Every finding on record at Allied Services Center City Skilled Nursing

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage for medications on one of three nursing units (Nursing Unit 3).Findings include: A review of the facility policy titled Disposition of Medications: Discontinued Medications, last reviewed by the facility on October 1, 2025, revealed it is the policy of the facility that under circumstances where medications are discontinued by physician order, a resident is transferred or discharged and does not take medications with him or her, or in the event of a resident's death, the medications are marked as discontinued with a label closure. Medications can be disposed of on-site with a witness and completion of the medication disposition form or returned to the pharmacy for disposal with that document. The facility policy indicated medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up for destruction by the pharmacy. An observation on November 14, 2025, at 10:21 AM revealed an unsecured drawer in the Unit 3 Nursing Station. Employee 1, Registered Nurse (RN), indicated that she had no knowledge of medications stored in that drawer in the nursing station. Employee 1, RN, explained that medications for disposition should be secured in the medication room and not in a drawer at the nursing station. The unsecured drawer contained a brown paper bag with the following medications: 3 tablets Baclofen 10 mg-a muscle relaxer used to reduce muscle spasms.1 tablet Sertraline 50 mg-an antidepressant used for mood and anxiety.8 tablets Midodrine 25 mg-a medication used to raise low blood pressure.4 tablets Levetiracetam 250 mg-a seizure-prevention medication.2 tablets Levetiracetam 500 mg-a seizure-prevention medication.3 tablets Atorvastatin 40 mg-a cholesterol-lowering medication.1 tablet Atorvastatin 80 mg-a cholesterol-lowering medication.1 tablet Ezetimibe 10 mg-a medication used to lower cholesterol.1 tablet Tamsulosin 0.4 mg- a medication used to improve urination in prostate problems.1 tablet Trazodone 50 mg-a sleep and mood medication.1 tablet Allopurinol 300 mg-a medication used to prevent gout.1 tablet Plavix (clopidogrel) 75 mg-a blood-thinner used to prevent clots.1 tablet Mirtazapine 7.5 mg-a mood medication that can also help appetite and sleep.1 tablet Thera-M-a daily multivitamin.4 tablets Pantoprazole 40 mg-a medication used to reduce stomach acid and treat reflux.12 tablets Meclizine 25 mg-a medication used to treat dizziness or vertigo.7 tablets Apixaban 2.5 mg -a blood-thinner used to prevent clots and stroke.1 tablet Apixaban 5 mg-a blood-thinner used to prevent clots and stroke.4 tablets Atenolol 25 mg-a heart and blood pressure medication.7 tablets Folic acid 1 mg-a vitamin used to treat or prevent deficiency.1 tablet Donepezil 10 mg-a medication used for memory problems in dementia.1 tablet Gabapentin 100 mg-a medication used for nerve pain or seizures.1 tablet Memantine 10 mg-a medication used for memory and thinking problems in dementia.1 tablet Metoprolol 25 mg-a heart and blood pressure medication.1 Humalog insulin pen-rapid-acting insulin used to lower blood sugar.1 tablet Buspirone 5 mg-a medication used to treat anxiety. During an interview on November 14, 2025, at 10:35 AM, Employee 2, RN, indicated that she stored the medications in the Unit 3 nursing station drawer because she left the unit to attend a meeting. Employee 2, RN, explained that it is facility policy to secure medications for disposition in the medication storage room. An interview with the Director of Nursing on November 14, 2025, at 11:45 AM confirmed that the facility failed to ensure acceptable storage of medications for disposition, as required by facility policy. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.9(j.1)(3) Pharmacy services. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to timely identify weight loss, failed to ensure weekly weights were obtained as required by policy for prompt intervention for two of 21 sampled residents (Residents 15 and 22), and failed to implement individualized nutritional support measures based on a resident's stated preferences to maintain or improve nutritional parameters for one resident (Resident 8) out of three sampled residents for weight loss. Findings include: A review of the facility's policy titled Weighing Residents/Reporting Significant Weight Changes, last reviewed by the facility on October 1, 2025, revealed it is the facility policy to monitor weights on all residents. The policy indicated the facility will investigate, report, and appropriately intervene when a weight change occurs that may impact the residents' well-being. Further review of the policy revealed the facility will obtain residents' weights on admission and weekly for four weeks. The nurse and/or dietician will check the weights and verify if there was a loss or gain of 5% of total weight in one month, or 5 pounds in one week. A re-weight within 48 hours will be performed to verify actual weight loss. A clinical record review revealed Resident 15 was admitted to the facility on [DATE], with a diagnosis of a fracture of the lower end of the right radius (a break in the larger forearm bone near the wrist). A review of an admission Minimum Data Set assessment (MDS, a federallymandated standardized assessment process conducted at specific intervals to plan resident care) dated October 29, 2025, revealed the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status, a tool to assess cognitive function) score of 13 (a score of 13 to 15 indicates cognition is intact). A review of Resident 15's October 23, 2025, weight record revealed that Resident 15 weighed 151.6 pounds on admission, 150.8 pounds on October 31, 2025, and 144.6 pounds on November 3, 2025. This represents a seven pound loss since admission and a weight loss of 6.2 pounds in one week. The clinical record did not contain evidence that the facility completed a reweight within forty-eight hours as required by facility policy for a weight loss of five pounds in one week. The clinical record also did not contain evidence that the facility implemented interventions to prevent further weight loss. There was no documentation of weights or reweighs after November 3, 2025. The surveyor notified the facility on November 13, 2025, at 10:30 AM that no weights had been documented since November 3, 2025, despite the policy requirement for weekly weights on four occasions after admission. After inquiries made during the survey, the facility weighed the resident and recorded a weight of 144 pounds. During an interview with Resident 15 on November 12, 2025, at 11:30 AM, the resident stated she was right hand dominant and that eating with a cast on her right arm was difficult. The resident stated she was not eating as much as she normally would at home. During an interview on November 13, 2025, at 1:30 PM, the Director of Nursing (DON) was unable to provide evidence that the facility timely identified Resident 15's weight loss and that interventions or discussion of the weight loss to prevent further weight loss was identified or completed prior to inquiries made during the survey. A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with a diagnosis of a urinary tract infection.A review of the weight record dated October 27, 2025, revealed an admission weight of 221.8 pounds. A subsequent weight dated November 2, 2025, revealed a weight of 217.9 pounds. Based on the facility policy, a weekly weight was required on November 9, 2025. No weight was obtained at that time. The weight was not obtained until November 13, 2025, at 9:30 AM, after notification by the surveyor, at which time the resident weighed 212.2 pounds. A review of a progress note dated November 13, 2025, at 2:30 PM, revealed that the resident's meal completion was as low as 26 percent. There was no evidence that the facility obtained Resident 22's weekly weights as required by policy to identify weight loss or initiate appropriate interventions, including discussion with staff or the resident. During an interview on November 14, 2025, at 10:00 AM, the DON was unable to provide evidence that the facility's Weighing Residents/Reporting Significant Weight Changes policy was implemented to timely identify weight loss.A clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included status post left above-knee amputation, right below-knee amputation, diabetes (a condition where the body has too much sugar, known as glucose, in the blood because it can't effectively use insulin, a hormone that helps glucose get into cells for energy), and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). A review of an admission Minimum Data Set assessment (MDS dated [DATE], revealed the resident was cognitively intact, with a BIMS score of 14, indicating intact cognition. The resident's care plan initiated September 18, 2025, and revised October 3, 2025, identified risk factors for weight loss that included decreased appetite, significant weight loss, diabetes, and recent amputation. The stated goals included maintaining or increasing weight, consuming more than fifty percent of meals, adhering to a therapeutic diet (meal plan designed to manage or treat a specific medical condition), and taking prescribed nutritional supplements (a product taken orally to supplement the diet with extra vitamins, minerals, calories, protein, or other substances to improve nutritional intake). Interventions planned included providing meal