Every finding on record at Brinton Manor Nursing and Rehabilitation Center

Based on clinical record reviews, resident interviews and staff interviews, it was determined that the facility failed to properly assess two of twenty-three residents reviewed (Resident 3 and Resident 66). Review of Resident 3's quarterly MDS assessment (MDS - periodic assessment of resident care needs) dated April 22, 2026, Section H0100 - Bowel and Bladder indicated that the resident had an indwelling foley catheter (a flexible tube inserted into the bladder to continuously drain urine.)No current, discharged , or completed orders for an indwelling foley catheter were observed in Resident 3's physician orders.Review of resident 3's care plan revealed no care plan or interventions for an indwelling foley catheter. During interview conducted with Resident 3 on June 3, 2026, at 1:04 p.m., Resident 3 denied ever requiring the use of an indwelling foley catheter. Interview conducted with Director of Nursing (DON) on June 4, 2026, when the above was presented, the DON confirmed Resident 3 did not require use of an indwelling foley catheter and the MDS was inaccurately documented.Review of Resident 66's medical diagnoses revealed a diagnosis for Diabetic Retinopathy (a serious eye condition caused by damage to the blood vessels in the retina due to Diabetes Mellitus (- a condition that occurs when the body can't properly use blood sugars, leading to high sugar levels) .)Resident 66's care plan revealed a focus dated April 14, 2025, indicating the resident has impaired visual function related to Diabetes Mellitus (DM- with bilateral DM retinopathy. During interview conducted with Resident 66 on June 2, 2026, at 11:35 p.m., Resident 66 stated that he/she had a visual deficit and was only able to see shadows. Review of Resident 66's May 7, 2026, Quarterly MDS, Section B1000 indicates the resident has adequate ability to see in adequate light.Interview conducted with Director of Nursing (DON) on June 4, 2026, at 10:15 a.m. when the above was presented, the DON confirmed Resident 66 had a visual deficit and the MDS was incorrectly documented. 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of the facility's policy and clinical records, observations, and interview with staff and residents, it was determined that the facility failed to appropriately monitor and follow a fluid restriction order for four of the four residents reviewed (Residents 1, 7, 37, and 53). Findings: A review of the facility's policy titled Encouraging and Restricting Fluid, undated, revealed, Be accurate when recording fluid intake. The same policy revealed, When a resident has been placed on restricted fluids, remove the water cup from the room. If the resident refuses to have the water removed, notify the supervisor and physician. A review of Resident 1's diagnosis list includes Chronic Congestive Heart Failure (CHF- When the heart cannot pump enough blood into the body to meet the metabolic needs) and Hepatic Failure (Occurs when the liver loses its ability to function properly). A review of Resident 1's physician order dated May 13, 2026, revealed Fluid restriction: 2000 ml daily every eight hours 24 hours total: Dietary 1320 ml: Breakfast 360 ml, lunch 480ml, dinner 480 ml. Nursing 680 ml: 7-3 270 ml, 3-11 270 ml, 11-7 140 ml. A review of Resident 1's May and June 2026 Medication Administration Record revealed that the resident's total fluid intake each shift was not monitored/documented. An observation conducted on June 3, 2026, at 1:30 p.m., revealed a 16 ounce of white styrofoam cup filled with cold water on the resident's bedside table. An interview with Resident 1 was conducted on June 3, 2026, at 1:30 p.m. The resident reported that the staff provides the cup of water and refills it. The residents do not know how many fluids they're allowed to take every meals/shift. A review of Resident 7's diagnosis list includes CHF and Chronic Kidney Disease (CKD-Gradual loss of kidney function, which can result in renal failure). A review of Resident 7's physician's order dated May 20, 2026, revealed an order for Fluid Restriction: 1500ml daily every 8 hours 24 Hour Total: 1500ml Dietary: 840ml. Breakfast 360ml, Lunch 240ml, 240ml Nursing: 660ml. 7-3 270ml, 3-11 270ml, 11-7 120ml. A review of Resident 7's May and June 2026 Medication Administration Record revealed that the resident's total fluid intake each shift was not monitored/documented. Further MAR review revealed the resident receives Ensure Plus (237 ml) twice daily at 10:00 a.m. and 4:00 p.m., where total amount consumed were not monitored/documented. An observation conducted June 3, 2026, at 1:37 p.m., revealed a 16 ounce of white styrofoam cup filled with cold water on the resident's bedside table and an extra cup of coffee. An interview conducted with Resident 7 on June 3, 2026, at 1:37 p.m., revealed that they requested an extra cup of coffee. The resident reported that the staff provides and refills the cup of water. The residents reported that they were aware of the fluid restriction but did not know how many fluids to take every shift/meal. An interview was conducted with the Director of Nursing on June 5, 2026, at 10:24 a.m. The DON confirmed that the cup of water should not have been placed in the resident's room. The DON also confirmed that the resident's fluid intake was not appropriately monitored and followed. The facility failed to ensure Resident 1 and 7's fluid restriction orders were followed. A review of Resident 37's diagnosis list revealed the resident has a diagnosis of chronic diastolic congestive heart failure, (a sudden worsening of a long term condition associated with fluid retention, and the heart is too stiff to fill properly, causing fluid buildup in the lungs or body and the need for controlled fluid intake). A review of Resident 37's physician order dated April 24, 2026, at 10:00 p.m., revealed an order for, Fluid restriction: 2000 ml three times a day 24 hours total: Dietary 1320 ml: Breakfast 360 ml, lunch 480ml, dinner 480 ml. Nursing 680 ml: 7-3 270 ml, 3-11 270 ml, 11-7 140 ml. A review of Resident 37's May 2026 and June 2026 Medication Administration Record (eMAR) revealed the resident's total fluid intake each shift was not monitored or documented. There was no documentation identifying the amount of fluid provided to Resident 37. An observation conducted on June 2, 2026, at 11:54 a.m., revealed one 8-ounce Styrofoam cup and two 16-ounce Styrofoam cups full of water, along with a 16-ounce Coca-Cola bottle on Resident 37's sliding table. An observation conducted on June 3, 2026, at 12:55 p.m., revealed one 8-ounce Styrofoam cup and two 16-ounce Styrofoam cups on Resident 37's sliding tray. An interview conducted with Resident 37 on June 3, 2026, at 12:55 p.m., revealed the resident was unable to state the amounts of fluids they were permitted to have per meal or per shift. An interview conducted with Licensed Nursing Employee E9 on June 03, 2026, at 1:00 p.m., confirmed Resident 37 on is on a fluid restriction and should not have the soda or multiple cups of water on the sliding tray. An interview conducted with the Director of Nursing (DON) on June 5, 2026, at 10:24 a.m., confirmed Resident 37 was on a fluid restriction and should not have had soda or multiple cups of water at the bedside. The DON confirmed that the cups of water should not have been placed in Resident 37's room and