Every finding on record at Belle Terrace

Based observations and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. (Unit B)Findings include: Observations on June 17, 2026, at 10:30 a.m., and 1:45 p.m., revealed that the grab bars on the left side of the toilets in the bathrooms of rooms B 48 and B 52 were loose. In an interview on June17, 2026, at 2:30 p.m., the Administrator confirmed the grab bars in the bathrooms in rooms B 48 and B 52 needed to be repaired. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to maintain the environment in a clean, comfortable, and homelike manner on two of two nursing units. (A and B wing)Findings include: Observations on December 3, 2025, from 10:45 a.m. through 2:00 p.m., and on December 4, 2025, from 10:45 a.m. through 2:00 p.m., revealed the following environmental issues: In the shower room on A wing, the first room to the right of the door had a sink with brown stains and the faucet had white stains on it. The toilet had a black ring inside. In the shower room's central shower area, there were open holes in the wall around the shower valve system where the water flow and temperature were controlled. The bathtub room to the left of the central hallway had a marred wall on the left back side of the room, the bathtub had blue and brown stains inside, around the drain, and on the side wall by the faucet. The bathtub faucet had white stains. The shower stall in the back of the shower room had a brown ring around the floor where the floor met the wall and a large gray stain on the floor. In the bathroom shared by resident rooms [ROOM NUMBERS], there were stains on the mirror, a brown ring on the toilet base, a marred wall behind the toilet, a used brief opened and laying across the top of the bathroom garbage can, and pieces of paper garbage on the floor. In resident room [ROOM NUMBER] (bed 1), there were four plastic wrappers and a large syringe (no needle) on the floor. The clock was displaying the wrong time. In the hallway between resident rooms [ROOM NUMBERS], there was a hole in the wall. In resident room [ROOM NUMBER] (bed 1), there was a plastic lid, tissue, and paper debris on the floor. In resident room [ROOM NUMBER] (bed 1), there was a full can of garbage and paper and food debris on the floor around the bed. In the bathrooms of resident rooms [ROOM NUMBERS], there were marred walls along the length of the wall adjacent to the toilet. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 14 sampled residents. (Resident 19) Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed on November 20, 2025, revealed that residents had the right to self-administer medications if the staff and practitioner determined it was clinically appropriate for residents to do so. Clinical record review revealed that Resident 19 had diagnoses that included chronic obstructive pulmonary disease (COPD) and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated October 10, 2025, revealed that the resident's cognitive ability was intact and that he used oxygen. On October 31, 2025, a consulting specialist physician recommended that Resident 19 start taking an inhaler medication to treat COPD daily and that the patient must have this inhaler in his room to be taken immediately upon awakening. The attending physician noted that he agreed with this recommendation. A review of Resident 19's medication administration record revealed a physician's order dated October 31, 2025, and updated November 14, 2025, directing staff to administer one puff of the inhaler in the morning at 7:00 a.m. There was no indication that Resident 19 was evaluated to self-administer his inhaler medication prior to December 4, 2025. On, December 4, 2025, at 12:05 p.m., Resident 19 was observed sitting in a wheelchair in his room. In an interview at that time, Resident 19 stated that the inhaler medication was not readily available and was locked in the medicine cart. The resident stated that the specialist told him to self-administer it when he awakened. Resident 19 stated that he was very frustrated with the nursing staff for not following the physician's recommendation. In an interview on December 5, 2025, at 12:30 p.m., the Director of Nursing confirmed that the resident was not assessed to self-administer the medication as per the facility policy and the physician's orders prior to December 4, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of two of 14 sampled residents. (Residents 1 and 4) Findings include: Clinical record review revealed that Section C (Brief Interview for Mental Status) of Resident 1's MDS assessment dated [DATE], was incomplete. In an interview on December 3, 2025, at 9:00 a.m., the Administrator confirmed that Resident 1's MDS assessment was incomplete. Clinical record review revealed that Resident 4 received hospice services starting on November 13, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving hospice services during the previous seven days. In an interview on December 3, 2025, at 9:59 a.m., the Director of Nursing confirmed that Resident 4's MDS assessment was inaccurate.