buttocks: unstageable pressure injuries (wounds obscured by slough - soft, yellow dead tissue - or eschar - hard, black dead tissue). The left buttock measured 4 cm x 3 cm x 0.1 cm, and the right buttock measured 5 cm x 3 cm x 0.1 cm Wounds contained 20% granulation tissue and 80% slough. Treatment changed to cleanse with normal saline and wet-to-dry dressings (used to assist with gentle debridement). March 7, 2025 Wounds remained unstageable with the same measurements and tissue composition. Treatment regimen unchanged. A review of a nurses note dated March 10, 2025, at 12:25 PM revealed, described the resident being combative during care, striking staff. The eschar from one wound was dislodged, revealing 1 cm depth and red granulation tissue. Minor drainage was noted. The resident's wife was informed at the time of observation. A review of a nurses note dated March 12, 2025, at 11:58 AM documented providing the resident's wife with education about the wounds to the resident's buttocks and provided treatment supplies. The resident's wife verbally acknowledged understanding the wound condition and treatment needs. A review of interdisciplinary discharge instructions dated March 13, 2025, revealed wound care treatment instructions. However, no measurements or detailed descriptions of the wounds were documented as being provided to the resident's wife prior to discharge An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 10, 2025, at approximately 1:00 PM, confirmed the facility failed to implement timely and adequate preventive measures necessary to prevent the development of pressure ulcers to the sacrum and buttocks for Resident 1. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to the physician's parameters for two out of 19 sampled residents. (Resident 75 and 11). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Medication Administration last reviewed by the facility on November 13, 2024, revealed that medications are administered as prescribed to all residents in a timely fashion and within prescribed parameters. Medications are administered in accordance with written orders of the attending physician. Prior to administering a medication to a resident, the nurse will verify: 1) The correct resident 2) The correct medication, dosage, and route, as per physician order 3) The correct time for the medication 4) Any special instructions are followed 5) Required parameter (s) are obtained prior to administration, as per order A review of the clinical record revealed Resident 75 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2025, revealed that Resident 75 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of the physician's order dated January 4, 2025, revealed an order for Humalog injection (medication used to treat high blood glucose) 5 units twice a day and 8 units once daily, HOLD for BS<120 mg/dl (a blood sugar less than 120 mg/dl) for diabetes. A review of the physician's order dated January 19, 2025, revealed an order for Humalog injection 8 units in the morning, 12 units in the afternoon and 15 units in the evening, HOLD for BS<120 (a blood sugar less than 120) for diabetes. Review of the Medication Administration Record (MAR) for January 2025, and February 2025, revealed Resident 75's Humalog was administered on the following dates two times outside of the physician ordered parameters: January 8, 2025: 5 units of Humalog administered at 7:45 AM despite a blood glucose level of 117 (below the prescribed threshold). February 10, 2025: 8 units administered at 7:34 AM with a blood glucose level of 102. (below the prescribed threshold). During an interview on February 21, 2025, at approximately 12:30 PM, the Director of Nursing (DON) confirmed that nursing staff failed to follow the physician-ordered parameters and did not adhere to professional nursing standards during medication administration. A clinical records review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, benign prostatic hyperplasia (BPH enlarged prostate), and history of COVID-19. A physician order, initially dated February 17, 2025, was noted for Midodrine (medication to treat low blood pressure) 5 mg one tablet by mouth two times a day for hypotension (low blood pressure) with instructions to hold the medication if the resident's systolic blood pressure (measures pressure inside the arteries and is the top number of a blood pressure reading) is greater than 120 mm/Hg. According to the resident's February 2025 Medication Administration Record, nursing administered Midodrine 5mg tablet on February 17, 2025, at 5:00 p.m. Further review of the MAR revealed that the medication was administered when Resident 11's systolic blood pressure was 132 mm/Hg, exceeding the prescribed threshold of 120 mm/Hg. During an interview on February 21, 2025, at approximately 1:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed the medication was improperly administered, contrary to the physician's orders. The facility failed to adhere to professional standards of nursing care by not ensuring prescribed medications were administered according to the specific physician-ordered parameters for two residents. 28 Pa. Code 211.5 (f) (ix) Medical Records 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters (April 2024 and January 2025). Findings include: A review of QAPI Committee meeting sign-in sheets for the period of April 2024 through January 2025, revealed the Medical Director or designee was not in attendance at the quarterly QA meeting held on April 25, 2024, and January 30, 2025. Interview with the director of nursing on February 21, 2025, at 11:00 AM confirmed the Medical Director or designee failed to attend the facility's QAPI meetings on a quarterly basis. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 201.18 (e)(1)(3) Management.

