Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a change in the condition of a resident's urinary status for one of the three residents reviewed (Resident 39). Findings include: A review of the facility's policy titled Change in Resident status Notification, revised on May 17, 2023, revealed that the charge nurse will notify the resident's physician or on-call physician when there has been a significant change in the resident physical/mental/emotional condition, and a need to alter the resident's medical treatment. Notification will be made promptly with the exemption of non-emergency incidents on the 11-7 shift. Notification of non-emergent incidents on the 11-7 shift may be passed on to the 7-3 shift for a morning notification. Clinical record review revealed Resident 39 had an Indwelling Urethral Catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine) for diagnosis of urinary retention and neuromuscular dysfunction of the bladder. A review of the Resident laboratory report dated March 5, 2025, revealed a normal WBC (White Blood Cell count) result (Normal range 4.8-10.8). (a blood test that measures the number of white blood cells in your blood, helping to identify infections, inflammation, and other conditions.) A review of the nursing progress notes dated March 9, 2025, at 1:47 a.m., revealed that during the start of the shift, resident's family member reported feeling something was off with the resident. Further assessment revealed no urine output in the urine drainage bag, but the resident's brief was wet twice. The same note revealed that the catheter (tube) was outside the body more than normally should be. The same note revealed the following, Indwelling cath (catheter) removed and new 18Fr/10cc (size of the tube) placed with immediate frank red bloody urine, then odorous amber colored urine, ending with tan sludge - 1700 cc. The responsible party was notified. The review of the clinical records failed to reveal that the physician was notified of the significant change in the resident's urinary status and change in the condition of urine. A review of the physician's note dated March 13, 2025, at 4:55 p.m., revealed that during the visit, the resident was noted to be somnolent (sleepy, lethargic, drowsy), not as vocal as his baseline. The condition was discussed with the wife and nursing, urine, and blood work was ordered. A review of Resident 39's blood work dated March 15, 2025, revealed WBC was 21.6 and the urine had (+) 3 Leucocytes (indicative of a urinary tract infection). Urine culture and sensitivity (test to determine the kind of bacteria causing the infection and the antibiotics that are effective against the bacteria) were pending. Clinical records review revealed that the physician was notified of the laboratory result and ordered to start the Resident with Macrobid (antibiotic) 100mg twice daily for seven days while waiting for the culture and sensitivity. The physician's order was followed. An interview was conducted with the Director of Nursing on April 4, 2025, at 10:00 a.m. The DON confirmed that there was no documented evidence that the physician was notified when Resident 39 had 1700 cc of bloody, with tan sludge and odorous urine output on March 9, 2025. The facility failed to ensure physician was notified of Resident 39's significant change in urinary status resulting in a delay in treatment. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interview, it was determined that the facility failed to ensure wound treatment for a pressure ulcer was provided for one of five residents reviewed (Resident 39). Findings include: A review of the nursing progress notes dated March 13, 2025, at 7:40 a.m., revealed that a new DTI (Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration) was observed on the resident's left lower back. The wound was cleansed with a wound cleanser and Desitin (An ointment used to treat and prevent a rash) was applied. The Nurse practitioner was notified. A review of the skin assessment dated [DATE], revealed a DTI to the left lower back measuring 8.9 x 4.5 cm (centimeters). A review of Resident 39's March TAR (Treatment Administration Record) failed to reveal a wound treatment was done for the identified DTI on the resident's left lower back from March 14, 2025, until the time the resident was sent to the hospital for an abnormal laboratory result on March 17, 2025. An interview with the DON (Director of Nursing) conducted on April 4, 2025, at 10:00 a.m., confirmed that there was no documented evidence that the Resident's identified DTI to the left lower back on March 13, 2025, was treated from March 14, 2025, until March 17, 2025. The facility failed to ensure wound treatment was provided for Resident 39's DTI to the left lower back. