**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review revealed that the facility failed to ensure that a rational was documented related to pharmacy recommendations for one of 35 residents reviewed. (Resident R2)Findings include:Review of facility policy titled Pharmacy Consultation Recommendations revised on October 1, 2018, revealed The Pharmacy Consultant will review all resident charts monthly and as needed to assess the resident's medication regimen, associated orders to assure proper medication selection, and potential risks associated with pharmacological interventions and to suggest therapeutic changes. Under Procedure, policy states The Unit Manager/ RN supervisor will document the Physician/CRNP's (Certified Registered Nurse Practitioner) response as a verbal order if the Physician/ CRNP has accepted the recommendation, or as a narrative in the progress notes if the Physician/ CRNP has declined the recommendation including the Physician/ CRNP's reason for not accepting the recommendation. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Type 2 diabetes (failure of the body to produce insulin), heart disease, and Hypertension (High Blood Pressure). Review of Resident R2's pharmacy review dated May 20, 2025, completed by Employee E9, Consultant Pharmacist revealed This resident receives a fasting blood sugar three times a day with Humalog sliding scale insulin (SSI) coverage. Current geriatric literature recommends avoiding SSI without concurrent Basal Insulin therapy regardless of care setting due to a higher risk of hypoglycemia without improvement in hyperglycemia management. Since SSI is being used minimally, please consider discontinuing SSI. If no changes in current diabetes management are indicated for this resident, please comment. Further review indicated that physician disagreed with the recommendation however provided no further rationale. 28 Pa Code 211.12(d)(1)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, review of facility policy, and interview with staff, it was determined that the facility did not develop and implement a comprehensive, resident-centered care plan for seven of 35 residents reviewed related to wounds and Enhanced Barrier Precaution's. (Resident R36, R71, R114, R156, R24, R187, and R41)Findings include:Review of facility policy Resident Centered Care Planning, revised on 06/06, indicates that purpose of policy is to utilize the Resident Assessment Process (RAP) according to Federal Regulations; further indicating that RAP is to be completed by Nursing staff for pressure ulcers.Review of Resident R36's clinical record revealed the resident was assessed with Stage IV (ulcer involving loss of skin layers, exposing muscle) pressure ulcer on coccyx.Review of R36's care plan revealed no evidence of goals or interventions related to Enhanced Barrier Precautions (EBP).Review of Resident R71's clinical record revealed the resident was assessed with Stage IV pressure ulcer on sacrum.Review of R71's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R114, clinical record revealed the resident was assessed with Stage III ( ulcer involving full thickness of skin loss, exposing tissue) pressure ulcer on intergluteal cleft/sacrum.Review of R114's care plan revealed no evidence of goals or interventions related to EBP's.Further review of clinical record revealed [AGE] year-old male resident R156, with diabetic foot ulcer on left lateral foot.Review of R156's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R24's clinical record revealed that the resident was assessed with full thickness venous ulcer on left medial lower leg.Review of R24's care plan revealed no evidence of goals or interventions related to EBP's and no evidence of goals or interventions related to venous ulcer.Review of Resident R187's clinical record revealed that the resident was assessed with full thickness arterial ulcer on right lower extremity.Review of R187's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R41's clinical record revealed that the resident was assessed with full thickness arterial ulcers on left lower extremity.Review of R41's care plan revealed no evidence of goals or interventions related to EBP's.28 Pa Code 211.10(a) Resident care policies28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to ensure that urinary catheter bag were properly position to prevent contact with the floor for one of one residents review with an indwelling urinary catheter. (Resident Review of facility policy titled Urinary Catheter Care, last reviewed on June 20, 2019, revealed the purpose of the policy is to reduce the risk of the indwelling urinary catheter becoming the source of infection and to reduce the transmission of infection to or between residents/ participants with indwelling urinary catheters. Furthermore, Drainage Bags should never touch the floor. Review of Resident R63's clinical record revealed that resident was admitted to the facility on [DATE] with the diagnoses of End stage renal disease (Kidney failure), Aphasia (disorder that affects a person's ability to communicate). Review of Resident R63's physician order date March 20, 2024, revealed Change suprapubic catheter every 4 weeks and irrigate as needed for clots, dislodgement or occlusion. 