Every finding on record at Corry Manor

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for five of seven residents reviewed (Residents R1, R2, R13, R22, and R23).Findings include: Review of facility policy dated 12/2/25, entitled Medication Administration - General Guidelines revealed the The individual who administers the medication dose records the administration on the resident's MAR (Medication Administration Record) directly after the medication is given. At the end of each medication pass the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medication. Resident R1's clinical record revealed an admission date of 10/23/24, with diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities), Osteoarthritis (degenerative joint disease that results from the breakdown of joint cartilage and bones), and high blood pressure. Resident R1's clinical record revealed a physician's order dated 12/11/25, for Dakins (1/4 strength) External Solution 0.125 % (type of antiseptic used for cleaning wounds) Apply to Coccyx (tail bone) topically (to the skin) every shift for Wound healing; Wound Treatment - Cleanse the pressure injury on the coccyx with 1/4 strength Dakins solution, gently pack the wound bed with 1/4 strength Dakins solution moistened gauze and cover with a silicone border dressing (type of wound dressing). Change twice daily and as needed. Review of Resident R1's Treatment Administration Records (TAR) from 12/11/25 to 2/3/26, lacked documentation indicating wound treatment was completed per physician's orders for 16 out of 109 opportunities. Resident R2's clinical record revealed an admission date of 12/27/25, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs), and pain. Resident R2's clinical record revealed a physician's order dated 1/2/26, for Triad Hydrophilic Wound Dressing External Paste (type of wound dressing) apply to buttocks topically every shift for wound healing. Review of Resident R2's TAR from 1/2/26 to 2/3/26, lacked documentation indicating wound treatment was completed per physician's orders for seven out of 65 opportunities. During an interview on 2/4/26, at 3:00 p.m. the Director of Nursing (DON) confirmed that Resident R1 and R2's clinical records were incomplete regarding treatment documentation. Resident R13's clinical record revealed an admission date of 6/15/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R13's clinical record revealed physician orders dated 6/10/25, for Oxygen at 2 liter per minute via nasal cannula as needed to maintain oxygen saturations at or above 90%; Check pulse oxygen levels every shift; monitor for pain every shift; Novolog (medication used to treat diabetes) 15 units subcutaneous (sq) three times a date; Anoro Ellipta Inhaler (medication used to treat COPD) one puff daily; Atorvastatin Calcium (medication used to treat high cholesterol) 40 mg daily; Nortriptylline HCL (medication used to treat depression); Levetiracetam (medication used to treat seizures) 1500 mg twice a day; oxygen maintenance (changing oxygen tubing, supply bag, wipe down concentrator, clean filter, and change water jug) weekly; gold bond healing lotion to bilateral feet every shift; monitor for bruising / bleeding every shift, and pressure reducing cushion to chair when out of bed. Physician orders dated 6/11/25, for Toujeo Solostar (medication used to treat diabetes) 66 units sq daily; Lasix (medication used to treat congestive heart failure) 40 mg twice a day; and Risperdal (medication used to treat bipolar disorder) 2 mg daily. Physician orders dated 7/1/25, for elevating head of bed to reduce shortness of breath. Physician orders dated 7/16/25, for apply compression stockings to bilateral lower legs in the morning and remove at bedtime. Physician orders dated 7/22/25, for Resident to continue chin tuck maneuver with swallowing. Physician order dated 7/23/25, for Baclofen (medication used to treat muscle spasms) 10 mg po (by mouth) three times a day. Physician orders dated 11/16/25, for Metoprolol Succinate ER (medication used to treat high blood pressure) 100 milligram (mg) daily. Physician orders dated 1/14/26, for Gabapentin (medication used to treat muscle spasm) 600 mg every eight hours. Review of Resident R13's MAR from 12/1/25, to 2/3/26, lacked documentation indicating medications and/or physician orders were completed as ordered for the following: Out of 45 opportunities to document Gabapentin, four were blank; Out of 65 opportunities to document Metoprolol Succinate two were blank, Toujeo Max Solostar three were blank, Anoro Ellipta Inhaler one was blank, Atorvastatin Calcium one was blank, Nortriptylline HCL one was blank, and Risperdal one was blank; Out of 130 opportunities to document Lasix three were blank, oxygen use three were blank, Levetiracetam one was blank, and [NAME] Tuck Maneuver one was blank; Out of 195 opportunities to document pulse oxygen levels 11 were blank, monitor resident for pain eight were blank, Novolog six were blank, and Baclofen one was blank. Review of Resident R13's TAR from 12/1/25, to 2/3/26, lacked documentation indicating treatments and/or physician orders were completed as ordered for the following: Out of nine opportunities to document oxygen maintenance two were blank; Out of 130 opportunities to document gold bond lotion 16 were blank, monitoring for bruising / bleeding six were blank, applying and removing compression stockings six were blank, elevating head of bed six were blank, and pressure reducing cushion six were blank. Resident R22's clinical record revealed an admission date of 12/11/24, with diagnoses that included Epilepsy (a chronic brain disorder which a group of nerve cells or neurons will sometimes send wrong signals and cause a seizure which temporarily affects your consciousness, muscle control, and behavior), Down Syndrome (congenital condition caused by defect involving chromosome 21 characterized by a distinctive pattern of physical characteristics including a flattened skull, pronounced folds of skin in the inner corner of the eyes, large tongue, and short stature and by some degree of limitation of intellectual ability and social and practical skills), and Hypothyroidism (a condition resulting from decreased production of thyroid hormones. The symptoms vary between individuals). Resident R22's clinical record revealed physician orders dated 12/11/24, for privacy bag for catheter every shift; Indwelling Catheter care every shift; monitor for signs and symptoms of bruising / bleeding every shift; pressure reducing cushion to wheelchair when out of bed; and maintain foley catheter to gravity drain every shift. Physician orders dated 12/23/24, for secure catheter in place at all times. Physician orders dated 3/20/25, for Phytoplex Protectant Ointment to buttocks every shift. Physician orders dated 4/13/25, to monitor for pain every shift. Physician orders for intake and output every shift. Physician orders dated 6/11/25 for Triad Hydrophilic paste to scrotum every shift. Physician orders dated 7/29/25, for Aricept (medication used to treat dementia) 10 mg daily; Flomax (medication used to treat difficulty urinating) 0.4 mg daily; Trazadone HCL (medication used to treat depression) 50 mg daily; Baclofen (medication used to treat pain) 10 mg twice daily' Lamictal (medication used to treat seizures) 150 mg twice daily; Memantine HCL (medication used to treat dementia) 10 mg twice daily; Zonisamide (medication used to treat seizures) 100 mg twice daily; Tylenol 500mg three times daily; Renacidin Irrigation Solution 30 cubic centimeters (cc) every night; and Nystatin-Triamcinolone Cream to groin every shift; Physician orders dated 8/14/25, for Artificial tears (medication used for dry eyes) 1.4% one drop in each eye twice daily. Physician orders dated 11/6/25 for cleansing skin tear to left groin with normal saline, apply collagen powder and triad cream and leave open to air. Physician orders dated 11/19/25, for Levothyroxine (medication used to