Based on review of facility documents and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs on one of two nursing units (B unit), and three of four residents reviewed (Residents 2, 3, and 4). Findings include: In an interview with Resident 3 on May 28, 2025, at 11:11 AM she stated she completes a lot of her care needs herself but does have to ring the call bell for staff and occasionally must wait some time for them. The resident was not specific on dates or times. A review of electronic call bell activation and response time logs for Resident 3's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 15, 2025, activated at 10:22 AM, response time of 21 minutes. May 15, 2025, activated at 1:07 PM, response time of 20 minutes. May 15, 2025, activated at 10:26 PM, response time of 16 minutes. May 15, 2025, activated at 10:49 PM, response time of 28 minutes. May 16, 2025, activated at 4:57 AM, response time of 22 minutes. May 18, 2025, activated at 10:13 AM, response time of 28 minutes. May 19, 2025, activated at 8:12 AM, response time of 16 minutes. May 19, 2025, activated at 7:06 PM, response time of 21 minutes. May 20, 2025, activated at 10:20 AM, response time of 32 minutes. May 20, 2025, activated at 1:30 PM, response time of 22 minutes. May 31, 2025, activated at 6:00 PM, response time of 31 minutes. May 22, 2025, activated at 7:59 AM, response time of 21 minutes. May 26, 2025, activated at 7:55 PM, response time of 26 minutes. May 27, 2025, activated at 8:36 AM, response time of 16 minutes. May 27, 2025, activated at 11:25 AM, response time of 16 minutes. May 27, 2025, activated at 3:54 PM, response time of 18 minutes. In an interview with Resident 2 on May 28, 2025, at 11:20 AM she stated that she waits an hour at times for staff to answer her call bell when she wants to transfer between her bed and chair or when she needs them to reach something she can't get. Resident 2 stated she waited a while for staff to answer her call bell as recent as this morning. A review of electronic call bell activation and response time logs for Resident 2's room from May 15 to 28, 2025, revealed the following call bell response times greater than 15 minutes: May 16, 2025, activated at 11:00 AM, response time of 16 minutes. May 17, 2025, activated at 7:38 AM, response time of 18 minutes. May 17, 2025, activated at 11:23 AM, response time of 17 minutes. May 17, 2025, activated at 1:19 PM, response time of 17 minutes. May 17, 2025, activated at 9:47 PM, response time of 28 minutes. May 19, 2025, activated at 7:42 AM, response time of 18 minutes. May 19, 2025, activated at 9:39 PM, response time of 18 minutes. May 22, 2025, activated at 8:38 AM, response time of 21 minutes. May 28, 2025, activated at 9:16 AM, response time of 25 minutes. In an interview with Resident 4 on May 28, 2025, at 1:15 PM, he pointed to a call bell lying on his tray table when asked how he got a hold of staff if he needed help. Resident 4 stated staff come to help him in an hour or in minutes, I just deal with it. A review of electronic call bell activation and response time logs for Resident 4's room from May 15 to 28, 2025, reveled the following call bell response time greater than 15 minutes: May 17, 2025, activated at 5:03 PM, response time of 41 minutes. May 17, 2025, activated at 6:43 PM, response time of 31 minutes. May 17, 2025, activated at 8:02 PM, response time of 47 minutes. May 17, 2025, activated at 8:52 PM, response time of 1 hour and 9 minutes. May 18, 2025, activated at 12:03 PM, response time of 22 minutes. May 19, 2025, activated at 11:42 PM, response time of 25 minutes. May 21, 2025, activated at 4:33 AM, response time of 24 minutes. May 21, 2025, activated at 6:56 PM, response time of 26 minutes. May 21, 2025, activated at 7:50 PM, response time of 16 minutes. May 23, 2025, activated at 7:07 PM, response time of 24 minutes. May 26, 2025, activated at 8:48 PM, response time of 22 minutes. May 26, 2025, activated at 9:11 PM, response time of 24 minutes. May 28, 2025, activated at 4:45 AM, response time of 19 minutes. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing on May 28, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Residents 7). Findings include: Clinical record review revealed the facility admitted Resident 7 on April 19, 2024, and added a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) on May 1, 2024. Review of Resident 7's social history and evaluation completed on April 23, 2024, revealed a trauma screening questionnaire (a group of questions related to symptoms that may occur due to a traumatic event) that indicated Resident 7 had difficulty concentrating at least twice in the past week. The questionnaire did not include questions related to her diagnosis of PTSD or triggers that may mitigate re-traumatization. Review of Resident 7's current care plan revealed a history of depression, PTSD, and anxiety. The care plan indicated that the PTSD was related to her husband's death and that she had panic attacks at times. The care plan did not identify what triggers her panic attacks related to her husband's death that occurred approximately 20 years ago or how she deals with them. Further review of Resident 7's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization. Resident 7's care plan was revised on September 13, 2024, and a progress note was entered into her clinical record on September 12, 2024, at 7:57 PM indicating a conversation was held with her to determine her potential triggers. This was after the surveyor made the facility aware that her clinical record failed to identify her potential triggers on September 12, 2024, at 2:00 PM. These findings were confirmed with the Director of Nursing on September 13, 2024, at 2:00 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to ensure daily nurse staff data was posted for both nursing units (A and B wing). Findings include: Observation on September 11, 2024, at 1:46 PM revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. Subsequent observations on September 12, 2024, at 2:48 PM, and September 13, 2024, at 11:12 AM again revealed the facility's posted nursing time did not include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care for first and second shifts. The posting did not include the facility's name. Interview with the Director of Nursing on September 13, 2024, at 11:42 confirmed these findings. 28 Pa. Code 201.14(a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to obtain physician ordered medications for two of five residents reviewed (Residents 1 and 3). Findings include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], at 3:36 PM. Review of Resident 1's admission physician orders for medications to be administered to the resident revealed the following medication were ordered on April 19, 2024: Bupropion HCL ER 150 mg (milligrams) tablet two times a day for depression to start April 19, 2024, at 8:00 PM Phos-NaK oral packet 280-160-250 mg (Potassium and Sodium Phosphate) one packet with meals to start April 19, 2024, at 6:00 PM A review of Resident 1's medication administration record for April 2024, revealed no evidence the above medications were administered as ordered. The medication administration log was blank for the administration dates and times indicated. There was no evidence to indicate why the doses were not administered. Clinical record review for Resident 3 revealed the resident was admitted to the facility on [DATE], with nursing admission assessment completed at 2:00 PM. A review of Resident 3's admission physician ordered medications revealed the resident was ordered the following medications on May 3, 2024, to start at 9:30 PM: Amitriptyline HCL 25 mg to be given at bedtime for depression. Calcium-Vitamin D 600-200 mg unit two times a day for supplementation Diclofenac Potassium 50 mg one tablet three times a day for back pain Lorazepam tablet 1 mg at bedtime for anxiety Pregabalin capsule 100 mg three times a day for pain management. A review of Resident 3's medication administration record for May 2024, revealed no evidence Resident 3 was administered the above medication for the dosage and time indicated above. The medication administration record was left blank for the dates and times indicated for the above medications. There was no documented evidence as to why Resident 3 should not have received the medications as ordered. In an interview with the Nursing Home Administrator and Director of Nursing on May 8, 2024, at 12:30 PM the Director of Nursing indicated all medication orders are sent to the facility's pharmacy via the electronic record and medication deliveries arrive twice a day between 3:30-4:30 PM, and midnight - 2 AM. The Director of Nursing indicated since the pharmacy deliveries for the afternoon are already in route, residents admitted to the facility during the day have medications arrive on the midnight - 2 AM delivery. The Director of Nursing indicated some medications are available in the facility pharmacy stock, but not all that are ordered are available to utilize until medication deliveries arrive at the facility. In a follow up interview with the Director of Nursing on May 8, 2024, at 2:30 PM it was confirmed Residents 1 and 3 were not administered the above medications as ordered. 