Based on clinical record review and interviews with staff the facility failed to follow physician orders for one of 24 residents (R1). Findings include: Observations during the initial environmental tour, on May 8, 2023, revealed that Resident R1 was using oxygen provided through a concentrator. The nasal canula was attached to a canister of water dated April 10, 2023. The tubing for the nasal canula was not dated. An interview with the Nursing Home Administrator(NHA) revealed that the canister and tubing is changed monthly per the facility policy. Review of Resident R1's clinical record revealed a physician's order dated June 10, 2022, states to change O2 tubing one time a day every Friday. An interview with the NHA on May 11, 2023, agreed that the facility was not following the physicians order. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to provide appropriate staff supervision resulting in a fall for one of the nine residents reviewed (Resident 161). Findings include: A review of Resident 161's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 5, 2023, revealed resident was cognitively impaired. The same MDS revealed resident required extensive with two people assistance with transferring. Review of the resident's ADL (activities of daily living) care plan revealed an intervention as follows: Transfer-require extensive assistance by two staff to move between surfaces. Review of the nursing progress notes dated February 8, 2023, revealed the resident's leg buckled and was lowered to the floor during transfer. Review of the facility's documentation, Incident Report dated February 8, 2023, revealed that at 4:40 p.m., Nursing Assistant (NA) reported to the nurse that while assisting the resident off the toilet, the resident's legs buckled and were lowered to the floor. NA's statement dated February 8, 2023, revealed that at around 4:00 p.m., the resident was assisted to go to the toilet, when it was time to get him up, the resident stood up again, but his/her legs gave out and he/she was lowered to the floor. The nurse was called and together assisted the resident back to the chair. No injury was sustained. The care plan was updated on February 9, 2023, to use a total lift for transferring with two staff assistants. An interview with the Nursing Home Administrator on May 11, 2023, at 11:00 a.m., confirmed that the facility failed to provide appropriate supervision of a two-person staff for Resident 161 during a transfer resulting in a fall. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a wound treatment medication order was available for one of the 13 residents reviewed (Resident 159). Finding Include: Review of the facility's policy titled Pharmacy Services revealed, that the pharmacy ensures the provision of pharmaceutical services in an accurate, effective, and safe manner. Also, to provide routine and emergency medications and supplies to meet the needs of each resident following state and federal guidelines. Review of Resident 159's physician order sheet revealed an order on May 2, 2023, for A Dakin's solution to sacral wound, wet to dry cover with dressing daily. Review of the nursing progress notes dated May 3, 2023, at 11:32 a.m., revealed Dakin's not on hand, physician was made aware. Review of the nursing progress notes dated May 5, 2023, at 8:10 a.m., revealed Dakin's solution was not available from the pharmacy, will follow up. Review of the May 2023, Treatment Administration Record (TAR) revealed the ordered Dakin's solution treatment to the resident's sacral wound was not done from May 3, 2023, until May 8, 2023. Review of the pharmacy records revealed that Dakin's solution ordered on May 2, 2023, was not delivered to the facility until May 8, 2023. Interview with the Nursing Home Administration conducted on May 11, 2023, at 11:00 a.m., confirmed the Dakin's solution treatment to the resident sacral wound was not followed due to the unavailability of the medication. The facility failed to ensure medication for wound treatment to Resident 159 sacral wound was available. 28 Pa. Code 211.5(f) Clinical records Previously cited 6/24/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/24/22

Based on clinical record review, staff interview and policy and procedure review it as determined the facility failed to notify the physician of a change in resident's status for one of 24 residents reviewed. (Resident 43) Findings Include: Review of facility policy and procedure titled Physician Notification, revised June 2014, revealed the licensed nurse is responsible for notifying the resident's physician at a minimum when there is: a significant change in the resident's physical, mental or psychosocial status. A need to significantly alter treatment. A decision to transfer or discharge the resident from the community. Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident. Review of resident 43's progress notes revealed a nursing entry dated May 27, 2022 at 7:41 a.m. stating resident noted with slight nose bleed. MD (Medical Doctor) was notified and ordered to hold Coumadin (blood thinner) tonight and to continue with weekly labs for PT/INR (blood test to determine the effectiveness of Coumadin). Review of progress note dated May 28, 2022 at 11:51 a.m. stated at 9:00 a.m. CNA (certified nurse aide) summoned this nurse to the resident's room, arrived to find resident with active nose bleed. Resident stated it started as soon as he got out of bed. MD gave order to hold todays Plavix (blood thinner) and to hold tonight's Coumadin dose and obtain a stat PT/INR in a.m. and call MD with results. Further review of the resident clinical record including Progress Notes revealed a nursing entry on May 28, 2022 at 8:39 p.m. stating resident had a nose bleed after dinner this evening. This nurse used a tampon to help with stopping bleeding and it worked. Review of the clinical record revealed the PT/INR (blood test to determine the effectiveness of Coumadin a blood thinner) was completed on May 29, 2022 and was a high result of 30.8/3.34 indicating the resident blood is too thin. A progress note dated May 29, 2022 at 10:13 revealed the MD was notified and they were awaiting a call back. Review of resident's Progress note dated May 29, 2022 at 11:57 p.m. stated, resident complained of right leg and thigh pain. Will pass on to oncoming nurse to follow-up with complaint in the morning. Review of progress notes dated May 30, 2022 at 7:19 a.m. revealed the resident complained of pain of right thigh. Repositioning in bed did not relieve pain. Message left for on call clinician regarding pain. Oncoming shift made aware to follow up. Review of progress notes dated May 30, 2022 at 3:15 p.m. revealed the resident complained of right thigh/buttock pain. As needed Tylenol was administered due to pain intolerance. This note made no mention of talking to a physician. Review of progress notes dated May 30, 2022 at 7:38 p.m. revealed the resident's daughter came to the nursing station saying Resident 43's leg pain had increased. The pain was now in the right groin. Resident stated the pain was a 10 on the pain scale (most intense pain), and was unable to straighten his leg. Daughter and resident informed that resident should be evaluated in the ER and resident agreed. Resident sent via EMT at 6:30 p.m. Review of progress note dated May 31, 2022 at 1:43 a.m. stated off going nurse informed this nurse that resident was admitted to the hospital with a diagnosis of hematoma to the right iliopsoas (bruise of the hip muscle that is a complication that occurs in patients receiving anticoagulant therapy). Interview with the Nursing Home Administrator on June 24, 2022 at approximately 11:00 a.m. confirmed there was documented evidence the resident physician had never been notified after Resident 43 had the second nosebleed or with the elevated PT/INR result obtained on May 29th, 2022 or when the resident developed leg pain unrelieved by medications. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 14 residents reviewed (Resident 22). Findings include: Review of the facility's policy titled Incident Reporting/Injury Investigation Residents and Visitors, undated, revealed all staff shall be responsible for promptly reporting all injuries/incidents to the charge nurse on duty. Upon receipt of a report of incident/injury, the charge nurse or supervisor shall immediately evaluate the resident, provide any needed intervention, and complete all areas of the Incident Investigation Form. The same policy indicated that if the incident is of unknown etiology and further investigation is needed for any incident including unwitnessed falls, staff on the three shifts over the 24 hours preceding the incident will be interviewed and will complete written statements concerning their observation of the incident. Review of Resident 22's diagnosis revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severe enough to interfere with daily life). Review of Resident 22's admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 4, 2022, revealed resident had severe cognitive impairment. Review of the progress notes dated May 24, 2022, revealed Resident 22 was with confusion and need redirecting at the time. The same note revealed resident was able to self-propel a wheelchair and required moderate assistance with ADLs (activity of daily living). Observation conducted on June 22, 2022, at 11:00 a.m., revealed Resident 22 with a bruise on his/her right forearm, close observation of the bruise revealed the bruise was above the wrist to forearm, dark purple in the inner part of the arm extending to the outer part of the arm. Interview with licensed nurse, Employee E3 conducted on June 22, 2022, at 11:10 a.m., Employee E3 reported that she/he was not a regular employee of the facility but was familiar with Resident 22's care. Employee E3 reported that she/he worked on the morning of June 21, 2022, and observed Resident 22's bruise on the right arm but does not know how it happened. Employee 3 looked at the resident's bruise, left then came back to inform the surveyor that she was informed by