18F/30mL change drainage bag as needed when foley catheter is changed. Observation of Resident R63's room on July 29, 2025 at 11:21am, revealed resident's foley catheter drainage bag touching floor. Interview with Employee E7, Licensed Practical Nurse on July 29, 2025 at 11:25am, confirmed findings of Resident R63's foley catheter drainage bag touching floor. Observation of Resident R63's room on July 31, 2025 at 10:46am, revealed resident's foley catheter drainage bag touching floor. Interview with Employee E8, Licensed Practical Nurse on July 31, 2025 at 10:50am, confirmed findings of Resident R63's foley catheter drainage bag touching floor. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza for 51 of 54 residents reviewed (Resident R41, R26, R28, R29, R30, R34, R42, R3, R43, R50, R12, R64, R65, R73, R75, R86, R97, R114, R117, R119, R120, R132, R136, R140, R141, R143, R11, R146, R151, R154, R171, R8, R178, R18, R24, R77, R107, R130, R139, R1, R152, R162, R173, R175, R21, R22, R25, R10, R27, R32, R35) Findings include: Review of facility policy ‘Influenza vaccine - protocol for residents,' reviewed January 14, 2025, indicates that the immunization records of all residents in the facility will be reviewed annually. All residents will be offered the influenza vaccination unless there is a documented contraindication. Residents/Responsible Representative will be offered a copy of the current year Vaccination Information Statement (VIS) annually. Interview with facility's infection preventionist, Employee E6, on Wednesday, July 30, 2025, at 10:00 am, revealed that education on risks vs benefits for influenza immunizations is not completed unless a resident declines the vaccine.Review of facility provided documentation revealed Resident R41, received influenza immunization on October 18, 2024; review of Resident R41's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R26, received influenza immunization on October 2, 2024; review of Resident R26's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R28, received influenza immunization on October 2, 2024; review of Resident R28's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R29, received influenza immunization on October 2, 2024; review of Resident R29's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R30, received influenza immunization on October 2, 2024; review of Resident R30's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R34, received influenza immunization on October 2, 2024; review of Resident R34's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R42, received influenza immunization on October 2, 2024; review of Resident R42's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R3, received influenza immunization on October 2, 2024; review of Resident R3's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R43, received influenza immunization on October 2, 2024; review of Resident R43's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R50, received influenza immunization on October 2, 2024; review of Resident R50's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R12, received influenza immunization on October 2, 2024; review of Resident R12's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R64, received influenza immunization on October 2, 2024; review of Resident R64's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R65, received influenza immunization on October 2, 2024; review of Resident R65's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R28, received influenza immunization on October 2, 2024; review of Resident R28's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R73, received influenza immunization on October 2, 2024; review of Resident R73's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R75, received influenza immunization on October 2, 2024; review of R75's clinical record revealed no evidence of education provided. Resident Review of facility provided documentation revealed Resident R86, received influenza immunization on October 2, 2024; review of Resident R86's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R97, received influenza immunization on October 2, 2024; review of Resident 97's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R114, received influenza immunization on October 2, 2024; review of Resident R114's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R117, received influenza immunization on October 2, 2024; review of Resident R117's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R119, received influenza immunization on October 2, 2024; review of Resident R119's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R120, received influenza immunization on October 2, 2024; review of Resident R120's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R132, received influenza immunization on October 2, 2024; review of Resident R132's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R136, received influenza immunization on October 2, 2024; review of Resident R136's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R140, received influenza immunization on October 2, 2024; review of Resident R140's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R141, received influenza immunization on October 2, 2024; review of Resident