Based on facility documentation and staff interview it was determined the facility failed to follow physician orders for bowel protocol for one of 16 residents reviewed. (Resident 15) Findings Include: Review of Resident 15's physician orders revealed an order dated August 31, 2022 for Milk of Magnesia (laxative), give 30 cc (cubic centimeter or milliliters) by mouth as needed for constipation if no BM (Bowel Movement) in 3 days: an order dated August 31, 2022 for Bisacodyl Suppository (laxative inserted rectally) 10mg (milligrams) as needed for constipation administer the next shift if no results from the Milk of Magnesia; and an order dated August 31, 2022 for Fleets Naturals Cleansing Enema (rectal cleanser), insert 1 unit rectally as needed for Constipation administer next shift if no results from Bisacodyl Suppository. Review of Resident 15's bowel continence report for May 2024 and June 2024 revealed the resident had no bowel movement from May 29th, 2024 on evening shift until the day shift of June 4, 2024, totaling 5 days. Review of Resident 15's Medication Administration Record (MAR) for the month of June 2024 revealed the resident was administered Milk of Magnesia on June 2, 2024 at 1:58 p.m., review of the Bowel continence reports revealed that was ineffective and was indicated as ineffective on the MAR. Further review of the MAR revealed there was no Suppository administered as ordered due to the ineffectiveness of the Milk of Magnesia. Further review of Resident 15's bowel continence record for June 2024 revealed the resident did not have a bowel movement from Evening shift on June 4, 2024 until day shift of June 13, 2024, a total of 9 days. Review of Resident 15's MAR for June 2024 revealed the resident received Milk of Magnesia on June 8, 2024 at 8:10 a.m. that was ineffective. There was no Suppository administered for the ineffective Milk of Magnesia on evening shift of June 8, 2024 as ordered and no other medications administered as ordered until the resident had a bowel movement on June 13, 2024. Further Review of Resident 15's MAR for June 2024 revealed the resident had a dose of Milk of Magnesia administered on June 14 2024, at 12:49 p.m. which was not indicated due to the resident having a documented bowel movement the day before. Further review of Resident 15's Bowel record revealed the resident did not have a bowel movement from evening shift on June 13 until day shift on June 23 a total of 10 days. Review of Resident 15's MAR for June 2024 revealed a dose of Milk of Magnesia as administered on June 19, 2023 at 2:17 a.m. and documented as effective but review of the bowel record revealed the resident did not have a bowel movement on the night shift on June 14. Further review of Resident 15's bowel record revealed the resident had no bowel movement from evening shift of June 24, 2024 until the end of the month. Review of Resident 15's MAR for June 2024 revealed there was a dose of Milk of Magnesia that was administered on June 28, 2024 at 12:48 p.m. that was documented as ineffective and there was no Suppository administer as ordered. Interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2024 at 10:00 a.m. confirmed that Resident 15's physician order for bowel regimen were not being followed as written. 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) Nursing Services

Based on observation, facility policy and procedure review, and staff interview it was determined the facility failed to properly label and date vials of insulin for one of three med carts reviewed. (second floor) Findings Include: Review of facility policy and procedure titled Medication Labeling and Storage, dated 2001, revealed Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation on September 11, 2024 at 9:20 a.m. of the medication cart on the second floor for the high number rooms revealed there were four insulin pens that were opened and being used that were undated. Interview with Nursing Employee E3 at the time of the above findings confirmed the four insulin pens were opened and being used and should have been dated with the date they were opened. 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) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical and hospital records and staff interviews, it was determined that the facility failed to ensure wound treatment was initiated upon admission for two of the six residents reviewed (Resident 149 and 151). Findings include: Review of Resident 149's nursing progress notes dated October 13, 2023, revealed resident was admitted to the facility from the hospital with a diagnosis of Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Review of Resident 149's admission assessment, dated October 13, 2023, revealed resident was admitted with a Deep Tissue Pressure Injury (persistent non-blanchable deep red, maroon, or purple discoloration) to the coccyx (tail bone). Further review of Resident 149's clinical record failed to reveal, a wound treatment was completed on Resident 149's coccyx DTI until October 16, 2023; three days after resident was admitted to the facility and assessed with a DTI to the coccyx. Interview conducted with the wound nurse, licensed nurse Employee E4 on October 20, 2023, at 10:00 a.m., revealed that upon the resident's admission, the resident ' s skin will be assessed by an RN (Registered Nurse). Identified skin impairment will be reported to the physician, an order will be made, and wound treatment will be initiated. Employee E4 confirmed that a wound order treatment was not placed upon resident admission and wound treatment was not done until October 16, 2023, three days after a resident was admitted and a skin impairment was identified. Review of Resident 151's hospital records, and Discharge summary dated [DATE], revealed resident had a stage three (Full-thickness skin loss) to the right ischium/buttock wound). Recommended wound treatment was Aquacel ag (anti-microbial dressing used in wounds that are infected or at risk for infection) to wound, covered with foam dressing daily. Review of Resident 151's clinical records and admission assessment revealed resident was admitted to the facility on [DATE], with a stage two to the right buttock, measuring 4.0 x 2.0 x 0.1 cm. Review of the physician's order dated October 14, 2023, revealed a wound treatment order was made to cleanse the right ischium/buttock with normal saline solution, pat dry, apply Aquacel ag and cover with a foam dressing. Review of the October 2023, Treatment Administration Record revealed wound treatment to Resident 151's right ischium/buttock wound was not followed until October 15, 2023, two days after resident was admitted to the facility and identified with a skin impairment. Iinterview conducted with Employee E4 on October 20, 2023, at 10:00 a.m., reported that Resident 151's wound order and treatment should have been done upon admission. Employee E4 confirmed that Resident 151's wound treatment order was not completed until October 15, 2023, two days after a resident was admitted with identified skin impairment. The facility failed to ensure Residents 149 and 151 were provided with a wound order and treatment upon admission. 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/8/22 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 12/8/22

