Every finding on record at East End Health & Rehab Center

Based on review of facility policy and documents, and interviews with staff, it was determined that the facility staff failed to implement policies and procedures to notify the local law enforcement in a timely manner after a visitor verbalized threats of harm, physical intimation, and/or allegedly threatened to use a weapon on facility property against an employee, on one of three resident care units (Fourth Floor Nursing Unit).Findings include: Review of the facility Violence in the Workplace Policy last reviewed 4/1/26, indicated the facility enforces zero tolerance for acts of violence, threats of harm, physical intimation, and/or bringing or using weapons on facility property. Emergency Situations: If any threat of violence is perceived, supervisors and/or employees should enlist the assistance of management staff and local authorities. If any threat of violence exists, call 911 and notify law enforcement officials of the problem and request their assistance. Inform those involved and contact the Administrator. Review of an anonymous complaint filed against the facility on 7/29/26, indicated Resident R1 was visiting with her family (grandson and his girlfriend). Nurse Aide (NA) Employee E1 placed the resident's tray down vertically instead of horizontally. Resident R1 didn't like it and words were exchanged. NA Employee E1 told Resident R1 they had a license to carry and always had her gun on her. The complainant indicated they did not see the gun, but heard an exchange of words from the hallway. Resident R1 asked her grandson if he had his gun with him, he said he didn't. Complainant did not see the grandson's gun, and only heard the exchange from the hallway. The grandson was aggressive with NA Employee E1 and said he'd tear this sh*t up! Review of facility provided witness statements indicated that on 6/26/26, at 10:24 p.m. Registered Nurse (RN) Employee E2 sent an email to the Director of Nursing, alerting her to an event that happened at the facility between NA Employee E1 and Resident R1's grandson that evening. The grandson was offended by the way NA Employee E1 placed the dinner tray on Resident R1's bedside table. Apparently, they thought NA Employee E1 had a negative attitude. The grandson followed NA Employee E1 out of the room and down the hallways, escalating the situation. At some point the grandson's girlfriend joined grandson in the hallway. Apparently either the Resident R1 or one of her guests mentioned something about carrying a firearm trying to intimidate NA Employee E1. This is when NA Employee E3 came down to the second floor to notify me about what was going on. RN Employee E2 went to the fourth floor to assess the situation. The grandson's girlfriend kept instigating NA Employee E1 that she'd be waiting for her after work to beat her up. RN Employee E1 indicated he kept trying to calm everyone down and to deter any thoughts or acts of violence. RN told Resident R1's guests that they had to leave the facility, and that another NA would be assigned to Resident R1. Review of NA Employee E1's signed witness statement dated 6/27/26, indicated she was passing dinner trays and placed Resident R1's sideways because there were a lot of items on the table. She walked away to continue passing trays when a young man screamed down the hall saying NA Employee E1 had a problem with his grandmother (Resident R1), because of how she placed the dinner tray on the table. The NA walked down the hall to call the supervisor, when the resident and the young man started yelling, he was going to do something to the NA. Then Resident R1 asked the young man if he had a gun. NA Employee E1 then found the supervisor and she and the other aides told the supervisor they were being threatened with a gun. NA Employee E3 asked the young man and girlfriend to leave due to putting our residents in harm's way and NA Employee E3 was told to shut the f**k up or would also be beat up. NA Employee E1 indicated she didn't feel safe with Resident R1 or her guests. Review of NA Employee E3's signed witness statement dated 6/27/26, indicated yesterday (6/26/26) during dinner tray meal pass she and NA Employee E1 were passing trays. NA Employee E1 dropped off Resident R1's dinner tray and then walked out of the room and we proceeded to pass meal trays. The grandson of Resident R1 started screaming down the hall, is there a problem? NA Employee E3 stepped in and said, We don't do that here. Resident R1 stated Mind your business fat as* b***ch. The grandson said he can get it too and he's licensed to carry a gun. NA Employee E3 removed herself from the situation to go get RN Employee E2. When RN got to the floor the family was still yelling and Resident R1 mentioned her grandson had a gun. RN Employee E2 went to deal with the family. Review of e-mail correspondence from the Director of Nursing to facility staff and the Nursing Home Administrator on 6/30/26, at 2:14 p.m. indicated no visitors for Resident R1. Police report filed and resident and grandson are both aware. Resident R1 will be discharged oncer the apartment is ready. If at any point the staff are feeling threatened, being threatened.Please call 911 immediately. No calls should be placed to other staff/department heads, the only people that can help in this situation are the police. Interview on 7/30/26, at 2:00 p.m. the Director of Nursing indicated she did not report the event to the state survey agency because nobody every visualized a gun in the facility. The DON indicated the Nursing Home Administrator notified the police on 6/30/26, and confirmed the facility should have called the police immediately if there was any threats of harm, physical intimation, and/or threat to use a weapon on facility property. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on a review of facility policy and staff interview, it was determined the facility failed to ensure that the Infection Prevention and Control Program (IPCP) was overseen by an individual who adequately assesses, develops, implements, monitors, manages and has appropriate knowledge, skills and time to perform the IPCP for eleven of twelve months.Findings included: Review of the facility policy Infection Prevention and Control Program last reviewed 4/1/25, indicated to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contracted healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health.The infection preventionist responsibilities for infection control include but not limited to: Conducts surveillance of staff and residents for the facility-associated infections and/or communicable disease. Provide education, based on surveillance findings, outbreak analyses or changes in scientific knowledge/guidelines in the areas of infection prevention and control to employees, residents and families. Review of facility policy Antibiotic Stewardship Program last reviewed 4/1/25, indicated the Antibiotic Stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics. The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist (IP) who works collaboratively with the medical director, pharmacist, nursing and administrative leadership. During an interview completed on 9/9/25, at 2:00 p.m. IP Licensed Practical Nurse (LPN) Employee E5 stated that from September of 2024, thru March of 2025, I worked the floor on a cart, I also do the restorative program, I got caught up in April for the months of September 2024, thru March 2025. We have no mapping of infections, we don't use the maps, can't see if anything is spreading through the building. Upon asking the Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 concerning the antibiotic stewardship program stated, I don't have an answer to that you would have to ask the Director of Nursing she would know the answers to that. During an interview on 9/9/25, at 2:30 p.m. the Director of Nursing confirmed the facility failed to ensure that the Infection Prevention and Control Program (IPCP) was overseen by an individual who adequately assesses, develops, implements, monitors, manages and has appropriate knowledge, skills and time to perform the IPCP for eleven of twelve months. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for eleven of eleven months (September 2024 thru August 2025).Findings include: Review of facility policy Antibiotic Stewardship Program last reviewed 4/1/25, indicated the Antibiotic Stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics. The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist who works collaboratively with the medical director, pharmacist, nursing and administrative leadership. Review of the facility's Infection Control surveillance for September 2024, thru August 2025, failed to include documentation to indicate that antibiotic monitoring was completed. During an interview completed on 9/9/25, at 2:00 p.m. Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 confirmed that antibiotic monitoring of infections was not completed for eleven of twelve months (September of 2024, thru August of 2025). Further interview revealed that upon asking Infection Preventionist LPN E5 concerning the antibiotic stewardship program stated, I don't have an answer to that you would have to ask the Director of Nursing she would know the answers to that. During an interview on 9/9/25, at 2:29p.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for eleven of eleven months (September 2024, thru August 2025). 