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure a significant weight change was timely addressed for one 10 residents (Resident 42). Findings include: A review of the facility's policy titled Weights, last revised on October 11, 2024, revealed the facility will have the residents' weights monitored as an indicator of their health and wellness. Residents will be weighed weekly for a total of four weeks to monitor health status. Weights will be reviewed by the nurse and dietitian. Weights that are three pounds greater than or less than the resident's prior weight will be reweighed within 24 hours to verify accuracy. Weights that are less than 5% of the previous weight will be reported to the physician and noted on the resident record. A plan of care will be developed to address residents with weight concerns. Clinical records review revealed resident was admitted to the facility on [DATE], with a diagnosis of Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Dysphagia (Difficulty in swallowing). A review of the resident nutritional care plan initiated on December 30, 2024, revealed: Screening Score 7-Malnourished (Resident 42) have the potential for continued alteration in nutrition r/t (relate to) history of dysphagia. Interventions include monitoring the need for the addition of appropriate high-calorie/protein house supplements within the limits of the therapeutic diet order. A review of Resident 42's weights revealed an admission weight of 122.6 pounds on December 27, 2024. Weekly weights were done with the following result: 124.3 pounds on December 31, 2024, 124 pounds on January 1, 2025, and 116.8 pounds on January 10, 2025, an 8.8 pounds (5.81%) weight loss in five days. Clinical record review failed to reveal that the resident was reweighed within the 24-hour period to verify the significant weight loss. There was no documented evidence that a nurse and/or the dietitian reviewed the resident's identified weight loss. There were no interventions put in place to prevent further weight loss. There was no documented evidence that the physician was notified of the significant weight loss until January 30, 2025. A review of Resident 42's weight and vitals revealed a weight of 113.6 on March 24, 2025, a 7.34 % weight loss from admission. There were no interventions put in place upon identifying further weight loss within tthree-month period from December 27, 2024, until March 24, 2025. An interview with the Dietitian and the DON (Director of Nursing) conducted on April 4, 2025, at 11:00 a.m., confirmed that there were no interventions put in place for the significant weight loss identified on January 10, 2025, and further weight loss from admission identified on March 24, 2025. The facility failed to ensure Resident 42's significant weight loss was addressed. 28 Pa Code 211.10(c) Patient care policies Previously cited 5/3/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/3/24

Based on review of facility policy and clinical record review, it was determined that the facility failed to ensure one of 18 residents was treated for constipation in a timely manner (Resident 12). Findings include: Review of facility policy, Bowel Protocol, last reviewed/revised June 2, 2022, revealed: If a resident has not moved their bowels for 6 shifts .the 3-11 charge nurse is to give Milk of Magnesia at [bedtime] to the resident with an order. Review of Resident 18's physician's orders revealed an order dated April 4, 2024, for Milk of Magnesia 400mg/5ml - give 30ml by mouth every 24 hours as needed for constipation. Review of Resident 18's bowel records revealed the resident had no recorded bowel movement from April 22, 2024, through April 26, 2024, for a total of 15 shifts. Review of Resident 18's April 2024 Medication Administration Record revealed the resident was not given Milk of Magnesia until April 27, 2024. Interview with Licensed Nurse Employee E3 confirmed the facility failed to administer Resident 12's Milk of Magnesia after 6 shifts with no bowel movement. 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of 24 residents reviewed was free of accidents related to activities of daily living care. (Resident 44). Findings include: Review of information dated March 20, 2024 submitted by the facility on March 20, 2024; revealed Resident 44 was receiving morning care from non licensed staff, Employee E1. Employee E1 was performing a morning care with Resident 44 when Employee E1 rolled Resident 44 over, subsequently Resident 44 rolled out of the bed and fell onto the floor. Review of clinical record for Resident 44 revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Anemia (deficiency of healthy red blood cells in blood), and Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 44's clinical record including his/her care plan (provides direction on the type of nursing care the individual needs) revealed an intervention dated January 20, 2023, stating Nursing staff are to provide paired care (2 staff members). Review of facility investigation dated, March 20, 2024, revealed Resident 44 While receiving AM care by (Employee) E4, resident rolled out of bed onto the floor onto [his/her] left side, Small abrasion 1.5 x 1.0 cm (centimeters) noted on left upper forehead, Resident 44 reported no pain. Review of written statement from non licensed, Employee E4 dated March 20, 2024, states the following I [Employee E4] was giving care to [Resident 44] and I didn't get any report that [Resident 44] was a two assist and giving [his/her] care [Resident] rolled out of bed. Interview conducted with Nursing Home Administrator (NHA) on May 2, 2024, at 11:20 a.m. confirmed Resident 44 rolled out of bed due to Employee E4 not following the care instructions indicated on care plan of Resident 44. NHA also reported that Employee E4 was reeducated on following resident care plans. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services