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 14 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included depression. According to the Minimum Data Set Care Area Assessment summary dated January 22, 2025, the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration record from January through December 2025, revealed the resident received an antidepressant (trazodone) during the review period. There was no documented evidence that interventions to address Resident 1's psychotropic drug use were included in the current care plan. In an interview on December 5, 2025, at 10:00 a.m., the Director of Nursing confirmed there was no documented evidence that the care area was addressed Resident 15's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, observation, and staff and resident interviews, it was determined that the facility failed to accommodate food preferences for one of 14 sampled residents. (Resident 54)Findings include:Review of the facility's weekly menu revealed that the lunch meal for December 3, 2025, was spaghetti noodles with meat, breadstick, tossed salad, and fruit cocktail. Clinical record review revealed that Resident 54 had diagnoses that included anxiety, gastroesophageal reflux disease, and major depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and able to make her needs known. During an interview on December 3, 2025, at 12:25 p.m., Resident 54 stated that her meals did not match what was on her ticket and she received foods she did not like. On December 3, 2025, at 12:30 p.m., her lunch tray was observed on her bedside table and had spaghetti noodles and meat sauce. Resident 54 stated that she did not like pasta, did not want spaghetti noodles, and would not eat them. The resident's tray card indicated that the resident was on a regular diet and did not like pasta.In an interview on December 5, 2025, at 9:00 a.m., the Administrator stated that the dietary department did not follow Resident 54's food preferences identified on the meal ticket. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and use of personal protective equipment (PPE) to prevent the spread of infection for one of four sampled residents observed during medication administration. (Resident 4)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on November 20, 2025, revealed that staff was to wear a gown and gloves during high contact resident care activities, such as using the resident's feeding tube and for residents with indwelling medical devices to minimize the spread of multidrug resistant organisms. Clinical record review revealed that Resident 4 had diagnoses that included dysphagia (difficulty swallowing) and lung cancer. Review of the Minimum Data Set (MDS) assessment, dated November 18, 2025, revealed that Resident 4 had an enteral feeding tube (a soft plastic tube inserted into the digestive system used to provide nutrition directly through the stomach.) On November 3, 2025, a physician's order directed staff to implement enhanced barrier precautions every shift for infection control. Review of the care plan revealed that Resident 4 received his nutrition and medications through the feeding tube and staff was to follow enhanced barrier precautions when providing care. Observations on December 4, 2025, from 9:15 a.m. to 9:30 a.m., revealed licensed practical nurse (LPN) 1 gave Resident 4 medications and food through Resident 4's feeding tube. LPN 1 did not wear a gown while providing care related to the feeding tube in accordance with the facility policy. In an interview on December 5, 2025, at 8:37 a.m., the Administrator confirmed that LPN 1 should have worn a gown when providing care related to Resident 4's feeding tube. CFR 483.80 Infection ControlPreviously cited 12/28/23, 8/1/24, 1/16/25 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, atrial fibrillation (irregular rapid heart rhythm that can lead to bloods clots or a stroke), muscle weakness and angiodysplasia of the stomach and duodenum (an abnormality characterized by dilated, fragile blood vessels). The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and had pulmonary hypertension (high blood pressure that affects the arteries in the lungs). On April 3, 2025, there was a physician's order that directed staff to schedule a chest X-ray for Resident 1 related to pleural effusion hypoxia (excessive fluid build-up in the lungs), and a physician's order dated April 7, 2025, that directed staff to obtain a stool specimen to rule out clostridium difficile (a bacterial infection of the colon). There was no documented evidence that the chest X-ray was completed, and that the stool specimen was obtained as ordered. In an interview on April 23, 2025, at 2:20 p.m., the Director of Nursing confirmed there was no documented evidence that Resident 1's chest X-ray and stool specimen were completed as ordered. CFR 483.25 Quality of care. Previously cited 8/10/24, 1/16/25 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, observation, and interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for three of eight sampled residents. (Residents 1, 2, 3). Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, atrial fibrillation (irregular rapid heart rhythm that can lead to bloods clots or a stroke), muscle weakness, pulmonary hypertension (high blood pressure that affects the arteries in the lungs), and angiodysplasia of stomach and duodenum (an abnormality characterized by dilated, fragile blood vessels). According to the Minimum Data Set (MDS) assessment, dated March 19, 2025, the resident was at risk for pressure ulcers, had limited mobility of her lower legs, and could communicate her needs. On March 12, 2025, a physician's order directed staff to apply heel boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown related to immobility. Multiple observations on April 23, 2025, between 11:30 a.m. and 1:20 p.m., revealed Resident 1 in bed and the heel boots were not applied. Clinical record review revealed that Resident 2 had diagnoses that included vascular dementia (brain damage from impaired blood flow to the brain) diabetes, heart disease, and muscle weakness. The MDS assessment dated [DATE], revealed that the resident was nonresponsive and was at risk for pressure ulcers. On April 20, 2025, a physician's order directed staff to apply Prevalon boots (devices that help reduce the risk of heel pressure injury). Review of the comprehensive care plan revealed that the resident had diabetes and was at risk for skin breakdown related to immobility and medical condition. Multiple observations on April 23, 2025, between 11:20 a.m. and 1:30 p.m., revealed Resident 2 in bed and the Prevalon boots were not applied. Clinical record review revealed that Resident 3 had diagnoses that included diabetes and muscle weakness. The MDS assessment dated [DATE], revealed that the resident was at risk for pressure ulcers and could communicate her needs. On March 29, 2024, the physician's order directed staff to float heels (elevate the lower legs so the heels don't touch the bed) while in bed. On April 23, 2025, at 11:30 a.m., the resident was observed with her heels directly on the bed. In an interview on April 23, 2025, at 2:20 p.m., the Director of Nursing confirmed that Residents 1 and 2 did not have the devices to protect their skin to prevent heel pressure injuries and that Resident 3's lower legs were not elevated as ordered. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, employee file review, and staff interview, it was determined that the facility failed to initiate an employee criminal background check, verify professional license/registration, and/or ensure employees completed required abuse training in a timely manner for six of six newly hired employees. (Employees RN 1, RN 2, RN 3, NA 1, NA 2, DA 1) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, last reviewed October 10, 2024, revealed that the facility was to screen potential employees for a history of abuse, neglect, or mistreating residents prior to employment. This included attempts to obtain information from previous employers and checking with the appropriate licensing boards and registries. The facility was also to educate staff upon hire and annually thereafter regarding the facility's policy to prevent Abuse, Neglect, and Exploitation of residents, and Misappropriation of Resident Property. Review of employee files revealed the following: NA 1 had been working at the facility as a nurse aide since October 21, 2024. The facility failed to conduct a criminal background check. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. NA 2 had been working at the facility as a nurse aide since December 6, 2024. The facility failed to conduct an inquiry to the State nurse aide registry. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. RN 1 had been working at the facility as a registered nurse since August 14, 2024. The facility failed to collect employment references. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. RN 2 had been working at the facility as a registered nurse since January 6, 2025. The facility failed to conduct an inquiry to the State licensing authority or gather employment references. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. RN 3 had been working at the facility as a registered nurse since August 12, 2024. The facility failed to conduct a criminal background check, an inquiry to the State licensing authority, or gather employment references. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. DA 1 had been working at the facility as a dietary aide since December 9, 2024. There was a lack of evidence to support that required training to prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property had been completed upon hire. In an interview on January 16, 2025, at 1:20 p.m., the Administrator confirmed that pre-employment screening and required training had not been completed in a timely manner as per facility policy for the newly hired employees listed above. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19(3)(7)(8) Personnel policies and procedures.