fluid intake was not appropriately monitored. The facility failed to ensure Resident 37's fluid restriction order was followed. A review of Resident 53 physician diagnosis list includes history of falling (meaning Resident has fallen before and is at higher risk of falling again). A review of Resident 53's physician order dated April 21, 2025, at 3:00 p.m. revealed an active order for Fall mat to the window side of the bed-check placement every shift. A review of Resident 53's care plan revealed Fall mat to the window side of the bed. An observation conducted on June 02, 2026, at 10:10 a.m. revealed the fall mat on the left side of the bed and no mat on the right side (window) of the bed. An observation conducted on June 03, 2026, at 2:10 p.m. revealed the fall mat on the left side of the bed and no mat on the right side (window) of the bed. An observation conducted on June 04, 2026, at 1:27 p.m. revealed the fall mat on the left side of the bed and no mat on the right side (window) of the bed. An interview conducted with the Licensed Nursing Employee E10 confirmed the care plan and physician orders state there should be a fall mat placed on the right side of the resident's bed. RN confirmed floor mat was placed on the left side, not on the right side as indicated in Resident's care plan intervention and physician order. The facility failed to ensure Resident 53's fall mat order was followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on observation review of facility's policy and clinical records, and interview with resident and staff, it was determined that the facility failed to follow a respiratory order and provide sanitary measures for handling, cleaning and storage of respiratory equipment for two out of eight residents reviewed (Resident 34, and 37).Findings include: Review of facility policy Administering Medications through a Small Volume (Handheld) Nebulizer (a medical device that coverts liquid medication into a fine mist for inhalation directly into the lungs for the treatment of breathing difficulty. It consists of a mask or mouthpiece, a medicine cup, tubing and a machine that converts the liquid medication into a mist, dated2001, revealed: Rinse and disinfect the nebulizer equipment according to facility protocol; or a. wash pieces in warm, soapy water; b. allow to air dry on a paper towel. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Observation of Resident 34's bedside table on June 4, 2026, at approximately 9:30 a.m. revealed a nebulizer mask attached to a medicine cup and tubing laying on top of various belongings on Resident 34's bedside table. The tubing was unlabeled and there was a small amount of clear liquid in the medication cup. Observation of Resident 34's bedside table on June 5, 2026, at approximately 1:05 p.m. revealed a nebulizer kit laying on top of various belongings on Resident 34's bedside table. There was no label on the tubing, indicating when it had last been changed, and there was asmall amount of clear liquid in the medication cup. The observation was witnessed by E9 on June 5, 2026, at approximately 1:10 p.m. A review of Resident 37's diagnosis list revealed that the resident was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia (meaning your lungs aren't getting enough oxygen, both long term and suddenly, causing dangerously low oxygen levels in the blood), and chronic respiratory failure with hypercapnia (meaning your lungs aren't getting enough oxygen and they cannot get rid of carbon dioxide, both long term and suddenly). A review of Resident 37's physician's order dated March 20, 2026, at 7:00 p.m., revealed and active order for 0xygen at 2L/min continuously via nasal canula every shift for COPD. Baseline o2 saturation is 90%. An observation conducted on June 2, 2026, at 11:00 a.m., revealed an oxygen concentrator set at 4–5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min. An observation conducted on June 2, 2026, at 1:00 p.m., revealed an oxygen concentrator set at 4–5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min. An observation conducted on June 3, 2026, at 12:45 p.m., revealed an oxygen concentrator set at 4–5 L/min, with the flowmeter ball fluctuating between 4 and 5 L/min. An interview with the Director of Nursing (DON) conducted on June 5, 2026, at 10:00 a.m., confirmed Resident 37's oxygen concentrator was not set according to the physician's order. The DON stated the resident should have been receiving 2L/min as ordered. The facility failed to ensure Resident 37's oxygen was administered in accordance with the physician's order. A review of Resident 37's physician's order dated June 20, 2026, revealed an order Resident to use [their] own AVAP (Average Volume-Assured Pressure Support a noninvasive ventilator with automatic mode that adjusts pressure to deliver a consistent targeted volume of air, q HS (every bedtime) setting in accordance with pre-set up. An observation conducted on June 2, 2026, at 1:00 p.m., June 3, 2026, at 9:00 a.m., and June 4, 2026, at 10:00 a.m., revealed a bedside machine that was labeled CPAP (Continuous Positive Airway Pressure- This delivers a steady stream of pressurized air through a tube and mask to keep your throat open as you sleep) The machine was set up at 6.0 cm H2o. An interview was conducted with Resident 37 on June 4, 2026, at 2:00 p.m. Resident 37, who was alert and oriented, confirmed that they have been using the CPAP machine since the machine that they brought from home broke a few weeks ago. The residents reported that the facility provided the current machine that they have been using. A review of the nursing progress notes dated April 16, 2026, at 10:23 p.m., revealed Called to [respiratory company name] therapist to set up a new BIPAP (A non-invasive ventilation device that delivers two distinct levels of air pressure to assist breathing) machine because the resident's own has malfunctioned. Awaiting call back. An interview with the Director of Nursing (DON) was conducted on June 5, 2026, at 10:00 a.m. The DON confirmed that the residents' order for an AVAP was not followed. The facility failed to ensure Resident 37's order for an AVAP at bedtime was followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to monitor the resident's behaviors, medication side effects, and document indications for a resident receiving a psychotropic medication for one of the five residents reviewed (Resident 13). Findings: A review of the facility's policy titled Psychotropic Medication Use, undated, revealed that psychotropic medication management is an interdisciplinary process that involves determining adequate indication for use, and adequate monitoring for efficacy and adverse consequences. The same policy revealed that residents receiving psychotropic medications are monitored, and the response to treatment is documented. In addition, residents are monitored for adverse consequences associated with psychotropic medications, including anticholinergic effects, cardiovascular effects, metabolic effects, neurologic effects, and psychosocial effects. A review of Resident 13's diagnosis list includes bipolar disorder (A Disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 13's physician's order dated November 5, 2025, revealed an order for Olanzapine (An anti-psychotic medication) oral tablet 20 mg one tablet at bedtime for Bipolar. A review of Resident 13's physician's order revealed an order for Lorazepam 1 mg, one tablet every 12 hours as needed for anxiety. The order was renewed every 14 days. A review of Resident 13's May 2026 Medication Administration records revealed that from May 1 until May 31, 2026, the resident was administered as-needed Lorazepam 41 times without an appropriate indication. In addition, residents' behaviors and psychotropic side effects monitoring were not documented. An interview conducted with the Director of Nursing (DON) on June 5, 2026, at 9:28 a.m., confirmed that Resident 13 was administered as-needed Lorazepam without appropriate indications. The DON further confirmed that behavior and side effects monitoring for the use of anti-psychotic medication was not done. The facility failed to ensure Resident 13 had an appropriate indication before administering an as-needed anti-anxiety medication, and their behaviors and medication side effects were monitored. