**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 ensure that the pharmacy provided medications timely for two of four residents reviewed (Residents 1 and 3). Findings include: Review of Resident 1's clinical record revealed Resident 1 was admitted [DATE], with diagnoses of but not limited to hypertension (high blood pressure), hyperlipidemia (high levels of fats in the blood), COPD (chronic obstructive pulmonary disease - progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and surgical aftercare following aortocoronary bypass graft (heart bypass surgery - procedure to restore blood flow to areas of the heart), Review of physician's admissions orders revealed a start date of March 30, 2025, for the following medications: Metoprolol Succinate ER (extended release) 50 MG (milligrams), one tablet by mouth twice a day for hypertension (high blood pressure), Spironolactone Oral Tablet 25 MG, one tablet by mouth one time a day for Hypertension, Ezetimibe Oral Tablet 10 MG one tablet by mouth one time a day for hyperlipidemia (high cholesterol), Anoro Ellipta Inhalation Aerosol one puff inhale orally one time a day for COPD/shortness of breath/wheezing, guaifenesin ER Oral Tablet 600 mg one tablet by mouth two times a day for cough/acute bronchitis, Clopidogrel Bisulfate Oral Tablet 75 mg one tablet by mouth one time a day for ASHD (ateriosclerotic heart disease)/history of long term anticoagulant (blood thinner) use, and Viactiv Calcium Immune Oral Tablet Chewable one tablet by mouth one time a day for supplement. Review of the March 2025 Medication Administration Record (MAR) revealed that the above medications were not administered as ordered. Review of orders administration note of March 30, 2025, revealed staff were waiting for delivery for the above medications. Review of Resident 3's clinical record revealed that Resident was admitted [DATE], with a diagnosis of , but not limited to hypopituitarism (decreased secretion of one of the hormones normally produced by the pituitary gland). Review of physician admission orders revealed a start date of April 16, 2025, for Desmopressin Acetate Oral Tablet 0.1 MG one tablet by mouth two times a day for hypopituitarism and Hydrocortisone Oral Tablet 5 MG 0.5 tablet by mouth two times a day for hypopituitarism. Review of the April 2025 MAR revealed that the above medications were not administered as ordered. Review of orders administration note of April 16, 2025, revealed staff were awaiting pharmacy. Interview with the Director of Nursing on April 30, 2025, at 12:15 p.m. confirmed that Residents 1 and 3 did not receive their medications as ordered because they were not available from the pharmacy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/9/24

Based on review of facility policy, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to one of seven residents reviewed for catheters (Resident 94). Findings include: Review of facility policy, Catheter Care, implemented March 1, 2024, revealed: Catheter care will be performed every shift and as needed by nursing personnel .Document care and report any concerns noted to the nurse on duty. Observation of Resident 94 on October 7, 2024, at approximately 12:30 p.m. revealed the resident had a suprapubic catheter (tube that drains urine from the bladder through a small incision in the abdomen). Review of Resident 94's clinical record failed to reveal documented evidence that staff were providing catheter care. Interview with the Director of Nursing on October 9, 2024, at approximately 11:15 a.m. confirmed there was no documented evidence of catheter care for Resident 94's suprapubic catheter. 28 Pa Code 211.12(d)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to report results for laboratory studies to the ordering physician timely for one of 40 residents reviewed. (Resident 22) Findings Include: Review of Resident 22's Physician orders revealed an order dated September 11, 2024 for a UA C+S (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 22's Laboratory report for the UA C+S revealed the report was final and was reported on September 15, 2024. Review of Resident 22's Progress Notes revealed a nursing entry on September 18, 2024 stating the results were posted and reported to the physician who ordered antibiotics to treat the urinary tract infection. Interview with the DON on October 9, 2024 at 11:30 a.m. confirmed the results were final on September 15, 2024 but not reported to the physician for orders to begin treatment until September 18, 2024. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food in the dry storage located next to the main kitchen. Findings include: Review of the facility's policy entitled, Labeling and storage, dated 2017, revealed that All food should be dated upon receipt before stored, food labels must include the food item name, and the use-by date . Observations during the tour of the main kitchen on October 6, 2024, at 9:12 a.m., revealed the following: Observation of the dry storage 2 area, noting eight opened bags of uncooked pasta without a label and use-by date and were nor properly sealed. Interview conducted on October 6, 2024, at 9:15 a.m., with the Dietary Director E3 confirmed the eight bags of uncooked pasta should have had a label with the name of the item and a use-by date. E3 also stated the above items should have been properly sealed. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record and facility documentation review and resident/staff interview, it was determined that the facility failed to timely treat a burn and failed to follow a physician medication parameter for two of 33 residents reviewed (Residents 32 and 58). Findings include: Interview with Resident 32 on November 28, 2023, at 9:10 a.m. revealed the resident had a burn on her abdomen from spilling coffee in September. Review of Resident 32's progress notes revealed a nurse's note dated September 10, 2023, at 10:31 a.m. which stated: notified by aide that resident had a skin area on upper abdomen. Upon arrival to room, this nurse noted 4x4 gauze pad on abdomen and once removed, a slightly red non-opened area noted (measured 4cm W x 4 ½ L). Resident stated 'I burnt myself with coffee on [September 8] a blister appeared and it popped [September 9, 2023.]' Nursing supervisor notified. Cleansed area with [normal saline], applied [triple antibiotic ointment], and covered with bordered gauze. Review of facility documentation revealed on September 8, 2023, at approximately 11:00 a.m., the resident spilled coffee on herself during a coffee social witnessed by Employee E3. Review of facility documentation dated September 12, 2023, revealed Employee E3 received individualized education for failing to report the burn to nursing. Review of facility witness statement from nurse aide Employee E4 revealed on September 8, 2023, the employee noticed a blister on Resident 32's abdomen while putting the resident to bed. Nurse aide Employee E4 notified licensed nurse Employee E5 about the area. Review of facility documentation dated September 12, 2023, revealed licensed nurse Employee E5 failed to assess Resident 32 after nurse aide Employee E4 notified them about the area. Review of Resident 32's September 2023 Treatment Administration Record revealed that a treatment was not started on the burn until September 10, 2023. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Employee E3's failure to report the burn initially and licensed nurse Employee E5's failure to assess Resident 32 resulted in a two-day delay in treating Resident 32's burn. Review of Resident 58's physician order dated October 25, 2023, revealed an order for Midodrine (medication to treat low blood pressure that causes severe dizziness and fainting) HCL Oral tablet 5mg given two tablets by mouth three times a day for Orthostatic Hypotension (A form of low blood pressure that happens when standing up from sitting or lying down). Give if blood pressure is less than 95/60 mmHg. Review of Resident 58's October 2023 Medication Administration Record (MAR) revealed that from October 25, 2023, until October 30, 2023, the medication Midodrine was administered to the resident seven times with a blood pressure above 95/60 mmHg. Interview with the Director of Nursing on November 30, 2023, at 10:00 a.m., confirmed that Resident 58 was administered with Midodrine outside of the ordered blood pressure parameter. The facility failed to follow Resident 58's physician's order regarding blood pressure parameters for Midodrine medication. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records facility documentation review and staff interview, it was determined that the facility failed to timely assess a resident's skin impairment and inform the physician of a newly found skin impairment for one of six residents reviewed (Resident 58). Findings include: Review of Resident 58's clinical records revealed resident was admitted to the facility with a diagnosis of Malignant Prostate Cancer, Diabetes, and Severe Protein Calorie Malnutrition. The admission skin assessment dated [DATE], revealed no skin impairment in the resident's midback area. Review of facility documentation, and staff statement dated November 7, 2023, revealed that on November 3, 2023, a bandage gauze dressing was observed on the resident's upper back which was not present during initial assessment. Review of Resident 58's clinical records failed to reveal a completed skin assessment of the mid-upper back upon observing a bandage gauze dressing on November 3, 2023. Review of Resident 58's clinical records, Physician's order, revealed no treatment order the resident's mid-upper back wound on November 3, 2023. Interview was conducted with the Director of Nursing on November 30, 2023, at 10:00 a.m. The DON was unable to provide documented evidence that Resident 58's mid upper back skin was assessed on November 3, 2023, after observing a bandage dressing. The DON also confirmed that although a bandage dressing was observed on the resident's upper mid back, there was no physician's order for a wound treatment on Resident 58's mid-upper back on November 3, 2023. The facility failed to assess Resident 58's skin and notify the physician upon observing a bandage dressing to the resident's upper mid back on November 3, 2023. 