alternatives when meals were refused, administering dietary supplements, weighing the resident weekly for four weeks and then monthly, and reporting decreased meal intake. A review of the resident's weight record revealed the following recorded weights: September 18, 2025: 179 pounds (completed three days after admission)September 23, 2025: 172.6 pounds (3.5% weight loss)October 1, 2025: 164.6 pounds (8% weight loss in 15 days)October 3, 2025: 164.4 pounds (reweight for October 1, 2025, 8.2% weight loss in 17 days)October 6, 2025: 161.4 poundsOctober 13, 2025: 160.7 poundsOctober 20, 2025: 160.6 poundsNovember 4, 2025: 160.2 pounds (10.5% significant weight loss in 47 days). A review of a nutritional weight warning note dated October 3, 2025, revealed that the resident had a significant weight loss of 14.2 pounds, which is 8.2 percent, in less than one month The registered dietitian (RD) recommended Glucerna (a nutritional drink for people with diabetes, which provides extra calories, protein, and nutrients) once daily to prevent further weight loss. A review of a nutritional weight warning note dated October 14, 2025, revealed that the resident continued to lose weight, with an additional loss of 3.7 pounds, which was 2.2 percent, since the October 3, 2025, note. The registered dietitian discontinued the Glucerna supplement and recommended no sugar added Mighty Shakes (a nutritional drink without added sugar that provides extra calories, proteins, and nutrients) with meals to prevent further weight loss. A review of the resident's Task Documentation Record from October 14 through October 31, 2025, revealed that staff documented the resident consumed between 0 percent and 100 percent of the Glucerna supplement once daily, despite Glucerna being discontinued on October 14, 2025. Staff also documented consumption of Mighty Shakes three times per day during this same period. A review of the resident's Task Documentation Record from November 1 through November 13, 2025, revealed that staff continued to document the resident consumed between 0 percent and 100 percent of the Glucerna supplement once daily, although the supplement remained discontinued. Staff also documented the resident consumed between 0 percent and 100 percent of the Mighty Shakes three times per day. During an interview with Resident 8 on November 13, 2025, at 2:15 PM, the resident stated that he was aware he had lost weight. The resident stated he did not like the Mighty Shakes because he felt they raised his blood sugar. The resident stated he preferred Glucerna and reported he had not received Glucerna in some time. An interview with the foodservice director (FSD) on November 13, 2025, at 2:45 PM confirmed that Glucerna was discontinued on October 14, 2025, and that Mighty Shakes three times per day were initiated by the registered dietitian. The Foodservice Director was unable to provide documented evidence that the resident's preferences were considered prior to discontinuing the Glucerna supplement. An interview with the director of nursing (DON) on November 14, 2025, at 9:00 AM confirmed that staff were responsible for accurately documenting on the resident's Task Documentation Record to accurately reflect what is consumed by a resident. The Director of Nursing confirmed that Glucerna continued to appear on the resident's October and November Task Documentation Records despite being discontinued on October 14, 2025. 28 Pa Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined that the facility failed to provide person-centered care as prescribed to meet the current clinical needs and failed to follow physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for three of 21 sampled residents (Residents 12, 75, and 76). Findings include: A review of the facility policy entitled Central Venous Catheter/PICC Care/Flush/Medication Administration, last reviewed October 1, 2025, indicated the facility is to provide dressing changes, medication, and flushes to residents with a PICC line access (a thin flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream) and that all residents with a PICC lines will have emergency care measures in place in the event of line breakage or dislodgement. Dressing changes are to be made weekly and as needed with the extension tubing, if applicable, stabilization device, if applicable, and cap change, unless ordered otherwise by the physician. Further review revealed that the PICC line should be flushed with 10 milliliters (ml) of normal saline prior to medication being administered and after the medication is complete to flush with 10 ml of normal saline. All residents with a PICC line will have a clamp and dressing kit taped to the back of their bed's headboard or wall, and placement of these emergency items will be checked every shift by the designated nurse and documented on the Medication Administration Record (MAR). A review of clinical records revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis (bone infection) of the lumbar spine and sepsis due to Escherichia coli (E. coli, a bacterium) and was receiving intravenous (IV, within the vein) antibiotics through a PICC line. A physician order dated October 12, 2025, directed that an emergency PICC line kit be kept at the bedside and on the resident's wheelchair and checked every shift. An emergency PICC line kit is a small set of supplies kept immediately available for residents who have a PICC line. The emergency kit contains a sterile clamp and dressing materials used to quickly secure the catheter site if the PICC line becomes loose, breaks, leaks, or is accidentally pulled out. The kit is necessary because a disruption of the PICC line can allow air or bacteria to enter the bloodstream or cause bleeding. Immediate access to the clamp and dressing allows staff to stabilize the site until a medical provider can evaluate the resident. Keeping this kit at the bedside or wheelchair enables staff to respond without delay and reduces the risk of infection, catheter occlusion, loss of IV access, or other complications. A review of Resident 12's MARs (medication administration record) for October and November 2025 indicated that nursing staff documented the presence of the emergency PICC line kit at bedside and on the wheelchair each shift from October 12, 2025, through November 12, 2025. However, an observation conducted on November 12, 2025, at 11:00 AM, revealed that no emergency PICC supplies were present at the bedside or on the wheelchair. An interview with Employee 2, Registered Nurse, on November 12, 2025, at 11:30 AM, confirmed that Resident 12 had a physician's order for emergency PICC line supplies but that no such supplies were present. A physician order for Resident 12, dated October 12, 2025, noted an order for ceftriaxone (an antibiotic) 2000 milligrams (mg) intravenous one time daily for sepsis due to E. coli until November 13, 2025. A physician order for Resident 12, dated October 12, 2025, noted an order for Sodium Chloride 0.9% flush and to use 10 ml intravenously every shift to maintain patency. A review of Resident 12's physicians' orders and October and November 2025 MARs failed to indicate the resident's PICC line was flushed before and after the administration of each IV antibiotic as per facility policy. A review of clinical records revealed Resident 75 was admitted to the facility on [DATE], with diagnoses to include sepsis (a medical emergency where the body has an overwhelming inflammatory response to an infection, which can damage tissues and organs) due to methicillin-susceptible Staphylococcus aureus (MSSA, a type of Staphylococcus aureus that responds to certain antibiotics), that was present in a left pleural effusion (buildup of excess fluid in the space between the lungs and chest wall) and was receiving intravenous antibiotics through a PICC line. A review of physician orders dated November 8, 2025, revealed orders for an emergency PICC line kit to be kept at the bedside and on the resident's wheelchair and to be checked every shift. A review of Resident 75's Treatment Administration Record (TAR) for November 2025 indicated that nursing staff documented the emergency PICC line kit at the bedside and on the wheelchair as present each shift from November 8, 2025, through November 12, 2025. However, an observation conducted on November 12, 2025, at 11:05 AM, revealed no emergency PICC line supplies were available in the resident's room or on the wheelchair. An interview with Employee 2, Registered Nurse, on November 12, 2025, at 11:30 AM, confirmed that the emergency supplies were not present despite the physician order.Further review of physician orders dated November 8, 2025, indicated that the resident's PICC dressing and caps were to be changed weekly on Saturdays and as needed. Observation of the resident's PICC line dressing on November 14, 2025, at 9:10 AM, in the presence of Employee 1, Registered Nurse, revealed that the dressing was last changed on November 5, 2025. Employee 1 stated that the dressing should have been changed on November 12, 2025, seven days after the last change. A physician order for Resident 75 dated November 8, 2025, revealed an order for Cefazolin Sodium (an antibiotic) 2 grams (gm) intravenous every eight hours related to sepsis until December 9, 2025. A physician order for Resident 75, dated November 8, 2025, noted an order for Sodium Chloride 0.9% flush and to use 10 ml intravenously every shift to maintain patency. A review of Resident 75's physicians' orders and the November 2025 MAR failed to indicate the resident's PICC line was flushed before and after the administration of each IV antibiotic as per facility policy. A review of the clinical record revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses that included MSSA after having a right knee replacement surgery on October 7, 2025, and was receiving intravenous antibiotics through a PICC line. A physician order for Resident 76 dated November 7, 2025, revealed an order for Cefazolin Sodium (an antibiotic) 2 gm intravenous every eight hours related to wound infection until December 13, 2025. A physician order for Resident 76, dated November 7, 2025, noted an order for Sodium Chloride 0.9% flush and to use 10 ml intravenously every shift to maintain patency (ensuring the line remains open and fluids can be administered without blockage). A review of Resident 76's physicians' orders and the November 2025 MAR failed to indicate the resident's PICC line was flushed before and after the administration of each IV antibiotic as per facility policy. During an interview with the Director of Nursing on November 14, 2025, at 11:00 AM the above findings were reviewed and confirmed regarding Resident 12, Resident 75 and Resident 76's PICC lines. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents had reasonable and safe access to operate their over-the-bed lighting for four residents out of 21 residents reviewed (Residents 32, 50, 9, and 41). Findings include: The facility policy titled Environment last reviewed by the facility on October 1, 2025, indicated that the facility shall provide extra lighting to provide sufficient light to assist residents with tasks such as reading, and provide lighting for residents who need to find their way from the bed to the bathroom at night. During observations conducted on November 13, 2025, at 9:45 AM, it was noted that Residents 32, 41 and 9 had over-the-bed lighting fixtures; however, each fixture had a pull cord measuring two inches in length, making the light inaccessible to residents. An interview with Resident 41during the observation revealed that she was unable to reach the over-the-bed light while in bed or while seated in the wheelchair. She stated, I would really like to. In fact, I need to. I get up a lot during the night and take myself to the bathroom, and I should have a light on so I can see what I'm doing. During an observation of Resident 50's room on November 13, 2025, at 10:15 AM, it was revealed that although an extension chain had been attached to the over-the-bed light, the resident's bed was positioned too far away for her to reach it. Resident 50 explained that the cord was not long enough for her to access from either the bed or wheelchair. She reported that her physical limitations, including upper body contractures (permanent tightening of muscles, tendons, ligaments or skin that limits normal movement) and deformities, further limited her reach. She stated, I like to read at night. When I'm done, I need to call the staff to turn it off. Sometimes I fall asleep before they come to turn it off and they wake me up to ask what I need. If they could give me a long enough cord, that would be very helpful. During an interview with the Nursing Home Administrator on November 14, 2025, at 9:30 AM, it was confirmed that the facility failed to ensure resident access to operate over-the-bed lights for multiple residents, representing a failure to accommodate individual needs and preferences. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, controlled substance records, and staff and resident interviews, it was determined that the facility failed to follow physician orders, complete timely pain assessments, implement measures to reduce or alleviate pain, reassess the effectiveness of pain interventions within a reasonable time frame, and accurately document these activities in the clinical record for three of 21 sampled residents (Residents 15, 45, and 23). Findings include:A review of the facility's policy entitled Pain Management Process, last reviewed by the facility on October 1, 2025, indicated that the facility was to ensure resident comfort and that documentation of assessments, interventions, and outcomes utilized to control pain would be established. Resident pain levels are to be assessed by staff utilizing a numeric pain scale. Residents who can verbalize their degree of pain would be directed to provide a numerical number between zero and ten. Zero (0) would indicate no pain. A numeric number between one and four (1-4) would indicate mild pain. A numeric number between five and seven (5-7) would indicate moderate pain. A numeric number between eight and ten (8-10) would indicate severe pain. According to the policy, the physician would be notified of the resident's assessed pain levels, and then medications for the degree of pain would then be prescribed. The Pain Management Process policy directs staff to attempt non-pharmacological interventions (non-medication-related interventions to relieve pain such as repositioning, heat or cold packs, massage and relaxation techniques) prior to administration of pain medications and to document the results. If non-pharmacological interventions were not successful, a licensed nurse would then document that a medication was administered and would reassess the resident to evaluate the effectiveness of the pain relief within a reasonable time frame. A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with a diagnosis of a fracture of the lower end of the right radius (a break in the larger forearm bone near the wrist). A physician's order dated October 23, 2025, directed staff to administer hydromorphone 2.0 milligrams (an opioid pain-relieving medication) every four hours as needed for moderate to severe pain. A review of the Individual Resident's Controlled Substance Record dated October 27, 2025, showed the resident received hydromorphone at 11:40 PM. A review of nursing documentation initiated on October 23, 2025, failed to show documentation of the resident's pain level at the time of administration, any attempted non-pharmacologic measures prior to administration, or any reassessment of the resident's pain relief after the medication was provided. During an interview on November 14, 2025, at 11:00 AM, the Director of Nursing (DON) was unable to produce evidence that staff implemented the facility's pain management policy for Resident 15. A clinical record review revealed that Resident 45 was readmitted to the facility on [DATE], with a diagnosis of fibromyalgia (a chronic condition that causes widespread pain and fatigue) and had recent history of falls .A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 12, 2025, revealed that Resident 45 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of nursing documentation dated November 11, 2025, at 9:35 PM, revealed that Resident 45 was prescribed Hydrocodone 10-325 milligrams (an opioid pain-relieving medication) with directions to give one tablet by mouth every six hours as needed for a moderate pain level of five through seven (5-7) and Hydrocodone Oral Tablet 10-325 milligrams with directions to give two tablets by mouth every six hours as needed for severe pain of eight through ten (8-10). A subsequent nurse's note dated November 12, 2025, at 1:41 AM documented that at 11:30 PM on November 11, 2025, the resident was yelling out for pain medication, but staff informed her that the ordered medication was not available in the facility and would need to be delivered by the pharmacy. Review of the November 2025 controlled substance record showed that the resident did not receive the medication until 12:36 AM, more than one hour after staff were notified of her pain, confirming a delay in administration. The Director of Nursing confirmed on November 13, 2025, at 1:30 PM that the ordered medication was not kept on-site and had to be obtained from the pharmacy once staff communicated the need. Further review of the clinical record revealed no documentation that staff notified the physician about the medication's unavailability or requested alternative pain intervention during the delay. At the time the resident requested pain relief, her pain was assessed at a level 7 (moderate pain), requiring the administration of one tablet; however, the controlled substance record showed that two tablets were administered, constituting an incorrect dose. During an interview on November 14, 2025, at 9:30 AM, the resident confirmed receiving two tablets. During an interview on November 13, 2025, at 1:30 PM, the Director of Nursing confirmed both the delay and the incorrect dosage. A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with a diagnosis to include osteoarthritis (degenerative joint disease where the cartilage that cushions the ends of the bones wears down, leading to pain). A physician's order dated November 6, 2025, revealed that Resident 23 was to be administered Tylenol 650 mg (an over-the-counter pain reliever) as needed for mild pain. A review of nursing documentation dated November 6, 2025, at 2:15 PM revealed that Resident 23 requested pain medication for neck discomfort. Further review of the clinical record and the Medication Administration Record (MAR), dated November 2025, failed to indicate that the resident's pain level was assessed on the numeric scale, that non-pharmacological interventions were offered, or that pain medication was administered. A review of Resident 23's care plan dated November 1, 2025, showed that planned interventions included administering pain medication as ordered and documenting its effectiveness. During an interview on November 14, 2025, at 11:30 AM, the DON was unable to provide evidence that Resident 23's pain was fully evaluated or that interventions were timely implemented to relieve the pain. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to prevent the development of pressure sores for one resident out of 21 residents sampled (Resident 76).Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. The largest medical specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility policy titled Wound Management/Pressure Reduction, last reviewed October 1, 2025, indicated it is the policy of the facility to assess each resident's potential for skin breakdown based on clinical risk factors, and the plan of care will be established to address prevention and treatment as needed, and that all residents will have a prevention or specialty mattress as needed. Further review revealed to apply pressure-relieving boots, heel/elbow protectors, or heel elevators as recommended by the wound nurse practitioner, therapist, or physician. A review of the clinical record revealed that Resident 76 was admitted to the facility on [DATE] with diagnoses that included methicillin susceptible staphylococcus aureus (MSSA, a type of bacterial infection caused by staphylococcus aureus bacteria that are susceptible to treatment with methicillin and other beta-lactam antibiotics) after having a right knee replacement surgery on October 7, 2025, and required use of a right knee immobilizer (a brace that holds the knee joint straight to prevent bending). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 10, 2025, revealed that Resident 76 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of the resident's care plan, initiated November 7, 2025, revealed a potential skin breakdown related to alteration in mobility due to recent surgery and that Resident 76 had actual skin breakdown caused by pressure with the presence of a Stage II ulcer ( partial-thickness skin loss with loss of the outermost layer of the skin, usually shallow with a pink to red wound base) to the coccyx (the small bone at the very bottom of the spine) noted on admission. A Braden Scale for Predicting Pressure Sore Risk form on admission dated November 7, 2025, identified Resident 76 as being at moderate risk for pressure injury development. Physician's orders dated November 8, 2025, included a pressure-reducing mattress for the bed, a pressure-reducing cushion for the chair, and a Prevalon boot (a medical device designed to protect the heels and prevent pressure ulcers) for the right lower extremity while in bed. An observation of Resident 76 on November 12, 2025, at 11:00 AM revealed the resident lying down in bed wearing a right knee immobilizer, without the presence of a Prevalon boot on the right lower extremity. Observation of Resident 76's room revealed no Prevalon boot. A second observation on November 13, 2025, at 9:00 AM revealed Resident 76 was lying down in bed wearing a right knee immobilizer, without the presence of a Prevalon boot on the right lower extremity, which was confirmed by Employee 6, Licensed Practical Nurse. An interview with the resident revealed he never had a Prevalon boot placed on his right lower extremity since being admitted to the facility. A review of Resident 76's treatment administration record (TAR) from November 2025 indicated the Prevalon boot on the right lower extremity was documented as being on the resident from November 8, 2025, through November 12, 2025, with no documentation of refusals noted. During an interview with the Nursing Home Administrator on November 13, 2025, at 9:45 AM, it was confirmed the facility did not consistently implement the planned interventions to prevent a right heel pressure ulcer for Resident 76. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 21 residents sampled (Resident 2). Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on October 1, 2025, revealed it is the facility's policy to assist residents in maintaining or achieving the highest level of functioning through the intervention of restorative nursing. The policy indicates therapy will develop and recommend a plan of care, certified nursing aides are responsible for ensuring the program is performed per the plan of care, and the restorative nurse or designee will be responsible for overseeing the restorative aides. A clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that include chronic kidney failure (gradual loss of kidney function) and neuropathy (damage to the peripheral nervous system, which carries signals between the brain and the rest of the body). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 7, 2025, revealed that Resident 2 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A physical therapy Discharge summary dated [DATE], revealed discharge recommendations for Resident 2 to receive 24-hour care and a functional maintenance program (a program designed to help the resident maintain their current level of physical ability and prevent decline through routine, targeted exercises or activities) and restorative nursing program(a nursing-led program providing ongoing, repetitive exercises to help the resident maintain or improve physical function after skilled therapy ends). A review of Resident 2's plan of care revealed a focus indicating he would receive a restorative nursing program with active range of motion (AROM exercises in which the resident moves their own joints through their available range without assistance)) and passive range of motion (PROM exercises in which staff move the resident's joints for them because the resident cannot move the joints independently) initiated on September 29, 2025. The plan of care indicated Resident 2 would receive the following exercises: (1) 15 left lower extremity (LLE) AROM hip flexion repetitions for two sets(2) 15 abduction and adduction repetitions for two sets(3) 15 knee flexion and extension repetitions for two sets(4) 15 right lower extremity (RLE) AROM and PROM hip flexion repetitions for two sets(5) 15 abduction and adduction repetitions for two sets(6) 15 knee flexion and extension repetitions for two sets During an interview on November 12, 2025, at 11:20 AM, Resident 2 indicated that he no longer receives therapy services at the facility. He explained that he does not receive any restorative nursing program interventions such as passive range of motion (PROM) or active range of motion (AROM) exercises. Resident 2 indicated he has not had any restorative nursing exercises for over a month. A review of Resident 2's documentation survey report (an electronic health record that indicates tasks completed for resident care) dated November 2025, revealed the facility provided the resident with 15 to 30 minutes of active range of motion exercises on each day from November 1, 2025, through November 13, 2025. The document indicated that Employee 3, Nurse Aide (NA), provided Resident 2 with 15 minutes of active range of motion exercise on November 13, 2025, at 11:28 AM. During an interview on November 13, 2025, at 11:32 AM, Resident 2 indicated that he had not received any restorative nursing interventions that morning and he further stated he had not received any exercises with staff since therapy ended over a month ago. During an interview on November 13, 2025, at 11:44 AM, Employee 3 (Nursing Assistant) confirmed she did not provide Resident 2 with the 15 minutes of active range of motion exercises identified in his care plan. She acknowledged she documented the intervention as completed in the resident's medical record even though it had not been provided. Employee 3 confirmed it is not the facility's policy for staff to document completion of care plan interventions before they are carried out. During an interview on November 13, 2025, at 12:05 PM, the findings were reviewed with the Director of Nursing. The Director of Nursing confirmed it is not the facility's policy for staff to document care plan interventions as completed prior to implementation. The Director of Nursing acknowledged the facility did not ensure that Resident 2's restorative nursing program interventions were implemented as outlined in his plan of care and did not ensure that Resident 2 was provided with the services needed to maintain mobility to the extent possible. 28 Pa. Code: 211.5(f)(ix) Medical records. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for three residents out of the 21 residents sampled (Residents 28, 33, and 56) and failed to properly store resident hygiene and personal products in two out of three resident shower rooms (3rd and 4th floor shower rooms). Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on December 30, 2024, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds and indwelling medical devices are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates any resident who requires enhanced barrier precautions will have a blue circle sticker on their door (indicating gowns and gloves are required when providing any high-contact resident care activities). A clinical record review revealed Resident 28 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and chronic kidney disease (gradual loss of kidney function). A physician's order for Resident 28 to have isolation precautions-contact (interventions implemented to reduce the risk of spreading healthcare-associated infections) related to staphylococcus aureus MRSA (methicillin-resistant staphylococcus aureus- a bacteria resistant to antibiotic therapies) in urine initiated on December 29, 2024. An observation of Resident 28's room on January 7, 2025, at 11:15 AM, revealed no signs or postings identifying that Resident 28 was on enhanced barrier precautions or contact precautions. A clinical record review revealed Resident 33 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body). A physician's order for Resident 33 to have enhanced barrier precautions related to percutaneous endoscopic gastrostomy (PEG- an indwelling device that allows for the delivery of fluids, drugs, and nutrition to patients who are unable to eat orally) tube. An observation of Resident 33's room on January 7, 2025, at 11:59 AM, revealed no signs or postings identifying that Resident 33 was on enhanced barrier precautions. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (a bone infection). A physician's order for Resident 56 to have enhanced barrier precautions {related to indwelling urinary catheter} initiated on December 18, 2024. An observation of Resident 56's room on January 7, 2025, at 12:20 PM, revealed no signs or postings identifying that Resident 56 was on enhanced barrier precautions. During an interview on January 8, 2025, at 8:25 AM, Employee 1, Registered Nurse (RN), confirmed there was no signage or postings in Resident 28, 33, and 56's rooms or doorways indicating to staff that gown and gloves are required when providing any high-contact resident care activities. Employee 1, RN, indicated the rooms should be marked with a blue dot to indicate precautions are ordered and in place to prevent the spread of infections. During an interview on January 10, 2025, at approximately 9:00 AM, Employee 2, Infection Preventionist (IP), confirmed that Residents 28, 33, and 56's rooms should be identified to notify facility staff that additional personal protective equipment is required when providing any high-contact resident care activities in order to reduce the risk of spreading infections. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to fully implement infection control procedures, including transmission-based precautions, and enhanced barrier precautions. An observation on January 7, 2025, at 11:09 AM in the 3rd-floor shower room, revealed two packages of resident incontinence briefs, a hair dryer, and sanitizing wipes stored on the shower room floor. An observation on January 7, 2025, at 12:08 PM in the 4th-floor shower room revealed three packages of resident incontinence briefs and one package of opened resident sanitizing wipes stored in the shower room bathtub. Also, four packages of resident incontinence briefs, multiple loose incontinence briefs, and a hairdryer were observed on the shower room floor. During an interview on January 7, 2025, at 12:10 PM, Employee 1, Registered Nurse (RN), confirmed the resident briefs and wipes should not be stored directly on the shower room floors or in the shower room bathtub. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to fully implement infection control procedures, including the proper storage of resident hygiene and personal products to reduce the risk of spreading infections. The facility failed to ensure proper storge of these products by storing them on the floor. This practice poses a significant risk of contamination from dirt, dust and microbial pathogens compromising the cleanliness of these items. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa code 211.12 (d)(1)(5) Nursing services.

Based on a review of clinical records, facility-provided manufacturers' medication information, and staff interviews, it was determined the facility failed to demonstrate the physician timely acted upon irregularities identified by pharmacy services during drug regimen reviews for one resident out of the five sampled (Resident 56). Findings include: A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (a bone infection) and gastro-esophageal reflux disease (GERD- a digestive disorder that occurs when stomach acid flows into the esophagus). A clinical record review revealed a pharmacy note to the attending physician or prescriber dated November 4, 2024, indicating that Resident 56 was prescribed sucralfate (an antiulcer medication) one gram every six hours for GERD. The note indicated the medication is usually administered on an empty stomach prior to meals and/or bedtimes to assure disintegration in the stomach acid and binding to stomach mucosa, forming a protective layer. If clinically appropriate for this patient, consider altering times of administration. A physician's response to the pharmacist indicating disagreement that Resident 56 has a gastrointestinal bleed. However, the response failed to address the pharmacist's recommendation for medication administration times to match the medication's manufacturer's direction. A review of facility provided medication information for sucralfate revealed recommended instructions for medication administration was 1 hour prior to meals and given on an empty stomach 1 hour before meals. A medical record review revealed no changes to physician's orders following recommendations by the pharmacist. A physician's order for Resident 56 to receive Carafate tablet 1 GM (sucralfate-an anti-ulcer medication) with direction to give 1 gram by mouth every six hours for gastric protection was initiated on December 17, 2024. During an interview on January 9, 2025, at approximately 10:00 AM, Employee 3, CRNP, indicated she reviewed the recommendation made by the pharmacist note from November 4, 2024. Employee 3, CRNP, was not able to provide a clinical rationale for disagreeing to consider altering times of Resident 56's sucralfate administration. Following questions asked during the survey, Resident 56's physician's order for sucralfate was revised to include recommendations indicated by the pharmacist from November 4, 2024. A clinical record review revealed a physician's order for Resident 56 to receive Carafate tablet 1 GM (sucralfate-an anti-ulcer medication) with direction to give one gram by mouth before meals and at bedtime for gastric protection initiated on January 9, 2025. During an interview on January 10, 2025, at approximately 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility to ensure the physician timely acts upon irregularities identified by pharmacy services during drug regimen reviews. 28 Pa. Code 211.2 (d)(3)(9) Medical Director

Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 21 sampled (Resident 22). Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of cerebral infarction (a pathological process, also known as ischemic stroke, the result of disrupted blood flow to the brain) and essential hypertension (high blood pressure). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2024, revealed that Resident 22 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition ). A review of Resident 22's clinical record revealed a physician's order dated October 22, 2024, for [NAME] Stockings (Thrombo-Embolus deterrent compression stockings, or anti-embolism stockings, which are specially designed to help reduce the risk of developing deep vein thrombosis (DVT) or blood clots in your lower leg after surgery) to be on in the morning and removed in the evening. During a resident interview on January 7, 2025, at 10:29 AM, Resident 22 reported that staff did not assist her with applying her TED stockings that day, despite a physician's order requiring their use. Observations made on January 7, 2025, at 10:29 AM and 1:39 PM revealed that Resident 22 was not wearing her TED stockings as ordered. A review of Resident 22's January 2025 Treatment Administration Record revealed that staff documented the TED stockings were applied at 6:00 AM on January 7, 2025. This documentation was inconsistent with the resident's statements and observed findings. On January 8, 2025, at 10:30 AM, Resident 22 stated she had to remind the nurse on duty to apply her TED stockings, indicating a lack of adherence to the prescribed care plan. She explained that if she does not tell the nurse, then they do not apply her TED stockings. On January 9, 2025, at 1:30 PM, the Director of Nursing confirmed that staff did not consistently follow the physician's orders regarding the application and removal of Resident 22's TED stockings. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services