treat thyroid disorder) 200 micrograms (mcg) daily. Physician orders dated 12/25/25, for Ceftriaxone Injection (medication used to treat infection) 1 gram (gm) intramuscular (IM) x one dose. Physician orders for 1/22/26 for skin prep to blisters on left foot three times a day. Review of Resident R22's MAR from 12/1/25, to 2/3/26, lacked documentation indicating medications and/or physician orders were completed as ordered for the following: Out of one opportunity to document Ceftriaxone one was blank; Out of 65 opportunities to document Levothyroxine three were blank, Aricept two were blank, Flomax two were blank, and Trazadone two were blank; Out of 130 opportunities to document Baclofen two were blank, Lamictal two were blank, Memantine HCL two were blank, Zonisamide two were blank, Artificial tears two were blank, and monitor for pain one was blank; Out of 195 opportunities to document Tylenol three were blank. Review of Resident R22's TAR from 12/1/25, to 2/3/26, lacked documentation indicating treatments and/or physician orders were completed as ordered for the following: Out of two opportunities to document cleansing skin tear to left groin, two were blank; Out of three opportunities to document Triad Hydrophilic Paste two were blank; Out of 19 opportunities to document skin prep to left foot blisters, two were blank; Out of 46 opportunities to document Renacidin Irrigation 12 were blank; Out of 130 opportunities to document Phytoplex Protectant Ointment 12 were blank, Indwelling catheter care eight were blank, Monitor for bleeding seven for blank, Nystatin - Triamcinolone 17 were blank, Pressure reducing cushion to chair when out of bed seven times were blank, secure catheter in place seven times were blank, and privacy bag for catheter two were blank; Out of 195 opportunities to document intake and output 35 were blank and maintain foley catheter to gravity 26 were blank. Resident R23's clinical record revealed an admission date of 2/20/24, with diagnoses that included COPD, Diabetes, and Atrial Fibrillation. Resident R23's clinical record revealed physician orders dated 9/9/25, for changing oxygen tubing, nebulizer tubing, blue tubing, and trach mask weekly; check oxygen saturation every four hours; and Tracheostomy care twice a day. Physician orders dated 9/12/25, for monitor for pain every shift; change enteral feeding syringe every night; Trazadone HCL (medication used to treat depression) 50 mg daily; Apixaban (medication used to prevent blood clots) 5 mg po twice daily; Bactroban to enteral feed insertion side three times a day; flush enteral tube with 20 to 30 cc of water before and after medications; Diabetasource AC formula 1.2 at 50 cc per hour every shift; Clonazepam (medication used to treat anxiety) 0.5 mg twice daily, Docusate Sodium (medication used for constipation) 100 mg twice daily; Sodium Chloride Nasal Spray (medication used for dryness) one spray each nostril twice daily; document total intake of enteral feeding and water flushed three times a day; Baclofen (medication used for pain) 5 mg twice daily; Metoprolol Tartrate (medication used to treat high blood pressure) 25 mg twice daily; indwelling catheter care every shift, monitor for signs and symptoms of bruising / bleeding; maintain foley catheter to gravity drainage every shift; triple antibiotic ointment to tube site every shift; Pressure reducing cushion to chair every shift; pressure reduction mattress to bed every shift; and privacy bag to catheter every shift. Physician orders dated 9/13/25, for Nexium (medication used to treat gastric reflux) 40 mg daily. Physician orders dated 9/15/25, for head of bed elevated thirty degrees at all times in bed; and oxygen at 5 liters per minute to trach with F1O2 of 28% every shift. Physician orders dated 10/5/25, for change enteral feeding bag and tube daily. Physician orders dated 10/8/25, for checking gastric tube residual and placement before formula, medications, flushes or at least every eight hours. Physician orders dated 11/14/25, for Acetylcysteine Solution (medication used to thin mucus and secretions) 20% 3 milliliters (ml) inhaled every eight hours. Physician orders dated 11/24/25, for Zinc Oxide to coccyx and buttocks every shift. Physician orders dated 11/25/25, for Skin prep to bilateral toes and left medial hallux every shift. Physician orders dated 12/23/25, for Diabetasource AC formula 1.2 at 60 cc per hour every shift. Physician orders dated 1/13/26, for Piperacillin (medication used to treat infection) 3.375 grams three times a day; Sodium Chloride 0.9% 5 ml IV flush three times a day; change midline dressing every 7 days; and monitor for signs and symptoms of infection every shift. Review of Resident R23's MAR from 12/1/25, to 2/3/26, lacked documentation indicating medications and/or physician orders were completed as ordered for the following: Out of nine opportunities to document Piperacillin one was blank; Out of 37 opportunities to document Sodium Chloride IV flush two were blank; Out of 65 opportunities to document changing enteral feeding syringe eight were blank, change enteral feeding bag and tubing one was blank, Trazadone two were blank, and Nexium 10 were blank; Out of 67 opportunities to document Diabetasource AC at 50 cc / hr 2 were blank; Out of 70 opportunities to document Bactroban to enteral tube insertion site four were blank; Out of 127 opportunities to document Diabetasource AC at 60 cc / hr 10 were blank; Out of 130 opportunities to document Apixaban two were blank, Clonazepam three were blank, Docusate Sodium three were blank, Sodium Chloride Nasal Spray three were blank, Baclofen two were blank, and Metoprolol Tartrate two were blank; Out of 195 opportunities to document monitor for pain 16 were blank, checking gastric tube residual and placement 21 were blank, 20 - 30 cc of water flush before and after meals 21 were blank, Acetylcysteine 18 were blank, and documenting total intake of enteral feeding and water flushes 29 were blank. Review of Resident R23's TAR from 12/1/25, to 2/3/26, lacked documentation including treatments and/or physician orders were completed as ordered for the following: Out of three opportunities to document change midline dressing one was blank; Out of eight opportunities to document changing oxygen tubing, nebulizer tubing, blue tubing, and tach mask weekly two were blank; Out of 43 opportunities to document monitoring site for infection five were blank; Out of 130 opportunities to document pressure reducing cushion to chair eight were blank, pressure reduction mattress eight were blank, skin prep to bilateral toes and left medical hallux 15 were blank, tracheostomy care 23 were blank, privacy bag to catheter eight were blank, head of bed elevated eight were blank, indwelling catheter care nine were blank, monitor for bruising / bleeding nine were blank, oxygen at 5L 10 were blank, and zinc oxide to coccyx / buttocks 19 were blank; Out of 195 opportunities to document maintain foley drainage to gravity 30 were blank, and triple antibiotic to tube site 58 were blank; Out of 266 opportunities to document oxygen saturations 82 were blank. During an interview on 2/4/26, at 1:49 p.m. the DON confirmed that Resident R13's, R22's, and R23's clinical records were incomplete regarding MARs and TARs documentation. 