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on interview and record review, the facility failed to incorporate PASSAR level 2 recommendations into the resident's care plan for one out of eight residents reviewed (Resident 9).Findings include:Review of Resident 9's annual Minimum Data Set (MDS - a mandatory assessment of a resident's care needs and medical condition) dated December 5, 2025 revealed that Resident 9 was completely dependent on facility staff for the completion of activities of daily living and required substantial assistance for mobility. Resident 9 had diagnoses that included anxiety disorder, bipolar disorder (a severe mood disorder) and schizophrenia (severe mental disorder affecting how a person thinks, feels, and behaves). Resident 9 received antipsychotic (for the treatment of bipolar disorder and schizophrenia) medication, anti-platelet (for the prevention of blood clots) medication, hypoglycemic (for the treatment of increased blood sugar) medication and anti-seizure medication. The facility failed to indicate on the MDS that the resident qualified for a Level II Preadmission Screening and Resident Review (PASARR - a mandatory screen of all residents entering long term care for severe mental illness or disability that determines if a resident qualifies for a higher level of care while in the facility due to that severe mental illness or disability) determination.Review of Resident 9's PASARR dated June 25, 2019, revealed that Resident 9 requires a further Level II (indicating that a resident may require certain care and services provided by the nursing home, and/or specialized services provided by the State) evaluation Review of Resident 9's facility care plan revealed that Resident 9 meets the criteria PASARR II level of determination secondary of serious mental illness. Review of Resident 9's care plan interventions revealed Consult MCO (managed care organization - a contracted service provider).Review of Resident 9's facility care plan specified the name of the MCO and the name of a contact but did not specify the specialized services the resident was to receive or the frequency with which they were to be provided.Review of the Person-Centered Service Plan provided by the MCO dated June 17, 202, revealed that Resident 9 was to receive specialized services thorough the MCO weekly for 90 days between January 13, 2025, and June 16, 2026, a total number of two times. Interview with Employee E4 on June 4, 2026 at approximately 11:00 a.m. with the Director of Nursing in attendance revealed that the resident was to receive specialized services but could not indicate what those specialized services entailed. Further interview revealed that the facility failed to maintain any documentation of these services in the resident's record.

Based on record review, the facility failed to ensure that the attending physician documented their rationale for not addressing a medication irregularity documented by the pharmacist during their monthly review of medications for three of 16 residents reviewed (Residents 3, 9, and 18). Findings include: Review of Resident 3's monthly Pharmacist Medication Regime Reviews (MRR) revealed a regime review dated June 1. 2026, noting a recommendation for the resident's Voltaren gel (a topical anti-inflammatory drug used for relief of joint pain) order, indicating on for 12 hours and off 12 hours. A recommendation was made to please remove these instructions since the gel can be applied up to four times daily. The physician signed and disagreed with the recommendation on June 1. 2026, but did not provide a rational as to why he/she disagreed with the recommendation. Review of Resident 3's physician orders revealed the changes were not made. Review of Resident 9's physician order summary revealed an order dated March 28, 2025, for Protonix Tablet Delayed Release 40MG (milligrams). Give 1 tablet by mouth in the morning for GERD (gastro-esophageal reflux disease where stomach acid flows back up the tube connecting the mouth to the stomach). Review of Resident 9's Medication Reconciliation Review dated June 1, 2026 revealed the following: Currently receiving Protonix (pantoprazole) since 3/2023. Long term use of PPIs has been associated with increased risk of pneumonia, c. Difficult, hypomagnesemia fractures, and both B12 and iron deficiencies. Please consider a reduction to 20mg daily. The physician checked disagree on the Medication Reconciliation Review form and provided no rationale for the disagreement. Review of Resident 18's monthly Pharmacist Medication Regime Reviews revealed a regime review dated January 4, 2026, indicating the resident has been receiving Loratadine routinely since December 2024. A recommendation was made to please evaluate current need and consider PRN (as needed) use if appropriate. The physician signed and disagreed with the recommendation on January 6. 2026, but did not provide a rationale as to why he/she disagreed with the recommendation. Review of Resident 18's physician orders revealed the changes were not made. Review of Resident 18's monthly Pharmacist Medication Regime Reviews revealed a recommendation dated June 1, 2026, indicating the resident has been receiving Loratadine routinely since December 2024. Please evaluate current need and consider PRN use if appropriate. The physician signed and disagreed with the recommendation on June 1. 2026, but did not provide a rationale as to why he/she disagreed with the recommendation. Review of Resident 18's physician orders revealed the changes were not made. 28 Pa. Code 211.10(c) Resident care policies Pa Code 211.12 (c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on interview, observation, and record review, the facility failed to deliver rehab services for one out of eight residents reviewed (Resident 34).Findings include:Review of facility policy Therapy Services Policy (undated) revealed Services will be designed to assist residents in attaining and maintaining their highest practicable level of physical.well-being.Review of Resident 34's annual Minimum Data Set (MDS - a mandatory assessment of a resident's care needs and medical condition) dated March 20, 2026, revealed that Resident 34 was cognitively intact, dependent on facility staff for the completion of activities of daily living and mobility. Resident 34's diagnoses included traumatic brain injury (TBI - a disruption of normal brain function caused by an external force ranging from mild concussions to severe, life-threatening