Based on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure that Minimum Data Set Assessments accurately reflected the status of three residents out of 21 sampled (Residents 34, 8, and 31). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section K0300 Weight Loss the facility is to record loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A clinical record review revealed Resident 34 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 31, 2024, indicated in Section K0200 that the resident's height was 64 inches and weight was 163 pounds. Review of Section K0300 indicated that Resident 34 did not experience a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of Resident 34's Weight Record revealed that on April 3, 2024, the resident weighed 181.2 pounds. On October 5, 2024, the resident weighed 163 pounds which is indicative of a 10.04 % significant weight loss in 6 months. During an interview on January 9, 2025, at 11:30 AM the Registered Dietitian (RD) confirmed that Resident 34 did experience a 10.04% weight loss between April 3, 2024, and the quarterly MDS assessment dated [DATE], Section K0300 was inaccurate. A clinical record review revealed that Resident 8 was admitted to the facility on [DATE]. A review of an annual MDS assessment dated [DATE], indicated in Section A1600 Most Recent Admission/Entry or Reentry into the facility noted the most recent entry date into the facility was July 4, 2024, and Section A 1700 Type of Entry indicated admission. Further review of the clinical record revealed that Resident 8 was transferred to the hospital on June 29, 2024, and readmitted to the facility on [DATE]. During an interview with the Registered Nurse Assessment Coordinator (RNAC) on January 10, 2024, at 10:30 AM confirmed that the annual MDS assessment dated [DATE], Section A 1700 Type of Entry was not accurate and was incorrectly coded as admission instead of reentry. A clinical record review revealed that Resident 31 was admitted to the facility on [DATE]. A review of an admission MDS dated [DATE], Section N Medications N 0350, Insulin indicated Resident 31 received one insulin injection in the last seven days. Further clinical record review revealed no other documented evidence that Resident 31 was administered any insulin injections in the last seven days. The MDS was coded as the resident receiving insulin despite no physician order. During an interview on January 8, 2024, at 12:40 PM the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident 31 did not receive insulin as indicated in Resident 31's MDS assessment dated [DATE], Section N 0350 Medications, Insulin. The RNAC confirmed the admission MDS assessment dated [DATE], was coded in error as it relates to insulin. 28 Pa. Code 211.5(f)(i) Medical records. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of select facility policy and controlled drug records, observation and staff interview, it was determined that the facility failed to implement procedures to promote accurate medication administration, and records accounting for controlled drugs for one of three residents sampled (Resident 57), and reconciliation of controlled drugs on three of three medication carts (4th, 2 east, and 2 west). Finding include: A review of the facility policy Medication storage, controlled medication last reviewed by the facility [DATE], indicated that at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on the controlled substances accountability record. Observation of the medication administration pass, on [DATE], at approximately 9:50 AM, revealed Employee 1, Licensed Practical Nurse (LPN), on the 4th floor medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 4th floor, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: [DATE], and 9, 2024, and February 22, 2024. Interview with Employee 1, LPN, on [DATE], at approximately 9:59 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed, and that the expectation is that it should have been signed by nursing staff according to facility policy During the observation of the medication administration pass, on [DATE], at approximately 10:10 AM, revealed Employee 2, Licensed Practical Nurse (LPN), on the 2nd floor East medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 2nd floor East, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 23, 2024. Interview with Employee 2, LPN, on [DATE], at approximately 10:21 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed to verify that nursing staff had counted the controlled drugs. During the observation of the medication administration pass, on [DATE], at approximately 10:38 AM, revealed Employee 3, Licensed Practical Nurse (LPN), on the 2nd floor [NAME] medication cart. A review of the shift-to-shift accountability forms, titled controlled substance signature sheet, for the 2nd floor West, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify that nursing staff counted the controlled drugs in the respective medication cart: February 29, 2024, and [DATE]. Interview with Employee 3, LPN, on [DATE], at approximately 10:46 AM, confirmed the above observation that the shift to shift, controlled substance record was not signed by nursing staff A review of Resident 57's clinical record revealed admission to the facility on [DATE], with diagnoses to include anxiety, and hypertensive heart disease. The resident had a physician order dated [DATE], for admission to hospice care for a diagnosis of end stage hypertensive heart disease. The resident had a physician orders dated, [DATE], for Dilaudid (Hydromorphone HCL -an opioid pain medication) oral liquid, 1 milligram (mg)/ milliliter (ml), give 1 ml by mouth every 6 hours for pain management and Lorazepam (an antianxiety medication) oral concentrate 2 mg/ml. Give 0.25 ml by mouth every 6 hours for anxiety/restlessness. A nursing note dated [DATE], 0135 hours (1:35 AM), indicated that the resident had expired. The individual resident's controlled substance record, accounting for Resident 57's supply of Lorazepam, 0.25 ml revealed 30 mls had been received from pharmacy for the resident's use. On [DATE], 0000 hours (12:00 AM), a dose given 0.25 ml was given with the amount remaining 25.75 ml. The disposition of the remaining doses, and quantity was not recorded. The individual resident's controlled substance record, accounting for Resident 57's supply of Dilaudid, Hydromorphone HCL, give 1 ml by mouth every 6 hours for pain management, revealed 120 mls was received from pharmacy for the resident's use. The record revealed no evidence that a dose had been administered. The controlled substance record did not identify the disposition of the amount and doses remaining upon the resident's discharge. During an interview with the Director of Nursing (DON) on [DATE], at approximately 10:15 AM, that the controlled substance record should accurately reflect accounting, use and amount awaiting final disposition/disposal. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure necessary resident information was communicated to the receiving health care provider for four transferred residents out of five sampled residents (Residents 11, 13, 36, and 45). Findings include: A review of Resident 36's clinical record revealed that the resident was transferred to the hospital on September 16, 2023, and returned to the facility on [DATE]. A review of Resident 11's clinical record revealed that the resident was transferred and admitted to the hospital on September 19, 2023, and returned to the facility on [DATE]. A review of Resident 13's clinical record revealed the resident was transferred from the facility and admitted to the hospital on January 10, 2024, and returned to the facility on [DATE]. A review of Resident 45's clinical record revealed the resident was transferred from the facility and admitted to the hospital on February 5, 2024, and returned to the facility on [DATE]. Further review of the above clinical records revealed no documented evidence of the information communicated to the receiving health care facility upon the residents' transfer to the hospital. An interview with the director of nursing on March 6, 2024, at 9:00 AM, confirmed that the facility was unable to provide documented evidence that all special instructions or precautions for ongoing care, as appropriate, and comprehensive care plan goals were communicated to the receiving health care facility. 28 Pa. Code 211.5 (f) Medical records

Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean environment on one of two nursing units (Nursing Unit 2). Findings include: An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:26 AM revealed a 2-inch brown/tan stain on the wall in the resident's bathroom, near the call bell and several brown/tan substance droplets on the wall to the left of the call bell. Brown/red stains were observed on the floor to the left of the toilet. A buildup of dirt and debris was observed along the edge of the bathroom floor. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:35 AM revealed tan discolored rings on two ceiling blocks with and a black and gray substance on one ceiling block An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:40 AM revealed tan discolored stains on nine ceiling blocks. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 10:55 AM revealed tan discolored stains on three ceiling blocks and two ceiling blocks stained with a black and gray substance. An observation in resident room [ROOM NUMBER] on March 5, 2024, at 11:00 AM revealed brown stains on the window blinds. An observation in the Unit 2 resident shower and bathing room on March 5, 2024, at 11:48 AM revealed strands of white and black hair were observed in the drain in the large white bathtub. Multiple strands of hair and debris were also observed in the tub basin. A light gray pool of water and debris was observed on the shower floor. Hair strands were observed in the first shower floor drain. A clump of hair and a tan piece of paper were observed in a second shower floor drain. Dark hair strands were also observed on the tile shower floor. An observation of resident room [ROOM NUMBER] on March 5, 2024, at 11:55 AM revealed dark tan discolored stain rings on five ceiling blocks During an interview on March 6, 2024, at approximately 11:15 AM, the Facility Maintenance Manager explained that the ceiling tiles were discolored and stained due to condensation on the piping above the residents' rooms that was dripping onto the ceiling tiles. During an interview on March 7, 2024, at approximately 12:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility should be maintained in a clean and sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management