Based on review of select facility policies and procedures and clinical records, observations, and staff interviews, it was determined the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three out of 19 residents sampled (Resident 2, 16, and 82). Findings include: Review of facility policy entitled Oxygen Administration, last reviewed November 13, 2024, revealed that oxygen is administered under orders of a physician, except in the case of an emergency. Infection control measures performed during the administration of oxygen include change and date oxygen tubing and mask/cannula every two weeks and as needed. Change and date humidifier bottle every 72 hours and keep delivery devices covered in plastic bag when not in use. Observation of Resident 2 on February 19, 2025, at 10:57 a.m. revealed the resident was receiving oxygen via nasal cannula set (tube with two prongs placed in the nostrils to deliver oxygen) at 3.0 liters per minute (l/m) with humidification. The humidifier bottle, dated February 15, 2025, was empty, and the oxygen tubing was not dated as per facility policy. Observation of Resident 16 on February 19, 2025, at 10:45 a.m. revealed nebulizer tubing and mask in a clear bag on the resident's nightstand. The tubing was dated January 26, 2025-indicating that it had not been replaced for over 25 days, exceeding the recommended timeframe. Observations were confirmed by Employee 2, licensed practical nurse (LPN), on February 19, 2025, at approximately 9:30 a.m. Resident 82: On February 20, 2025, at 9:32 a.m., the resident was observed resting in bed while the oxygen concentrator was on. The nasal cannula was placed in a clear bag attached to the concentrator rather than applied to the resident. The oxygen tubing was also not dated. An interview with Employee 1, a licensed practical nurse, revealed the resident was being evaluated for discontinuation of oxygen therapy; however, a review of the resident's clinical records showed no physician order to withhold oxygen therapy, as a current order dated January 29, 2025, prescribed 2.5 liters/min via nasal cannula. Additional interview with Employee 1 on February 20, 2025, confirmed that Resident 82 was not receiving oxygen as prescribed and acknowledged the lack of a physician's order for discontinuation. Interview with Nursing Home Administrator (NHA) and the Director of Nursing on February 21, 2025, at 1:00 p.m. confirmed that nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices. The Director of Nursing further confirmed that nursing staff failed to consistently provide oxygen therapy to Resident 82 in accordance with the physician's order. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report resident physical abuse to the State Survey Agency for one of the 20 residents reviewed (Resident 5). Findings include: A review of the facility's Prevention of Abuse/Neglect/Involuntary Seclusion/Exploitation: The Facility Procedures Policy, last reviewed by the facility in October 2023, revealed that the facility's policy is for staff to report any allegations of abuse, neglect, misappropriation of property, exploitation, or involuntary seclusion to their supervisor immediately. The facility administrator or designee will be responsible for the follow-up investigation and reporting to the required agencies within the required time frames. The policy indicated that the investigation results will be reported to the State Survey Agency and all other required agencies within five days of the allegation. Facility investigation documents dated February 29, 2024, indicated that a nurse aide observed Resident 4 use the back of her hand to hit Resident 5 in the mouth. A Resident Incident Investigation form dated February 29, 2024, revealed that Employee 2, a Nurse Aide, observed Resident 4 in the hallway telling Resident 5 to shut up and was holding her {Resident 5's} left wrist. {Resident 4} let go of Resident 5's wrist and slapped {Resident 5} with the backside of her hand across {Resident 5's} mouth. The residents were separated, and the incident was reported to supervisory staff. A progress note dated February 29, 2024, at 5:25 PM indicated that {Resident 4} hit her roommate with the back of her hand. Resident 4 stated that she wouldn't knock it off! I want her to shut up! A progress note dated February 29, 2024, at 5:25 PM indicated that Resident 5 was unable to describe details of the interaction but indicated to staff that I'm okay. Resident 5 was assessed with no skin impairments, open areas, bruising, swelling, or dental issues. During an interview on March 21, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to report physical abuse of Resident 5 perpetrated by Resident 4 to State Survey Agency within the required time frames. 28 Pa Code 201.14 (c) Responsibility of licensee 28 Pa Code 201.18 (e)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to develop a comprehensive person-centered plan of care to meet the individualized needs of one resident out 20 sampled (Resident 19). Findings include: Review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include heart failure (a condition in which the heart fails to sufficiently pump blood throughout the body) and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest). A review of a cardiology progress note dated January 26, 2024, revealed that the resident had a single AICD implanted for heart failure. The cardiologist indicated that the resident was seen due to a planned move to the skilled nursing facility. He further indicated that a note was sent to the facility to ensure that the move does not affect his AICD device. A review of the resident's current comprehensive care plan, conducted during the survey ending March 22, 2024, indicated that the facility identified a problem area of Resident 19's diagnosis of coronary