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen. Findings include: During an observation of the main designated kitchen on 9/08/25, at 9:30 a.m. the following was observed: -Dish room walls, brown debris, paint peeling-Ice machine, brown debris During an interview on at om 9/8/25 at 10:30 a.m. Dietary Manager Employee E7 couldn't provide proof of documentation when the ice machine was last serviced. During an interview on 9/8/25 at 10:45 a.m., Dietary Manager Employee E7 confirmed that the facility failed to maintain sanitary conditions which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four of eight residents (Residents R25, R81, R88 and R104). Findings include: Review of the facility policy Self-Administration of Medication last reviewed 4/1/25, indicated the facility, in conjunction with the interdisciplinary care team, should access and determine whether self-administration of medications is safe and clinically appropriate. The facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer. If a resident self-administers their medication the facility should routinely assess the residents cognitive, physical, and visual ability. Review of the facility policy General Dose Preparation and Medication Administration last reviewed 4/1/25, indicated during medication administration facility staff observe the resident's consumption of the medication(s). Review of the facility policy Storage and Expiration Dating of Medications and Biologicals last reviewed 4/1/25, indicated the facility should not administer/provide bedside medication or biologicals without a Physician/Prescriber order and approval by the interdisciplinary care team and facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/9/25, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and constipation. Observation on 9/8/25, at 9:51 a.m. Resident R25 had a pill cup with one pink oblong pill and a white oblong pill in a medicine cup. During an interview on 9/8/25, at 9:53 a.m. Registered Nurse, Employee E8 confirmed Resident R25 was left unattended with medications. RN, Employee E8 confirmed Resident R25 failed to have a care plan for self-administration of medications. Review of the clinical record indicated Resident R81 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/14/25, indicated diagnoses of dementia (the loss of cognitive functioning — thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), dependence on renal dialysis, and high blood pressure. Observation on 9/8/25, at 9:44 a.m. a pill cup with four pills were left unattended at Resident R81's bedside. During an interview on 9/8/25, at 9:47 a.m. the Assistant Director of Nursing (ADON), Employee E9 confirmed Resident R81's was left unattended with medications. The ADON confirmed Resident R81 failed to have a care plan for self-administration of medications. Review of the clinical record indicated Resident R88 was admitted to the facility on [DATE]. Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/25, indicated diagnoses of anemia (low iron on the blood), diabetes (high sugar in the blood) and high blood pressure. Observation on 9/8/25, at 10:32 a.m. a tube of Voltaren gel (topical pain reliever) was sitting on Resident R88's over the bed table, a tube of Aspercream (topical medication for minor aches and pains) was on her lap in bed. During an interview completed on 9/8/25, at 10:38 a.m. Registered Nurse (RN) Employee E4 confirmed the topical medications were in Residents R88's room. RN Employee E4 removed the items from the room. Upon asking RN Employee E4 concerning the topical medications stated, I haven't seen an order for the Aspercream, I believe there is one for the Voltaren. Review of Resident R88's physician orders on 9/8/25, at 10:46 a.m. failed to reveal orders for the Voltaren or Aspercream. During an interview completed on 9/10/25 at 12:14 p.m. the Director of Nursing confirmed no orders were in place for Resident R88's Voltaren gel or Aspercream and an assessment for medication self-administration was not completed. Review of the clinical record indicated Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's MDS dated [DATE], indicated diagnosis of diabetes (high sugar in the blood), hyperlipidemia (high fats in the blood) and high blood pressure. Observation on 9/8/25, at 9:51 a.m. Resident R104's bedside stand had a bottle of Flonase nasal spray (reduces inflammation and allergic symptoms) sitting on it. During an interview completed on 9/8/25, at 10:14 a.m. RN Employee E2 confirmed the Flonase was on Resident R104's bedside stand and stated, I gave it to him, he was finishing breakfast, so I left it in room for him to use later. During an interview on 9/8/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to determine the ability to self-administer medications for four of eight residents (Residents R25, R81, R88 and R104). 28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on review of clinical records, facility policy and staff and interviews it was determined the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R14 and R81), and failed to ensure resident's receiving dialysis received care and treatment as ordered and ensured fluid restrictions were maintained for one of two residents (Resident R81) Findings include: Review of facility Fluid Balance Policy dated 4/1/25, indicated the facility will track intake and/or output with a provider order. The amount of fluid allowed in a 24-hour period will be specified in the provider order. The Nursing and Nutrition Services Team will work together to distribute the restricted fluid amount daily. An allocation for each department will be developed for each level of limitation and will be included in the order. Review of the facility policy Hemodialysis Care Policy last reviewed 4/1/25, indicated licensed staff with