Based on observation, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three of the five residents attending a group meeting (Residents 1, 7, and 23) and two out of the 17 residents sampled (Residents 13 and 23). Findings include: A clinical record review revealed that Resident 13 had diagnoses, which included congestive heart failure (a chronic condition in which the heart does not pump enough blood). A review of the resident's annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 22, 2024, indicated that Resident 13 is moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). An observation of Resident 13's room on March 7, 2024, at 10:45 AM revealed that the nurse call light above Resident 13's door was lit indicating that the resident's call bell was activated. Observation at this time of the call bell alert system located at the nurses station revealed that the call bell began ringing at 10:29 AM (16 minutes). An interview with Resident 13 during the observation revealed that her call bell had not yet been answered and that she needed staff assistance to be toileted. Resident 13 stated that it often takes staff between 20 and 45 minutes for the call bell to be answered and assistance provided because the staff are busy. Following this interview, and the surveyor informed Employee 3, LPN, of the resident's unmet toileting need and at that this time staff assistance was provided. A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included lumbar vertebra fracture and heart failure. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 23 is cognitively intact with a BIMS score of 15. During an interview on March 5, 2024, at 12:00 PM, Resident 23 indicated that she experiences long wait times for staff after ringing her call bell for assistance. She explained that she sometimes waits for 20 minutes before staff respond. During a resident group interview with residents on March 6, 2024, at 10:00 AM, three of the five residents in attendance (Residents 1, 7, and 23) stated that they have experienced long wait times for staff to respond to their call bells and requests for assistance. During the resident group interview on March 6, 2024, Resident 1 stated that she frequently experienced long waits for staff to respond to her requests for assistance via the nurse call bell system. She explained that it is a problem when she needs to go to the bathroom because she is unable to remain continent when she feels the urge to go. Resident 1 stated that she has waited 35 to 40 minutes for staff to respond to requests for assistance. Resident 1 also stated that after staff assist her to the toilet, it may take another 35-40 minutes for them to come back to assist her from the toilet. She explained that staff response is the worst during the day shift of nursing duty. During the resident group interview on March 6, 2024, Resident 7 stated that she waits 25 to 30 minutes for staff assistance after ringing her call bell. Resident 7 explained that she experiences the longest wait times on the night shift. During the resident group interview on March 6, 2024, Resident 23 stated that she experiences long waits for staff to respond to her call bell and provide needed assistance. She explained that she sometimes waits for 20 minutes before staff respond to her call bell and the longest wait times occur on the night shift. During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect, including timely response to their requests for assistance The DON was unable to explain why multiple residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(4)(5) Nursing services

Based on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for two out of the 17 residents sampled (Resident 15; Resident room [ROOM NUMBER], Resident 13 room [ROOM NUMBER]). Findings include: A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment. Observation on March 5, 2024, at 11 AM revealed that Resident 15 did not have a roommate and resided in resident room [ROOM NUMBER]. During an interview and observation on March 5, 2024, at 11:00 AM, Resident 15 stated that she was worried that people could see in through her room window at night and when staff were assisting her with clothing changes or providing personal care. She explained that she was concerned that her window blinds would not close completely. An observation at the time of the interview in resident room [ROOM NUMBER] revealed a window that measured approximately 5.0 feet tall x 10.0 feet wide, covered by multiple 3-inch vertically hanging blinds. When in the closed position, some of the blind slats remained open, creating a line of sight into and out of the room. A courtyard and other facility windows were visible through the opening in the blinds. Further observation revealed that the window blinds were missing slats. During an additional observation on March 7, 2024, at 8:35 AM, Employee 2, Licensed Practical Nurse, confirmed that the vertical blinds in resident room [ROOM NUMBER] would not fully close allowing for a line of sight into and out of the room. Observation of Resident room [ROOM NUMBER] on March 6, 2024, at approximately 10:00 AM revealed that the vertical window blinds were partially opened and one of the slats was twisted. Observation at this time also revealed that when the blinds were fully closed the middle slat was missing. Interview with Resident 13 at this time revealed that the middle slat has been missing for a while. Resident 13 stated that the missing slat prevented her from having full privacy (from the outside) when the blinds are closed. During an interview on March 7, 2024, at 9:00 AM, the Director of Nursing (DON) confirmed that each resident room should be designed and equipped to assure privacy. The DON indicated that action would be taken to ensure Resident 15 and Resident 13's room window blinds were functioning properly and providing full privacy. 28 Pa Code 201.18 (e)(2.1) Management

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to maintain the mobility and functional abilities of one of the 17 residents sampled (Resident 15). Findings included: A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include encephalopathy (dysfunction in brain processes including attention, cognition, and consciousness) and pneumonia. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care, dated January 25, 2024, revealed that Resident 15 is severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 severe cognitive impairment. During an interview on March 5, 2024, at 11:00 AM, Resident 15 stated that she was not currently receiving restorative nursing services. A clinical record review revealed a Physical Therapy (PT) Discharge Summary dated February 22, 2024, which indicates that Resident 15 was discharged from skilled physical therapy at this time because her highest practical level of functioning was achieved. The PT discharge summary indicated that Resident 15 was provided skilled services to improve the resident's ability to transfer, balance, ambulate, and improve her overall functional status. The PT discharge summary further noted that to maintain Resident 15's current level of performance and to prevent decline, development of, and instruction in an ambulation restorative nursing program, was completed with the resident's interdisciplinary team. Further review of the resident's clinical record, conducted during the survey ending March 7, 2024, revealed no documented evidence that restorative nursing program was developed and implemented for Resident 15 following discharge from skilled therapy. During an interview on March 7, 2024, at 12:00 PM, the Director of Nursing (DON) confirmed that the failed to provide restorative nursing services to Resident 15 as recommended upon discharge from skilled therapy. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on observation, review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to timely and effectively monitor a resident's use of a therapeutic device to preserve skin integrity and prevent pressure sore development, which resulted in the development of an avoidable pressure sore by one resident out of three reviewed (Resident 53). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of Resident 53's clinical record revealed she was admitted to the facility on [DATE], with diagnoses of included motor vehicle collision, fractures of the nasal bone, multiple right sided rib fractures, left thumb, patella (knee), right bimalleolar (ankle) fractures. An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 12, 2024, revealed that the resident was cognitively intact, had impairment on both lower extremities with functional range of motion, and was dependent on staff for toileting, lower body dressing, and putting on/taking off footwear. The resident's care plan indicated she was at risk for potential for or actual skin breakdown related to alteration in mobility, initiated January 5, 2024, with a goal that the resident will comply with therapeutic regimen, including preventative measures and nutritional interventions through next review, with a target date of April 18, 2024. Planned interventions included pressure redistribution cushion to chair as ordered, pressure redistribution mattress to bed, turn and re-position per schedule, employ good transfer technique to avoid friction, and skin checks at least weekly on scheduled bathing days, date initiated, January 5, 2024. The resident's care plan also indicated that a skin breakdown or interference with structural integrity of layers of skin on left inner heel, caused by pressure from device worn by resident initiated January 11, 2024, and resolved on February 21, 2024. The goal was that the area will improve with no signs of infection by April 18, 2024, resolved on February 21, 2024. Planned interventions, included suspected deep tissue injury (DTI) left inner heel with treatment as ordered, remove immobilizer left lower extremity for skin check, initiated January 11, 2024, and treatment to area, which will provide padding and protect area until healed initiated January 12, 2024. A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated January 5, 2024, revealed that the resident scored a 19, indicating the resident was very low or no risk for pressure sore development. A review of a nursing note, a late entry by a CRNP, dated January 9, 2024, 5:48 PM, reflecting an admission visit with the resident indicated that the resident has a brace LLE (left lower extremity) and a soft cast to the right ankle. The entry noted that the resident required assistance with activities of daily living. A nursing note dated January 10, 2024, 2:31 PM, revealed that during routine wound rounds by nurse, the resident complained of a burning feeling to the left heel. The immobilizer was removed for a skin check and the nurse found a discolored area to the left inner heel. A physician order dated January 10, 2024, was noted for staff to remove the immobilizer left lower extremity for skin check every shift. Cleanse left inner heel with soap water, pat dry, apply skin prep and dry dressing daily and as needed for soiling or dressing displacement. An incident report dated January 10, 2024, at 2:25 PM, revealed that the resident was complaining of burning feeling to left heel. Immobilizer removed for skin check, discolored area noted left inner heel. Immobilizer removed and deep tissue injury (DTI) was noted to the inner aspect of her heel. New treatment order received. The facility noted, however, that the pressure area was unavoidable as the immobilizer necessary for bone healing. New treatment will provide padding and protect area while immobilizer is in place. Review of witness statement, pressure injury/MASD by Employee 4 (Licensed Practical Nurse - LPN), dated January 11, 2024, revealing that vascular checks had been performed, and no area noted at time. The witness statement pre-typed question asked: did you see anything in the environment that could have contributed to the area? If yes, explain: immobilizer. A review of the resident's Treatment Administration Record (TAR), for January 2024, revealed the task of removing the left lower extremity (LLE) immobilizer for skin checks, was not initiated until January 10, 2024, five days after the resident's admission and the day the resident's pressure sore was discovered. A review of facility wound-skin healing record, dated February 14, 2024, indicated that the resident's pressure injury, DTI, left inner heel, measured 4.0 (cm) x 2.0 cm x 0 cm. No exudate (drainage), no odor, no s/s infection. Two small areas of intact purple/maroon discolored skin separated by flesh tone skin edges, normal in appearance, surrounding skin normal in temp. A review of a wound consultant note dated February 20, 2024, indicated the resident's left heel pressure sore was s now resolved. Interview with Employee 5 (Registered Nurse, Assistant Director of Nursing) on March 7, 2024, at approximately 9:50 AM, confirmed the resident's January 2024 TAR failed to identify the removal of the left lower extremity immobilizer, to check the integrity of the resident's skin to prevent pressure sore development, until after the pressure ulcer/injury was identified. Interview with Resident 53 on March 7, 2024, at approximately 11:05 AM, indicated she had been experiencing discomfort in her left heel, for a brief period of time, so she alerted staff. Observation of the left inner heel on March 7, 2024, at approximately 11:10 AM, with the resident's approval, and in the presence of Employee 6 (LPN), revealed an intact, slightly reddened, small, circular area. The area measured 1 cm x 1.5 cm (as measured by Employee 6 LPN). During the observation the resident displayed and vocalized no pain and or discomfort. The facility was unable to provide documented evidence that staff had timely and consistently conducted skin integrity checks under the brace prior to the development of this unstageable DTI to promptly identify declines in skin integrity and prevent the development of the deep tissue injury. During an interview with the Director of Nursing (DON) on March 7, 2024, at approximately 10:15 AM, confirmed that the facility was unable to demonstrate that staff had timely implemented consistent removal of the immobilizer to conduct checks the integrity of the resident's skin and there was no evidence that this task was completed until after the pressure ulcer/injury was identified. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on record review and interview, it was determined that the facility failed to submit accurate staffing information in the Payroll-Based Journal (PBJ) system for two of the four quarters reviewed (October 1, 2023, through December 31, 2023, and July 1, 2023, through September 30, 2023). Findings include: A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 4 2023 (July 1 - September 30) revealed that the facility's data triggered for no registered nurse (RN) hours on August, 5, 2023, August 6, 2023, August 27, 2023, September 2, 2023 and September 4. 2023. A review of the Payroll-Based Journal (PBJ) Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D for fiscal year quarter 1 2024 (October 1 - December 31) revealed that the facility's data triggered for no registered nurse (RN) hours on October 1, 2023, October 14, 2023, November 18, 2023, November 19, 2023, November 23, 2023, and November 25, 2023. A review of staffing time sheets and daily nurse assignment sheets revealed that the facility had RN staffing working on each date that triggered for no RN hours on the PBJ Staffing Data Reports. During an interview on March 7, 2024, at approximately 10:00 AM, the facility [NAME] President of Skilled Nursing Operations indicated that the PBJ trigger for no RN hours was due to a coding error that occurred when the facility updated their system to identify charge nurses. He explained that charge nurses were added to the facility's reporting system in July of 2023, but the facility failed to code the charge nurses as registered nurses for submissions through the PBJ system. 28 Pa. Code 201.18 (e)(2) Management

Based on a review of clinical records and the facility's bed hold policy and staff and family interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy, to include the duration and reserve bed payment, to a resident's resident's representative upon the resident's transfer to the hospital for one resident out of six sampled (Resident CR1). Findings include: A review Resident CR1's clinical record revealed admission to the facility on [DATE]. The resident was severely cognitively impaired with a BIMS score of 4 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information) and a diagnosed intellectual disability. Resident CR1 was transferred to the hospital on August 24, 2023. Interview with the resident's representative on September 11, 2023, that upon the resident's admission to the facility he was provided a copy of the facility's bed hold policy, but he was not provided a second notice at the time of Resident CR1's transfer, or within 24 hours. He confirmed that he was not provided written information that explained the duration of bed-hold, if any, the reserve bed payment policy and addressing permitting the return of resident to the next available bed in the facility. There was no documented evidence that the facility provided the representative of the cognitively impaired resident with an intellectual disability, written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) at the time of transfer, or within 24 hours, detailing the duration of bed-hold, if any, and the reserve bed payment policy and addressing permitting the return of residents to the next available bed. Interview with the business office manager (BOM) on September 11, 2023, indicated that the facility provides the bed hold information to residents and/or their representatives upon admission. However, the BOM stated she was unaware that the facility was required to provide a second notice at the time of transfer . Interview with the Nursing Home Administrator on September 11, 2023, at approximately 3:35 PM confirmed the facility did not provide written notice of the facility's bed hold policy to the resident's representative upon Resident CR1's transfer to the hospital. The NHA stated that a copy of the facility's bed hold policy is sent with the resident upon transfer, but is not provided to the resident's representative if the resident is cognitively impaired. responsible party if the resident is not capable. The NHA also verified that the information regarding the facility's bed hold policy does not include the duration, costs and permitting the resident to return to the facility. 28 Pa Code 201.18 (e)(1) Management 28 Pa Code 201.29 (b)Resident rights