28 Pa Code 211.5 (f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure one of 33 residents reviewed was free of unnecessary medications (Resident 137). Findings include: Review of Resident 137's physician's orders revealed an order dated May 20, 2021, to evaluate for verbal and non-verbal signs and symptoms of pain every shift. Review of Resident 137's July 2023 Medication Administration Record (MAR) revealed the resident reported no pain a total of 78 times. Review of Resident 137's August 2023 MAR revealed the resident reported no pain a total of 48 times. Review of Resident 137's September 2023 MAR revealed the resident reported no pain a total of 42 times. Review of Resident 137's October 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's November 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's clinical record revealed a nurse's note on November 24, 2023, at 8:39 a.m. which stated that the resident approached this writer stating she will not take any of her prescribed medications unless a provider re-enters a script for Percocet [(narcotic pain reliever.)] When asked if resident was experiencing discomfort, she states I don't think you need to worry about that. I have been taking Percocet for longer than you have been alive. You just do what [you] need to do if you want me to take the medication you want me to take. I need those Percocets. Discussed risks of non-compliance with all medications and [resident] disregarded education stating Just get my Percocet. MD (Medical Doctor) aware of resident request and refusals of all other medications and will assess med regimen. Awaiting return call from provider. Further review of Resident 137's progress notes revealed a nurse's note on November 24, 2023, at 8:47 a.m. which stated that the physician called back and wrote an order for Percocet 5-325 milligrams (mg) every 8 hours as needed for 14 days. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Resident 137's refusal to take other medication unless provided with Percocet was not an appropriate reason to continue the resident on narcotic pain medication. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, staff, and resident interviews, it was determined that the facility failed to follow a physician's order regarding multiple diabetic ulcer treatments for one of the five residents reviewed (Resident 371). Findings include: Review of Resident 371's diagnosis list revealed Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Peripheral Vascular Disease (PVD -A blockage or narrowing of the blood vessels outside of the heart and brain that gets worse over time), and Osteomyelitis (Bone infection) of the foot. Secondary to Review of the wound care consult dated December 20, 2022, revealed resident was admitted to the facility on [DATE], for rehabilitation, acute admission secondary to acute Osteomyelitis. Current treatment includes IV (Intravenous - medication administered through a vein) antibiotic for 40 days. The same consult revealed the presence of a diabetic foot ulcer on the left 1st MTP (Metatarsophalangeal- located in the forefoot where the metatarsal and phalanx meet), right 1st MTP, right 2nd MTP, right 4th MTP, and right 5th MTP. The same consult revealed Osteomyelitis of the 4th and 5th MTP. Review of the Physician's Order Sheet (POS) dated December 21, 2022, revealed an order to cleanse diabetic ulcer to the left 1st MTP, right 1st, 2nd, 4th, and 5th MTP with NSS (Normal Saline Solution) or wound cleanser, apply Betadine to wound base and leave open to air everyday shift. Review of the December 2022 MAR revealed that the treatment order was not done on December 22, 23, 25, 26, 29, 30, and 31. Interview with Resident 371 was conducted on January 19, 2023, at 1:00 p.m. Resident 371 confirmed that the wound treatment was not being done daily. The Resident stated that the wound treatment was spotty. Interview with the Director of Nursing (DON) on January 20, 2023, at 9:00 a.m., was conducted. The DON was unable to provide a reason or documentation for wound treatment not being done on the above-mentioned dates. The facility failed to follow the physician's order for Resident 371 diabetic foot ulcers. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/21, 11/1/22

Based on review of facility policy, resident and staff interview, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to prevent urinary tract infections for one of two residents reviewed (Resident 24). Findings include: Review of facility policy, Foley (Indwelling Urinary) Catheters and Care, effective date September 2020, revealed: Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter .Routine meatal care is performed daily and as needed. Interview with Resident 24 on January 18, 2023, at 11:56 a.m., revealed the resident had a foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine) and was complaining of burning pain at the catheter site due to having a urinary tract infection (UTI). Further interview with Resident 24 revealed that staff were not consistent with providing catheter care. Review of Resident 24's clinical record revealed a physician's order dated January 17, 2023, for levofloxacin (antibiotic) 250 milligrams one tablet by mouth at