28 Pa. Code 211.9 (f)(4)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide dignity with dining for one of two main dining rooms (Assisted Dining Room, Residents 21 and 22), and for one of one resident reviewed for dignity in toileting (Resident 41) Findings include: Observation of the dining area on October 3, 2023, from 11:55 AM to 12:20 PM revealed that the staff failed to provide resident dignity based on the following: Observation of Employee 1, registered nurse, revealed that she attempted to feed Resident 21 with a spoon while standing up on the resident's left side. The surveyor briefly left the dining room where residents were being fed or assisted with feeding to observe the adjacent dining room where residents feed themselves. On return to the assisted dining room, Employee 1, was standing up attempting to feed Resident 22 with a spoon on the left side of the resident. Employee 1 voiced that is all she could get the resident to take. It is undignified for staff to stand over a resident to feed them. The surveyor reviewed the findings for Residents 21 and 22 with the Nursing Home Administrator and Director of Nursing during a meeting on October 4, 2023, at 1:15 PM. Observation on October 4, 2023, at 2:33 PM revealed that the door to Resident 41's room was open. Resident 41 resided in the semi-private room next to the window. The surveyor entered Resident 41's room after receiving permission from the responsible party. The bathroom door was open, and Resident 41 was sitting on the toilet with the lower part of her body undressed. Employee 2, nurse aide, was bending over and was removing the resident's incontinent brief, which was down to her feet at the time. Resident 41 was visible to the surveyor, responsible party, and roommate. During an interview with Employee 2 on October 4, 2023, at 2:40 PM she confirmed that she should have closed the door to Resident 41's room to provide her privacy and dignity. The surveyor reviewed the findings for Resident 41 during a meeting with the Director of Nursing on October 5, 2023, at 9:00 AM. 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for one of one resident sampled for activities of daily living (Resident 74). Findings include: Resident 74 was unable to be interviewed due to his current cognitive status. A clinical record review revealed the facility admitted Resident 74 on August 2, 2023. A review of Resident 74's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 8, 2023, indicated nursing staff assessed Resident 74 as requiring extensive physical help from one staff for bathing. A review of Resident 74's task documentation (ADL, activities of daily living charting) revealed he has not received a shower since August 5, 2023. Nursing staff documented Resident 74 refused showers since August 5, 2023. Further review revealed that 74's bathing preference was identified as preferring a shower once a week. A review of Resident 74's plan of care revealed no documentation that the facility addressed or implemented individualized interventions for Resident 74's refusal to shower. The facility failed to provide activities of daily living as scheduled and per their preference for Resident 74. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of five residents reviewed (Resident 65). Findings include: Clinical record review revealed the facility admitted Resident 65 on November 10, 2022. Further review of Resident 65's clinical record revealed the following weight assessments: August 26, 2023, 147 pounds September 12, 2023, 141 pounds September 15, 2023, 137 pounds October 2, 2023, 135 pounds (a 12-pound, 8.16 percent significant weight loss) A review of a nutrition progress note dated September 18, 2023, confirmed significant weight loss, and the dietician's intervention included a re-weight to confirm Resident 65's significant loss, and to notify Resident 65's physician. There was no evidence that staff obtained a re-weight or notified Resident 65's physician. Interview with the Director of Nursing on October 6, 2023, at 9:44 AM confirmed she was unable to provide any documentation that the facility obtained a re-weight or notified Resident 65's physician of his significant weight loss. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen. Findings include: Observation of the facility's kitchen on October 3, 2023, at 11:07 AM revealed the following in the facility's dry storage area: Two unopened double chocolate boxed cake mixes with a manufacture's date of August 13, 2022 An unopened bag of vanilla wafers/cookies with a use by date of April 7, 2023 Three-quarters of a case of individual servings of Jiff peanut butter with a use by date of June 29, 2023 Four unopened containers of thickened orange juice with a use by date of April 23, 2023. Interview with Employee 3, dietary manager on October 3, 2023, at 11:07 AM and again on October 5, 2023, at 9:30 AM confirmed the items in the dry storage were out of use by dates and should not be available for resident