R141's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R143, received influenza immunization on October 2, 2024; review of Resident R143's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R11, received influenza immunization on October 2, 2024; review of Resident R11's clinical record revealed no evidence of education provided.Resident Review of facility provided documentation revealed Resident R146, received influenza immunization on October 2, 2024; review of Resident 146's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R151, received influenza immunization on October 2, 2024; review of Resident 151's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R154, received influenza immunization on October 2, 2024; review of Resident 154's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R171, received influenza immunization on October 2, 2024; review of Resident R171's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R8, received influenza immunization on October 2, 2024; review of Resident R8's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R178, received influenza immunization on October 2, 2024; review of Resident R178's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R18, received influenza immunization on October 24, 2024; review of Resident R18's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R24, received influenza immunization on October 24, 2024; review of Resident R24's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R77, received influenza immunization on October 24, 2024; review of Resident R77's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R107, received influenza immunization on October 24, 2024; review of Resident R107's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R130, received influenza immunization on October 24, 2024; review of Resident R130's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R139, received influenza immunization on October 24, 2024; review of Resident R139's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R1, received influenza immunization on October 24, 2024; review of Resident R1's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R152, received influenza immunization on October 24, 2024; review of Resident R152's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R162, received influenza immunization on October 24, 2024; review of Resident R162's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R173, received influenza immunization on October 24, 2024; review of Resident 173's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R175, received influenza immunization on October 25, 2024; review of Resident R75's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R21, received influenza immunization on October 3, 2024; review of Resident R21's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R22, received influenza immunization on October 3, 2024; review of Resident R22's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R25, received influenza immunization on October 3, 2024; review of Resident R25's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R10, received influenza immunization on October 3, 2024; review of Resident R10's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R27, received influenza immunization on October 3, 2024; review of Resident R27's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R32, received influenza immunization on October 3, 2024; review of Resident R32's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R35, received influenza immunization on October 3, 2024; review of Resident R35's clinical record revealed no evidence of education provided28 Pa Code 201.18(b)(1)(d) Management28 Pa Code 211.12( c)(d)(1) Nursing services

Based on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for seven of seven residents reviewed (Residents R120, R24, R141, R43, R145, R156, R83) Findings include:Review of facility policy ‘Covid Vaccine protocol for staff and residents,' reviewed January 14, 2025, indicates that education will be provided for decline referencing CDC guideline.Interview with facility's infection preventionist, employee E6, on Wednesday, July 30, 2025, at 10:00 am, revealed that education on risks vs benefits for covid-19 immunizations is not completed unless a resident declines the vaccine.Review of facility provided documentation revealed Resident R120, received covid-19 immunization on March 25, 2025; review of R120's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R24, received covid-19 immunization on March 28, 2025; review of R24's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R141, received covid-19 immunization on March 28, 2025; review of R141's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R43, received covid-19 immunization on March 29, 2025; review of R43's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R143, received covid-19 immunization on April 5, 2025; review of R143's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R156, received covid-19 immunization on April 8, 2025; review of R156's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R83, received covid-19 immunization on April 15, 2025; review of R83's clinical record revealed no evidence of education provided.28 Pa Code 201.18(b)(1)(d) Management28 Pa Code 