injuries), multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves), muscle wasting and atrophy (thinning of muscle mass due to diseasesor lack of use), and muscle weakness (generalized). Resident 34 was not receiving therapy services at the time of the annual assessment.Interview with Resident 34 on June 2, 2026, at approximately 9:30 a.m. revealed that they had been evaluated for therapy a couple of weeks ago and they came to my room a couple of times, but they stopped, and I don't know why. Review of Physical Therapy Evaluation & Plan of Treatment dated May 13, 2026, revealed that Resident 34 was certified for physical therapy for 12 times within the 30-day period between May 13, 2026, and Jun 11, 2026. The evaluation revealed Pt (patient) is a 35 y.o. (year old) female, history of TBI s/p (status post - after) MVA (motor vehicle accident). Pt was referred to PT (physical therapy) per pt's request. The evaluation revealed: patient demonstrates good rehab potential. Review of Physical Therapy Treatment Encounter Notes revealed that Resident 34 received therapy services on May 13, 2026, May 14, 2026, May 21, 2026, and May 23, 2026. Review of the Summary of Daily Skilled Services dated May 23, 2026, revealed actively participates with skilled interventions and Complexities/Barriers Impacting Session: None Present. Interview with E6 on June 5, 2026, at approximately 12:30 p.m. revealed that the resident was receiving therapy, but had been discharged on June 3, 2026. No discharge summary had been entered into Resident 34's chart. Interview with the E7 on June 5, 2026, at approximately 1:30 p.m., with the Director of Nursing and Nursing Home Administrator present, confirmed that Resident 34 had been discharged from therapy on June 3, 2026, but could not provide the discharge summary. E7 confirmed that Resident 34 could continue therapy services by asking for them. The facility failed to provide evidence documenting why Resident 34 was discharged from therapy after only 4 sessions or why Resident 34 went 11 days without therapy services without notification of discharge. E7 confirmed that Resident 34 could resume therapy services by asking for them. 28 Pa. Code: 211.12 (d)(1)(3) Nursing services28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on a review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to comprehensively assess and timely provide treatment to a wound for one of two residents reviewed (Resident CL1).Findings: A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, revealed that the staff will examine the skin of a new admission for ulcerations or alterations in skin. The nurse shall describe and document/report the full assessment of pressure sore, including location, stage, length, width, and depth, presence of exudates (a protein-rich fluid that leaks from blood vessels into surrounding tissues commonly seen in wounds, inflammation, or infection) or necrotic (dead, non-viable) tissue. A review of Resident CL1's hospital records Assessment and Plan dated December 28, 2025, revealed the resident had a sacral (The triangular bone just below the lumbar vertebrae), unstageable wound (Obscured full-thickness skin and tissue loss. A wound VAC (Also known as Negative Pressure Wound Therapy- is a medical device that uses continuous or intermittent suction to accelerate healing in complex or chronic wounds) treatment was made, and dressing was changed three times weekly. A review of Resident CL1's admission skin assessment dated [DATE], revealed the following assessment: sacrum (The triangular bone just below the lumbar vertebrae), pressure, unstageable (Obscured full-thickness skin and tissue loss). The same assessment review failed to reveal the wound measurements, slough (is non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) presence/percentage and presence of exudate. A review of the physician's progress notes dated January 6, 2026, revealed: holding wound vac at this time as patient has a lot of slough. A review of the physician's order dated January 6, 2026, revealed an order to discontinue the wound vac and cleanse the resident's sacrum with normal saline solution (NSS) apply medical honey (An ointment/cream that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns) to wound base cover with dry dressing everyday shift. A review of Resident CL1's January 2026 Treatment Administration Records (TAR) failed to reveal that the wound vac order was initiated from admission. The same TAR revealed the resident's sacral wound was not treated until January 7, 2026, two days after an unstageable sacral ulcer was identified on admission [DATE]). A review of Resident CL1's wound consults dated January 7, 2026, revealed the resident's sacral wound was assessed as unstageable, measuring 6.8 x 7.7 x 1.0 cm. with 60% slough, 6 o' clock - 7 o'clock undermining (A wound complication where tissue destruction occurs under intact skin at the wound edge, creating a shelf or pocket). A new treatment to cleanse the sacral wound: Dakins solution (An antiseptic solution used to treat and prevent skin/tissue infections in wounds), apply Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin), and cover with a dry dressing. An interview was conducted with the Director of Nursing on March 16, 2026, at 1:00 p.m. The DON confirmed that Resident CL1's unstageable sacral wound, identified upon admission, was not comprehensively assessed until seen by the wound doctor on January 7, 2026. The DON also confirmed that there was no documented evidence that Resident CL1's sacral wound was provided with treatment until January 7, 2026, two days after the wound was identified on admission [DATE]). The facility failed to ensure Resident CL1's unstageable wound was comprehensively assessed and provided with treatment in a timely manner. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(1)(3)(5) Nursing services

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for two of the two residents reviewed (Resident R3 and R33). Findings include: Review of Resident R3's clinal record revealed the following diagnosis, dialysis-induced hypotension (low blood pressure occurring during dialysis treatment) and congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident R3's clinical record revealed the following order, Midodrine (used to treat low blood pressure) HCL 5 milligrams (MG), give 2 tablets by mouth two times a day for hypotension hold if blood pressure greater than 120/70. Review of Resident R3's medication administration record (MAR) for the month of December 2025, revealed the facility administer the above medication outside parameters 24 times. Review of Resident R33's clinical record revealed the following diagnosis, hypotension, unspecified (low blood pressure), and acute respiratory failure with hypoxia (the lungs can not provide enough oxygen to the body). Review of R33's clinical recorded revealed the following order, Midodrine HCL 5 MG, give 1 tablet by mouth three times a day for hypotension, Hold for [systolic blood pressure] greater than 120 or diastolic blood pressure greater than 80. Review of Resident R33's medication administration record for the month of March 2025, revealed the facility administered the above medication outside of parameters 13 times. Interview with the Director of Nursing (DON) on March 18, 2025, at 12:17 p.m., confirmed the above medication errors. The facility failed to ensure Resident R3 