Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 15) Findings included: Review of the facility policy entitled, Foley Catheter, Maintenance, last reviewed June 2, 2025, revealed that catheter maintenance was completed with current standards of care which included not to place the catheter bag on the floor. Clinical record review revealed that Resident 15 had diagnoses that included neuromuscular dysfunction of the bladder and congestive heart failure. On April 12, 2025, the physician ordered for the resident to have an indwelling catheter every shift. On July 1, 2025, at 10:39 a.m. and 1:28 p.m., Resident 15 was observed lying in bed with the catheter bag containing urine on the floor and the overbed tray table wheels on top of the bag. On July 2, 2025, at 12:35 p.m., Resident 15 was observed sitting in a reclining chair with the catheter bag containing urine on the floor. In an interview on July 2, 2025, at 1:20 p.m., the Director of Nursing confirmed that the indwelling catheter bag should not be in contact with the floor. CFR 483.25(e) Incontinence Previously cited 5/13/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident was provided individualized care and services in regard to diagnostic testing and was not catheterized unless necessary for one of four sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Bladder Care/Foley Catheter Insertion, Removal/Obtaining Specimen, revealed that foley catheter insertion, maintenance, and removal were to be completed in accordance with current standards of care. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included heart failure, anemia, malignant neoplasm of the prostate, and acute kidney failure. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented and was continent of bladder. A review of the care plan dated April 2, 2025, revealed that he was at risk for incontinence due to impaired mobility and that he was continent of bladder. There was an intervention to assist the resident to the toilet as needed and to ensure that he had an unobstructed path to the bathroom. Further review of nursing documentation dated April 4, 2025, revealed that the resident was alert and oriented and was able to independently ambulate to and from the bathroom. A review of the care plan dated April 7, 2025, revealed that Resident 1 had a fever of unknown origin. There was an intervention for staff to obtain a urine specimen for analysis to rule out a UTI. On April 7, 2025, a physician ordered for staff to obtain a urine specimen for analysis due to fever. On April 8, 2025, at 5:54 a.m., a registered nurse noted that the resident had been straight catheterized for the urine specimen. The nurse further noted that the urine was yellow with some sediment noted and that his bladder had emptied for almost 500 cubic centimeters (cc) of yellow urine. The nurse also noted that at the end of the output the resident had hematuria (blood in the urine). At 4:15 a.m., the resident rang the call bell because he had taken himself to the bathroom and staff had noted hematuria in the toilet. In an interview on May 13, 2025, at 12:30 p.m., the Director of Nursing stated that the nurse had collected the urine specimen via catheterization as per the policy; however, the resident was alert and oriented, able to make his needs known to staff, able to urinate on his own, and able to take himself to the bathroom. The facility failed to ensure the resident was not catheterized unless necessary and failed to provide individualized care and services in order to obtain a urine specimen by means other then catheterization when the resident was able to voluntarily void. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 19 sampled residents. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included hypotension and Parkinson's disease. A physician's order dated May 5, 2023, directed staff to administer a medication (midodrine hydrochloride) three times a day for orthostatic hypotension (low blood pressure when standing, sitting, or lying down). Staff was not to administer the medication if the resident's systolic blood pressure (SBP) was 140 millimeters mercury (mm/Hg) or higher. Review of Resident 19's Medication Administration Record revealed that staff administered the medication when the resident's SBP was above 140 mm/Hg on four occasions in May 2024 and one occasion in June 2024. In an interview on June 13, 2024, at 12:10 p.m., the Director of Nursing confirmed that the medications were administered outside of established parameters for Resident 19. 28 Pa. Code 211.12(d)(1)(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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 17 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 was readmitted to the facility on [DATE], and had diagnoses that included anemia, peripheral vascular disease, diabetes mellitus, arthritis, and dementia. Review of a nursing admission assessment dated [DATE], revealed no documentation that Resident 15 had a pressure ulcer. On May 17, 2023, a nurse noted that staff identified a suspected deep tissue injury to the right heel. Review of section M (assessment that determined the condition of the resident's skin) of the MDS assessment dated [DATE], indicated that the resident had an unhealed pressure ulcer that was present upon admission to the facility. In an interview on July 7, 2023, at 9:40 a.m., Registered Nurse 1 confirmed that Resident 15 had a pressure ulcer to the right heel and that the ulcer developed after the resident was readmitted to the facility.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent on one of two nursing units observed during medication administration. (Second floor nursing unit) Findings include: Clinical record review revealed that Resident 7 had a physician's order dated June 7, 2023, that staff was to administer divalproex (an anticonvulsant medication) every morning. The order indicated that the medication was to be given whole and was not to be crushed. Clinical record review revealed that Resident 47 had a physician's order dated June 28, 2022, that staff was to administer aspirin every morning. The order indicated that the medication was to be given whole and was not to be crushed. During observation of medication administration on July 6, 2023, at 8:49 a.m., Licensed Practical Nurse (LPN1) crushed both medications which resulted in a medication error rate of 5.41%. In an interview on July 7, 2023, at 1:29 p.m., Registered Nurse 1 confirmed that the medications were not to be crushed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.