bedtime for seven days for UTI. Further review of Resident 24's physician's orders, Medication Administrator Records, Treatment Administration Record, and care plan failed to reveal evidence that the resident was receiving routine catheter care. Interview with nurse aide Employee E4 on January 20, 2023, at 11:56 a.m. revealed the aide's responsibility to Resident 24's catheter was to empty it and report the output to nursing. Interview with licensed nurse Employee E5 on January 20, 2023, at 11:50 a.m. revealed it is nursing's responsibility to perform catheter care. Employee E5 confirmed there was no evidence in Resident 24's clinical record that staff were performing routine catheter care to Resident 24. The above findings were discussed with the Director of Nursing on January 20, 2023 at approximately 1:30 p.m. 28 Pa Code 211.12(d)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and address weight loss in one of seven residents reviewed for nutrition (Resident 20). Findings include: Review of facility policy, Nutrition, effective date February 2, 2022, revealed: Each resident will be weighed upon admission and re-admission weekly for 4 weeks during the resident's stay .Weight variances will be reviewed by dietician and [interdisciplinary team] .If a resident refuses to be weighed refusal will be noted in the electronic medical record .The Dietitian/designee will reassess the nutritional needs and intakes of any resident with a significant weight change .Interventions will be evaluated, documentation made in the electronic medical record, and the resident's plan of care updated. Observation of Resident 20 on January 17, 2023, at 12:49 p.m. revealed the resident had a jejunostomy tube (J-tube) (soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Review of Resident 20's clinical record revealed diagnoses including, but not limited to, Dysphagia (difficulty swallowing) and Spastic Quadriplegia Cerebral Palsy (disorder that affect a person's ability to move and maintain balance and posture; spastic quadriplegia is the most severe form and affects all four limbs, the trunk, and the face.) Further review of Resident 20's clinical record revealed the resident was readmitted to the facility following a prolonged hospital stay on July 13, 2022, where the resident first received the J-tube. Review of Resident 20's weights revealed a weight was not obtained on Resident 20's readmission from the hospital until July 22, 2022, where the resident was documented as weighing 140.2 pounds (lbs.) The next weight recorded in Resident 20's clinical record was on August 8, 2022, where the resident was documented as weighing 145.3 lbs. The next weight recorded in Resident 20's clinical record was on September 6, 2022, where the resident was documented as weighing 121.1 lbs., a 19.98% loss in one month. Further review of Resident 20's weights revealed the next weight obtained was on September 20, 2022, where the resident was documented as weighing 122.2 lbs. Review of Resident 20's progress notes revealed a weight change note on September 26, 2022 from the dietitian, Employee E3, which stated: Last three hospital visits were due to J-tube dislodgement (8/31), hematuria and UTI [(blood in urine and urinary tract infection)] 9/3 and then J-tube not flushing 9/8-9/9. Weight fluctuations difficult to explain, some error may be a cause as well as prolonged hospitalization and fluid shifts may be a factor with surgery and new J-tube. Currently, res. is at a desirable weight and goal would be to stabilize at this time. Review of Resident 20's hospitalizations revealed the resident went to the hospital August 31, 2022, and returned the same day due to j-tube dislodgement. The resident transferred to hospital again on September 3, 2022 and returned the same day with a diagnosis of UTI. The resident went out again September 8, 2022, and returned September 9, 2022, due to j-tube dislodgement. Further review of Resident 20's progress notes revealed weight change notes from Employee E3 on September 28, 2022 which stated that the physician and resident's responsible party were notified of the resident's weight loss, which was first documented on September 6, 2022; 22 days prior to notification. Further review of Resident 20's progress notes revealed a physician's note on September 30, 2022 which stated: Weight fluctuating but no change clinically. Further review of Resident 20's weights revealed that on November 10, 2022, the resident weighed 122.1 lbs. On December 14, 2022, the resident weighed 112 pounds which is an 8.27 % loss in one month. There were no weights documented between the November 10th and December 14th weights, despite the resident being hospitalized on [DATE] and readmitted to the facility November 28, 2022. Review of Resident 20's progress notes revealed a weight change note from the dietitian, Employee E3, on December 28, 2022, 14 days after the resident's significant weight loss was first documented, which attributed the resident's weight loss to multiple hospitalizations. Review of Resident 20's hospitalizations revealed the resident went to the hospital November 13, 2022 and returned the same day for