28 Pa. Code 211.5(f)(ii)(viii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of one of 16 residents reviewed (Resident R2).Findings include: MDS instructions for section N Medications, subsection N0415E1 High-Risk Drug Classes: Use and Indication Anticoagulant - check if the resident is taking any medications by pharmacological classifications, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Resident R2's clinical record revealed an admission date of 12/27/25, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs), and pain. Resident R2's admission MDS with an ARD of 12/30/25, revealed section N0415E Anticoagulant - check if the resident is taking any medications by pharmacological classifications, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. was coded as No. Resident R2's physician orders revealed an order dated 12/28/25, for Rivaroxaban (an anticoagulant medication that decreases the ability of blood to clot) 15 milligrams (mg) once a day. Medication Administration Record for December 2025, revealed Resident R2 received Rivaroxaban once a day from 12/28/25 through 12/31/25. During an interview on 2/5/26, at 12:50 p.m. the Social Worker confirmed that Resident R2 received an anticoagulant medication since admission/entry and his/her 12/30/25 admission MDS, was coded inaccurately regarding use of anticoagulant medication. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one of 16 residents reviewed (Resident R2).Findings include: A facility policy entitled, Care Plan Policy dated 12/2/25, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident R2's clinical record revealed an admission date of 12/27/25, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs), and pain. Review of Resident R2's physician orders revealed an order dated 12/28/25 for Rivaroxaban (an anticoagulant medication that decreases the ability of blood to clot) 15 milligrams (mg - metric unit of measure) once a day. Review of Resident R2's comprehensive plan of care failed to reveal a care plan for the use of an anticoagulant medication and how to manage anticoagulant therapy. During a telephone interview on 2/05/26, at 12:50 p.m. the Social Worker confirmed that Resident R2's comprehensive plan of care did not include a care plan for the use of an anticoagulant. The Social Worker revealed there should have been a care plan initiated for Resident R2 for the use of an anticoagulant. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to review and/or revise resident care plans for two of 16 residents reviewed (Residents R2 and R13). Findings include: Review of facility policy dated 12/2/25, entitled Care Plan Policy revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. And Periodically reviewed and revised by a team of qualified persons after each assessment. Resident R2's clinical record revealed an admission date of 12/27/25, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs), and pain. Review of Resident R2's comprehensive care plan on 2/5/26, revealed that of the nine care plans present, nine had an outstanding target date (date that the care plan would be reviewed and revised with a new target date determined) of 1/13/26. The care plans included the problem categories of: allergies, self-care deficit, risk for skin breakdown, risk for falls, pain, nutrition/hydration needs, discharge, elopement, and code status. Resident R13's clinical record revealed an admission date of 6/15/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Review of Resident R13's comprehensive care plan on 2/5/26, revealed that of the nine care plans present, nine had an outstanding target date of 1/11/26. The care plans included the problem categories of: discharge plan, psychotropic medications, altered nutrition and hydration, risk for skin breakdown, self-care deficit, risk for falls, smoker, code status, and altered respiratory status. During a telephone interview on 2/5/26, at 11:30 a.m. the Social Worker confirmed that Residents R1 and R13's care plans were not reviewed and/or revised within the required timeframes. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician sign and date all orders during each of his/her visits for five of 25 residents reviewed (Residents R1, R2, R29, R98 and R100). Findings include: Review of facility policy entitled Physician Services dated 12/4/24, indicated Physician visits will comply with the following: The resident must be seen every thirty (30) days for the first ninety (90) days after admission, then every sixty (60) days thereafter. The resident's total plan of care (including medication and treatments) must be reviewed with each scheduled visit. and All orders must be recorded in the resident's clinical record and renewed every thirty (30) days. Resident R1's clinical record revealed an admission date of 6/12/24, with diagnoses that included congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R1's clinical record revealed that the last time his/her physician reviewed, signed, and dated his/her physician orders was on 3/28/25. Resident R2's clinical record revealed an admission date of 7/16/24, with diagnoses that included COPD, heart failure (a condition where the heart cannot supply the body with enough blood), and hypertension (high blood pressure). Review of resident R2's clinical record revealed that the last time his/her physician reviewed, signed, and dated his/her physician orders was on 2/2/25. Resident R29's clinical record revealed an admission date of 6/18/24, with diagnoses that included COPD, hyperlipidemia (high cholesterol), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of resident R29's clinical record revealed that the last time his/her physician reviewed, signed, and dated his/her physician orders was on 10/31/24. Resident R98's clinical record revealed an admission date of 4/19/24, with diagnoses that included hypotension (low blood pressure), hyperlipidemia, and benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to become enlarged and cause difficulty urinating). Review of resident R98's clinical record revealed that the last time his/her physician reviewed, signed, and dated his/her physician orders was on 2/2/25. Resident R100's clinical record revealed an admission date of 10/23/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension, and hypothyroidism. Review of resident R100's clinical record revealed that the last time his/her physician reviewed, signed, and dated his/her physician orders was on 6/3/25. During an interview on 9/10/25, at 10:40 a.m. the Director of Nursing (DON) confirmed that physician orders for Residents R1, R2, R29, R98, and R100 were past due to be reviewed and signed by the physician. The DON also confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for two of 25 residents reviewed (Residents R12 and R56). Findings include: The facility policy entitled Advance Directives dated [DATE], revealed .We recognize each resident's right to refuse treatment, to live a dignified life, and to self-determination.Documentation, written or oral, of informed consent to withhold or withdraw treatment must be placed in the resident's clinical record together with the attending physician's order regarding the withholding or withdrawal of treatment. The physician's order should also be noted on the resident's plan of care and on the inside of the resident's clinical record . Resident R12's clinical record revealed an admission date of [DATE], with diagnoses that included anxiety, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Resident R12's physician's orders dated [DATE], indicated for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). Resident R12's clinical record revealed a POLST dated [DATE], indicated Do Not Resuscitate-Allow Natural Death (DNR). Resident R56's clinical record revealed an admission date of [DATE], with diagnoses that included heart failure, hypertension, and muscle weakness. Resident R56's physician's orders dated [DATE], indicated Do Not Resuscitate-Allow Natural Death (DNR). Resident R56's clinical record revealed a POLST indicated cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). During an interview on [DATE], at approximately 2:30 p.m. the Director of Nursing confirmed Residents R12 and R56's physician's orders and POLST's were not consistent with each other. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(i)((vii) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days for one of five residents reviewed (Resident R8).Findings include: Review of facility policy entitled PRN Order for Anti-Psychotic Medications dated 12/4/24, indicated . limits PRN orders for anti-psychotic medication to 14 days and cannot be renewed unless the attending physician. evaluates the resident for appropriateness of that medication. Review of Resident R8's clinical record revealed an admission date of 6/10/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and hypertension (high blood pressure). Review of Resident R8's physician's orders revealed an order dated 7/9/25, for Ativan (anti-anxiety medication) 0.5mg (milligram) by mouth every eight hours as needed. Review of Resident R8's August 2025 Medication Administration Record (MAR) revealed that Ativan was used on 8/3/25, 8/7/25, 8/17/25, 8/21/25, and 8/31/25. Review of the September 2025 MAR revealed that Ativan was used 9/3/25. During an interview on 9/10/25, at 2:45 p.m. with the Director of Nursing (DON) he/she confirmed that Resident R8's PRN Ativan order lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of seven residents reviewed (Residents R1, R4, and R11).Findings include: Review of facility policy entitled Transfer, Discharge and Room Change dated 12/4/24, indicated clinical records describing the residents needs, including list of orders and medications, as directed by the attending physician, shall accompany the resident. Resident R1's clinical record revealed an admission date of 6/12/24, with diagnoses that included congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Resident R1's progress notes revealed a note dated 12/26/24, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R4's clinical record revealed an admission date of 3/10/25, with diagnoses that included hypertension (high blood pressure), dementia (a disease that affects short term memory and the ability to think logically), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Resident R4's progress notes revealed a note dated 5/28/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R11's clinical record revealed an admission date of 1/30/25, with diagnoses that included diabetes dependence on renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), and hypertension. Resident R11's progress notes revealed a note dated 7/31/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 9/10/25, at 1:50 p.m. the Director of Nursing (DON) confirmed that there was no evidence that Residents R1, R4 and R11 necessary clinical information was provided to the receiving healthcare provider upon transfer and also confirmed when the transfers occurred clinical information should be provided to the receiving healthcare provider upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 18 residents reviewed (Resident R8).Findings include: Review of Resident R8's clinical record revealed an admission date of 6/10/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and hypertension (high blood pressure). Resident R8's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R8 and/or his/her representative. During an interview on 9/11/25, at 11:53 a.m. the Director of Nursing confirmed that the clinical record of Resident R8 lacked evidence that a written summary of the baseline care plans, and order summaries were provided the Resident and/or their representative upon admission to the facility. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans for a resident requiring oxygen therapy that included measurable objectives and timetables to meet a resident's needs for one of 25 residents reviewed (Resident R88). Findings include: A facility policy entitled, Care Plan Policy dated 12/4/24, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs . Review of Resident R88's clinical record revealed an admission date of 5/7/25, with diagnoses that included respiratory failure (a condition where your lungs don't exchange air properly), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R88's physician's orders revealed an order for oxygen two liters per minute PRN (as needed) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen). Review of Resident R88's oxygen saturation percentages from 8/8/25, through 9/11/25, revealed Resident R88 had used his/her oxygen on 31 of the days. Review of Resident R88's person centered plans of care lacked evidence that a plan of care for respiratory care with use of oxygen was developed. During an interview on 9/11/25, at 1:20 p.m. the Director of Nursing confirmed that a plan of care for respiratory care with use of oxygen was not developed for Resident R88 and also confirmed that a respiratory plan of care with use of oxygen should have been developed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to review and/or revise resident care plans to reflect resident's current condition and failed to ensure that resident care plan meetings were held timely for two of 25 residents reviewed (Residents R22 and R56). Findings include: Review of facility policy entitled “Care Plan Policy” dated 12/4/24, revealed that the care plans are periodically reviewed and revised by a team of qualified persons after each assessment. The policy further indicated that the Resident will have the opportunity to discuss their goals for care including their preferences for advanced care planning with the interdisciplinary team. Resident R22's clinical record revealed an admission date of 6/21/19, with diagnoses that included obstructive and reflex uropathy (urinary tract disorder that occurs when urine flow is obstructed), benign hyperplasia prostatic (an enlarged gland below the bladder that causes difficulty urinating) with lower urinary tract symptoms, weakness and dementia (a condition that causes a decline in cognitive functions, such as memory, thinking, and problem solving). Review of Resident R22’s physician's orders revealed an order dated 6/25/25, for a suprapubic catheter (tube directly into the bladder to drain urine). Resident R22 had a previous order for a foley catheter. Review of Resident R22's care plan revealed a foley catheter care plan created on 1/20/20, with a revision date of 7/7/25. The care plan lacked any evidence that Resident R22 had a suprapubic catheter. During an interview on 9/11/25, at 10:40 a.m. the Director of Nursing confirmed that Resident R22's care plan was not updated to reflect Resident R22’s current status and care needs. Resident R56’s clinical record revealed an admission date of 11/21/24, with diagnoses that included heart failure, hypertension (high blood pressure), and muscle weakness. Resident R56's clinical record lacked evidence that a care plan meeting was scheduled timely. He/she had a care plan meeting on 1/21/25, and the next care plan meeting was held on 8/10/25. During an interview on 9/10/25, at 11:45 a.m. the Social Worker confirmed that Resident R56’s care plan meeting was not scheduled timely after the meeting held on 1/21/25, and that his/her next care plan meeting should have been scheduled and completed in May 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of two residents reviewed for respiratory services (Resident R88). Findings include: Review of facility policy entitled Oxygen Concentrators dated 12/4/24, indicated external filters are to be cleaned weekly. Prefilled bubble humidifier bottles. need to be changed weekly and as needed. Review of Resident R88's clinical record revealed an admission date of 5/7/25, with diagnoses that included respiratory failure (a condition where your lungs don't exchange air properly), Chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R88's physician's orders revealed orders for oxygen (O2) two liters per minute PRN (as needed) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) dated 8/7/25, and oxygen maintenance change O2 tubing and supply bag weekly, wipe down concentrator and clean filter weekly, change water jug weekly dated 8/7/25. Review of Resident R88's oxygen saturation percentages between 8/8/25, through 9/11/25, revealed Resident R88 had used his/her oxygen on 31 of the days. Observations on 9/8/25, at 1:15 p.m., and again at 3:30 p.m. revealed Resident R88 sitting in his/her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at