other staff that the resident had a fall over the weekend. Observation conducted on June 24, 2022, at 10:30 a.m., with the presence of licensed nurse Employee E4. Resident 22's right arm bruise was measured by Employee E4 and revealed 12 x 11 cm (centimeter) in size, the color remained dark purple from the inner arm extending to the outer arm. Interview with licensed Employee 4 conducted on June 24, 2022, at 10:30 a.m., revealed no knowledge of the bruise and its origin. Interview with the Director of Nursing (DON) on June 24, 2022, at 11:00 a.m., was conducted. The facility failed to provide documented evidence the bruise on Resident 22's right arm was investigated upon discovery. The DON confirmed that Resident 22's right arm bruise was not investigated. The facility failed to investigate Resident 22's right arm bruise. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/27/21 28 Pa. Code 211.5(f) Clinical records Previously cited 5/27/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/27/21 28 Pa. Code 211.10(c) Resident care policies

Based on clinical records review and staff interview, it was determined that the facility failed to follow a physician's order regarding medication administration for two of 14 residents reviewed (Resident 22, and 44). Findings include: Review of Resident 22's diagnosis list revealed Congestive Heart Failure, and Hypertension (elevated blood pressure). Review of Resident 22's Physician's Order (POS) dated May 2, 2022, revealed an order for Amlodipine (medication used to treat high blood pressure) 10 mg (milligram) give one tablet by mouth one time a day. The same order had administration parameter order to hold the medications for SBP (systolic blood pressure) less than 110. Review of Resident 22's May 2022, Medication Administration record (MAR) revealed Resident 22 was administered Amlodipine 27 times without a blood pressure parameter noted. Interview with the Nursing Home Administrator (NHA)was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 22's blood pressure was checked before administration of Amlodipine. The NHA confirmed the lack of documented evidence that Resident 22's physician's order to administer Amlodipine with blood pressure parameter was followed. Review of Resident 36's diagnosis list revealed Atrial Fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and Thrombosis on the right femoral vein (blood clot on the large blood vessel in the thigh). Review of Resident 36's POS revealed an order on June 4, 2022, for Apixaban (medication used to treat and prevent blood clots and prevent stroke) tablet 5 mg, give one tablet by mouth two times a day for DVT (Deep Vein Thrombosis) prophylaxis. Review of Resident 36's June 2022, MAR revealed Apixaban was not administered on the morning of June 9, and on the evening of June 11, and 12, 2022. Interview with the Nursing Home Administrator on June 24, 2022, at 10:00 a.m., was conducted. The NHA was unable to provide explanation as to why Resident 36's Apixaban was not administered on the dates mentioned above. Review of Resident 36's POS revealed an order on May 25, 2022, for a Midodrine HCL tablet (medication to treat a kind of low blood pressure that causes severe dizziness and fainting) 2.5 mg. Give one tablet by mouth in the morning for hypotension (low blood pressure) and hold for SBP (Systolic Blood Pressure) greater than 140. Review of Resident 36's May 2022, MAR revealed Midodrine was administered to the resident seven times without a blood pressure parameter noted. Interview with the Nursing Home Administrator was conducted on June 24, 2022, at 10:00 a.m. The facility failed to provide documented evidence that Resident 36's blood pressure was checked prior to the administration of Midodrine. The NHA confirmed that there was no documented evidence that Resident 36's physician's order to administer Midodrine with blood pressure parameter was followed. The facility failed to follow the physician's medications order for Resident 22, and 36. 28 Pa. Code 211.5(f) Clinical records Previously cited 5/27/21 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/27/21

Based on clinical record review and staff interview it was determined the facility failed to complete laboratory studies as ordered by the physician for one of one residents reviewed. (Resident 43) Findings Include: Review of Resident 43's physician orders revealed an order dated May 17, 2022 for a PT/INR (blood test to determine the effectiveness of Coumadin a blood thinner) to be completed every Tuesday. Review of Resident 43's Medication Administration record revealed the lab study was documented as being completed on May 24, 2022. The facility was asked to provide the results of the PT/INR test but were unable to produce evidence the test was completed. Interview with the physician who ordered the laboratory study on June 24, 2022 at 1:00 p.m. confirmed after checking with the laboratory that the study had not been completed as ordered. 20 Pa Code 211.2 Physician services 28 Pa. Code 211.12(d)(1)(3) Nursing services