Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to administer a medication per physician's orders for one of 19 residents reviewed (Resident R227). Findings include: Resident R227's clinical record revealed an admission date of 2/18/25, with diagnoses that included fracture of the right hip, arthritis, anxiety disorder, and Type 2 diabetes (a long term condition in which the body has difficulty controlling blood sugar and using it for energy.) Resident R227's clinical record revaled a physician's order for Janumet (an anti-diabetic medication that can treat Type 2 diabetes) Oral tablet 50/500 mg (milligrams) by mouth two times per day with a start date of 2/19/25 at 8:30 a.m. Observation of medication administration on 2/19/25, at approximately 8:55 a.m. with Licensed Practical Nurse (LPN) Employee E1, revealed that Resident R227's medication Janumet 50/500 mg one tablet by mouth two times per day, was not available to be administered. LPN Employee E1 stated that Resident R227 was a new admission and the medication had not come from the pharmacy and when the medication arrives, it will be administered. There was no evidence of follow-up with the physician and the orders for the resident regarding the medication being unavailable/not administered. Review of Resident R227's progress notes on 2/20/25 at approximately 2:00 p.m. revealed that Resident R227 missed doses of Janumet 50/500 mg that included on 2/19/25,the morning and evening doses and on 2/20/25, for the morning dose. During an interview on 2/20/25, at approximately 3:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to administer Janumet as ordered upon admission to the facility and Resident R227 missed three doses of the medication Janumet since admission to the facility. 28 Pa. Code 211.5(f)(i)(ii)(iii) Medical records 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to transcribe physician's orders for an anticoagulant (medication to thin your blood to prevent blood clots) medication and dressing change to a surgical incision for one of four residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 10/25/24, with diagnoses that included anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), atelectasis (when part or your entire lung collapses resulting in symptoms such difficulty breathing, wheezing, and cough), and fractured right hip. Resident R1's clinical record contained a document from an area hospital entitled Patient Summary dated 10/25/24, which identified a list of medications Resident R1 was to continue while at the facility. The Patient Summary indicated that Resident R1 was ordered Lovenox (injectable anticoagulant medication) 40 milligram (mg) per 0.4 milliliters (ml) - give 0.3 ml subcutaneous (sq) daily for 30 days. Resident R1's physician's orders and Medication Administration Record (MAR) lacked evidence that the facility transcribed and administered Lovenox as ordered on 10/26/24 and 10/27/24. During an interview on 11/26/24, at approximately 2:15 p.m. the Nursing Home Administrator confirmed the facility failed to transcribe Resident R1's admission orders to include Lovenox resulting in the Lovenox not being administered as ordered. Resident R1's clinical record also contained a document from an area hospital entitled Ortho - Final Progress dated 10/25/24, that revealed under Incision / Wound Care that Resident R1 was to have a dry dressing change completed daily until completely dry for two days, then it was okay to leave incision open to air. Review of Nurse to Nurse admission Report revealed the area hospital informed the facility that Resident R1 had a dressing to her leg. Review of Resident R1's admission Assessment completed by the facility on 10/25/24, Section I entitled Skin Condition and History revealed a right thigh surgical incision with two dressings present. Review of Resident R1's physician's orders and Treatment Administration Record (TAR) lacked evidence that the facility transcribed and changed the right hip dressing as ordered. During an interview on 11/26/24, at approximately 3:00 p.m. the Director of Nursing confirmed the facility failed to transcribe the dressing change order regarding Resident R1's right hip and failed to provide evidence that if clarification was needed, that the facility contacted the primary care physician and/or surgeon to obtain clarification so care could be provided. 28 Pa. Code 211.5(f)(i)(ii) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documentation, and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure residents were free from neglect for one of 14 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse and neglect clinical protocol Revised March 2018, revealed Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitled Falls-Clinical Protocol Revised March 2018, revealed Falls should be categorized by: those that occur while trying to rise from a sitting or lying to a standing position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Review of Resident R1's clinical record revealed an admission date of 3/15/24, with diagnoses that included fracture of the head and neck of the left femur, atrial fibrillation (irregular heart beat), and heart failure. Review of Resident R1's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], revealed under section G transfers, that Resident R1 required extensive assistance with transfers. Review of Resident R1's Care Plan revealed that the resident was an assist of two with transfers, resident was non-weight bearing. Review of information submitted by the facility dated 8/21/2024, revealed Resident R1 was incorrectly transferred by one employee after receiving a shower in the shower room and was lowered to the floor resulting in a fall to him/her. Review of the facility's investigation revealed an employee statement by Nurse Aide (NA) Employee E1 that identified that NA Employee E1 confirmed on 8/21/24, at about 8:10 p.m. he/she transferred Resident R1 to the shower with Employee E2 and Resident R1 was then assisted onto the shower chair. The shower was completed. Resident R1 apparently kept leaning forward during the shower. Employee E1 then stated, helped her stand and tried to pull lounge chair behind her. It would not move very well, so I yelled four times I need help in here. No one came so I had to lower her to the floor and came out to get help. Review of NA Employee E2's statement revealed, This aid helped get Resident on shower chair and helped get her into shower. This aid told the aid to let any of us know to help get her back in to the chair after the shower. This aid proceeded to leave shower room to change and get into bed a resident. This aid proceeded to stay at nurse's station to wait for aid to say they were done. Aid finally opened door for help and this aid went to help when this aid opened door, this aid saw resident sitting on the floor. Four people went in to help get her into her chair. [He/she]stated [he/she] yelled for help four times, but we were all at the nurse's station and did not hear anything. Review of Registered Nurse (RN) Supervisor Employee E3's statement revealed that the resident was being showered in shower room; Employee E1 did not ask for assistance and did not hit the call bell in shower room for assistance; He/she stated he/she lowered the resident to the floor; and the resident was found on tile floor and was assessed. Review of documentation submitted by the facility dated 8/23/24, revealed that the facility initiated an investigation, regarding resident neglect. NA Employee E1 was suspended from work during the investigation process. NA Employee E1 was terminated from work on 8/27/24, due to failing to follow the resident plan of care resulting in resident suffering a fall in the shower room. Employee Education was conducted. During an interview on 10/02/24, at 12:30 p.m. the Nursing Home Administrator (NHA) confirmed that NA Employee E1 transferred Resident R1 by physically lifting him/her and not obtaining assistance of two people resulting in a fall in the shower with no harm or injury to Resident R1. He/she also confirmed that the resident should have been transferred as care planned with the assist of two people to a wheelchair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services