and R33 midodrine medication order was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure, clinical records review, and staff interview, it was determined the facility failed to ensure that staff met the professional standards upon identifying a skin impairment for one of three residents reviewed (Resident 39). Findings include: The Professional Code, Title 49, Professional and Vocational Standards (Pennsylvania Professional Nursing Practice Act), Chapter 21.145(a) states that the Licensed Nurse is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, and experience in nursing competency. The nurse participates in the planning, implementing, and evaluating nursing care, using focused assessment in settings where nursing takes place. A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, revealed that the nursing staff would assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall describe and document/report the following: a full assessment of the pressure sore, including location, stage, length, width, and depths, and the presence of exudates or necrotic (dead) tissue. A review of Resident 39's care plan developed on November 22, 2022, revealed the following interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness; and check the body for breaks in the skin and treat promptly as ordered by the physician. A review of the nursing progress notes dated March 11, 2025, at 12:11 p.m., revealed that nursing was notified by the wound team that a new unstageable wound was observed on the resident's left heel measuring 2.0 x 2.6 x 0.1 cm. The same note revealed that there was a dressing applied to the wound which was not dated or initialed. A review of the facility's investigation titled New Pressure Injury, dated March 11, 2025, at 11:37 a.m., revealed that during wound rounds, an unstageable wound measuring 2.0 x 2.6 x 0.1 cm was found on the resident's left heel. Staff statement of licensed Employee E3, dated March 11, 2025, revealed the following statements I was notified by the wound team that resident has an unstageable wound on [his/her] left heel. I was also informed that [he/she] has a dressing on, but it wasn't dated so we have no idea how long it had been on for. An interview with licensed nurse Employee E4 was conducted on April 18, 2025, at 8:44 a.m. Employee E4 reported that all treatment medications, dressing, and supplies are all kept in the treatment cart or medication room which is always locked with access only to the nurses. An interview with the Director of Nursing (DON) was conducted on April 18, 2025, at 11:00 a.m. The DON reported that a bordered dressing (An absorptive wound dressing) was observed during wound rounds on the resident's left heel on March 11, 2025. An unstageable left heel ulcer was discovered upon removing the bordered dressing to the left heel. The DON reported that the facility investigation was not able to identify the person responsible for applying the wound dressing to the resident's left heel, however, the DON confirmed that the dressing placed on the resident's heel is kept on the treatment cart and medication with access only to the nurses. The above was discussed with the DON on April 18, 2025, at 11:20 a.m. The DON confirmed that upon identifying the skin impairment on Resident 39's already compromised left leg, the person/staff that applied the bordered dressing should have instead assessed, notified the physician, and provided appropriate monitoring and treatment to the resident's left heel. 28 Pa. Code 211.5(f) Clinical Record Previously cited 3/19/25, 5/10/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 3/19/25, 5/10/24

Based on review of facility policy, clinical record, facility documentation, and staff interview, it was determined the facility failed to assess timely, monitor, and provide appropriate treatment to a skin impairment for one of three residents reviewed (Resident 39). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, revealed the nursing staff would assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall describe and document/report the following: a full assessment of the pressure sore, including location, stage, length, width, and depths, and the presence of exudates or necrotic (dead) tissue. Review of Resident 39's diagnosis list included Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), and Peripheral Vascular Disease (PVD-circulatory condition that affects blood vessels outside the heart and brain, particularly in the legs and arms). Review of Resident 39's care plan developed on November 22, 2022, revealed the following interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness; and check the body for breaks in the skin and treat promptly as ordered by the physician. Review of Resident 39's clinical record including skin check assessment dated [DATE], revealed that aside from the existing skin impairment to the resident's right hip, it failed to reveal any other skin impairments identified during the skin check. Review of the nursing progress notes dated March 11, 2025, at 12:11 p.m., revealed nursing was notified by the wound team that a new unstageable wound was observed on the resident's left heel measuring 2.0 x 2.6 x 0.1 cm. The same nursing progress note revealed there was a dressing applied to the wound which was not dated or initialed. Review of the facility's investigation titled New Pressure Injury, dated March 11, 2025, at 11:37 a.m., revealed during wound rounds, an unstageable wound measuring 2.0 x 2.6 x 0.1 cm was found on the resident's left heel. Immediate Action Taken: The old dressing was removed, the wound was assessed, and a new wound treatment was ordered. Review of staff statement by licensed nurse Employee E3, dated March 11, 2025, revealed, I was notified by the wound team that resident has an unstageable wound on [his/her] left heel. I was also informed that [he/she] has a dressing on, but it wasn't dated so we have no idea how long it had been on for. Review of the wound nurse practitioner (NP) note titled Skin and Wound Note, dated March 11, 2025, at 3:43 p.m., revealed resident was seen on a follow-up for the wound to the right hip, resident was also noted to have a wound to the left heel with dressing in place at the time of assessment. The wound was identified as a Pressure Ulcer/Injury. Further review of the wound nurse practitioner assessment note revealed the left heel wound measured 2.0 x 2.6 x 0.1 cm (centimeter) with 80% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Further review of the same note revealed that a surgical debridement (medical procedure where dead or infected tissue is removed from a wound using surgical instruments) with an indication for removal of necrotic (dead cells in the body tissue) tissue was done on March 11, 2025. A new wound treatment of Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) daily was ordered. Interview with licensed nurse Employee E4 was conducted on April 18, 2025, at 8:44 a.m. Employee E4 revealed all treatment medications, dressing, and supplies are located in the treatment cart or medication room which is locked with access only to the nurses. Interview with the Director of Nursing (DON) was conducted on April 18, 2025, at 11:00 a.m. The DON indicated a bordered dressing (absorptive wound dressing) was observed during wound rounds on the resident's left heel on March 11, 2025. An unstageable left heel ulcer was discovered upon