use. Employee 3 also indicated that the double chocolate cake was to be used within one year of the manufacture's date (August 13, 2023). This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on October 4, 2023, at 1:00 PM. 28 Pa. Code 211.6(c)(f) Dietary services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement interventions to maintain a resident's continence status for one of four residents reviewed (Resident 1). Findings include: The MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) Resident Assessment Indicators (RAI) 3.0 Manual, Section H indicated that each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. Clinical record review for Resident 1 revealed that the facility admitted him on August 11, 2023. Upon admission, the facility identified that Resident 1 was capable, with a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; 13-15 indicates cognitively intact) of 15, was continent of bowel, and aware of the need to defecate. Resident 1 was ordered to be non-weight bearing on his right lower extremity due to a recent hip fracture with surgical repair, therefore requiring staff assistance for toileting. Review of Resident 1's task interventions (an action intended to improve the resident's health and comfort) revealed that he frequently needed limited to extensive assistance from one staff member with his toileting needs. Further review from August 11, 2023, through August 30, 2023, revealed that Resident 1 was incontinent of bowel 13 times, with evening and night shift incontinence occurring for 11 of the 13 times. Resident 1 had loose stool from August 12, 2023, to August 18, 2023. Review of Resident 1's nursing and physician documentation dated August 16, 2023, revealed that Resident 1 was complaining of diarrhea almost every time he eats with nine episodes over the past several days. The physician ordered Imodium for the diarrhea, with noted positive results and Resident 1's diarrhea ceased on August 18, 2023; however, Resident 1's incontinence continued. Interview with Resident 1 on August 30, 2023, at 12:49 PM confirmed that he was continent of bowel prior to admission and that he becomes incontinent of bowel when staff fail to respond to his call bell, especially on the evening and night shifts. He revealed that he notified staff after supper on August 29, 2023, of the need to defecate. Staff indicated that they could not provide assistance at that time. Resident 1 indicated that he waited over an hour for staff to return. By that time, he had become incontinent of bowel and was forced to sit in it while in his wheelchair, until staff returned to provide care. Resident 1 indicated that he could not access his call bell because of being in his wheelchair at the time of staff notification and while awaiting staff return. He did reveal that when he does ring his call bell it sometimes takes staff over an hour to respond and provide incontinence care. Review of nursing documentation dated August 29, 2023, at 10:56 PM (the time of the entry) revealed that Resident 1 was out of bed in his wheelchair and went down to the dining room for supper. Resident 1 informed staff that he was not going again because he always needs the bathroom after he eats, and they told him they would get him back after he ate, and they did not. Review of facility call bell logs for Resident 1's room revealed the following call bell response times: August 12, 2023, 7:03 PM until 8:06 PM, 1 hour, 3 minutes until staff responded August 12, 2023, 10:02 PM until 10:44 PM, 41 minutes until staff responded August 13, 2023, 7:13 PM until 8:19 PM, 1 hour 6 minutes until staff responded August 17, 2023, 1:56 PM until 2:28 PM, 31 minutes until staff responded August 17, 2023, 2:36 PM until 3:14 PM, 36 minutes until staff responded August 19, 2023, 7:07 PM until 7:45 PM, 37 minutes until staff responded August 23, 2023, 6:17 PM until 7:02 PM, 45 minutes until staff responded August 25, 2023, 6:51 PM until 7:26 PM, 34 minutes until staff responded Review of Resident 1's continence documentation revealed that staff documented bowel incontinence on the following dates, potentially due to lengthy call bell response times noted above: August 13, 2023, evening shift August 17, 2023, evening shift August 25, 2023, evening shift Review of the facility's nursing time and staff ratios revealed that the facility failed to meet the following: On August 13, 2023, the facility did not meet the licensed practical nurse (LPN) state required ratio of one LPN to 25 residents on day shift and one LPN to 30 residents on evening shift. On August 13, 2023, the facility did not meet the state required nursing time of 2.87 direct nursing care on August 13, 2023. Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the resident census: August 13, 2023, 6 NAs for a census of 81, requires 7 NAs. August 18, 2023, 6 NAs for a census of 86, requires 8 NAs. August 19, 2023, 7 NAs for a census of 85, requires 8 NAs. August 23, 2023, 7 NAs for a census of 87, requires 8 NAs. August 24, 2023, 7 NAs for a census of 87, requires 8 NAs. August 25, 2023, 7 NAs for a census of 85, requires 8 NAs. This surveyor reviewed the above information with the Nursing Home Administrator on August 30, 2023, at 1:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for one of 18 residents reviewed (Resident 8). Findings Include: Observation of Resident 8 on October 26, 2022, at 9:40 AM revealed the resident had a CPAP (continuous positive airway pressure machine worn during sleep where air is pumped into the lungs through the nose and or/mouth during breathing and used in the treatment of sleep apnea and other respiratory issues) machine and associated equipment at the bedside. A concurrent interview confirmed the resident wears the CPAP at night. Clinical record review for Resident 8 revealed a current physician's order dated September 26, 2022, that indicated the resident is to wear the CPAP at bedtime with two liters per minute (LPM) of oxygen at the previous settings prior to hospitalization for obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and results in brief episodes where breathing stops). A review of the current care plans for Resident 8 revealed no care plan related to the CPAP. An interview with the Director of Nursing on October 28, 2022, at 11:30 AM confirmed there was no care plan implemented for the CPAP. Observation of Resident 8 on October 26, 2022, at 9:40 AM revealed the resident had an indwelling foley catheter (a sterile tube inserted into the bladder to drain urine). A review of the clinical documentation for Resident 8 revealed a current physician's order dated October 6, 2022, that instructed staff to insert a foley catheter due to a worsening sacral wound (a wound that occurs on the lower back) and a possible neurogenic bladder (a loss of normal bladder control due to a problem with the nerves). A review of the current care plans for Resident 8 revealed no care plan related to the foley catheter or the associated care. An interview with the Director of Nursing on October 28, 2022, at 11:30 AM confirmed there was no care plan implemented for the foley catheter. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to store supplemental oxygen equipment and CPAP equipment per professional standards of practice for two of 18 residents reviewed (Residents 63 and 8). Findings include: A review of the policy titled Oxygen Therapy / Pulse Oximetry, last reviewed without changes on January 7, 2022, revealed the purpose is to administer oxygen in a safe sanitary manner in conditions in which insufficient oxygen is caried by the blood to the tissues. Further review indicated that all tubing and respiratory equipment not in use will be placed in a plastic bag and stored neatly with the machine. Observation of Resident 63's oxygen equipment on October 26, 2022, at 9:30 AM, 11:30 AM, and 12:16 PM revealed a nasal cannula (device used to deliver supplement oxygen into the nostrils) that was not bagged and observed draped over the oxygen concentrator in the resident's room. Observation of Resident 63 on October 26, 2022, at 2:00 PM revealed the resident was in bed with the nasal cannula in her nose. Clinical record review for Resident 63 on October 26, 2022, at 2:05 PM revealed a current physician's order that instructed staff to administer oxygen at two liters per minute (LPM) to keep the oxygen saturation greater than 90 percent and staff may titrate. A review of the clinical documentation for Resident 8 revealed a current physician's order dated September 26, 2022, that indicated the resident is to wear the CPAP (continuous positive airway pressure machine worn during sleep where air is pumped into the lungs through the nose and or/mouth during breathing and used in the treatment of sleep apnea and other respiratory issues) at bedtime with two liters per minute (LPM) of oxygen at the previous settings prior to hospitalization for obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and results in brief episodes where breathing stops). Observation of Resident 8's oxygen equipment on October 26, 2022, at 9:40 AM revealed a CPAP mask unbagged and draped over a drawer with crossword puzzle books. Observation of Resident 8's oxygen equipment on October 26, 2022, at 1:53 PM revealed the CPAP mask was unbagged and in the drawer. A concurrent interview with Resident 8 revealed that staff would put the mask on top of the bedside dresser, but it would fall off, so staff started putting the mask in the drawer. An interview with Employee 2, Licensed Practical Nurse, revealed the CPAP mask should be in a bag. The above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator on October 26, 2022, at 2:08 PM. The DON further indicated it is an expectation that the mask and cannula should be bagged when not in use. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Resident 168). Findings include: The facility's medication error rate was 11.11 percent based on 27 medication opportunities with three medication errors. The facility policy entitled, Medication Administration - General Guidelines, last reviewed without changes on January 7, 2022, revealed that medications are prepared by licensed nursing staff utilizing the five rights: right resident, right drug, right dose, right route, and right time, in accordance with written orders of the prescriber. Medications are administered within 60 minutes of the scheduled time according to the established medication administration schedule for the facility. Observation of a medication administration pass on October 25, 2022, at 10:26 AM revealed that Employee 1, licensed practical nurse, administered the following medications, without food, to Resident 168: Pregabalin (for pain) 100 milligrams (mg) two tablets PO (by mouth) Cyclobenzaprine Hydrochloride (for muscle spasms/pain) 5 mg one tablet PO Metoprolol Tartrate (for high blood pressure) 100 mg 1.5 tablets PO Clinical record review for Resident 168 revealed current physician orders for Pregabalin 100 mg two tablets PO TID (three times daily scheduled at 8:00 AM, 2:00 PM, and 8:00 PM) for pain, Cyclobenzaprine Hydrochloride 5 mg one tablet PO TID (three times daily scheduled at 8:00 AM, 2:00 PM, and 8:00 PM) for muscle spasms/pain, and Metoprolol Tartrate 100 mg 1.5 tablets PO BID (twice daily scheduled at 8:00 AM and 8:00 PM) for Hypertension (high blood pressure). Take with food. Employee 1 administered Resident 168's 8:00 AM medications at 10:26 AM, 2 hours, 26 minutes after the physician ordered times and without food. The surveyor reviewed the above information during an interview on October 26, 2022, at 1:42 PM with the Nursing Home Administrator. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to dispose of expired medications, bandages, sterile water, and saline solution on one of two nursing units (200 nursing unit). Findings include: A review of the policy and procedure titled Medication Storage in the Facility, last reviewed without changes on January 7, 2022, revealed that medications and biologicals are to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The policy revealed the following regarding expired medications: outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of, and reordered from pharmacy if a current order exists; drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date; no expired medications will be administered to a resident and all expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Observation of the 200 nursing unit treatment cart on October 27, 2022, at 10:20 AM with Employee 2, licensed practical nurse, revealed a container of expired normal saline solution (a solution that can be used to irrigate wounds). Employee 2 confirmed the saline expired as of October 19, 2022. Observation of the 200 nursing unit supply closet on October 27, 2022, at 10:34 AM with Employee 2, revealed 20 bottles (250 milliliter ml each) of sterile water that expired on June 9, 2022, five bottles (100 ml each) of sterile water that expired on October 21, 2022, and a box of plastic adhesive bandages that expired in May of 2022. Further observation of the 200 nursing unit treatment cart on October 27, 2022, at 10:41 AM with Employee 2 revealed one bottle (100 ml) of normal saline solution that expired on August 26, 2021, and Miconazole powder (topical antifungal) two percent that expired on October 24, 2022. The above findings were reviewed with the Director of Nursing and Nursing Home Administrator on October 28, 2022, at 10:30 AM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(i) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding wound assessments and diabetes management for three of three residents reviewed (Residents 2, 40, and 55). Finding include: Review of the policy entitled admission and Weekly Skin Observations, indicates that the facility should monitor skin impairment, which can include abrasions, excoriations, skin tears, and surgical wounds weekly on the Open Lesion progress note until healed. Review of Resident 2's clinical record revealed a nursing note dated September 29, 2022, at 3:07 PM indicating that Resident 2 had an area between buttocks 6 cm (centimeters) by 0.25 cm. Review of the facility's investigation into Resident 2's open wound dated