j-tube dislodgement. The resident went to the hospital again on November 24, 2022 for j-tube dislodgement and returned November 28, 2022 with diagnoses of covid-19 and UTI. The resident went to the hospital again on December 7, 2022, and returned December 8, 2022, for j-tube dislodgement. Further review of Resident 20's progress notes revealed progress notes from the dietitian, Employee E3, on December 30, 2022, stating they notified the physician and responsible party of the resident's weight loss. Interview with Employee E3 on January 20, 2023, at 11:23 a.m. confirmed readmission weights and reweights for Resident 20 were not done in a timely manner. Employee E3 stated that Resident 20 refuses weights at times, though refusals were not documented in the resident's clinical record. The facility's failure to obtain readmission weights and weekly weights for four weeks, reweights in a timely manner, and the delays in addressing Resident 20's weight loss were discussed with the Director of Nursing on January 20, 2023, at 1:30 p.m. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on clinical records review, staff, and resident interviews, it was determined that the facility failed to provide treatment and service of a Peritoneal Dialysis (PD- treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body) in the facility for one of three records reviewed (Resident 370). Findings include: Review of Resident 370's diagnosis list revealed End Stage Renal Disease (ESRD- gradual loss of kidney function reaches an advanced state). Review of Resident 370 Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated January 18, 2023, revealed resident was cognitively intact. Review of the physician's order dated January 13, 2023; revealed an order for Peritoneal Dialysis every evening shift. BP (blood pressure) and weight before hook up and record. Total volume 9,000 ml every evening shift. Review of the nursing progress notes dated January 15, 2023, (12:40 a.m.), revealed: no nurse 3-11 shift tonight has been oriented to PD (Peritoneal Dialysis). On-call PD nurse notified, reported PD can be done in the morning if there's a nurse who knows how to do the PD, DON and on-call physician notified. Review of nursing progress notes dated January 15, 2023, at 8:38 a.m., revealed resident will go to the hospital to have PD done. The same note revealed No one here at this facility to perform PD, on-call MD made aware, ok to transfer the resident to the hospital. Interview conducted with Resident 370 on January 19, 2023, at 12:00 p.m., confirming not receiving PD on the night of January 14, 2023, and ended up going to the hospital because the staff does not know how to do PD. The resident reported not getting PD in the hospital and was eventually transferred back to the facility. Interview with the Director of Nursing (DON) was conducted on January 19, 2023, at 1:00 p.m. The DON reported getting a call on the weekend (not sure of the exact day). The DON reported that the nurse on duty reported not comfortable doing PD treatment to the resident thus a decision was made to transfer the resident to the hospital to receive PD. The facility failed to ensure treatment and service (PD) were provided to the resident. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/21, 11/1/22

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for one of 32 residents reviewed (Resident 131). Findings include: Review of Resident 131's physician's orders included an order for Oxycodone IR (immediate release pain medication) 10 milligrams one tablet by mouth every four hours as needed for moderate pain and two tablets every four hours as needed for severe pain. Review of Resident 131's December 2022 controlled drug administration record revealed that between December 9, 2022 and December 31, 2022, one tablet of Oxycodone was administered seven times; however, the adminstration of one tablet was not documented on the Medication Administration Record (MAR). Two tablets of Oxycodone were adminstered on 66 occasions, but on 17 occasions was not documented on the MAR. Review of the January 2023 controlled drug administration record revealed that between January 1, 2023 and January 19, 2023, one tablet of Oxycodone was administered two times; however, the adminstration of one tablet was not documented on the MAR. Two tablets of Oxycodone were administered on 45 occasions, but was not documented on the MAR for 12 occasions. Interview with the Director of Nursing on January 20, 2023 at 11:45 a.m. confirmed that the documentation on the MAR was incomplete. 28 Pa. Code: 211.5(f) Clinical records Previously cited 11/1/22, 12/16/21 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 11/1/22, 12/16/21