removing the bordered dressing to the left heel. The Director of Nursing reported, the facility investigation was not able to identify the person responsible for applying the wound dressing to the resident's left heel, however, the Director of Nursing revealed the type of bandage placed on Resident 39's heel is kept on the treatment cart and it must have been a nurse who applied it to Resident 39's wound as nurses are the only ones with access to the cart. The above information was discussed with the Director of Nursing on April 18, 2025, at 11:20 a.m. The DON acknowledged Resident 39's left foot was already compromised because of his/her medical diagnosis and right leg amputation. The DON confirmed that upon identifying skin impairment to the left heel, the wound should have been timely assessed, appropriately treated, and monitored. The facility failed to ensure Resident 39's skin impairment was properly assessed, appropriately treated, and monitored resulting in the harm of an advanced unstageable pressure ulcer to the left heel and undergoing a surgical procedure of wound debridement which could result in unnecessary pain. 28 Pa. Code 211.5(f) Clinical Record Previously cited 3/19/25, 5/10/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 3/19/25, 5/10/24

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of medications for one of the 9 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical records revealed medical diagnosis that include Cochlear Implant (electronic device to improve hearing), Hypothyroidism (thyroid gland not making enough thyroid hormone), Hyperlipidemia (high level of lipids (fat, oil cholesterol) in the blood), Diabetes Mellitus type 2 high blood sugar), and Legally Blind. Review of Resident 1's clinical records revealed a progress note dated January 18, 2025, at 11:06 p.m. documenting while administering evening medication writer explained resident's medication to orientee and instructed orientee to give medication to resident. Orientee went into room introduced self and called [Resident 10] (another resident's name) and [Residen 1] answered. Orientee informed [Resident 1] that he/she had [Resident 10's] medication and administered medication. Orientee asked door bed (Resident 10) did he/she want his/her medications, the resident replied yes and orientee informed writer of resident's response. Writer realized orientee misheard and gave medications to the wrong resident. Writer informed supervisor, on call doctor was notified and ordered resident to be monitored for 9 shifts. Family was notified. Further review of Resident 1's clinical records revealed the resident had no change in mental or functional status following the incident. Review of facility records revealed a medical error incident report dated January 18, 2025. Review of the incident report notes the Interdisciplinary Team met on January 23, 2025. Disciplinary action given as well as education on the five rights of medication administration. Interview on March 19, 2025, at 12:55 p.m., with the Nursing Home Administrator (NHA) and Director of Nursing (DON) when the above was presented, the DON confirmed that Resident 1 was mistakenly given his/her roommate's medications which included Gabapentin (used to treat nerve pain and seizures), Baclofen (a muscle relaxer), and Vistaril (used to treat itching, anxiety and nausea). The DON confirmed that Resident 1 exhibited no side effects from taking the wrong medications. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations, and staff interview it was determined that the facility failed to provide a safe and sanitary environment on one of five rooms reviewed (Resident 1's room). Findings include: Observation conducted on October 8, 2024, at 9:45 a.m. revealed Resident 1's sink located in the room had a black substance surrounding the faucet fixture. Observation conducted on October 8, 2024, at 11:30 a.m., in the presence of the Nursing Home Administrator revealed that the black substance on Resident 1's sink faucet was still present. The black substance easily comes off when wiped with a paper towel. The above information was discussed with the NHA on October 8, 2024. The facility failed to ensure a safe and sanitary environment for Resident 1. 28 Pa. Code 207.2 (a) Administrator's responsibility

Based on observation, review of drug manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled for two of two medication carts and one of two medication rooms observed (Medication Cart A, Medication Cart B, and Medication Room A). Findings include: Review of the manufacturer's storage guidelines for Insulin Aspart (Novolog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of manufacturers' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Levemir FlexTouch (long-acting insulin), revealed in-use Levemir insulin must be discarded 42 days after opening. Review of the manufacturer's storage guidelines for Humalog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. Observation of the Medication Cart B side in the presence of licensed nurse Employee E3 was conducted on October 8, 2024, at 10:00 a.m. The observation revealed the following: One vial of Lispro opened and undated; one vial of Lantus opened and undated, with no label; one vial of Aspart, opened and undated; two Lantus pen, both were opened, undated with no label; one Levemir pen, opened, undated with no label, and two Humalog pens, both were opened, undated and no label. Interview with Employee E3 was conducted on October 8, 2024, at 10:05 a.m. Employee E3 confirmed that the above insulins should have been dated once opened. Employee E3 was unsure why the above-mentioned insulins were not labeled with the resident ' s name. Employee E3 reported that the label might have come off. Observation of the Medication Cart A side in the presence of licensed nurse Employee E4 was conducted on October 8, 2024, at 10:35 a.m. The observation revealed the following: Two vials of Aspart, opened and undated; one Lispro vial, opened and undated; two Aspart pens, both were opened and undated; one Lispro pen, opened and undated; two Lantus pens, both were opened and undated. Additional observation on the top drawer revealed a medication cup with 30 green tablets and another medication cup with four big yellow capsules. Interview with Employee E4 conducted on October 8, 2024, revealed that the green tablets were Iron pills and the yellow capsules were Omega 3 (fish oil). Employee E4 reported that the medication bottles (Iron and fish oil) were too big to be placed on the top drawer, so the medications were placed on a medication cup for easy access during the medication administration pass. Observation of the Medication Room A side was conducted in the presence of the Director of Nursing (DON) on October 8, 2024, at 10:40 a.m. The observation revealed the following: The medication refrigerator door does not close; The top tray area was covered in frozen water, the refrigerator thermometer, a bag of 250 cc normal saline and two insulin pens were imbedded in the frozen water. The bottom tray area had 25 unopened insulin vials and seven unopened insulin pens. Unable to read the temperature reading of the refrigerator since the thermometer was embedded in the frozen water. Review of the facility's refrigerator log revealed refrigerator's temperature was last taken on September 25, 2024. The above information was conveyed to the Director of Nursing on October 8, 2024. The facility failed to ensure Medication Carts A and B and Medication Room A's medications were properly stored and labeled. 28 Pa. Code 201.18 (B)(3) Management 28 Pa. Code 211.9(g)(h) Pharmacy services 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(5) Nursing services