artery disease (damage or disease in the heart's major blood vessels) due to hypertension, atrial fibrillation, AICD, and ischemic cardiomyopathy. However, the resident's care plan did not include AICD checks or monitoring for signs and symptoms of AICD complications. The resident's care plan did not include any emergency care of the AICD device and actions to be taken if the AICD was activated (i.e., consulting the physician, obtaining vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] and keeping the resident and staff safe from the electrical shock. The resident should notify staff if a shock is felt, and staff should be aware not to touch resident is being shocked since the shock can be felt). Interview with Employee 1 (RN, MDS Coordinator) on March 20, 2024, at 2:16 PM confirmed that the facility failed to fully address the care and management of Resident 19's AICD on the resident's person-centered plan of care. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 4). Findings include: A clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2024 revealed that Resident 4 has severe cognitive impairment with a BIMS score of 02 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). Nursing progress notes dated January 10, 2024, at 11:25 AM that indicated that Resident 4 was having increased behaviors that morning, incessantly calling out different things at staff, yelling for help, and yelling for different people. A progress note dated January 13, 2024, at 4:46 AM indicated that the resident was calling out and yelling, Get me the hell out of here! On January 23, 2024, at 4:30 PM progress notes indicated that the resident was consistently yelling out help, entering other residents rooms, arguing with other residents, and stating, I am going to throw myself to the floor. Nursing noted January 24, 2024, at 12:38 PM that the resident was agitated during a shower. The note indicated that the resident was swinging a shower head and attempting to bite and kick staff. On February 16, 2024, at 12:34 AM, nursing noted that the resident was calling out continually, Help! Help! Who the hell am I? Does anybody know me? Nursing progress notes dated February 28, 2024, at 10:43 PM indicated that the resident was agitated and restless throughout the shift, wheeling herself into other residents' rooms, yelling, and pulling apart her oxygen tubing and on February 29, 2024, at 5:25 PM the resident hit her roommate with the back of her hand. Resident 4 stated that she wouldn't knock it off! I want her to shut up! Nursing documentation dated 2, 2024, at 1:57 AM indicated that the resident was screaming and yelling throughout the shift; on March 7, 2024, at 10:30 PM it was noted that the resident was entering other residents rooms, yelling at other residents, and attempting to open locked doors like the maintenance closet; and on March 15, 2024, at 3:50 AM it was documented that the resident was continually calling out and disrupting other residents. A review of Resident 4's care plan, conducted during the survey ending March 22, 2024, revealed that the resident's plan of care did not include the resident's behaviors, such hitting, biting, yelling out, screaming, and entering other residents' rooms. The facility failed to demonstrate the provision of necessary care and services, including individualized interdisciplinary non-pharmacological approaches to care, purposeful and meaningful activities, that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. There was no evidence that the facility provided the resident with specialized services and supports, such specialized activities, nutrition, and environmental modifications, based on the individual's abilities and dementia related behaviors. During an interview on March 21, 2024, at approximately 1:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to demonstrate the development or implementation of an individualized interdisciplinary person-centered care plan that addressed Resident 4's dementia care and behaviors. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and resident and staff interviews, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for two out of the 20 residents sampled (Residents 8 and 43). Findings include: A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that included cervical and intervertebral disc disorders (conditions characterized by the breakdown of one or more of the discs that separate the bones of the spine and neck, causing pain in the back, neck, or frequently in the legs and arms). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2024 revealed that Resident 43 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The MDS Section J-Health Conditions indicated that the resident almost constantly experiences pain or was hurting. Resident 43's care plan noted the resident's potential for pain related to his disc disorders, which was initiated on November 10, 2023. Interventions developed to assist the resident with his pain included monitoring, recording, and reporting complaints of pain or requests for pain treatment, evaluating the effectiveness of pain treatment, and offering and encouraging non-pharmacological pain relieving methods such as repositioning, back rubs, soothing or distraction activity, guided imagery, breathing exercises, offering pillows or blankets, bathing, or elevation. A physician's order was initiated on November 9, 2023, for Resident 43 to receive oxycodone HCL oral tablet 5 mg (an opioid medication) with instructions to give 1 tablet every 6 hours as needed for moderate to severe pain. The resident's medication administration record (MAR) for March 2024 revealed that Resident 43 received oxycodone 5 mg on 22 occassions from March 1, 2024, through March 21, 2024. There was no evidence that staff attempted any non-pharmacological attempts to