Based on clinical record review, and family and staff interview, it was determined that the facility failed to provide ostomy (an opening of the bowel through the abdomen), care in accordance with the resident's care plan for one of one sampled resident who had an ostomy. (Resident 158) Findings include: Review of a facility policy entitled, Colostomy/Ileostomy Care, last reviewed October 10, 2024, revealed that staff were to document the date and time the ostomy care was provided, as well as, the name and title of the person who provided the care in the resident's medical record. Clinical record review revealed that Resident 158 was admitted to the facility on [DATE], and had a diagnoses that included Dementia. Review of the care plan revealed that the resident had an ileostomy. The interventions were for staff to keep the skin around the stoma clean and dry, monitor the skin for irritation, and observe the stoma for unusual changes. In an interview on January 14, 2025, at 12:35 p.m., the resident's family member reported that the resident's ostomy supplies had not been changed since admission. There was a lack of evidence in the clinical record to support that staff provided ostomy care or changed the supplies prior to January 14, 2025. There were no physician orders for ostomy care in place until January 14, 2025, six days after the resident was admitted to the facility. The physician orders dated January 14, 2025, directed staff to change the ileostomy wafer every three days and change the ileostomy bag once daily or as needed. In an interview on January 16, 2025, at 11:10 a.m., and 12:54 p.m., the Director of Nursing confirmed that there was no documented evidence that staff changed the resident's ostomy supplies or provided ostomy care prior to January 14, 2025, and that ostomy care should be documented in the resident's clinical record. 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for two of 16 sampled residents. (Residents 27 and 35) Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed October 10, 2024, revealed that enhanced barrier precautions were to be used with any resident with a wound or medical device during encounters when contact is expected, including during wound care and the care of feeding tubes. Precautions included the use of protective gowns during the high risk activities. Clinical record review revealed that Resident 27 had diagnoses that included a Stage 3 pressure sore on his lower back. On January 15, 2025, at 9:06 a.m., a physician (MD 1) was observed entering Resident 27's room to examine his pressure sore. MD 1 did not use a protective gown in accordance with facility policy. Clinical record review revealed that Resident 35 had diagnoses that included a history of stroke with difficulty swallowing. She received all nutrition through a feeding tube. On January 14, 2025, at 10:37 a.m., LPN 1 was observed flushing the feeding tube without wearing a gown as required by facility policy. CFR 483.80 Infection Control Previously cited 12/28/23, 8/1/24 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency for one of 16 sampled residents. (Resident 16) Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, last reviewed October 10, 2024, revealed that all incident and allegations of abuse were to be reported immediately to the administrator or designee. Clinical record review revealed that Resident 41 had diagnoses that included anxiety, cognitive decline, and Alzheimer's disease. On October 12, 2024, staff noted that in the morning during the day (7:00 p.m. to 3:00 p.m.) shift, that Resident 41 put a brief over Resident 16's head. Resident 41 started punching Resident 16 and stated she was going to smash her in the face with a heavy object. Resident 41 also stated that she wanted to kill Resident 16 multiple times throughout the shift. There was no evidence that staff notified the Administrator until the evening (3:00 p.m. to 11:00 p.m.) shift. There was no evidence that the facility reported the incident to the State Survey Agency. In an interview on January 16, 2025, at 12:37 p.m., the Director of Nursing (DON) confirmed that staff did not immediately notify the Administrator of the incident per the facility policy. In an interview on January 16, 2025, at 2:40 p.m., the DON confirmed that the facility did not report the incident to the State Survey Agency. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted dignity for one of 16 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included dysphagia, dementia, and need for assistance with personal care. Review of the care plan revealed that the resident had neurological deficiencies and a history of weight loss. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment. Observation of lunch on January 15, 2025, from 12:25 p.m., through 12:45 p.m., revealed that Resident 5 was sitting at a table with the meal tray on the table with more than 75% of the meal uneaten. There was food on the resident's sweater. The resident proceeded to bite at and lick the food on her sweater. The resident did not obtain utensils or food from her tray and continued to chew and suck on her sweater for the remainder of the observation period. The resident was not redirected. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed by the physician in a timely manner for one of 16 sampled residents. (Resident 41) Findings include: Clinical record review revealed that Resident 41 had diagnoses that included anxiety and Alzheimer's disease. Review of a pharmacist's recommendation dated August 1, 2024, revealed that the pharmacist noted that the resident was prescribed melatonin and trazodone at hour of sleep (HS). The pharmacist recommended that the physician review the need for both medications and determine if the melatonin could be discontinued to reduce the resident's amount of medication. There was no evidence that the physician addressed the pharmacist's recommendations until October 1, 2024, or that the melatonin was discontinued until October 2, 2024. In an interview on January 16, 2025, at 12:37 p.m., the Director of Nursing stated that pharmacy recommendations should be addressed by the physician within five to seven days and there was no evidence that the physician addressed the pharmacy recommendation until October 1, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meetings, the first and fourth, of 2024. Findings include: Review of the facility ' s Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records for meetings held in the first quarter of 2024 revealed the facility's Medical Director failed to attend. Review of facility ' s monthly Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records for meetings held in the fourth quarter of 2024 revealed the facility's Medical Director failed to attend. In an interview on January 16, 2025, at 11:39 a.m., the Administrator confirmed that the Medical Director did not attend all of the quarterly meetings. 28 Pa Code: 201.18(e)(1)(2)(3) Management.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 40) Findings include: Clinical record review revealed that Resident 40 had diagnoses that included heart failure and reduced mobility. According to the Minimum Data Set assessment, dated November 23, 2024, the resident was at risk for pressure ulcers, had limited mobility of her lower legs, and could communicate her needs. On March 12, 2024, the physician ordered that staff float heels (elevate the lower leg so the heel doesn't touch the bed) while in bed. On January 14, 2025, at 11:32 a.m., Resident 40 was observed with her heels directly on the bed. That same day at 1:55 p.m., the resident stated that staff had not been floating her heels, and she was observed with her heels directly on the bed. The resident was again observed on January 15, 2025, at 9:54 a.m., with her heels directly on the bed. CFR 483.25 Quality of care Previously cited 12/28/23, 8/10/24 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of three sampled residents who were transferred to the hospital. (Resident 11, 13, 56) Findings include: Clinical record review revealed that Resident 11 was transferred to the hospital on October 12, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 13 was transferred to the hospital on December 11, 2024, after a fall and change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 56 was transferred to the hospital on November 4, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. In an interview on January 16, 2025, at 9:35 a.m., the Administrator confirmed that the residents or resident representatives were not given written notices regarding their transfers.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of four sampled residents. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included intervertebral disc displacement (when a disc in the spinal column shifts and presses on against the spinal nerves) and morbid obesity. A physician's order dated July 2, 2024, directed staff to cleanse surgical incision to lower back with normal saline solution and pat dry, to keep incision clean and dry, to keep the incision open to air, and to apply folded abdominal pad dressing (ABD) on each side of the incision due to skin fold two times a day. A review of the July 2024 Treatment Administration Records (TARs) revealed that there was no evidence the treatment was done as ordered on July 3, 4, and 6, 2024. Clinical record review revealed that Resident 2 had diagnoses that included metabolic encephalopathy and cellulitis of bilateral lower extremities. A review of physician's orders dated August 1 through 10, 2024, the Medication Administration Record (MAR) for August 2024, and the Treatment Administration Record (TAR) for August 2024, revealed the following: Staff were to apply ammonium lactate external lotion 12% to bilateral lower extremities daily for venous stasis. There was no evidence that the lotion was applied as ordered on August 5, 2024. Staff were to administer doxycycline monohydrate (an antibiotic) oral capsule 100 milligrams (mg) two times a day. There was no evidence that the medication was administered as ordered on August 8, 2024. Staff were to administer Suboxone sublingual film (a narcotic) 2-0.5mg 1 film four times a day for narcotic dependence. There was no evidence that the medication was administered as ordered on August 5, 2024. A physician's order dated July 2, 2024, directed staff to apply moisturizing lotion to the entire left lower leg then cover with ACE bandage from bottom of foot and work up to below the knee every day shift to maintain skin integrity. A review of the August 2024 TAR revealed that there was no evidence the treatment was done as ordered on August 4 through 8, 2024. In an interview on August 10, 2024, at 2:05 p.m., the Manager on Duty confirmed that there was no documented evidence that Residents 1 and 2 received the treatments and/or medications as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review and staff interview, it was determined that the facility did not have a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control. Findings include: Review of the facility policy entitled, Infection Prevention and Control Plan, last reviewed March 28, 2024, revealed that the IP was to provide oversight for the infection prevention and control program, conduct surveillance of any facility and community associated infections, and serve as a resource to all staff regarding infection prevention and control. In an interview on August 1, 2024, at 1:15 p.m., the Administrator stated the facility did not have a qualified Infection Preventionist. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.