one and a half liters/minute. Further observations revealed no water bottle attached to the oxygen concentrator, and no filter on the back of the concentrator. Observations on 9/9/25, at 11:16 a.m. and again at 2:15 p.m. revealed Resident R88's oxygen continued to be set at one and a half liters/minute and continued to have no water bottler or filter attached to the oxygen concentrator. Observations on 9/10/25, at 11:15 a.m. and again at 1:30 p.m. revealed Resident R88's oxygen continued to be set at one and a half liters/minute and continued to have no water bottler or filter attached to the oxygen concentrator. Observations on 9/11/25, at 10:00 a.m. and again at 12:58 p.m. revealed Resident R88's oxygen continued to be set at one and a half liters/minute and continued to have no water bottler or filter attached to the oxygen concentrator. During an interview on 9/11/25, at 12:58 p.m. the Director of Nursing (DON) confirmed that Resident R88's oxygen concentrator was on and set at one and a half liters/minute which was not in accordance with the physician's order dated 8/7/25, for oxygen at two liters/minute and that there was no water bottler or filter attached to the oxygen concentrator. The DON also confirmed that Resident R88's oxygen flow rate should be set per physician order and that there should have been a water bottle and filter attached to the oxygen concentrator. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, observations,and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of two medication carts reviewed and one of one medication rooms reviewed (facility medication room and A wing medication cart). Findings include: Review of facility policy entitled Medication Storage dated 12/4/24, indicated Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations. and Outdated, contaminated, or deteriorated medications. are immediately removed from stock. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the pen still contains insulin. Review of manufacturer's guidelines revealed that an open pen of Aspart Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open vial of Tubersol should be discarded within 30 days after opening. Observation of drug storage on 9/8/25, at 2:35 p.m. of the facility medication room revealed an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) with no date indicating when the Tubersol was opened. Further observations of the A wing medication cart, revealed an open Aspart insulin pen with an open date of 7/12/25, another open Aspart insulin pen with an open date of 7/14/25, and an open Lantus insulin pen with no date indicating when the insulin was opened. During an interview on 9/8/25, at the time of observation Licensed Practical Nurse (LPN) Employee E1 confirmed that the open dates on the aspart insulin pens were 7/12/25, and 7/14/25. LPN Employee E1 also confirmed that the open vial of Tubersol, and the open Lantus insulin pen lacked opened dates, and staff were unable to determine the discard dates. He/she also confirmed that the Aspart insulin pens, the Lantus insulin pen and the Tubersol should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of Hospice contract, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that Hospice documentation was maintained in the clinical record for one of 25 residents reviewed (Resident R74).Findings include: Review of the facility Hospice contract indicated that coordination of care between the nursing facility staff and the Hospice Interdisciplinary Team. It further indicated that Hospice will maintain a medical record of hospice services provided and that the record will be incorporated into the nursing facility medical record. Hospice personnel will chart the services in this record. Review of facility policy Hospice Policy, dated 12/04/24, indicated that the facility shall take direction from the Hospice agency regarding implementation of the coordinated plan of care related to the resident's terminal illness. The policy also indicated that the attending physician will make an order for Hospice services. Review of Resident R74's clinical record revealed an admission date of 7/18/25, with diagnoses that included interstitial pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, and diabetes, and a physician's order dated 9/08/25, to admit Resident R74 to Hospice services. Further review of Resident R74's clinical record revealed a care plan dated 7/18/25, for Hospice services to coordinate care with the facility. A nurse's note dated 7/18/25, revealed Resident R74 was a new admission on Hospice with lung issues. Resident R74's clinical record revealed a hospice plan of care dated 8/3/25, and a nurse's visit assessment dated [DATE]. The clinical record lacked any other evidence of collaboration/communication of Hospice and documentation of Hospice communication detailing Hospice services and service dates. During an interview on 9/11/25, at111:50 a.m. the Director of Nursing confirmed that there was no evidence of communication sheets provided to the facility from the Hospice provider other than the 8/11/25, nurse's assessment and confirmed that the physician's order was not obtained upon Resident R74's 7/18/25, admission date. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to notify the resident's emergency contact/representative regarding a transfer to the emergency room and a change in condition in a timely manner for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy entitled Notification of Changes dated 12/4/24, revealed that The Manor must inform the resident immediately, the attending physician, and the resident's representative or interested family member when there is a significant change in the resident's physical, mental, or psychosocial status. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood-pressure), muscle weakness, and a presence of an aortocoronary bypass graft (a surgical procedure that improves blood flow in the heart by treating narrowed or blocked arteries). Review of Resident R1's clinical record revealed a progress note dated 2/2/25, at 2:15 a.m. indicating the resident was hallucinating, had an unsteady gait, and had increased confusion resulting in transport to the emergency room . The clinical record lacked evidence that the resident's emergency contact/representative was notified of Resident R1's transfer to the emergency room . Further review of the clinical record progress notes dated 2/5/25, at 11:08 p.m. revealed that Resident R1 was wheezing, fatigued, had a non-productive cough, required a breathing treatment, and required administration of an as needed cough medicine. Therapy progress notes dated 2/6/25, at 12:00 a.m. revealed Resident R1 was having coughing fits and was extremely fatigued throughout therapy sessions. A progress note dated 2/6/25, at 6:07 a.m. revealed Resident R1 had a very moist cough during position changes which required a breathing treatment and as needed cough medicine to be administered. A progress note dated 2/6/25, at 7:42 a.m. indicated an in-house chest x-ray was ordered due to Resident R1's symptoms. A progress note dated 2/6/25, at 8:03 p.m. revealed the emergency contact/representative was notified of Resident R1 having increased coughing and that he/she was using accessory muscles when breathing, at this time the emergency contact/representative requested Resident R1 to be transferred to the emergency room and he/she was admitted to the hospital with Respiratory Syncytial Virus (RSV). These progress notes in Resident R1's clinical record revealed the emergency contact/representative was not notified of Resident R1's change in condition until approximately 21 hours after his/her onset of symptoms. During an interview on 3/6/25, at 11:55 a.m. the Nursing Home Administrator confirmed that the clinical record lacked evidence of Resident R1's emergency contact/representative being notified of the above transfer to the emergency room and change in condition in a timely manner and that the facility staff should have notified the resident's emergency contact/representative and documented the notification in the clinical record. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans for each resident that included measurable objectives and timetables to meet a resident's needs for one of 25 residents reviewed (Resident R95) and for one of five residents reviewed with an indwelling catheter (tube inserted into the bladder to drain urine) (Closed Record Resident CR12). Findings include: A facility policy entitled, Comprehensive Care Plan, dated 12/26/23, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; be developed within seven days after the completion of the comprehensive assessment, prepared by the interdisciplinary team, be periodically reviewed and revised by a team of qualified personal after each assessment, and provide services that meet professional standards of quality. Review of Resident R95's clinical record revealed an admitted [DATE], with diagnoses that included compression fracture of unspecified lumbar vertebra, pain in left hip, low back pain and major depressive disorder. Review of Resident R95's admission assessment dated [DATE], indicated that Resident R95 was a Full Code (all life sustaining measures to be done if resident is without pulse and respirations) and also revealed the resident had severe pain in the left hip and back. Admission physician's orders for Resident R95 revealed an order for weekly weight times four weeks then monthly and as needed. A physician's order dated 9/30/24, revealed an order for weekly standing weight per request every seven days. Review of Resident R95's weights revealed one documented weight on 6/22/24, and documented refusals thereafter. Clinical record review for Resident R95 revealed consistent multiple refusals of care including weights, showers, out of facility appointments and behaviors of yelling, screaming, demanding pain medications and calling 911 to go to hospital for pain. Review of Resident R95's person centered plans of care revealed only a plan of care for nutrition dated 6/25/24. The care plan for Code Status wasn't developed until 10/23/24; the Pain, Skin breakdown and Self Care deficit care plans weren't developed until 10/30/24. The Impaired Coping Mood Disorder and Behavior Management, New disruptive behavior and New refusal of care plans were recently developed on 11/04/24. During an interview on 11/06/24, at 9:50 a.m. the Nursing Home Administrator confirmed that Resident R95's comprehensive plans of care were not completed timely after admission. Resident CR12's clinical record revealed an admitted [DATE], with diagnoses that included stroke, hydronephrosis (condition where the kidneys swell and stretch due to a buildup of urine), epilepsy (chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and hemorrhagic cystitis (urinary bladder lining becomes inflamed and bleeds) diagnosed [DATE]. Further review of Resident CR12's clinical record revealed no evidence that a care plan was developed for maintaining an indwelling catheter; departmental progress notes since 7/11/24; revealed five progress notes that included documentation of the presence of an indwelling catheter (9/24/24, 9/26/24, and 10/24/24); and monthly physician's progress notes (8/15/24, 9/26/24, 10/29/24) revealed documentation of the presence of an indwelling catheter. During an interview on 11/07/24, at 8:16, a.m. the Director of Nursing confirmed that there was no comprehensive care plan developed for Resident CR 12 to address the indwelling catheter. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 25 residents reviewed (Residents R51 and R91). Findings include: Review of a facility policy entitled Comprehensive Care Plan dated 12/26/23, indicated that Periodically reviewed and revised by a team of qualified persons after each assessment. Resident R51's clinical record revealed an admitted [DATE], with diagnoses that included Hyperlipidemia (high cholesterol), Hypertension (high blood pressure), and Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R51's Plans of Care revealed a plan of care for risk for skin breakdown with a target date (a date that the care plan is to be updated by) of 8/07/24. During an interview with the Registered Nurse Assessment Coordinator (RNAC) on 11/06/24, at 1:10 p.m. he/she confirmed the care plan for Resident R51 was not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary. During an interview on 11/07/24, at 9:30 a.m. a family member of Resident R91 revealed Resident R91's plan of care has not been reviewed or revised, and no care plan meeting has taken place since May of 2024. Review of Resident R91's clinical record lacked any evidence of a care plan meeting and care plan revisions/review since May 2024. During an interview with the Regional Director of Clinical Services on 11/07/24, at 1:15 pm. he/she confirmed the care plan for Resident R91 was not reviewed/revised to reflect current resident care and services and no care plan meeting was conducted since May of 2024. He/she further confirmed that care plans should be reviewed and revised as necessary and care plan meetings should occur quarterly. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical and hospital records, a review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and staff interviews, it was determined that the facility failed to provide needed care or services resulting in an actual or potential decline in one or more residents' physical, mental, and/or psychosocial well-being for one (Closed Record Resident (CR12) of five residents with an indwelling catheter (tube inserted into the bladder to drain urine) and reposition two of 25 residents reviewed (Residents R15 and R38). Findings include: A facility policy, entitled Quality of Care Policy/Activities of Daily Living, dated 12/26/23, revealed each resident will receive and the Manor will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. A resident's abilities in activities of daily living will not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. A resident who is unable to carryout activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included rheumatoid arthritis (a chronic inflammatory disorder affecting joints in the hands and feet), weakness, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to arms and legs), and anxiety. Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact, and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Review of a Minimum Data Set (MDS- periodic assessment of resident care needs) dated 9/30/24, under Section C0500 revealed that Resident R15 had a BIMS of 3/15, severe cognitive impairment. Resident R15's MDS Section G - Functional Status dated 10/22/24, revealed Resident R15 required extensive assistance with two (+) persons physical assist for bed mobility and transfers. Resident R15's care plan dated 7/10/24, revealed a focus as potential for (chronic) pain related to diseases and conditions including rheumatoid arthritis, weakness, impaired mobility, dry eye syndrome, on comfort measures, etc. with interventions included to provide non-pharmacological interventions (heat/cold, dim lighting, calm environment), turning and repositioning, offer food/fluids as per dietary order, diversional activities of choice, and decreased stimuli in environment, etc Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort. Resident R15's care plan further revealed a focus as ADL Self Care Performance deficit with interventions as OT (Occupational Therapy) recommends out of bed to wheelchair daily with peri care every two hours due to incontinence/resident not indicating need to toilet. Transfer: require partial to moderate assistance from staff with transfers. Bed Mobility: partial to moderate assistance require one person extensive assist for bed mobility. Resident R15's progress notes lacked evidence that Resident R15 was refusing to get out of bed on 11/04/24, 