Based on review of facility policy and personnel records, it was determined that the facility failed to complete a criminal background check upon hire for one of five employee personnel records reviewed (Employee E4). Findings include: Review of facility policy, Background Screening Investigations, last revised March 2019, revealed: The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. Review of nurse aide Employee E4's personnel record revealed a hire date of February 23, 2024, with a criminal background check obtained May 8, 2024. Interview with the Nursing Home Administrator on May 9, 2024, at 1:30 p.m. confirmed nurse aide Employee E4 did not have a criminal background check upon hire. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights

Based on clinical record review, it was determined that the facility failed to provide treatment and services to maintain/restore bladder continence for one of two residents reviewed for bowel and bladder (Resident 31). Findings include: Review of Resident 31's Quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated January 9, 2024, revealed under Section H - Bladder and Bowel, that the resident was coded as being always continent of bladder. Review of Resident 31's Quarterly MDS dated [DATE], revealed under Section H - Bladder and Bowel, that the resident was coded as being occasionally incontinent of bladder. Review of Resident 31's Bowel and Bladder Program Screener dated March 25, 2024, revealed the resident voided appropriately without incontinence at least daily, was independently but slowly able to get to the bathroom/toilet/commode/adjust clothing/and wipe self, was forgetful but able to follow commands, and was usually mentally aware of the need to toilet. The evaluation concluded that Resident 31 was a candidate for scheduled toileting/timed voiding. Review of Resident 31's clinical record failed to reveal a plan of care in place addressing the resident's incontinence and failed to reveal evidence that the resident was ever offered scheduled toileting/timed voiding. The abovementioned findings were presented to the Nursing Home Administrator and Director of Nursing on May 9, 2024, at approximately 2:00 p.m. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor weight changes in a timely manner for one of seven residents reviewed for nutrition (Resident 62). Findings include: Review of facility policy, Weight Assessment and Intervention, last revised March 2022, revealed: Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. Review of Resident 62's weights revealed that on November 25, 2023, the resident was recorded as weighing 180 pounds (lbs.) On December 5, 2023, the resident was recorded as weighing 199.3 lbs., a 19.3 lb. gain or 10.72% weight change in 10 days. Review of Resident 62's progress notes revealed a Weight Change note from the dietitian on December 6, 2023, which stated: Reweight requested for 19 [pound] gain x 2 weeks. No noted fluid retention. Reviewed provider notes 12/5, [abdomen] pain noted. Intake trending >75%. Will follow. Review of Resident 62's weights revealed the next weight obtained was on December 18, 2023, 13 days past the initial weight change recording and 12 days following the dietitian's request for a reweight. Interview with the dietitian, Employee E3, on May 9, 2024, at 12:10 p.m. confirmed the facility failed to obtain a reweight for Resident 62 in a timely manner. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident reviewed (Resident 20). Findings include: Review of Resident 20's Minimum Data Set (MDS, periodic assessment of resident needs) dated April 19, 2024, reviled in Section J (Health Conditions) that Resident 20 receives a scheduled pain medication regimen. Review of Resident's 20 clinical record revealed an active order for Oxycodone (semi-synthetic opioid used medically for treatment of moderate to severe pain) HCL 10 MG (milligrams) with a start date of April 11, 2023, Further review of the order revealed the following, Give 1 tablet by mouth three times a day for severe pain 8-10. Review of Resident 20's electronic medication administration record (eMAR) for the month of April 2024, revealed Resident 20 was administered oxycodone 10 mg a total of 58 times to treat a reported pain of 0 out of 10 (0 being no pain and 10 indicating severe pain). An interview conducted with Registered Nurse (Employee E1) on May 9, 2024, at 12:34 p.m. reported we just write down 0, Resident 20 always has pain, or so she says. An interview conducted with the Nursing Home Administration (NHA) on May 9, 2024, at 1:50 p.m. confirmed Registered Nurse (Employee E1) should have been accurately recording Resident 20's pain severity in the eMAR prior to administering Resident 20's scheduled pain medication. 28 Pa Code 211.10 (c) Resident Care Policy 28 Pa Code 211.12 (d)(1) Nursing Services

Based on clinical record review, resident and staff interviews it was determined the facility failed to follow physician orders for medication treatments for one of three residents reviewed. (Resident R1) Findings Include: Review of Resident R1's clinical record revealed diagnoses of the following including but not limited to of Obstructive Sleep Apnea and Acute Respiratory Failure with Hypoxia. Interview conducted with Resident R1 on January 24, 2024, at approximately 2:40 p.m. revealed after resident's admission on December 8, 2023; Resident R1 went nearly two weeks without his/her CPAP (continuous positive airway pressure machine) which is required for him/her to breathe properly. Review of Resident R1's clinical record revealed the resident was admitted into the facility on [DATE]. Further review of the resident's clinical record revealed a progress note dated December 14, 2023, indicating the resident needed a new CPAP machine, due to previous machine malfunctioned. Review of Resident R1's progress notes dated December 15, 2023, thru December 21, 2023, indicated the resident did not receive a CPAP machine. Review of Resident R1's progress note dated December 21, 2023, at 4:23 p.m., indicated the resident was shown how to use new CPAP machine. Review of Resident R1's medications administration record for December 2023, revealed the resident was receiving the CPAP treatments on days when the progress notes documented the equipment was not available. During interview with the Director of Nursing (DON) on January 24, 2024, at 4:25 p.m. inquiry was made concerning the conflicting documentation. The DON failed to explain the conflicting documentation. Interview conducted with Nursing Home Administrator(NHA) and Director of Nursing (DON) on January 24, 2024, at 5:00 p.m., revealed Resident R1 was diagnosed with sleep apnea during a hospital stay. Director of Nursing indicated that Resident R1 never went without a CPAP machine. DON stated the progress notes were referring to the resident receiving a new CPAP machine to take home, although the resident does not have a discharge plan. The NHA and DON failed to explain why the progress notes indicated the resident had not received a new CPAP machine timely. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services