211.12( c)(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice on non-medical coverage (NOMNC) for one of three residents reviewed. (Resident 117) Findings Include: Review of Resident R117's clinical records shows the resident was re-admitted to the facility on [DATE]. Resident R117 remained at the facility after his last day of coverage was September 2, 2024. Review of the social service note from September 18, 2024 revealed Note Text: Resident Representative, notified on September 18, 2024 of resident's last coverage date of September 3, 2024. Resident Representative informed of right to appeal last coverage date. Resident Representative stated they would like resident to continue working with therapy. Social Services informed Resident Representative that resident will be picked up by rehab on Physical Therapy caseload per rehab Director. Social Services will provide Resident Representative copies of Notice of Medicare Non-Coverage and Advance Beneficiary Notification via email. Interview with facility Social Worker, Employee E12 held September 19, 2024 at 1:38 p.m. confirmed social services relies on an e-mail from the rehab department for the last date of coverage. Employee E12 stated that for Resident R117 they never received the e-mail from the rehab department. The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required. 28 Pa. Code 201.29(f) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview with staff and residents, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to use of a urinary catheter and discharge status for two of 38 records reviewed (Residents R50 and R178). Findings include: Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to the facility on [DATE], and had diagnoses of pressure ulcer of the sacral region, stage 4 (stage 4 pressure ulcers extend through the skin and fat layers into the muscle, and may extend to the bone), and muscle weakness. Also revealed was a physician order to discontinue the resident's urinary catheter, dated June 15, 2024. Continued review revealed that an MDS assessment (Minimum Data Set- a periodic assessment of resident care needs) was signed by the Registered Nurse Assessment Coordinator (RNAC), Employee E15, on August 9, 2024. In section H, Bladder and Bowel, Employee E15 recorded that the resident was utilizing an indwelling urinary catheter. Interview with RNAC, Employee E15 on September 20, 2024, at 12:15 p.m. confirmed that the catheter had been coded in error. A review of Resident R178's Discharge MDS assessment dated [DATE], revealed that he was admitted to the facility on [DATE], and discharged on August 4, 2024, and that Section A2105 Discharge Status revealed that Resident R178 was coded 04, Short-Term General Hospital (Acute Care). Review of Resident 178's clinical record revealed an August 4, 2024, progress note documenting that the resident is being discharged to home after successful stay for management of status post hospitalization for positive Covid 19 virus, urinary tract infection and sepsis. Interview with the Assistant Administrator, Employee E3 on September 20, 2024, at 11:30 a.m. revealed that Resident R178 had been discharged home with his family and that the MDS was coded in error as the resident did not discharge to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, clinical record review, and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related oxygen use for one of 35 records reviewed (Resident R167). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Review of clinical documentation for Resident R167 revealed that she was admitted to the facility on [DATE], and had diagnoses of asthma and obstructive sleep apnea. A physician's order was obtained on January 29, 2024, which stated O2 (oxygen) at 2LPM (liters per minute) via nasal cannula at bedtime for hypoxia (low blood oxygen levels). Review of the resident's care plan revealed that no care plan had been developed for the resident use of oxygen. Observations of rResident R167 conducted on September 17, 2024, at 10:45 a.m., revealed that the resident was wearing her oxygen cannula, with the concentrator running at 2 liters per minute. She stated that I wear it every night until I get up. Interview with Employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, on September 20, 2024, at 2:00 p.m., revealed that it is the expectation of the facility that the care plan for all residents utilizing oxygen should reflect that use. 28 Pa. Code 211.11(d) Resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not revise and update the resident's plan of care related to urinary catheter use for one of 35 records reviewed (Resident R50). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside, but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to the facility on [DATE], and had diagnoses of pressure ulcer of the sacral region, stage 4 (stage 4 pressure ulcers extend through the skin and fat layers into the muscle, and may extend to the bone), and muscle weakness. Also revealed was a physician order to discontinue the resident's urinary catheter, dated June 15, 2024. Continued review revealed that a care plan which stated, I have an indwelling catheter for .sacral wound management, which was created on December 24, 2023, and revised on February 2, 2024. The Last Care Plan Review Completed of the overall plan of care was dated on August 21, 2024. Interview with Employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, on September 20, 2024, at 2:00 p.m., confirmed that the care plan had not been updated to reflect the resident's current urinary status at the time of the care plan review. 