demonstrated competence will care for residents who require hemodialysis. Communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Pre-dialysis process: Document assessment in the dialysis communication tool. Assessment includes but not inclusive to vital signs, medications administered before treatment, time of last meal, fluid intake and any additional alerts or information. Post dialysis process: Receive report from the dialysis provider or review the dialysis communication tool documentation by the dialysis provider. Information post- dialysis will include but not inclusive to vital signs, lab draws and/or results, medication administered after treatment, any new orders additional alerts or information. Review of the admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump blood the way it should), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids) and high blood pressure. Review of Resident R14's physician orders dated 9/12/25, indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Chair time at 12:00 p.m. Observation completed on 9/10/25, at 1:25 p.m. Resident R14's dialysis communication forms indicated the following: -8/6/25, incomplete form. -9/3/35, incomplete form. -9/8/25, incomplete form. During an interview completed on 9/10/25, at 1:41 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the communication sheets failed to be complete as required. Review of the clinical record indicated Resident R81 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/14/25, indicated diagnoses of dementia (the loss of cognitive functioning — thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), dependence on renal dialysis, and high blood pressure. Review of Resident R81's care plan dated 9/29/24, revealed the resident requires dialysis and receives treatment on Tuesday, Thursday, and Saturday. Interventions included to monitor intake and output. Review of Resident R81's physician's order dated 1/16/25, revealed the resident was ordered a 1000 milliliters (ml) daily fluid restriction. Dietary to give a total of 600 ml and nursing to give up to 400 ml in 24 hours. Review of Resident R81's clinical record revealed the facility failed to adhere to the resident's fluid restriction on the following days: 8/11/25-1,160 ml 8/17/25-1,040 ml 8/18/25-1,070 ml 8/23/25-1,040 ml 8/26/25-1,160 ml 8/28/25-1,080 ml 8/30/25- 5,560 ml 9/8/25- 1,190 ml Review of Resident R81's dialysis communication binder on 9/10/25, at 12:07 p.m. failed to revealed evidence Resident R81's communication sheets were completed for 9/4/25, 9/6/25, and 9/9/25. During an interview on 9/10/25, at 12:08 p.m. Licensed Practical Nurse (LPN), Employee E1 confirmed there was no evidence Resident R81's dialysis communication sheets were completed for 9/4/25, 9/6/25, and 9/9/25. During an interview on 9/10/25, at 12:19 p.m. the Director of Nursing confirmed the facility failed to ensure Resident R81 fluid restriction were maintained as ordered and that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences for one of two residents (Resident R81) and failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R14 and R81). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement COVID monitoring, isolation, tracking, and testing in accordance with state and federal guidance for one of two residents (Resident R31), failed to prevent cross contamination during a dressing change for one of three residents (Resident R86), and failed to ensure enhanced barrier precautions were implemented for one of three residents (Resident R131). The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for eleven of twelve months (September 2024, thru August 2025).Findings include: Review of the facility Enhanced Barrier Precautions (EBP) Policy last reviewed 4/1/25, revealed enhanced barrier precautions are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminate hands and clothing of healthcare workers to high risk residents during high contact activities. Staff engaging in high-contact activities will don both gloves and gown before initiating the activity. Review of the facility policy Hand Hygiene/Handwashing last reviewed 4/1/25, indicated hand hygiene is the most important component for preventing the spread of infections. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications that include but not inclusive to after contact with blood, body fluids, or contaminated surfaces. Review of the facility policy Infection Prevention and Control Program last reviewed 4/1/25, indicated to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contracted healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health. The infection preventionist responsibilities for infection control include but not limited to: Conducts surveillance of staff and residents for the facility-associated infections and/or communicable disease. Infection prevention and control provide education, based on surveillance findings, outbreak analyses or changes in scientific knowledge/guidelines in the areas of infection prevention and control to employees, residents and families. During a review of the infection control program documentation on 9/9/25, it was revealed that no surveillance of infections was completed for eleven of twelve months (September 2024, thru August 2025). Upon asking Infection Preventionist Licensed Practical Nurse (LPN) Employee E5 concerning mapping of infections presented a blank map of the facility rooms and stated we don’t use the maps During an interview completed on 9/9/25, at 2:00 p.m. Infection Preventionist LPN Employee E5 confirmed that no surveillance of infections was completed for eleven of twelve months (September of 2024 thru August of 2025). Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE], with diagnoses dementia (the loss of cognitive functioning — thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems.), and high blood pressure. Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/16/25, indicated diagnoses were current. Review of Resident R31's progress note dated 9/3/25, at 1:03 a.m. revealed the resident was short of breath, with wheezing noted. The residents oxygen saturation was 60-70%. Oxygen was applied, and breathing treatment was administered. Resident continued to have wheezing and rhonchi in bilateral lungs. The physician was notified. There was no evidence the resident was tested for COVID. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath. Review of Resident R31's progress note dated 9/3/25, at 7:14 a.m. revealed the resident was observed coughing and wheezing. The residents oxygen saturation was 60-70%. Oxygen was applied, and the resident's pulse saturation went to 97%. The RN supervisor was notified and assessed the resident. The physician was notified. A breathing treatment and cough medication was administered. There was no evidence the resident was tested for COVID. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath. Review of Resident R31's progress note dated 9/3/25, at 10:30 a.m. revealed the resident was seen in follow up to recent reported cough and congestion symptoms. Resident was started on DuoNeb three time a day and as needed Guaifenesin (cough medication) along with supplemental oxygen due to hypoxia on room air. It was documented the resident refused labs and nasal swabs. The facility failed to implement droplet precautions upon identification of any COVID-19 symptoms such as cough and shortness of breath. Review of Resident R31's clinical record failed to include evidence the resident was tested for COVID on Day 1 (9/4/25), Day 2 (9/6/25), and Day 3 (9/8/25). During an observation on 9/9/25, at 11:45 a.m. Resident R31 was observed receiving a breathing treatment with the door open. There were no isolation precautions implemented. During an interview on 9/9/25, at 11:49 a.m. Licensed Practical Nurse, Employee E31 stated I am unaware if Resident R31 was tested for COVID. LPN, Employee E31 indicated they were in training, and this was their second day. During an observation of Resident R31's clinical record on 9/11/25, at 10:10 a.m. failed to include an order for isolation. During an observation on 9/11/25, at 10:11 a.m. Resident R31's was observed wheeling in their wheelchair throughout the unit. No mask was observed on the resident. During an interview on 9/11/25, at 10:11 a.m. Registered Nurse, Employee E2 confirmed Resident R31 failed to have an order for droplet precautions. RN, Employee E2 stated if a resident developed COVID-like symptoms such as cough, fever, or fatigue the next steps would be to isolate, notify physician, and test for COVID using the standing order. If negative, then the resident would be tested every two days until Day 5. During the testing period, the resident must stay in isolation and if they come out of the room, they should wear a mask. During an interview on 9/11/25, at 10:22 a.m. the Director of Nursing confirmed residents should be tested on Day 1, Day 3, and Day 5. The DON confirmed the facility failed to implement COVID monitoring, isolation, tracking, and testing in accordance with state and federal guidance for one of two residents (Resident R31). Review of Resident R86's clinical record indicated admission to the facility on 8/7/23. Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/18/25, indicated diagnoses of anxiety, depression and high blood pressure. Review of Residents R86's physician orders dated 8/12/25, indicate to cleanse sacrum with wound cleanser, pack with quarter strength Dakin's-soaked packing strips and cover with dry dressing daily. During an observation on 9/10/25, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E16 entered Resident R86's room to complete dressing change. After completing the dressing change LPN Employee E16 continued on and picked up the bottle containing the packing strip and pushed the packing that was out of the bottle back into the bottle, applied the lid, picked up the bottle of Dakins solution and repositioned it on the over bed tray table. LPN Employee E16 then removed gloves and completed hand hygiene. During an interview completed on 9/10/25, at 2:30 p.m. LPN Employee E16 confirmed not removing gloves and completing hand hygiene