relieve Resident 43's pain prior to administering as-needed opioid medication. There was no documented evidence that the facility had consistently assessed Resident 43's level of pain to ensure that the opioid medication was administered as per physician's orders, for moderate to severe pain. A review of progress note documentation and Resident 43's MAR for March 2024 revealed that the resident received oxycodone 5 mg on 18 occassions without documentation of the resident's pain level prior to administration of the medication. During an interview on March 19, 2024, at 10:10 AM, Resident 43 stated that he experiences consistent back pain. The resident explained that the facility provides a medicated ointment and pain medication that helps with the pain but further stated that the facility is not offering alternative non-pharmacological interventions to assist with his pain relief. During an interview on March 22, 2024, at approximately 10:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to pain medications prescribed on an as needed basis. The NHA and DON were not able to provide evidence that the facility was consistently assessing the resident's pain levels prior to medication administration to ensure medications were being administered consistent with physician's orders. A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include pyogenic arthritis, and spondylosis (degenerative arthritis of the spine). A review of Resident 8's physician order's initially dated January 11, 2024, revealed an order for oxycodone (a narcotic opioid pain medication) 5 mg tablet, give two tablets by mouth, every four hours, as needed, for severe pain. A review of the resident's February 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 48 times during the month of February. Of the 48 doses given, all were administered without non-pharmacological interventions attempted prior to giving the pain medication. A review of the resident's March 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 12 times during the month of March Of the 12 doses given, 11 were administered with no non-pharmacological interventions attempted prior to giving the pain medication. Interview with the Director of Nursing on March 22, 2024, at approximately 1:30 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of as needed pain medication. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services 28 Pa. Code 211.5 (f) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 17 sampled (Resident 46) Findings include: According to the RAI User's Manual, Section A1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment. An annual MDS assessment dated [DATE] of Resident 46 revealed that Section A1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. However, a review of Resident 46's clinical record revealed a Level I PASRR was completed on June 15, 2018, which indicated the resident met the criteria for a Level II PASRR, and a letter from PA Department of Human Services dated June 22, 2018, confirmed the level II PASRR. Interview with the Social Service Director on March 16, 2023, at 10:20 a.m. confirmed the resident's MDS assessment dated [DATE], was inaccurate, with respect to completion of Section A1500 related to the PASRR. Interview with the RNAC (Registered Nurse Assessment Coordinator) on March 16, 2022, at approximately 11:00 a.m. confirmed that Resident 46's MDS was inaccurate. 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to accurately transcribe physician medication orders in accordance with standards of practice resulting in administration of the incorrect dose of an antidepressant medication to one resident out of 17 sampled (Resident 37). Findings include: A review of the clinical record revealed that Resident 37 admitted to the facility on [DATE], with diagnoses that included gastro-esophageal reflux disease (GERD), chronic kidney disease, atrial fibrillation (an irregular and often very rapid heart rhythm), cellulitis, chronic respiratory failure, major depression, and dysphagia (difficulty swallowing). A Hospital Discharge Summary dated, February 20, 2023, indicated that upon the resident's discharge from the hospital the resident was to continue taking Sertraline (Zoloft) 50 milligram (mg), take 100 mg by mouth daily, with the next dose due on February 21, 2023 However, upon admission to the skilled nursing facility on February 20, 2023, the admission physician order was noted as Sertraline HCL oral tablet 50 mg, give 1 tablet by mouth at bedtime for anxiety and depression. The resident received 50 mg of Zoloft from February 20, 2023, through March 2, 2023, when the resident's son identified the error and reported it to facility nursing staff. Progress notes dated March 2, 2023, at 11:14 AM, indicated that the resident's representative, in reviewing the resident's clinical records, identified that the resident's physician order for the antidepressant medication Zoloft was 50 mg, but the resident had been taking Zoloft 100 mg for about a decade and was inquiring if the resident's dose of the antidepressant drug Zoloft could be increased to his usual dose. The entry noted that the charge nurse notified the CRNP (Certified Registered Nurse Practitioner) of the resident's representative's request and nursing was awaiting a response. A progress note dated March 2, 2023, at 1:43 PM, indicated that the CRNP ordered an increase in the resident's dose of Zoloft from 50 mg to 100 mg. Current physician orders dated March 2, 2023, were noted as Sertraline HCL oral tablet 50 mg, give 2 tablets by mouth at bedtime for anxiety and depression, 2 tablets (100 mg). Interview on March 17, 2023, at approximately 9:25 AM, with Employee 1 Registered Nurse Supervisor (RN supervisor), confirmed that the resident's hospital discharge summary identified that the resident was to receive Zoloft 100 mg, but the physician medication order was not accurately transcribed upon the resident's admission and as a result the resident received 9 doses of Zoloft 50 mg until his son identifed the error. During an interview on March 17, 2023, at approximately 9:40 AM, with the Nursing Home Administrator (NHA), he confirmed the error in transcribing the medication order upon the resident's admission, which resulted in the resident receiving the incorrect dose of Zoloft. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f) Clinical records. 28 Pa. Code 211.2 (a) Physician orders