Based on review of the facility's policy and clinical records, resident and staff interviews, it was determined that the facility failed to timely and comprehensively assess and provide treatment to residents multiple pressure wounds for two of five residents (Residents 1 and 371) and resulted in harm of a declined condition of wounds for one resident (Resident 371). Findings include: Review of the facility's policy and procedures titled Wound Prevention and Management, dated February 6, 2022, revealed wound treatments will be provided under the physician's orders, including the type of dressing and frequency of dressing change. Treatment decisions will be based on the etiology of the wound (pressure injuries, surgical, incidental, and atypical) and characteristics of the wound (pressure injury stage, size, exudate, location of the wound, and presence of pain). The facility will follow specific physician orders for providing wound care, treatments will be documented on the Treatment Administration Record (TAR). Review of Resident 371's admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated December 17, 2022, revealed resident was cognitively intact. The same MDS revealed resident required extensive two people assistance with bed mobility. Review of the hospital records dated December 13, 2022, revealed problem list including Osteomyelitis (infection in the bone), Cellulitis (bacterial skin infection), and diabetic ulcer of the left heel associated with Diabetes Mellitus, with bone involvement without evidence of necrosis. Review of nursing progress notes dated December 14, 2022, at 10:49 a.m., revealed Resident 371 was admitted to the facility from the hospital with a diagnosis of Cellulitis, and Osteomyelitis, all medication orders were reviewed by the on-call physician. Review of Resident 371's diagnosis list revealed Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Peripheral Vascular Disease (PVD -blockage or narrowing of the blood vessels outside of the heart and brain that worsens over time), and Osteomyelitis of the foot. Review of the nursing progress notes dated December 15, 2022, at 3:21 p.m., revealed Resident 371 had multiple open areas: a wound to the left ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone), left buttock, right buttock, right low back, left heel, right great toe, and redness to groin all open areas. Review of Resident 371's care plan goal for skin integrity initiated on December 15, 2022 revealed interventions of encourage good nutrition and hydration, follow facility protocols for treatment, and LAL (Low Air Loss)mattress. Clinical record reviews failed to reveal the above mentioned wounds were present upon admission. Further review of clinical record failed to reveal the wounds identified on December 15, 2022, were comprehensively assessed upon identification. Interview with the Director of Nursing (DON) conducted on January 20, 2023, revealed that upon admission, a head-to-toe skin assessment should be completed on every resident. Any identified open skin area will include location, size, color, and presence of drainage and odor. The DON confirmed that the admission skin assessment was not completed. The DON confirmed that the identified wounds noted on December 15, 2022, were not comprehensively assessed. Review of physician orders dated December 15, 2022, revealed the following treatment orders: Normal saline solution (NSS) or wound cleanser to the left ischium, right and left buttock, cover with dressing everyday shift; and Cleanse right low back with NSS or wound cleanser, apply bordered foam dressing everyday shift. Review of the December 2022 Treatment Administration Record (TAR) revealed that the left ischium, right and left buttock, and right low back wound treatment order was not administered until the morning of December 17, 2022; two days after the wound was identified. Review of the wound care consult dated December 20, 2022, revealed the following: Right lower back, full-thickness ulceration, 2.5 x 0.6 x 0.1 cm (centimeter) in size, 10% deep purple, 30% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture) with serous drainage, the wound was identified as an Unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer secondary to a slough; Left ischium, full thickness ulceration measures 6.0 x 7.5 x 0.1 cm, 10% deep purple with serous drainage, the wound was identified as Unstageable pressure ulcer; Left buttock, full thickness ulceration, measures 5.0 x 7.0 0.1 cm, 20% deep purple, 20% slough with serous drainage, the wound was identified as Unstageable pressure ulcer; and Right buttock, full thickness ulceration, measures 4.2 x 5.0 x 0.1 cm, 60% slough with serous drainage, the wound was identified as Unstageable pressure ulcer. The recommended treatment was to clean the right lower back, left ischium, and right and left buttock with NSS or wound cleanser, apply medical grade honey to wound bases daily and as needed cover with a dry dressing, and monitor the site for signs and symptoms of infection-bogginess, drainages, and erythema. Review of the physician order dated December 21, 2022, revealed an order to clean the right low back, left ischium, and right and left buttock with NSS or wound cleanser, apply Medihoney and cover with dressing everyday shift. Review of the December 2022 and January 2023, TAR revealed wound treatments for the right low back, left ischium, and right and left buttock were not completed on the following dates: December 22, 23, 25, 26, 29, 30, 31, 2022, and January 2, 2023. Interview with Resident 371 conducted on January 19, 2023, at 1:00 p.m. confirmed