Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 12 sampled residents. (Resident 18) Findings include: Review of the facility policy entitled, Pain Management, last reviewed January 2025, revealed that non-pharmacological interventions should be attempted prior to administration of pain medication that was prescribed on an as needed basis. Clinical record review revealed that Resident 18 had diagnoses that included muscle weakness, cellulitis, and chronic ulcers to the left foot. A physician's order dated December 12, 2024, directed staff to administer tramadol (a pain medication) every 12 hours, as needed, for severe pain. Review of the medication administration records (MAR) for December 2024, and January 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on 13 occasions in December and six occasions in January. There were no documented refusals of non-pharmacological interventions. In interviews on January 8 and 9, 2025, at 2:03 p.m., and 9:12 a.m., the Director of Nursing confirmed that non- pharmacological interventions should be documented in the MAR and that there was no evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to dispose of controlled medications in accordance with facility policy and in a manner to prevent potential diversion for one of five residents observed during the medication pass. (Resident 41) Findings include: Review of the facility policy entitled, Destruction of Unused Medications, last reviewed January 2025, revealed that drugs will be destroyed in a manner that renders the drugs unfit for human consumption. Medications were to be destroyed using a Drug Buster (a device that renders medications inert prior to disposal) and witnessed by a second licensed nurse. Clinical record review revealed that Resident 41 had diagnoses that included nerve pain. On January 5, 2025, the physician ordered that staff apply fentanyl patch (a narcotic pain medication) 75 micrograms/hour every three days. On January 8, 2025, at 8:13 a.m., RN 1 administered a fentanyl patch to Resident 41. At that time, she was observed removing the old patch and disposed of it in a syringe disposal container without a witness. In an interview on January 8, 2025, at 12:30 p.m., the Director of Nursing confirmed that RN 1 should have discarded the fentanyl patch in a Drug Buster with a second licensed nurse as a witness. 28 Pa. Code 211.9(j.1)(5) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, resident interview, family interview, and staff interview, it was determined that the facility failed to ensure that each resident's wishes regarding the provision of cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest be considered and consistent with the physician's order for two of 12 sampled residents. (Resident 26, 87) Findings include: Review of the facility policy entitled, Advance Directives - Skilled Nursing, reviewed by the facility on [DATE], indicated that it was the policy of the facility to support the rights of all residents to participate in their own health care decisions, including the right to decide whether they wished to accept or refuse life-prolonging measures or other treatments. At admission, the facility must determine if the resident had an advance directive, that a copy would become a part of the medical record, and the resident's wishes would be communicated to the resident's direct care staff and physician. Clinical record review revealed that Resident 26 had diagnoses that included paroxysmal atrial fibrillation (intermittent irregular heart rhythm), hypertension (high blood pressure), and diabetes mellitus. The physician's order dated [DATE], directed staff to provide full code. (Meaning if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process could include chest compressions, intubation, and defibrillation, which is referred to as CPR.) A social services assessment dated [DATE], identified that Resident 26 had an advance directive (no specifics documented) with no evidence that it was communicated to the direct care staff and physician. During an interview on [DATE], at 11:13 a.m., the resident and the resident's family member stated that Resident 26 had an advance directive of DNR (do not resuscitate). Clinical record review revealed that Resident 87 was admitted to the facility on [DATE], and had diagnoses that included dementia and paroxysmal atrial fibrillation. A physician's order dated [DATE], through [DATE], directed staff to provide full code. The social services assessment dated [DATE], identified that the resident had an advance directive (no specifics documented) with no evidence that it was communicated to the direct care staff and physician. On [DATE], nursing documentation indicated that the family member called and stated that Resident 87 had an advance directive of DNR. During an interview on [DATE], at 11:27 a.m., the nurse (RN 1) confirmed that the resident's physician's order for code status in the electronic record was consulted to identify current advance directive information. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative of a change in condition and treatment for one of 12 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included hypertension, muscle weakness, and heart failure. On March 13, 2023, staff documented that the resident experienced a syncopal episode (a temporary loss of consciousness) while getting out of bed and the resident's blood pressure dropped to 70/40 millimeters of mercury (mmHg) from an average usual blood pressure of 141/65 mmHg. The physician ordered increased monitoring of vital signs for three days. There was no evidence that the facility notified the resident's representative of the syncopal episode or the change to the resident's treatment plan. In an interview on March 6, 2023, at 12:30 p.m., the Director of Nursing stated that there was no evidence that staff notified the resident's representative and that staff were to notify a resident's representative of changes to the treatment plan. 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 review and revise the care plan for one of 12 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included hypertension, insomnia, and dysphagia. A physician's order dated June 12, 2021, directed staff to administer mirtazapine (an antidepressant medication), 15 milligrams at bedtime for depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident received an antidepressant medication seven days during the review period. Review of the Care Area assessment dated [DATE], revealed that the use of an antidepressant would be addressed on the resident's care plan. Resident 6's care plan was not updated to reflect the use of an antidepressant medication. In an interview on March 6, 2023, at 12:30 p.m., the Director of Nursing confirmed that Resident 6's care plan was not updated to reflect the use of an antidepressant medication. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain accurate clinical records for one of 12 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included heart failure, anxiety, stage four chronic kidney disease, and atrial fibrillation. A physician's order dated March 17, 2023, directed staff to restrict the resident's fluid intake to 1920 cubic centimeters (cc) per day. A physician's order dated March 25, 2023, directed staff to restrict the resident's fluid intake to 1500 cc per day. Review of physician progress notes dated March 20, 22, 27, 29, 2023, and April 3, and 5, 2023, revealed that the physician documented that the resident's fluid intake was to be limited to 1200 cc per day. There was no evidence that a physician ordered staff to restrict the resident's fluid intake to 1200 cc per day. In an interview on March 6, 2023, at 11:55 a.m., the Director of Nursing confirmed that the physician incorrectly documented that the resident's fluid intake was to be restricted to 1200 cc per day. 28 Pa. Code 211.5(f) Clinical records.

Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on the nursing unit. Findings include: Review of facility policy entitled, Outside Food, last reviewed January 17, 2023, revealed that all items would be labeled and dated with the resident's name and room number and that expired items would be discarded. Observation of the unit refrigerator in the common, activity area of the nursing unit on March 5, 2023, at 1:30 p.m., revealed a box of butter with an expiration date of November 4, 2022, and a bag of grapes, a bottle of water, and two bags of various food items that were not labeled. There were four pre-mixed pouches of smoothies with expiration dates of November 21, 2022, and January 7, 15 and March 5, 2023. 28 Pa. Code 201.18(b)(3) Management.