Based upon clinical record review and interview, it was determined the facility failed to communicate with a dialysis center regarding an incident and fall that occurred at the dialysis facility resulting in dialysis not being completed and failed to investigate the fall at the dialysis center for one of one resident reviewed (Resident 5). Findings include: Review of Resident 5's clinical progress note dated June 5, 2023, revealed Pt [patient] evaluated post fall while at dialysis (he tipped backwards in wheelchair going up a hill into the facility). Pt. denies injury or hitting head. [resident] does state [resident's] shoulders are sore. [resident's] pain is managed with Oxycodone. Pt. has been more compliant with dialysis and pleasant for the most part. However, [resident] did not receive tx [treatment] today bc [because] he was too late. Unit clerk aware. Will follow. Further review of Resident 5's clinical record failed to reveal evidence of investigation into Resident 5's fall at the dialysis center on June 5, 2023. Interview with the Director of Nursing on July 13, 2023, at 11:50 a.m. confirmed that no investigation into Resident 5's fall, which resulted in Resident 5 not receiving dialysis on June 5, 2023, was conducted. No investigation or information was available to determine Resident 5's arrival time at the dialysis center, where resident was dropped off or what time resident arrived at the facility. The facility failed to communicate with the dialysis center and failed to timely investigate a fall that occurred at the dialysis center. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services

Based upon review of facility policies and procedures and clinical record review, it was determined that the facility failed to provide appropriate care and services to prevent dehydration resulting in hospitalization and actual harm to one of six residents reviewed (Resident #59) and ensure that acceptable parameters of nutritional status were maintained for two of 23 residents reviewed (Resident #15 and Resident #269). Findings include: Review of Resident #59's [DIAGNOSES REDACTED]. Review of Resident #59's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 5, 2019 revealed Resident #59 required supervision of one staff member for eating and had upper and lower extremity impairment on one side. Review of Resident #59's active plan of care dated (MONTH) 16, (YEAR) revealed Resident #59 has dehydration or potential fluid deficit related to use of laxatives and poor nutritional intake. Interventions included monitoring of vital signs as ordered/per protocol and notify MD of significant abnormalities; monitor for signs and symptoms of dehydration - decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Review of Resident #59's Nutrition assessment dated (MONTH) 25, 2019 revealed Resident #59 had a weight loss of 6 percent within 30 days, required supervision, cueing and assistance with feeding. Further review of this Nutrition Assessment revealed resident required 1372 milliliters (ml) of fluid per day. Review of Resident #59's fluid intakes were as follows: (MONTH) 23, 2019 - 75 ml; (MONTH) 24, 2019 - no fluid intake recorded; (MONTH) 25, 2019 - 1000 ml; (MONTH) 26, 2019 -no fluid intake recorded; (MONTH) 27, 2019 - 400 ml; (MONTH) 28, 2019 - 400 ml; (MONTH) 29, 2019 - 95 ml; and (MONTH) 30, 2019 - 200 ml. Review of Resident #59's progress notes dated (MONTH) 30, 2019 revealed resident observed lethargic and confused. Resident b/p (blood pressure) noted 76/44, POX (blood oxygen saturation) 95%, temp 96.5, HR (heart rate) 69. MD made aware n/o (new order) to send to (acute care facility emergency room ) for evaluation and treatment. Resident given approx. 20 oz (ounces) of water and encouraged to drink plenty of fluids. Review of Resident #59's hospital laboratory blood test results dated (MONTH) 30, 2019 revealed that Resident #59's Blood Urea Nitrogen level (BUN - blood test that reveals kidney function - high levels of which indicate dehydration - normal level is 7-20 milligrams per deciliter) was 30 mg/dl. Review of Resident #59's hospital discharge summary dated (MONTH) 30, 2019 revealed [DIAGNOSES REDACTED]. Further review of Resident #59's hospital discharge summary revealed Resident #59 received a 500 ml bolus of normal saline solution and a maintenance infusion of 100 ml/hour of normal saline solution prior to discharge return to the facility. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 12, 2019 at approximately 11:00 a.m. confirmed that no interventions were put into place to prevent Resident #59 from dehydrating and further confirmed that the facility failed to ensure Resident #59 received adequate hydration to prevent dehydration during the month of (MONTH) 2019. The facility failed to ensure Resident #59 received adequate fluid intake to prevent dehydration resulting in transfer to the emergency room causing actual harm to the resident. Review of facility policy and procedure titled Weight Management, revised (MONTH) 17, (YEAR) revealed Weights are verified and documented in the medical record as they are obtained. Check the previous monthly weight(s) for any significant weight change. If there is a significant weight change of + or - 5% in 30 days , 7.5% in 90 days or 10% in 180 days, schedule resident to be reweighed within 24 hours. Review of facility policy and procedure titled Weight Assessment and Intervention revealed Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. Review of Resident #15's comprehensive care plan revealed Resident #15 had a nutritional problem with interventions including to weigh at same time of day and record/report significant changes to medical and dietitian per protocol. Review of Resident #15's clinical record revealed that on (MONTH) 10, 2019, Resident #15 weighed 210 pounds. Further review of Resident #15's clinical record revealed on (MONTH) 18, 2019 Resident #15 weighed 197.6 pounds indicating a 5.9% weight loss in eight days. Review of Resident #15's clinical record failed to reveal evidence that Resident #15 was reweighed and failed to provide evidence that the Dietitian and resident's physician were notified of Resident #15's weight loss. Review of Resident #269's [DIAGNOSES REDACTED]. Review of Resident #269's Admission Minimum Data Set (MDS- periodic assessment of resident needs) dated (MONTH) 29, 2019 revealed Resident #269 has forgetfulness. Further review of the same admission assessment revealed Resident #269 required staff assistance for eating and had diarrhea (loose bowel movement). Review of Resident #269's weight and vital summary revealed Resident #269's weight on (MONTH) 28, 2019 was 139.9 pounds. Further review of Resident #269's weight and vital summary revealed on (MONTH) 9, 2019 Resident #269 weighed 121.4 pounds, reflecting an 18.5 pound weight loss in 11 days. Further review of Resident #269's clinical record failed to reveal evidence that resident was re-weighed. Interview with Registered Dietitian, Employee #11, on (MONTH) 12, 2019, at approximately 12:43 p.m., revealed that Employee #11 was not notified of Resident #269's weight loss. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 12, 2019, at approximately 2:00 p.m. confirmed the above information. 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/17/17, 4/13/18, 6/10/19 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 11/17/17, 4/13/18, 10/31/18