the wound treatments were not administered daily. The Resident stated that the wound treatment was spotty. Interview conducted with the Director of Nursing on January 20, 2023, at 9:00 a.m., revealed the DON was unable to provide rationale or documentation for wound treatments not being done on the above-mentioned dates. Further review of Resident 371's clinical records failed to reveal the physician was notified of the missed wound treatments. Review of the wound care consults dated January 3, 2023, revealed: Left ischium wound measures 6.3 cm (centimeter) x 7.0 x 0.1 cm, 50% deep purple, the wound was still identified as unstageable stage secondary to slough and had declined; the Left buttock wound measures 4.2 x 7.0 x 0.1 cm, 50% deep purple, identified as an unstageable stage, and had declined due to discoloration; Right buttock wound measures 2.1 x 3.3 x 0.1 cm, moderate serosanguinous drainage, the wound was still identified as unstageable stage and had declined; the Right lower back wound was resolved. The Medihoney wound treatment order was continued. Review of the January 2023 TAR revealed from January 3, until January 12, 2023, left ischium, right and left buttocks did not have documented treatment for four days (January 4, 5, 7, and 11). The above information was conveyed to the Director of Nursing on January 20, 2023, at 11:00 a.m. The facility failed to timely assess and provide treatment to resident 371's left ischium, right low back, right and left buttock wounds resulting in the harm of a declined wound condition of the left ischium, right and left buttock wounds. Review of Resident 1's progress notes revealed a nursing entry dated| October 4, 2022 at 9:33 p.m. stating resident returned to this facility via stretcher, came from the hospital. Physical assessment found the following: Bruises on both arms upper and lower from the IV lines, wound on the left side of his buttock. It was covered with dressing. Further review of Resident 1's clinical record revealed no other documentation on the buttock wound when readmitted from the hospital on October 4, 2022. Further review of Resident 1's clinical record revealed a skin evaluation was completed on October 6, 2022 and October 10, 2022. Both skin evaluations indicated the resident had a current impairment but no measurements or description of the wound. Review of Resident 1's Wound CRNP (Certified Registered Nurse Practitioner) consultation report dated October 13, 2022 revealed staff reported resident returned from hospital with a dressing on his left buttock early last week full thickness ulceration of the left buttock measuring 6.5 x 8.0 x 0.1 centimeters, wound base 100% slough (dead tissue) and firm. Scant nonodorous serous (clear and watery) drainage Diagnosis: suspect soft tissue abscess of the buttock. Interview with the Director of Nursing on January 20, 2023 at 10:00 a.m. confirmed there was no complete documentation of Resident 1's wound when readmitted from the hospital on October 4, 2022 until seen by the CRNP on October 13, 2022. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/21, 11/1/22

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to date multidose insulin vials on one of three units. (2nd floor) Findings Include: Review of facility policy titled, Vials and Ampules of Injectable Medications revealed, opening a vial triggers a shortened expiration date that is unique for that product. The date opened, and this triggered expiration date are both important to be recorded on multi-dose vials. At a minimum, the date opened must be recorded. Guidelines recommend discarding multi-dose vials at 28 days after opened. Observation of the Middle medication cart on the second floor on [DATE] at 9:15 a.m. revealed two Lantus (long acting insulin) insulin pens, one Novolog (short acting insulin) pen, one Basaglar (long acting insulin) insulin pen, one Lantus insulin vial, 2 Humalog (short acting insulin) insulin vials, and a Novolog vial all undated. Further observations of the Middle medication cart revealed an undated Lantus insulin vial for a resident that was discharged on [DATE]. Further observations of the Middle medication cart revealed a Levemir (long acting insulin) vial dated [DATE] from a resident who was discharged on [DATE]. Interview with Licensed Nursing Employee E5 on [DATE] at the time of the observations confirmed the vials were undated and should have been dated the day they were opened and the vials that were dated were expired and should have been discarded. Observation of the North medication cart on the second floor on [DATE] at 9:30 a.m. revealed one vial of Lantus insulin that was undated. Interview with licensed Nursing Employee E6 at the time of the observation confirmed the insulin vial should have been dated when opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on facility policy and procedure review, clinical record review, and staff interview it was determined the facility failed to investigate an injury of unknown origin for one of four residents reviewed. (Resident 2) Findings include: Review of facility policy and procedure titled Injury of Unknown Origin, dated February 1, 2022 