11/05/24, or 11/06/24. Observations on 11/04/24, at 11:20 a.m., 1:35 p.m., 2:00 p.m., and 3:35 p.m. revealed Resident R15 in bed laying on his/her back. Observations on 11/05/24, at 9:30 a.m., 11:00 a.m., 12:30 p.m., and 3:15 p.m. revealed Resident R15 in bed laying on his/her back. Observations on 11/06/24, at 8:30 a.m., 9:30 a.m., 11:40 a.m., and 12:00 p.m. revealed Resident R15 in bed laying on his/her back. An interview with the Registered Nurse Assessment Coordinator (RNAC) on 11/06/24, at 3:55 p.m. confirmed Resident R15 is a two (+) persons physical assist for bed mobility and transfers, and needs staff assistance to turn and reposition and should be out of bed to wheelchair daily as noted in care plan by OT. Resident R38's clinical record revealed an admitted [DATE], with diagnoses that included protein-calorie malnutrition (a loss of appetite and lack of interest in food resulting in muscle wasting), hypertensive heart disease with heart failure (a group of conditions that can occur when high blood pressure damages the heart), chronic obstructive pulmonary disease (COPD - a group of lung disease that makes it difficult to breathe), and bradycardia (a condition where heart rate is slower than 60 beats per minute - low heart rate). Review of an MDS dated [DATE], revealed that Resident R38 had a BIMS of 6/15, severe cognitive impairment. Resident R38's MDS Section G - Functional Status dated 9/27/24, revealed Resident R15 requires extensive assistance with one-person physical assist for transfers. Resident R38's care plan dated 6/26/24, revealed a focus at risk for alteration in comfort related to skin cancer to right cheek, pain in right shoulder, general malaise (a sense of being unwell often accompanied by fatigue and/or pain), high blood pressure, COPD, bradycardia, dysphagia (difficulty swallowing), gastroesophageal reflux disease (a disease in which stomach acid or bile irritates the food pipe lining), anemia (a condition in which the blood doesn't have enough red blood cells to carry oxygen throughout the body), and history of falls with interventions as allow sufficient rest periods, assist with mobility and positioning as needed and will receive pain management throughout stay at the facility including to be positioned for comfort, pain will be monitored, assessed and treated using the appropriate pain scale as needed. Observations on 11/07/24, at 9:15 a.m. revealed Resident R38 out of bed sitting in his/her wheelchair. Observations on 11/07/24, at 11:10 a.m. revealed Resident R38 sitting in his/her wheelchair verbalizing to a staff member as the staff member walked past him/her, please can I get off my butt, it hurts so bad. Further observations between 11:10 a.m. and 11:50 a.m. revealed several staff members walking by Resident R38 with his/her arm reaching out to each staff member as they walked by him/her. Resident R38 was then observed in dining room at 11:53 a.m. for lunch and was still asking to be laid down due to her bottom hurting really bad. Resident R38 stated while sittng in dining room, I have been up since breakfast and my butt hurts so bad and they won't lay me down. This happens all the time. An interview on 11/07/24, at 11:54 a.m. with Licensed Practical Nurse (LPN) Employee E6 confirmed that Resident R38 has been out of bed since breakfast and should have been laid down between meals due to Resident R38 eats in the dining room for all meals. Resident CR12's clinical record revealed an admitted [DATE], with diagnoses that included stroke, hydronephrosis (condition where the kidneys swell and stretch due to a buildup of urine), epilepsy (chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and hemorrhagic cystitis (urinary bladder lining becomes inflamed and bleeds) diagnosed [DATE]. A physician's order for an indwelling catheter size 18 French with a 15-cc [cubic centimeter] balloon was discontinued on 11/05/23, and there was no evidence that Resident CR12 had an active physician's order for an indwelling catheter until 10/29/24, or a period of 359 days. A physician's order for providing indwelling catheter care every shift was discontinued on 11/05/23, and there was no evidence that Resident CR12 had an active physician's order for indwelling catheter care every shift until 10/29/24, or a period of 359 days. A physician's order for changing an indwelling catheter every evening shift, every 30 days was discontinued on 11/05/23, and there was no evidence that Resident CR12 had an active physician's order to change the indwelling catheter until 10/29/24, or a period of 359 days. Review of Resident CR12's treatment records revealed no evidence that staff provided catheter care and/or changed his/her indwelling foley catheter since 11/05/23, or a period of 359 days. Review of recent departmental progress notes since 7/11/24, revealed five progress notes that included documentation of the presence of an indwelling catheter (9/24/24, 9/26/24, and 10/24/24). Review of monthly physician's progress notes (8/15/24, 9/26/24, 10/29/24) revealed documentation of the presence of an indwelling catheter. During an interview on 11/07/24, at 8:16, a.m. the Director of Nursing (DON) confirmed there was no evidence of a physician's order for an indwelling catheter, changing the indwelling catheter, providing catheter care since 11/05/23, or a period of 359 days. The DON also confirmed that Resident CR12 had an indwelling catheter in place between 11/05/23, and 10/29/24 (date of discharge), and that there should have been physician's orders for the indwelling catheter, changing the indwelling catheter, and providing catheter care. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.5 (f)(i) Medical Records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for three of eight residents reviewed who smoke at the facility (Residents R11, R14, and R104). Findings include: A facility policy entitled, Smoking Policy, dated 12/26/23, revealed for those Manors that permit smoking the purpose is to provide maximum safety to all resident at all times. It is the intent of the Manor to provide an environment to all those residents, who wish to smoke, the opportunity to do so in a safe environment, with optimal safety to themselves, other residents, volunteers, visitors, and staff members. Residents will be informed of the written smoking policy prior to admission. Smoking will be allowed in designated areas only. Residents must be accompanied by staff, family, or properly trained volunteers while smoking. Smoking materials will be kept in a designated area accessible only by staff. This includes the safekeeping of electronic cigarettes. Staff members are strictly prohibited from furnishing their personal smoking materials to residents. Residents electing to smoke must provide their own smoking materials. Observations on all days on 11/04/24, 11/05/24, 11/06/24, and 11/07/24 throughout each day by all four surveyors revealed Resident R11, Resident R14, and Resident R104 smoking outside on the front patio entrance to facility. An interview with the Nursing Home Administrator (NHA) on 11/07/24, at 11:30 a.m. confirmed that Residents R11, R14, and R104 smoke outside on the front patio entrance to the facility, which is an unauthorized smoking area and against facility policy. The NHA further confirmed that these residents often refuse to adhere to the facility smoking policy and have access to their own lighters and cigarettes creating a safety hazard and unsafe environment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 209.3(a) Smoking