prior to replacing the packing strip into the bottle, applying the lid and repositioning the bottle of Dakins solution on the over bed tray table. Review of the clinical record indicated Resident R131 was admitted to the facility on [DATE], with diagnoses of left femur fracture, severe protein-calorie malnutrition, and flaccid neuropathic bladder (a condition that disrupts normal bladder function due to nerve damage. This can lead to problems with bladder control, resulting in either an overactive bladder or difficulty emptying the bladder). Review of Resident R131's physician order dated 9/5/25, revealed an order for enhanced barrier precautions. During an observation on 9/8/25, Licensed Practical Nurse, Employee E15 was observed flushing Resident R131's nasogastric tube without a gown. During an interview on 9/8/25, at 10:38 a.m. Licensed Practical Nurse, Employee E15 confirmed they failed to implement enhanced barrier precautions while flushing Resident R131's nasogastric tube. 28 Pa. Code: 211.10(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure resident's had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for two of three residents (Resident R82, CR315).Findings include:Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the admission record indicated Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/21/25, indicated the diagnoses of unspecified intellectual disabilities, diabetes mellitus and chronic kidney disease. Resident R82's MDS assessment section C0200 BIMS score was a four, indicating severe impairment. Review of Resident R82s Binding Arbitration Agreement indicated that the resident signed the document on 1/29/25, with a severe cognitive impairment. Review of the admission record indicated Resident CR315 was admitted to the facility on [DATE]. Review of Resident RCR315's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/22/25 indicated the diagnoses of diabetes mellitus, dementia (group of brain disorders that cause a decline in cognitive functions, such as memory, thinking, reasoning, and judgment) and major depressive disorder. Resident CR315's MDS assessment section C0200 BIMS score was a zero, indicating severe impairment. Review of Resident CR315's Binding Arbitration Agreement indicated that the resident signed the document on 2/28/25, with a severe cognitive impairment. During an interview on 9/10/25, at 11/15 a.m. the admission Director Employee E10 confirmed the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents (Resident R82, CR315). 28 Pa. Code: 201.14(a)(c) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management.

Based on review of clinical records, observations, staff, and resident interviews, it was determined that the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19).Findings include: Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE], with diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration can't see things directly in front of them), and muscle wasting. Review of Resident R19's MDS dated [DATE], revealed the diagnoses were current. During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated I don't know what I have, no one had told me. A biscuit was observed on Resident R19's plate. The resident's meal ticked said NO BREAD/NO PASTA. Resident R19 expressed frustration that the facility continuously fails to honor their food preferences of having no bread products. During an interview on 9/9/25, at 12:13 p.m. Registered Nurse, Employee E14 confirmed the facility served food products with bread. RN, Employee E14 confirmed the facility failed to follow Resident R19's food preferences. During an interview of 9/9/25, at 3:15 p.m. the Director of Nursing confirmed the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19). Pa Code: 201.14(a) Responsibility of licensee

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly andsecurely in one of five medications carts (fourth floor medication cart) and one of three medication rooms (fourth floor medication room).Findings include: Review of the facility policy General Dose Preparation and Medication Administration last reviewed 4/1/25, indicated facility staff should enter the date opened on the label of medication dates. Review of the facility policy Storage and Expiration Dating of Medications and Biologicals last reviewed 4/1/25, indicated the facility should ensure resident medication rooms are locked and do not contain non medication/biological items. Review of the facility policy Returning Medications to the Pharmacy last reviewed 4/1/25, indicated the facility should return medications with any associated paperwork to pharmacy immediately after such medications have been discontinued. Facility should securely store the medications to be returned to pharmacy until they are picked up by pharmacy. During an observation on 9/9/25, at 9:10 a.m. the Fourth-floor medication cart contained the following:-One Lovenox syringe not labeled with name and not stored in a bag.-One Lispro insulin pen not labeled with date opened.-One Lispro pen not stored in a bag and not labeled with date open. -One Lantus insulin pen not stored in a bag.