revealed all unexplained injuries, including bruises, and injuries of unknown source will be investigated. An injury should be considered as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The injury is suspicious because of: the extent of the injury. Review of Resident 2's progress notes revealed a nursing entry on September 9, 2022 at 7:22 a.m. stating Resident c/o (complained) of pain to the right leg. M.D. made aware, ordered x-ray for right leg. Review of the x-ray results revealed the results were reported to the facility on September 9, 2022 of a fracture involving the right femora neck (hip) with impaction without displacement (the bone is jammed together but still in alignment). There is mild osteoporosis (disease that causes bones to become weak and brittle). Review of Resident 2's clinical record revealed there was no explanation given for the cause of the fracture. Interview with the Nursing Home Administrator and the Director to Nursing on October 27, 2022 at 1:15 p.m. confirmed there was no investigation of an injury of unknown origin for Resident 2. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

Based on clinical record review and staff interview it was determined the facility failed to notify the physician of an x-ray result for one of four residents reviewed. (Resident 2) Findings Include: Review of Facility policy and procedure titled Notification of Change in Condition/Status, dated December 1, 2022, revealed the charge nurse, unit manager, or nursing supervisor will notify the physcian when there is a significant change in the residents physical, mental or psychosocial status. Review of Resident 2's progress notes revealed a nursing entry on September 9, 2022 at 7:22 a.m. stating Resident c/o (complained) of pain to the right leg. M.D. made aware, ordered x-ray for right leg. Review of the x-ray report revealed the results were reported to the facility on September 9, 2022 with the result of a fracture involving the right femora neck (hip) with impaction without displacement (the bone is jammed together but still in alignment), there is mild osteoporosis (disease that causes bones to become weak and brittle). Review of Resident 2's physician orders revealed an order dated September 20, 2022 for an ortho consult STAT (with no delay). Review of the Certified Registered Nurse Practitioners (CRNP) note dated September 23, 2022 revealed Pt (patient) seen and examined for follow up of right femur fracture. X-ray of right femur showed acute impacted right femoral neck fracture and mild osteoporosis, was made aware of results on 9/20/22. Review of resident 2's clinical record revealed there was no evidence the physician was notified of the fracture reported to the facility on September 9, 2022 until the CRNP note on September 23, 2022 stating they were first notified on September 20, 2022. Interview with the Nursing Home Administrator and the Director of Nursing on October 27, 2022 at 1:15 p.m. confirmed the results of the x-ray ordered and completed on September 9, 2022 was not reported to Resident 2's practitioner until September 20, 2022. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and procedure review, clinical record review, and staff interview it was determined the facility failed to administer medications per physician order for two of four residents reviewed. (Resident 3 and Resident 4) Findings Include: Review of facility policy and procedure titled Medications Not To Be Crushed revealed the medication metoprolol ER (extended release blood pressure medication) was not to be crushed before administration to a resident. Review of Resident 3's physician orders revealed an order for Metoprolol Succinate ER 100 milligrams give by mouth one time a day. Observation of medication administration to Resident 3 by Licensed Nursing Employee E3 on October 27, 2022 at 9:45 a.m. revealed Resident 3 was administered all of his/her medications crushed in applesauce, including the Metoprolol Succinate ER 100mg. Interview with the Director of Nursing and the Nursing Home Administrator on October 27, 2022 at 11:45 a.m. confirmed the Metoprolol ER should not have been given whole, not crushed when administered to Resident 3. Review of Resident 4's physician orders revealed the resident was admitted to the facility on [DATE] with an order for Carvedilol (blood pressure medication), 25 milligrams every 12 hours, give if systolic blood pressure (top number in a plod pressure reading) less than 100 or a heartrate less than 60. Review of Resident 4's Medication Administration Record (MAR) for September 2022 revealed on September 17, 18, 19, 21, 23, 24, 25, and September 27, 2022, the blood pressure and heartrate obtained for the 9:00 a.m. dose was identical to the 9:00 p.m. dose. Interview with the Director of Nursing and the Nursing Home Administrator on October 27, 2022 at 11:45 a.m. confirmed the 9:00 a.m. blood pressure and heartrate readings being identical on so many occasion was impossible and indicated staff were not obtaining a blood pressure and heartrate prior to the administration of the medication at 9:00 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services