Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 19 residents reviewed (Resident 36). Findings Include: Review of Resident 36's clinical record revealed diagnoses that included diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), psychosis (a mental disorder when a person has trouble telling the difference between what's real and what's not), and muscle weakness. Review of Resident 36's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 3, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days and that an insulin order had changed in the past 7 days. Review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days Review of Resident 36's physician orders revealed a once weekly injection for diabetes, but failed to reveal any orders for insulin during the ARD lookback period for the aforementioned assessments. Further review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed in Section N0450. Antipsychotic Medication Review it was coded no under Has a gradual dose reduction (GDR) been attempted? (GDR- stepwise decreasing of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose). Also, that the next section Date of last attempted GDR was disabled due to the response to the previous section. Review of Resident 36's clinical record revealed a Psychiatry Note dated September 10, 2024, noting a GDR of Resident 36's Seroquel (antipsychotic medication) had been completed on July 17, 2024. During an email correspondence with the Nursing Home Administrator and Director of Nursing (DON) on September 17, 2024, at 1:43 PM, the surveyor questioned if Resident 36's MDS assessments were accurate related to insulin use and GDR. Follow-up interview with the DON on September 18, 2024, at 10:32 AM, revealed Resident 36's MDS assessments were coded inaccurately for those sections, and she would expect resident MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 18, 69, and 81). Findings include: Review of facility policy, titled Care Plans, last reviewed December 28, 2023, read, in part, This facility will develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that include but are not limited to those identified in the comprehensive assessment. The plan of care will be reviewed in an ongoing manner and progress or lack thereof toward established goals will be documented within the medical record of the resident. If appropriate, the care plan will be revised as needed. Review of Resident 18's clinical record revealed diagnoses of muscle weakness (a lack of muscle strength) and disorders of phosphorus metabolism (a condition where blood phosphate levels are too low. Symptoms include muscle weakness, bone softening, and altered mental state). Review of Resident 18's electronic medical record revealed the diagnosis of post-traumatic stress disorder (PTSD) was added to her medical diagnoses on October 24, 2023. Review of Resident 18's physician orders on September 17, 2024, revealed an order for heel protectors to be worn while Resident in bed, with a start date of April 3, 2024. Review of Resident 18's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 18 is at risk for impaired skin integrity, including pressure injury, related to incontinence and decreased mobility: with a revision date of September 15, 2024. There is no mention of Resident 18's need for heel protectors anywhere in the care plan. Interview with the Director of Nursing (DON) on September 18, 2024, at 12:33 PM, revealed that Resident 18's care plan to contain instructions to apply heel protectors to Resident 18's heels when the Resident is in bed. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. During an interview with the DON on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan. Review of Resident 81's clinical record revealed diagnoses that included rheumatoid arthritis (an autoimmune disease that causes inflammation and damage in your joints and other body system), chronic pain, and muscle weakness. Interview with Resident 81 on September 16, 2024, at 9:55 AM, revealed she wears her splint at night to help with her rheumatoid arthritis. Review of Resident 81's physician orders revealed an order for Carrot splint to left hand at bedtime, off in AM-- skin checks every shift, every shift for skin integrity related to rheumatoid arthritis, with a start date of August 1, 2024. Review of Resident 81's care plan on September 17, 2024, revealed care plans for assistance with activities of daily living and chronic pain related to arthritis, but failed to reveal notation of her carrot splint. During an interview with the DON on September 18, 2024, at 12:26 PM, she revealed she would expect Resident 81's carrot splint to be on her care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents reviewed for pressure ulcers (Resident 69). Findings include: Review of the facility policy, titled Skin Integrity Interventions and Protocol for The Middletown Home, last reviewed on December 28, 2023, revealed that interventions for pressure ulcer preventions include: Implement pressure-relieving measures for residents at risk, including: frequent repositioning, use of pressure-reducing mattresses and cushions, proper skin care, including cleansing and moisturizing, adequate nutrition and hydration, and management of incontinence. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Observation of Resident 69 on September 16, 2024, at 9:57 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 16, 2024, at 1:19 PM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 18, 2024, at 10:14 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Review of Resident 69's clinical record revealed no progress notes documented by staff indicating that Resident 69 refused to wear their foam boots or requested them to be taken off during the dates and times above. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. During an interview with the Director of Nursing (DON) on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan, and that she spoke to staff on Resident 69's hall who said that Resident 69 will kick their foam boots off, but staff could document in progress notes on Resident 69's clinical record when they are taken off. DON revealed they could change Resident 69's physician order to include: foam boots as tolerated. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is informed of the items and services for which the resident may be charged and the amount of charges for those services at the conclusion of the Medicare A skilled services stay by issuing the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (SNF ABN) for two of three residents reviewed at the conclusion of the Medicare A covered stay (Residents 37 and 64). Findings Include: Review of Resident 37's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be September 22, 2023. Continued review of the form revealed the facility had not issued the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form [SNF-ABN, CMS-10055] at the conclusion of the Medicare Part A services stay. The SNF-ABN form is the liability form issued by skilled nursing facilities as the liability notice that describes an item or service that is usually paid for by Medicare, but may not be paid because it is not medically reasonable and necessary. Review of Resident 64's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be June 16, 2023. Continued review of the form revealed the facility had not issued the SNF-ABN, CMS 10055 form at the conclusion of the Medicare Part A services. An interview with Employee 4 (Social Worker) on November 6, 2023, at 10:29 AM, revealed an alternate form was used instead of the required SNF-ABN form for Residents 37 and 64. An additional interview with the Director of Nursing on November 7, 2023, at 8:41 AM, revealed an awareness that the required form had not been issued to Residents 37 and 64. 28 Pa. Code 201.14 Responsibility of licensee

Based on state regulations, surveyor observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 24 residents reviewed (Resident 27). Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. Review facility policy, titled Medication Administration General Guidelines, dated 2006, revealed in section B. Administration, Step 2. Medications are administered in accordance with written orders of the attending physician. Review of Resident 27's clinical record revealed diagnoses that include low back pain between the lower edge of the ribs and the buttock and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). Review of Resident 27's physician's orders on November 6, 2023, reveals a physician's order written on October 12, 2023, for Bengay ultra patch (a patch with pain relieving medication applied) for Resident 27's mid back, applied in the morning and removed in the evening daily. Review of Resident 27's MAR (Medication Administration Record) from the month of November 2023, revealed that on November 5, 2023, Employee 1 (LPN) documented that she removed the Bengay ultra patch from Resident 27's mid back. Observation of Resident 27 on November 6, 2023, at 8:02 AM, revealed Employee 2 (LPN) removed a patch from Resident 27's mid-back, dated November 5, 2023, so that she could apply the new patch that morning. Interview with the Director of Nursing on November 7, 2023, at 9:17 AM, revealed that she would expect the Bengay patch would have been removed from Resident 27's back on the evening of November 5, 2023, as ordered, by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, record review, and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents 38 and 53). Findings Include: Review of Resident 38's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 38's physician orders revealed an order for Geri Sleeves BUE (bilateral upper extremities) every shift for skin protection, may remove for care and soilage, with a start date of August 3, 2023. Observation of Resident 38 on November 5, 2023, at 1:28 PM, revealed Resident 38 asleep, sitting in a common area of the hall without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 10:18 AM, revealed Resident 38 in his room, drinking out of a cup without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 1:01 PM, revealed Resident 38 asleep in the hallway, without Geri sleeves on. Interview with the Director of Nursing (DON) on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. Review of Resident 53's clinical record revealed diagnoses that included Parkinson's Disease, dementia, and muscle weakness. Review of Resident 53's physician orders revealed an order for Geri sleeves to BL (bilateral) arms at all times every shift for altered skin integrity, may remove for care, with a start date of March 14, 2023. Observation of Resident 53 on November 6, 2023, at 10:24 AM, revealed Resident 53 asleep in a common area of the hall without Geri sleeves on. Interview with the DON on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, product label review, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas. Findings include: Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Storage of Goods, revealed, Remove goods from storage for which the expiration date has passed .All foods will be labeled with month/day/year received .Leftovers are to be covered, labeled, and dated with use by date .All foods must be labeled and dated. Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Foods Brought by Family/Visitors, revealed, Perishable foods must be destroyed daily .All food items must be labeled with the resident's name and use by date and the date brought in and/or opened. Observation of the dry storage area on November 5, 2023, at 9:39 AM, revealed: one bag of rice open without a date; one open bag of rotini without an open date; one open bag of spaghetti without an open date; and one open bag of egg noodles without an open date. Interview with Employee 3 (Dietary Supervisor) on November 5, 2023, at 9:43 AM, revealed food containers should be labeled with an open date once opened. Observation of the walk-in freezer unit on November 5, 2023, at 9:45 AM, revealed: four pie crusts not dated; one bag of fries open and not dated; one bag of tater tots open and not dated; three slices of pizza not dated; two bags of hoagie rolls not dated; and one pan of dessert without a label or date. Observation in the main kitchen on November 5, 2023, at 9:50 AM, revealed a bin of flour dated use by October 25, 2023; and a bin of rice dated use by November 1, 2023. Observation of the walk-in refrigerator on November 5, 2023, at 9:56 AM, revealed: one container of thousand island salad dressing not dated. Observation of the second walk-in refrigerator on November 5, 2023, at 10:00 AM, revealed: one bin of celery not dated; one bag of parmesan cheese not dated; one bag of feta cheese with a use by date of October 27, 2023; and one monster energy drink open and labeled Dee. Interview with Employee 3 on November 5, 2023, at 10:01 AM, revealed employee food and beverages should not be stored in food storage areas. Observation during initial tour of the station 2 pantry area on November 5, 2023, at 10:08 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Observation of the refrigerator and freezer temperature logs in the station 2 pantry area on November 5, 2023, at 10:09 AM, revealed temperatures failed to be recorded on September 7, 8, and 28, 2023; October 2, 27, and 30, 2023; and November 3 and 4, 2023. Further observation of the station 2 pantry area refrigerator on November 5, 2023, at 10:11 AM, revealed one carton of milk with a use by date of November 4, 2023, and the milk was leaking on the shelf; and two nutritional juice drinks not labeled with a thawed date. Interview with Employee 3 on November 5, 2023, at 10:12 AM, revealed nutritional drinks that are received frozen should be labeled with a thawed date once pulled from the freezer, and are good for two weeks after the thawed date. Observation during initial tour of the dining room nourishment area on November 5, 2023, at 10:13 AM, revealed: one container of flaked cereal, one container of bran cereal, one container of toasted o's cereal, and one container of frosted wheat cereal, all labeled October 18, 2023. Interview with Employee 3 on November 5, 2023, at 10:16 AM, revealed the cereal containers are to be used within a week and they have been filled since October 18, 2023, and should be relabeled. Observation during initial tour of the station 1 pantry area on November 5, 2023, at 10:18 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Further observation of the station 1 pantry area refrigerator on November 5, 2023, at 10:21 AM, revealed: one container of thickened cranberry juice with an open date of October 23, 2023, and one container of thickened water with an open date of October 28, 2023; both containers state they should be discarded seven days after opening. Observation during initial tour of the kitchenette pantry area on November 5, 2023, at 10:23 AM, revealed: four oatmeal cookies, two fudge cookies, and one brownie all not dated; and two containers of dairy creamer not dated. Further observation of the kitchenette pantry area refrigerator on November 5, 2023, at 10:25 AM, revealed: one container of potato salad for a resident labeled 10/31/23 from an outside source; one container of fruit from an outside source for a resident not labeled with residents name or date; and one container of olives from an outside source for a resident not labeled with resident's name or date. Observation of the refrigerator and freezer temperature logs in the kitchenette pantry area on November 5, 2023, at 10:27 AM, revealed temperatures failed to be recorded on September 7, 8, and 28, 2023; October 20, 27, and 30, 2023; and November 3 and 4, 2023. Interview with Employee 3 on November 5, 2023, at 10:28 AM, revealed she would expect food and beverages to be labeled and dated per facility policies and temperature logs to be filled daily. Interview with the Director of Nursing on November 6, 2023, at 2:14 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policies, food items are stored in accordance with professional standards, and temperature logs are filled. 28 Pa. Code 211.6(f) Dietary services

Based on document review and staff interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: During an interview with the Nursing Home Administrator (NHA) on November 7, 2023, at 11:00 AM, the NHA was unable to provide a policy that addressed water management or a list of water management team members. During the interview with the NHA on November 7, 2023, data was requested and unable to be provided, that would support implementation of a water management program, such as Legionella risk assessment, a water system flow chart that identifies risk areas such as, testing of shower heads, the ornamental fountain, or the pond that is active during Spring and Summer. The facility was able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning of the cooling systems for pH (acidity or basicity), total alkalinity, calcium hardness, PTSA (ultra violet dye for monitoring cooling systems), and temperature. The facility was also able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning two boilers for temperature, pH, hardness, molybdenum (a mineral), and sulfite; as well as cooling systems for conductivity, pH (acidity or basicity), total alkalinity, and calcium hardness. The company who performed the test made the following statement on the report, Standard water treatment is not meant to protect against health risks. The facility was able to show a form dated August 1, 2022, for a one time Legionella testing of the pond in the courtyard and one air condition intake grill in the facility that reported the detection of Legionella, but the final report did not detect the species of Legionella that affects humans and causes the disease in humans. The facility was unable to show control measures to prevent growth and spread of water-borne contaminants, no validation for routine environmental sample results of legionella testing, no monitoring of high risk areas, and no plan for when control limits are not met and/or control measures are not effective. During a final interview with the NHA on November 7, 2023, at approximately 11:00 AM, the NHA confirmed the facility hasn't developed a water management program. 28 Pa. Code 201.18(b)(1)(3) Management