Based on a review of the facility's policy, clinical record reviews, and staff interview, it was determined that the facility failed to investigate an injury of unknown origin for one of the 12 residents reviewed (Resident 8). Findings include: Review of the facility's policy titled Abuse Prevention Program, revised in July 2021, revealed that if the cause of the injury is unknown, the person gathering facts will document the injury, the location and time it was observed, any treatment given and whether the physician, responsible party and/or the Department of Health were notified. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if can be interviewed. Review of Resident 8's diagnosis list revealed Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety Disorder, Psychotic and Mood Disturbance. Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated July 6, 2022, revealed that the resident had severe cognitive impairment. The same MDS assessment revealed the resident required extensive bed mobility, transferring, personal hygiene, and grooming. Review of Resident 8's active care plan revealed resident had physical behaviors during hands-on care and was resistant to care. Both plans of care were developed on June 3, 2020. Review of Resident 8's clinical record including document titled Change in Condition, dated October 3, 2022 (6:57 p.m.), revealed the resident was observed with a bruise to the left forearm with a measurement of 6.5 x 4.0 cm. Interview with the Director of Nursing was conducted on December 7, 2022, at 1:00 p.m. The Director of Nursing reported the resident did not have documented falls or trauma. The DON confirmed the bruise observed on Resident 8's left forearm on October 3, 2022, was not investigated. An interview with the Nursing Home Administrator (NHA) was conducted on December 8, 2022, at 10:30 a.m. The NHA confirmed that the resident did not have falls/trauma before the discovery of the left forearm bruise. The NHA confirmed that Resident 8's left forearm bruise from an unknown source should have been investigated. The facility failed to ensure Resident 8's left forearm bruise (injury of unknown origin) was investigated. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(a)(b)(3) Management Previously cited 11/23/21 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/23/21 28 Pa. Code 211.10(a)(c)(d) Resident Care Policies Previously cited 11/23/21 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 11/23/21

Based on clinical record reviews, staff, and resident interviews, it was determined that the facility failed to ensure the physician's order was followed for one of the 12 residents reviewed (Resident 9). Findings include: Review of Resident 9's diagnosis list revealed End Stage Kidney Disease (condition when your kidneys no longer work as they should to meet your body's needs). Interview with Resident 9 conducted on December 5, 2022, at 10:00 a.m., revealed that she/he goes to Hemodialysis (process of purifying the blood /remove toxins of a person whose kidneys are not working normally) every Monday, Wednesday, and Friday. The resident reported being picked up around 10:30 a.m. and returning to the facility around 2:00 p.m. Review of Resident 9's Physician's order sheet revealed an order for a Calcium Acetate capsule given 667 mg (milligrams) by mouth with meals. The medication was ordered to be administered at 8:00 a.m., 12:00 noon, and 5:00 p.m. Review of Resident 9's November and December 2022, Medication Administration Record (MAR) revealed the Calcium Acetate medication was not administered at noon on the following dates: November 18, 23, 25, 28, 30, 2022, and on December 2, 5, and December 7, 2022. Interview with the Director of Nursing was conducted on December 8, 2022, at 10:00 a.m., and revealed that the medication was missed on the days mentioned above due the resident was out of the facility for Hemodialysis. A clinical records review failed to reveal the attending physician was notified of the missed medication doses. The above information was conveyed to the NHA on December 8, 2022, at 10:30 a.m. The facility failed to ensure Resident 9's medication order was followed. 28 Pa. Code 201.18(a)(b)(3) Management Previously cited 11/23/21 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/23/21 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 11/23/21