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a resident's physician thoroughly documented a review of the resident's current condition, progress, and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen for one (Closed Record Resident CR12) of 25 residents reviewed. Findings include: A facility policy entitled, Physician Services dated 12/22/23, indicated: 1. The resident's total plan of care (including medications and treatments) must be reviewed with each scheduled visit. 2. A progress note must be written, signed, and dated for each physician visit and that each progress note must contain. - An evaluation of the resident's condition, treatment, and a review of the continued appropriateness of the resident's current medical regimen. - Continuity of care in maintaining or improving a resident's condition and current medical regimen. - The resident's progress or problems in maintaining or improving his/her mental and physical functioning status. - Identification of the primary risk factors and causal factors contributing to clinical conditions, functional decline, deterioration, or potential for, and lack of improvement and whether those conditions or decline are avoidable. - Clinical validation of the need for medical interventions or justification for decisions regarding care. Resident CR12's clinical record revealed an admitted [DATE], with diagnoses that included stroke, hydronephrosis (condition where the kidneys swell and stretch due to a buildup of urine), epilepsy (chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), and hemorrhagic cystitis (urinary bladder lining becomes inflamed and bleeds diagnosed [DATE]). Review of Resident CR12's diagnostic labs revealed on 9/24/24, his/her hemoglobin A1C (blood test that measures a person's average blood sugar levels over the past two to three months) was 6.5, and the next most recent labs located in Closed Record Resident CR12's clinical record were on 11/20/23, his/her Dilantin (medication to treat seizures) level was 11.1, and on 10/02/23, his/her hemoglobin A1C was 6.3, and the Dilantin level was 15.6. Review of Resident CR12's clinical record revealed physician progress notes which included the following: 10/29/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, labs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7 range, early visit due to vacation next 2 weeks, no concerns from staff f/u sept visit with mar check and labs for a1c, Dilantin, etc, monthly catheter changes due to chronic foley. Dilantin level 21, borderline high but no seizures. No lethargy, leg swelling, still interactive and joking today, sugars good, flu shot upcoming, change foley monthly. 9/26/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7 range, early visit due to vacation next 2 weeks, no concerns from staff, f/u sept visit with mar check and labs for a1c, Dilantin, etc, monthly catheter changes due to chronic foley. Dilantin and a1c upcoming. Mar reviewed. Joking more. 8/15/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7 range, early visit due to vacation next 2 weeks, no concerns from staff f/u sept visit with mar check and labs for a1c, Dilantin, etc, monthly catheter changes due to chronic foley. 7/25/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7 range, update this visit very little changed encouraged to get out more but keeps to room, leg chronic edema and sore. 6/27/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7 range, color good more interactive. 5/30/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. Overall doing ok a1c much improved 6-7. 4/25/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back, overall this visit leg swelling, cough congestion, and abdominal distention seem pretty good. 3/27/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen, seems improved, less gassy and distention, more upbeat, chronic edema of leg, sp cva years back. 2/28/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Much better recently out in wheelchair enjoying the sunny weather belly soft far less distended, will continue current regimen. 1/24/24, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. Bowels still off and on, distended today but moving gas and appetite ok, watch closely, family aware, spoke to son recently. 12/22/23, Complicated year for patient in and out of hospital for abdominal distention, gi bleed, covid earlier in year, known diabetes, chronic dvt and seizure dx., old cva, left sided weakness, abs reviewed a1c 6.3, cbc good mildly low plts, cmp good, Dilantin level good 15, chol good. Exam clear adb distention gas, chest cta, no wheeze or rhonchi, cv regular a/p as above plus bowel issues on bowel regime family aware tough situation continue close assessment. During an interview on 11/07/24, at 10:45 a.m. the Nursing Home Administrator confirmed that the above listed physician progress notes did not accurately reflect Resident CR12's current health condition at the time of the physician's visit, that Resident CR12 was last COVID positive on 11/20/22, and that the hemoglobin A1C and Dilantin levels were not reflective of the resident's most recent values prior to the physician visits. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.5(f)(ii)(ix) Medical records

Based on review of a facility event report, clinical records, facility investigation documents and staff and resident interviews, it was determined that the facility failed to ensure that medications were administered in accordance with physician's orders [REDACTED]. The findings include: The 11/21/12 initial Minimum Data Set (MDS-assessment of resident needs) indicated Resident R1 was admitted to the facility 11/07/12, with [DIAGNOSES REDACTED]. The Event Report, submitted to the Department of Heath on 11/21/12, indicated that Resident R1 had neck surgery and went to a physician's office for a surgical follow-up visit on 11/21/12. Licensed Practical Nurse (LPN) Employee E1 instructed Nurse Aide (NA) Employee E2 to administer medications to Resident R1 and gave NA Employee E2 the wrong medications in error. Another resident's medication were sent with NA Employee E2, who accompanied Resident R1 to the physician's office. The medications were [MEDICATION NAME] (used for heart arrhythmia) which can cause significant harm when given in error according to the Institute for Safe Practices, [MEDICATION NAME] (diuretic), [MEDICATION NAME] (blood pressure/heart), [MEDICATION NAME] (blood pressure), [MEDICATION NAME] (used to treat heart failure) and [MEDICATION NAME] (an anticonvulsant). Resident R1 was given these medications at the physician's office by NA, Employee E2. The statement submitted to the facility by NA, Employee E2, revealed that Resident R1 had a blood pressure taken by the physician's nurse upon arrival at the physician's office which was 150/80 (millimeters of mercury). During an interview on 11/27/12, at 11:00 a.m., Resident R1 indicated that he/she felt very weak shortly after taking the medications at the physician's office and that the NA realized the resident had been given another resident's medications. When a nurse in the physician's office took Resident R1's blood pressure again after the administration of the wrong medications, it was 73/40 (millimeters of mercury). The resident was taken to the hospital and was admitted to the Intensive Care Unit. Resident R1 returned to the facility the next day. Nurses' Notes dated 11/20/12 at 12:12 p.m., indicated that Resident R1 was admitted to the hospital for observation. Facility incident investigation notes dated 11/21/12 at 10:17 a. m., indicated that Resident R1 reported to facility staff that the hospital administered two IV's (intravenous - fluid and electrolytes administered into a vein), and were monitoring her heart and pulse. During an interview on 11/7/12, at 10:00 a. m., the Director of Nursing (DON) confirmed that NA, Employee E2, was given another resident's medications by the wing nurse, LPN, Employee E1, and then administered these wrong medications to Resident R1 and that the resident was taken to the hospital and admitted overnight. The DON, when referring to the facility policy on residents leaving the facility with medications indicated that, "Our process is not well defined." The DON indicated that Resident R1 was not assessed for self-administration of drugs. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.