Based on clinical record review, policy review and interviews, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care and treatments consistent with professional standards of practice for one of three Residents reviewed (Resident 1). Findings include: A review of the facility's current wound care policy, titled Wound Care Packing, last revised 7/2011, states, pack and dress wound as ordered. The policy also requires that staff date and initial the wound dressing when applied. A review of the clinical record for Resident 1, revealed clinical diagnoses that included type II diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and malignant neoplasm occipital lobe (cancer in the brain). Further review revealed that Resident 1 had a wound assessment on February 2, 2023, that revealed a Stage 4 full thickness sacral pressure ulcer (ulcer involving loss of skin layers, exposing fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). A review of Resident 1's current physician orders dated February 2023, included an order for wound care to the sacrum (the portion of the spine between the lower back and tailbone) to be completed every evening shift and as needed for drainage. The wound care orders effective February 2, 2023, specify to cleanse area on sacrum with normal saline solution, apply Dakin's (cleansing) solution 1/4 strength daily for 30 days, and gauze roll 2.25 inch apply once daily for 30 days. Review of the Treatment Administration Record revealed that on February 9, 2023, the wound care treatment was not signed off that it was completed. A statement from Employee 1 (Licensed Practical Nurse) dated February 14, 2023, revealed that Employee 1 was requested by family to perform a wound care dressing change on February 10, 2023 at approximately 11:00 AM because the dressing was saturated. Employee 1 documented in a written statement that the dressing that was removed was dated February 8, 2023. She stated that she thought the reason why the date of 2/8/23 was on the dressing was that the wound doctor was rounding on 2/9/23 and typically does wound treatments. Review of the wound doctor progress note, dated February 9, 2023, revealed a note that stated, signing off on patient who remains in the facility being seen by Hospice. Sign off without visit. During a telephone interview with the Nursing Home Administrator (NHA) on February 15, 2023, at approximately 1:48 PM, the NHA agreed that the treatment should have been completed as ordered, but didn't agree that the missed treatment should rise to the level of a deficiency. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**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 and implement a baseline care plan for each resident within 48 hours of the resident's admission for one of 26 residents reviewed (Resident 50). Findings Include: Review of Resident 50's clinical record revealed an admission date of September 19, 2022, and diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily). Review of Resident 50's admission Fall Risk assessment dated [DATE], revealed that the Resident had experienced three or more falls in the last three months prior to admission, and that their fall risk score was 24. The guidelines on the Fall Risk Assessment indicated that a score of 10 or higher represents a high risk for fall. In the section of the Fall Risk Assessment titled Indicate Care Plan Action Taken, it was marked to Initiate Plan of Care. Review of Resident 50's clinical record and facility provided incident reports, it was noted that Resident 50 had a fall on September 24, 2022, at 6:15 AM, and on October 1, 2022, at 12:30 AM. Review of Resident 50's baseline care plan revealed that a care plan was not developed for their high risk of falling until October 1, 2022. During an interview with the Nursing Home Administrator, Director of Nursing, Employee 1, and Employee 2 on November 2, 2022, at 1:02 PM, Employee 1 confirmed that the admission Fall Risk Assessment was completed on September 19, 2022; which identified the Resident was at high risk for falls and that the care plan for falls was not created until October 1, 2022. The Director of Nursing indicated that she would have expected that the baseline care plan would have included falls at the time of the initial development as indicated on the admission Fall Risk Assessment. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy reviews, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory services consistent with professional standards of practice for two of 21 residents reviewed (Resident 32 and 89). Findings include: Review of facility policy titled Nebulizers - Use and Care dated June 2011 revealed After each use, wipe mouth piece with a paper towel, removing all moisture, and store in a plastic bag. Review of facility provided policy titled Oxygen therapy revised June 2019, revealed, Change the cannula, tubing, and humidifier bottle every week or more frequently, if needed. Review of Resident 32's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen, and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of Resident 32's current physician orders revealed the following orders: continuous positive airway pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while one sleeps) to be worn while sleeping with oxygen 3 liters---settings: minimum expiratory positive airway pressure (EPAP- creating pressure when exhaling, keeping airway open until next inhale of breath) is 6 cm; maximum inspiratory positive airway pressure (IPAP the inspiratory pressure when inhaling a breath) is 25 cm pressure support of 4 cm every evening and night shift dated October 14, 2022; Cleanse CPAP face mask with soapy water and rinse daily. Do on day shift after removal, dated October 11, 2022; change oxygen tubing, humidifier bottle, and mask or cannula, and rinse concentrator filter with water every night shift every Sunday, date and initial, label with resident name, make sure to change and label wheelchair oxygen tank tubing, dated May 15, 2022; Ipratropium-Albuterol Solution 0.5-2.5 MG/3 ML 3 ml inhale orally every four hours as needed for shortness of breath or wheezing via nebulizer while awake, dated March 31, 2022; and oxygen at 3 liters/minute via nasal cannula as needed and monitor oxygen saturation each shift that oxygen is used, dated March 31, 2022. Orders did not reveal that the Resident is independent in managing his oxygen and CPAP. During an interview with Resident 32 on October 31, 2022, at 10:18 AM, the following was noted: the Resident's nasal cannula for their oxygen was laying on the bed and not contained in a protective bag. It was connected to the oxygen concentrator, which was running; but the Resident was connected to their portable oxygen tank. The oxygen concentrator was noted to have gray colored, fuzzy particles on the vent on the top of the back of the concentrator; and the CPAP mask was laying on the night stand and not contained in a protective bag. During an observation of Resident 32's room on November 1, 2022, at 9:17 AM, the same findings were noted. During an observation of Resident 32's room conducted with Employee 2 on November 2, 2022, at approximately 9:27 AM, the following was noted: the nasal cannula that was connected to the running concentrator was laying on the bed and not contained in a protective bag; a nebulizer treatment mask was noted to be laying on the overbed table and not in a protective bag, and the CPAP mask remained on the nightstand and not contained in a protective bag. Resident 32 had left the facility around 8:45 AM for an outside appointment. Employee 2 confirmed that the nasal cannula, CPAP mask, and the nebulizer treatment should be bagged, but also shared that the Resident probably finished it before they left for their appointment, and that the nurse had not been back yet to clean it and place in the protective bag. Employee 2 further confirmed that the oxygen concentrator needed cleaned and indicated that they would get it all taken care of. Review of Resident 32's Medication Administration Record for November 2022, revealed that there was no documentation of the Resident receiving a nebulizer for the month of November thus far. During a follow-up interview with Employee 2 on November 2, 2022, at 10:32 AM, Employee 2 indicated that the nebulizer treatment was cleaned and bagged; the nasal cannula was bagged; the CPAP mask was bagged; and the concentrator was cleaned. She further indicated that the Resident often refuses the CPAP and that they would be following up with the MD. During an interview with the Nursing Home Administrator (NHA), Director of Nursing, Employee 1, and Employee 2, on November 2, 2022, at 1:19 PM, Employee 2 confirmed that the concentrator vent area was dusty and had to be cleaned, and that she bagged items accordingly. The Director of Nursing confirmed that she would expect the items to be bagged when not in use. During exit conference with the NHA, Employee 1, and Employee 2, on November 3, 2022, at approximately 1:00 PM, Employee 2 indicated that although the items were not placed in the protective bags at the time of the observations, there were protective bags present in the room. Employee 2 further indicated that Resident 32 is independent with his oxygen and CPAP. It was shared that the concern remains because, as staff are in and out of room throughout the day, the items could be placed in their protective bags. Review of Resident 89's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Observation of Resident 89 on November 2, 2022, at 9:55 AM, revealed the Resident lying in bed sleeping. Further observation revealed their oxygen concentrator sitting beside the bed with oxygen tubing attached to it. The oxygen tubing was dated September 2, 2022. Review of Resident 89's current physician's orders on November 2, 2022, revealed an order for supplemental oxygen, via nasal canula, at 2 liters per minute, as needed, to keep SPO2 (a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) greater than 90%. Further review revealed a current physician order to change oxygen tubing, humidifier bottle, and nasal canula night shift every Thursday and date and label with the resident's name. Review of Resident 89's Medication Administration Record/Treatment Administration revealed that staff documented that on September 8, 15, 21, and 29, 2022 and October 6, 13, 20 and 27, 2022 that the oxygen tubing was changed. Review of Resident 89's care plan on November 2, 2022, at 10:00 AM, revealed a care plan with a focus of oxygen use related to chronic obstructive pulmonary disease; and an intervention of continuous oxygen use for respirator comfort, 2 liters at rest and 4 liters with ambulation and bedtime. During an interview with the Employee 2 on November 3, 2022, at 9:00 AM, it was revealed that the expectation is that the oxygen tubing would be changed weekly, and that the facility policy would be followed. Also, Employee 2 revealed that she would expect the care plan to be updated to reflect current physician's orders for Resident 89's care. During an interview with the Nursing Home Administrator on November 3, 2022, at 9:00 AM, it was revealed that he would exprect the facility policy to be followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services