28 Pa. Code 211.12(d)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that services were provided to maintain hearing and vision for two of 35 records reviewed (Residents R53 and R142). Findings include: Review of Guidelines for Use of the Consult Tracking Log policy reviewed April 2022, revealed that a physician's order for a consult is entered in the electronic record as needed. A progress note should be written in PCC for the reason of consult by the nurses. Unit Clerk will review the order in PCC and schedule the appointment, notify the resident representative with the date and time, schedule the escort if needed, and transportation. Unit clerk or designee will write a note under consultation confirming the appointment, responsible party notification and transportation notification. In an interview with Resident R142 on September 17, 2024, at 1:45 p.m., the resident stated that they had checked her hearing a while ago and told her she was getting a hearing aide, and that she never got one. Review of clinical documentation for Resident R142 revealed that she was admitted to the facility on [DATE], and had diagnoses of cognitive communication deficit. Further review revealed a March 16, 2023, audiology consult which recommended a hearing aide evaluation and that the patient agreed. Review of Resident R142's physician orders revealed an April 15, 2024, order for Audiology and Ear, Nose and Throat (ENT) consult, evaluation, treatment as ordered by physician services, over a year later. Continued review of Resident R142's record revealed that the ENT consultation was done May 14, 2024, which indicated treatment was partial debridement of both ears and recommended debridement of both ears and an Audiology consult. Interview with Unit Clerk, Employee E14, on September 19, 2024, at 1:50 p.m. revealed that she was still following up with Audiology for that status of the hearing aids for Resident R142, and that Resident R144 is also waiting for Audiology for his hearing aids. Review of Resident R144's clinical documentation revealed that he was admitted on [DATE], with diagnosis to include having a stoke with aphasia (comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). Review indicated that Resident R144 had an ENT consult on April 6, 2023, which stated that the patient was cleared for hearing aids. A May 8, 2023, Audiology consult revealed hearing loss in both ears and recommended an ENT consult. Further review of Resident R144's clinical record revealed that the ENT consult was not done until April 3, 2024, which recommended an Audiology evaluation. An August 21, 2024, social services note indicated that an amplifier was added to Resident R144's room phone and that he was to be seen by Audiology on the next September 5, 2024, visit. No further documentation was available as to the status of Resident R144's hearing aids. Interview with Unit Clerk, Employee E14, on September 19, 2024, at 1:50 p.m. revealed that she had just called Audiology about the status of Resident R144's hearing aids and that they were to get back to her. Review of clinical documentation for Resident R53 revealed that she was admitted to the facility on [DATE], and had diagnosesof type 2 diabetes with diabetic retinopathy of the right eye. In an interview with Resident R53 on September 18, 2024, at 12:07 p.m., she stated that an outside care company is paying for my glasses. I've had my appointment back in May and I'm waiting for my new glasses. My friend bought the ones I'm wearing. The resident stated that she required bifocals to correct both near and far vision, but that her current pair were non-prescription reading glasses. Continued review of the clinical record revealed a nursing note signed by Registered nurse, Employee E16, on May 16, 2024, which stated Resident seen in house by optometry, N/O (new order) for new prescription glasses. Review of a consultation note from the consultant optometrist, Employee E17, dated May 15, 2024, revealed that it included an updated prescription for eyeglasses and stated that glasses were required and to encourage full-time use for distance and reading. Review of a document titled Eyeglass Dispense Log which listed all residents who received new glasses between January 20, 2024, and September 19, 2024, revealed that the resident was not documented as having received her eyeglasses. In an interview with the Director of Nursing, Employee E2, on September 19, 2024, at 1:34 p.m., she stated that the outside service paying for the glasses has a process, and that the prescription was sent to them. A subsequent interview with Employee E2 at 1:56 p.m. confirmed that the resident's new eyeglasses had not yet been delivered. No evidence was provided that the facility attempted to follow up with the service to ensure that the needed glasses were delivered in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E9). Findings include: An interview on September 17, 2024, at 10:30 a.m. with Employee E4, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on September 19, 2024, at 11:30 a.m. with the Administrator, the FSD's personnel file was reviewed, and his qualifications were discussed which revealed he had been working at the facility for many years, was promoted to FSD over a year ago and was not a Certified Dietary Manager or Certified Food Manager. The Administrator confirmed that the FSD had not completed these requirements. The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department. 