Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R20). Findings include: Review of facility policy entitled Psychotropic Medication Policy dated 1/21/25, revealed the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication. Review of Resident R20's clinical record revealed an admission date of 3/20/25, with diagnoses that included osteomyelitis (bone infection) of the right ankle and foot, anxiety, and anemia (condition of not enough healthy red blood cells to carry oxygen). The clinical record revealed that on 4/30/25, Resident R20's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 12 hours PRN for anxiety. Review of Resident R20's May 2025 Medication Administration Record revealed that the PRN Lorazepam was used on 5/4/25, 5/5/25, 5/8/25, and 5/9/25. Resident R20's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in May 2025. During an interview on 5/14/25, at 12:09 p.m. the Director of Nursing confirmed that Resident R20's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 20 residents reviewed (Residents R10 and R16). Findings include: Review of facility policy entitled Comprehensive Person-Centered Care Planning dated 1/21/25, indicated The care plans will be reviewed and revised as necessary by the Interdisciplinary Team at least quarterly after each MDS [Minimum Data Set-a periodic assessment of resident care needs] assessment ., or more often as changes occur. Review of Resident R10's clinical record revealed an admission date of 1/3/23, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R10's physician's orders revealed an order for O2 (oxygen) at 2 LPM (liters per minute) NC (nasal cannula oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) routine and PRN (as needed) dated 3/1/25. Review of Resident R10's care plan for alteration in cardio and respiratory lacked an intervention for his/her current use of oxygen. Resident R16's clinical record revealed an admission date of 3/26/19, with diagnoses including Parkinson's disease (a disorder that affects movement related to the central nervous system), major depressive disorder, and moderate intellectual disabilities (limitations to cognitive functioning and skills). Resident R16's clinical record revealed his/her anticoagulant medication Eliquis (a blood thinning medication that reduces the ability to clot) was discontinued on 2/24/25. Resident R16's care plan dated 3/7/25, with a target date of 6/1/25, revealed a care plan was in place related to his/her anticoagulant medication Eliquis. During an interview on 5/14/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that Resident R10's cardio/respiratory care plan was not reviewed/revised to reflect current resident care and services. During an interview on 5/14/25, at 1:45 p.m. the DON confirmed that Resident R16's anticoagulant care plan was not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to provide resident privacy during a wound dressing change for one of 22 residents reviewed (Resident R62). Findings include: The facility policy Privacy / Dignity dated 1/10/24, indicated that Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Observation of a wound dressing change for Resident R62 on 6/5/24, at 10:45 a.m. revealed that Licensed Practical Nurse (LPN) Employee E2 and LPN Employee E3 changed wound dressings to the resident's right heel and foot while the roommate was awake and watching the procedure. During an interview on 6/5/24, at 11:15 a.m. LPN Employee E3 confirmed that the privacy curtain should have been pulled. During an interview on 6/5/24, at 11:35 a.m. the Director of Nursing confirmed that during a dressing change the privacy curtain should have been pulled. 28 Pa. Code 211.12(d)(1)(2) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement a resident centered comprehensive care plan for one of 22 residents reviewed (Resident R58). Findings include: A facility policy entitled, Comprehensive Person-Centered Car Planning dated 1/10/24, indicated that a comprehensive person-centered care plan including necessary and appropriate care, attending physicians ordered, services and accommodation of resident needs and preferences for the resident to attain or maintain the highest practicable physical, mental, and psychological well-being will be established within 21 days of admission. Resident R58's clinical record revealed an admission date of 3/06/24, with diagnoses that included pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), arthritis, lower back pain, and restless leg syndrome. Resident R58's clinical record included physician's orders dated: 3/06/24, to give 650 milligrams (mg) of acetaminophen every six hours as needed for pain; 3/14/24, to give 650 mg of acetaminophen at bedtime for pain management; 4/01/24, to give 650 mg three times a day for back pain and 650 mg as needed for back pain once daily; and current physician's orders dated 5/09/24, to give 650 mg of Tylenol three times a day for other low back pain, and give 650 mg of Tylenol every four hours as needed for pain, may have one additional dose four plus hours after nine p.m. Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain. During an interview on 6/05/24, at 10:47 a.m. the Director of Nursing confirmed that Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain management. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of four residents reviewed for respiratory care (Resident R29). Findings include: Facility policy entitled Use of Oxygen dated 1/10/24, indicated that the facility changes oxygen cannulas (flexible tubing inserted into the nostrils for oxygen delivery) or masks every 30 days. Resident R29's clinical record revealed an admission date of 9/21/20, with diagnoses that included chronic obstructive pulmonary disease (lung disease resulting in difficulty breathing and persistent cough), high blood pressure, and diabetes. Resident R29's physician orders dated 4/5/21, indicated to change oxygen tubing on the 15th of each month. Observations on 6/2/24, at 2:08 p.m. and 6/4/24, at 9:00 a.m. revealed that Resident R29's oxygen tubing contained a piece of white tape wrapped around it with a date of 3/15/24. During an interview on 6/4/24, at 9:22 a.m. Licensed Practical Nurse Employee E1 confirmed that the oxygen tubing was dated for 3/15/24, and was not changed monthly as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for one of twenty-four residents (Resident R33). Findings include: Observations between 7/26/23, and 7/27/23, revealed Resident R33's arm cradle (a device on a wheelchair that a person's arm lays on when they cannot move that part of their body) was torn the whole way across the front with foam filling coming out. During an interview on 7/27/23, with resident R33 he/she stated that the torn area has been there for a long time and he/she has asked to have the torn arm cradle fixed several times and that it hasn't changed. During an interview on 7/27/23, at 1030 a.m. the Director of Nursing confirmed that the arm cradle was ripped with the foam filling coming out of the front, and that the arm cradle was not appropriate and needed repaired. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 20 residents reviewed (Resident R36). Findings include: Review of a facility policy entitled, Urinary Catheters, dated 1/13/23, indicated that the collection bag should be kept off the floor, and covered with a dignity bag. Review of Resident R36's clinical record revealed an admission date of 8/14/21, with diagnoses including kidney failure/disease, disorders of the bladder, and artificial opening of the urinary tract. The clinical record revealed a physician's order for the use of a catheter and to check the catheter every shift for placement and patency. Observation on 7/25/23, at 2:15 p.m. revealed that Resident R36 was in bed with his/her urine collection bag hanging on the side of the bed, uncovered and visible from hallway. Observations on 7/26/23, at 10:00 a.m. and 1:00 p.m. and on 7/27/23, at 8:30 a.m. revealed that Resident R36 was seated in his/her Geri-chair and the urine collection bag was hanging on the back lower frame of the chair, uncovered and resting on the floor. Interview on 7/27/23, at 8:30 a.m. with Registered Nurse Employee E1 confirmed that Resident R36's urine collection bag should have a dignity bag on and not be on the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of six medication carts ( A Wing North). Findings include: Review of a facility policy entitled, Medication Administration Control and Security dated 1/31/23, indicated that all medications are to be secured in a locked medication cart until such time as the medication(s) are administered to the resident. Observation on 7/26/23, at 9:44 a.m. revealed that the A Wing North medication cart unsecured and unattended, and had a medication cup of unidentified pills sitting on top, and the top drawer of the cart was ajar. Interview at that time with Registered Nurse Employee E2 confirmed that the cart should have been secured, drawers closed, and no prepared medications on top when the cart is not in view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services