September 30, 2022, at 4:00 PM indicated that Resident 2 had an open area 6 cm by 0.25 cm on his coccyx. The Director of Nursing added a comment to the investigation on October 3, 2022, that Resident 2's sacral slit was moist, red, and open. There was no documented evidence in the facility's investigation to indicate that the facility determined a clinical basis for Resident 2's wound for differentiating type of wound. A nursing note dated September 30, 2022, at 9:55 PM indicated that Resident 2's crease of 6 cm by 0.25 cm in the coccyx area was cleaned, and A&D ointment applied. A physician's order dated October 2, 2022, instructed nursing staff to cleanse Resident 2's open area between his buttocks, apply Silvadene 1% cream (a topical antimicrobial drug used for the prevention and treatment of infections in wounds) and leave open to air. There was no clarification in the order to indicate what nursing staff were to clean Resident 2's open area with. An In-service Training Record, dated October 4, 2022, indicated that the facility provided education to staff regarding Resident 2's gluteal fold skin tear, educating staff to utilize a pull sheet with repositioning and turning in bed to prevent shearing and/or tearing of the skin. Review of the facility's Skin Observation sheets dated October 5, 12, 19, and 26, 2022, revealed that an assessment was completed on Resident 2 to determine if any new skin alterations were present. The Skin Observation assessments did not include any documented evidence to indicate that the facility reassessed Resident 2's open wound to his gluteal crease. There was no documented evidence in Resident 2's clinical record to indicate that the facility monitored his open wound using the Open Lesion report. The last documented assessment of Resident 2's open wound was October 3, 2022. The facility continued to provide wound care to Resident 2's open wound until October 26, 2022, when this surveyor questioned the assessments and treatments. Interview with the Director of Nursing on October 27, 2022, at 10:40 AM, confirmed the above findings. Clinical record review for Resident 55 revealed current physician orders for staff to complete the following: Check Resident 55's blood glucose twice daily Notify Resident 55's physician if her blood greater than 400 mg/dL Review of Resident 55's blood glucose revealed that her levels on the following dates were: August 17, 2022, 4:00 PM, 408 mg/dL (Milligrams per Deciliter) September 14, 2022, 4:00 PM, 530 mg/dL September 20, 2022, 4:00 PM, 413 mg/dL September 23, 2022, 4:00 PM, 436 mg/dL October 16, 2022, 4:00 PM, staff indicated NA (not applicable) October 18, 2022, 4:00 PM, 461 mg/dL There was no documentation that staff notified Resident 55's physician after identifying a blood glucose level greater than 400 mg/dL. Clinical record review for Resident 40 revealed current physician orders for staff to complete the following: Humalog (insulin for high blood glucose) mix 75/25 suspension 100 u/ml (units per milliliter) inject 60 units SQ (subcutaneously, just under the skin) in the morning and inject 46 units SQ in the evening for diabetes If Resident 40's blood glucose was 60 to 80 mg/dL give 120 ml (milliliters of juice and recheck the blood glucose in 15 minutes. Repeat treatment if her blood glucose was less than 80 mg/dL. Notify Resident 55's physician if her blood glucose is greater than 400 mg/dL Review of Resident 40's blood glucose revealed that her levels on the following dates were: August 6, 2022, 5:00 PM, 433 mg/dL August 19, 2022, 7:00 AM, 80 mg/dL September 11, 2022, 5:00 PM, no documentation of Resident 40's blood glucose level October 8, 2022, 7:00 AM, 80 mg/dL October 14, 2022, 7:00 AM, 60 mg/dL There was no documentation that staff notified Resident 40's physician after identifying a blood glucose level greater than 400 mg/dL. On August 19, 2022, at 7:00 AM, and on October 8, 2022, at 7:00 AM, staff administered 60 units of Humalog 75/25 insulin for Resident 40's blood glucose level of 80 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's order. On September 11, 2022, at 5:00 PM there was no documentation indicating that staff administered Resident 40's Humalog 75/25 insulin. On October 14, 2022, at 7:00 AM staff administered 60 units of Humalog 75/25 insulin for Resident 40's blood glucose level of 60 mg/dL. There was no documentation that they provided 120 ml of juice or rechecked Resident 40's blood glucose per her physician's order. The surveyor reviewed the above information during an interview on October 27, 2022, at 2:05 PM with the Nursing Home Administrator and Director of Nursing. 483.25 Quality of Care Previously cited 11/5/21 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services