Based on a review of clinical records and select facility incident reports, and staff interview it was determined that the facility failed to implement an individualized fall prevention measure to prevent a fall for one resident (Resident 62) out of five sampled. Findings include: Review of Resident 62's clinical record revealed that the resident had diagnoses which included Alzheimer's disease. Review of Resident 62's quarterly Minimum Data Set (MDS- a federally mandated standardized assessment process completed periodically to plan resident care) dated December 2, 2022, revealed the resident was moderately cognitively impaired with a BIMS (tool used to screen and identify the cognitive impairment) score of 8 (8 to 12 indicating moderate cognitive impairment), was independent with transfers and ambulation in her room, and required one-person physical assistance for dressing. The resident's care plan, initially dated September 13, 2021, indicated that the resident was at risk for falls related to confusion, gait/balance problems, and unaware of safety needs. Interventions planned to prevent falls included keeping the resident's call bell within reach, ensure the resident is wearing appropriate non-skid footwear when ambulating or mobilizing in wheelchair, safe environment, bed in low position at night, items in reach, glare-free light, and clutter free environment. Review of a nurses note dated February 14, 2023, at 6:03 PM noted that at 4:15 PM on that date the resident was found seated on the floor next to the foot of the resident's bed and wheelchair. According to the note, no call bell was sounding, but surrounding residents called for help. Resident 62 was not wearing non-skid footwear and the note did not identify whether the resident's was barefoot or what type of footwear the resident was wearing at the time of the fall. The resident was not incontinent and was noted as independent in room. Neurochecks were completed and within normal limits. Nursing noted that the resident had a raised area on top of head non-open, non-worsening, ice applied. The resident stated that I just fell I don't know how just help me up. Nursing also noted that the current fall prevention interventions included non-skid footwear, bed low/locked, items in reach, room well lit and clutter free. The facility planned to provide education to the resident on proper footwear and initiate therapy re-eval at this time. The facility also educated staff to encourage proper footwear throughout the shift. Physician and responsible party made aware. Nursing noted that they will continue to monitor. A review of a facility incident report dated February 14, 2023, at 4:15 PM, revealed that the resident was observed on the floor with back against the foot of the bed. The suspected root cause analysis was that the resident ambulates independently without a device. The resident was re-educated to ensure proper footwear is intact prior to ambulating. The incident report noted that the resident was assisted to the bathroom at 4:00 PM (15 minutes prior to the incident). The incident report failed to indicate what type of footwear, if any, the resident was wearing at the time of the fall. There was no indication of who assisted the resident with dressing prior to the fall to ensure proper non-skid footwear was in place as per the resident's care plan as the resident was assessed as moderately cognitively impaired and required staff assistance with dressing. The facility failed to provide documented evidence that the planned intervention for non-skid footwear as per the resident's care plan was implemented at the time of the resident's fall. Interview with the assistant nursing home administrator on March 17, 2023, at 10:00 AM failed to provide documented evidence that the facility implemented the planned care plan intervention for non-skid footwear to prevent the resident's fall. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of the food and nutrition services department in the presence of Employee 2 (dietary supervisor) on March 17, 2023 at 11:15 AM, revealed the following sanitation concerns with the potential to introduce contaminants into food and increase the potential for food-borne illness: There was a layer of dust on the exterior surface of the metal fins of the hood vents located above the stove area. There was a layer of dust on the fins of the ceiling vent covers located near the diet office and the three-compartment sink. Observation of the three-compartment sink revealed the wash compartment of the sink contained dirty water with floating food debris. The sink's spray hose and nozzle, detergent hose, and sanitizer hose were submerged under the surface of the dirty water. Observation of the ice machine located in a room adjacent to the food and nutrition services department revealed a layer of dust on the outer fins of the ice machine's filter cover. Interview with employee 2 (dietary supervisor) on March 17, 2023 at 11:30 AM, confirmed that the food and nutrition services department is to maintain acceptable practices for food storage and the department is to be maintained in a sanitary manner. 28 Pa. Code 211.6 (c) Dietary services. 28 Pa. Code 207.2(a) Administrator's responsibility.