28 Pa. Code 211.6(c)(d) Dietary services 28 Pa Code 201.18(e)(1)(6) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and interview with staff, it was determined that facility failed provide resident with pressure injury measures to prevent the development or worsening of pressure injury for one resident. (Resident R1) Findings include: Review of facility policy on wound prevention and maintenance guidelines revealed that under section Policy: It is the policy for this facility that all residents are assessed for skin risk, using the Braden Scale, and that residents at risk, including those with pressure injury, will have appropriate plans of care implemented. Under section Purpose: To provide at-risk residents with pressure reducing or relieving surfaces and devices to reduce the mechanical forces of pressure, shear, friction and/or moisture, which contribute to tissue breakdown. Under section Procedure: #4. Based on the assessment and Braden Scale, a licensed nurse will initiate treatment with appropriate pressure redistribution and devices. #8. Products vary greatly in their ability to reduce pressure, shear, friction, and moisture. Care should be taken to match product efficiency with elder needs. A. Full Therapy Beds (pressure relief), i. Low air loss therapy, ii. Alternating air Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Pressure Ulcer (damage to the skin and/or underlying soft tissue) to Sacral Region, Type Two Diabetes Mellitus (failure of the body to product insulin), Hypertensive Heart Disease with Heart Failure, Unspecified Dementia (irreversible, progressive degenerative disease of the brain), Hypertension ( high blood pressure), Hyperlipidemia (high cholesterol). Review of Resident R1's admission Minimal Data Set (MDS- assessment of resident's care needs) dated March 23, 23, 2023, section C0500 BIMS (Brief interview for mental status) revealed that resident scored 7 suggesting that Resident R1 was severely impaired in cognition. Section G ADL (Activities of Daily Living) revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility. Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 (full thickness loss of skin, slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's quarterly MDS assessment dated [DATE], section C0500 BIMS revealed that resident scored 4 suggesting that Resident R1 was severely impaired in cognition. Section G ADL revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's quarterly MDS assessment dated [DATE], revealed that section C 0500 BIMS, revealed that resident scored 3 suggesting that Resident R1 was severely impaired in cognition. Section G ADL revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility. Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's current care plan revealed that Resident R1 had a plan of care for: risk for/ actual impairment to skin integrity related to coccyx stage 3 pressure injury -discoloration to both heels. Further, review of the care plan revealed intervention to Off-load pressure to affected areas, reposition patient at least every 2 hours while in chair/bed and continue repositioning in accordance to assessed needs. Review of Resident's R1's wound/skin nutrition note dated June 6, 2023, revealed that Resident R1 was seen on June 2, 2023, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with one of the treatments as follow: Continue re- positioning in accordance to assessed needs. Further review of resident's R1's wound/skin nutrition notes revealed that Resident R1 was seen on June 7, 2023, June 14, 2023; June 21, 2023; June 28, 2023; July 10, 2023; July, 12, 2023 and July 19, 2023, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with treatments as follow: Offload pressure to affected areas: re- positing patient at least every 2 hours while in chair/bed. Continue repositioning in accordance to assessed needs. Wound/skin nutrition note dated July 31, 2023, revealed that Resident R1 was seen, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with recommendation to continue: Off-load pressure to affected areas: reposition patient at least every 2 hours while in chair/bed Continue re- positioning in accordance to assessed needs and low air loss support surface. Review of Resident's R1's Wound Nurse skin impairment tracking note dated August 2, 2023, revealed Additional findings include full-thickness wound of the right heel measuring 5.0 x 3.5 x 0.0 cm. Purple / maroon localized area of discolored intact skin with blood-filled blister roof. With recommendations/plan to continue: Low-air loss support surface and, turn every 2 hours. Wound/skin nutrition note dated August 11, 2023, revealed that Resident R1 was seen, for weekly wound rounds for Stage 3 pressure and full thickness ulceration of the coccyx with recommendation to continue: Off-load pressure to affected areas: reposition patient at least every 2 hours while in chair/bed Continue re- positioning in accordance to assessed needs. Review of wound note from wound consultant dated August 23, 2023, revealed that Resident R1 was seen by wound consultant with recommendation for turning/repositioning precautions per protocol. Wound note from wound consultant dated August 30, 2023; September 6, 2023; September 13, 2023, and September 20, 2023, revealed that Resident R1 was seen by wound consultant. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, continue with turning and repositioning schedule per protocol for pressure prevention. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring Length: 4.00 cm, Width: 2.50 cm, Depth: 2.50 cm. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring: Length: 4.80 cm, Width: 2.50 cm, Depth: 2.50 cm. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring, Length: 4.80 cm, Width: 2.90 cm, Depth: 2.50 cm Nurses note dated September 22, 2023, 11:46 a.m. revealed that the resident was out of the facility to surgical appointment to wound clinic accompanied by daughter in stable condition at 9:06 a.m. no distress noted at this time. Review of resident's clinical record revealed no documented evidence that resident was turned and re-position at least every two hours while in chair/bed daily. Interview with Licensed nurse, Employee E3 conducted on October 12, 2023, at 11:18 am confirmed that Resident R1 required extensive assistance with two people assist with bed mobility as indicated on the admission MDS assessment dated . Further, Employee E3 confirmed that Resident R1 was not on a turning and positioning program. Interview with Licensed nurse, Employee E4 conducted on October 12, 2023 at 11:38 a.m. revealed that Resident R1's sacral pressure ulcer was getting larger and that Resident R1 had developed arterial ulcers to her lower extremities. Further Employee E4 also confirmed that Resident R1 was on a low air loss mattress. Further interview with Wound Care Nurse confirmed that Resident R1 was not placed on a turning and position program. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive, person-centered care plan related to behaviors, wound treatment and communication for two of 37 residents reviewed (Residen R36, and R149). Findings Include: Review of facility policy Resident Centered Care Planning revealed individual treatment goals should be identified. These goals should be resident specific, reasonable, and measurable. The plan of care should be revised whenever appropriate to reflect the resident's current needs. Review of facility policy titled Resident Centered Care Planning, dated January 2018, revealed that Long term care interdisciplinary assessments will be initiated within 24 hours and completed between 7 and 14 days of admission, and Individual treatment goals are identified. These goals are resident specific, reasonable, and measurable. Each resident's plan of care identifies goals that: Reflect the resident's unique needs/strengths/preferences .[and] Identify specific, individualized interventions/approaches, as well as Services and care are identified and planned to meet the resident's problems, needs and goals. Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnoses including, but not limited to, pressure ulcer of sacral region, stage 4, end stage renal disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. A physician order was reviewed dated January 13, 2023, which stated Check NPWT Negative Pressure Wound Therapy, also known as a wound vac- a treatment in which the wound is packed with foam and then a vacuum is applied to control moisture and drainage in order to improve wound healing) to Sacrum and right ischum for placement and functionality every shift. Foam should be collapsed, machine setting @125 mmHg continuous: charger in place. Review of the resident's care plan revealed that as of February 9, 2023, no care plan had been developed for the resident's wound vac. Interview with the Director of Nursing, employee E2 on February 9, 2023, at 12:30 p.m. revealed that the resident's wound vac had been present since admission and he confirmed that a care plan should have been developed for it, but that it had not been. Review of clinical documentation revealed that resident R149 was admitted to the facility on [DATE], with diagnoses including, but not limited to, unspecified hearing loss, unspecified ear, malignant neoplasm of prostate, and anxiety disorder. Interview with the responsible party for R149 on February 9, 2023, at 10:24 a.m. revealed that the resident is profoundly deaf and requires an interpreter to accompany him to physician appointments. Review of the resident's care plan revealed that a care plan for interpreter services was not developed before February 9, 2023. Interview with the Director of Nursing, employee E2 on February 9, 2023, at 12:30 p.m. revealed that the was receiving interpreter services, and that a care plan should have been developed for it, but that it had not been prior to the survey. 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services