-One bottle of Timolol eye drops opened and not labeled with a date. During an interview completed on 9/9/25, at 9:21 a.m. Registered Nurse (RN) Employee E4 confirmed the above observations and that the facility failed to store medications and biologicals properly and securely in one of five medications carts (fourth floor medication cart). During an observation of the Fourth-floor medication room on 9/9/25, at 9:25 a.m. revealed a grey tote sitting on the countertop that contained the following:-3 medication card packs containing 30 tablets of hydralazine 25 mg-1 medication card packs containing 23 tablets of hydralazine 25mg-1 medication card packs containing 2 tablets of hydralazine 25 mg-1 medication card pack containing 15 tablets of fluoxetine 10mg-1 medication card pack containing 30 tablets of carvedilol 12.5 mg-1 bottle of muscle and joint support-1 medication card pack containing 20 tablets of atorvastatin 20mg-1 medication card pack containing 24 tablets of amantadine 100mg-1 medication card pack containing 20 tablets of duloxetine 60mg-1 medication card pack containing 20 tablets of lisinopril 40mg 20 tabs-1 medication card pack containing 20 tablets of mirabegron ER 50mg-1 medication card pack containing 20 tablets of oxybutynin 15 mg -1 medication card pack containing 21 tablets of clozapine 100mg-1 medication card pack containing 21 1/2 tablets of clozapine 100mg-1 medication card pack containing 23 of Neurontin capsules300mgA clear plastic bag that contained:-1 medication card pack containing 6 tablets of Carbidopa- levodopa 25/100mg-2 medication card pack containing 30 tablets Carbidopa- levodopa 25/100mg-1 medication card pack containing 14 tablets of hydroxychloroquine 200mg-1 medication card pack containing 16 tablets of hydrochlorothiazide 5mg -1 medication card pack containing 23 tablets of sulfasalazine 500mg-1 medication card pack containing 23 tablets of disopyramide 150mg-1 medication card pack containing 1 tablet of disopyramide 150mg Further observation revealed an oxygen tank holder containing 1 black and 1 blue umbrella with a tan sweater hanging off the umbrellas. During an interview completed on 9/9/25, at 9:47 a.m. Registered Nurse (RN) Employee E3 stated the night shift nurse scans them with a hand scanner and places inwhite sealable bags for return to pharmacy, the sweater could possibly be staffs and confirmed that that the facility failed to store medications and biologicals properly andsecurely in one of three medication rooms (fourth floor medication room). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.@@@@@@@@@@@@@@@@@@@@@@@@@@@

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of three residents (Resident R84).Findings include: Review of the facility policy Administration of an Intermittent Infusion last reviewed 4/1/25, indicated am intermittent infusion allows the patient to be disconnected from the infusion/administration set between medication doses. Label medication/solution container and administration set with date, time and nurses initials. Review of the facility policy Midline Catheter Dressing Change last reviewed 4/1/25, indicated a sterile dressing change using a transparent dressing is performed upon admission. If transparent dressing is dated, clean, dry and intact the admission dressing change may be omitted and scheduled for seven days from the date on the dressing label. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE]. Review of Resident R84 's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of infection and inflammatory reaction due tointernal right knee prosthesis, atrial fibrillation (irregular and rapid heart rhythm) and high blood pressure. Review of Resident R84's physician orders dated 8/29/25, indicated Cefazolin Solution Reconstituted 2 gram (GM) Use 1 vial intravenously (IV) every eight hours. Review of Resident R84's care plan dated 9/4/25, focus indicates IV Medications/Fluids. The resident is on IV Medications related to infection of internal right knee prothesis and bacterial arthritis. Check dressing at site daily. Monitor/document/report to physician as needed signs and symptoms of infection at the site: drainage, inflammation, swelling, redness, warmth. Change PICC dressing weekly and as needed for soiling or dislodgement During an observation and interview on 9/8/25, at 10:47 a.m. Resident R84's right arm PICC site dressing was labeled with the date of 8/29/25, a large piece of tape was noted on the right side of the dressing with a date of 9/8/25. Resident R84 stated the tape was placed to hold the dressing down. An IV medication solution container was hanging on an IV pole, next to Resident R84's bed the medication solution container failed to be labeled with a date or time. During an interview completed on 9/8/25, 10:50 a.m. Registered Nurse (RN) Employee E3 confirmed the dressing to Resident R84's PICC site was dated 8/29/25 and was reinforced with a piece of tape dated 9/8/25. RN Employee E3 also confirmed the IV medication solution container was not labeled with a date and time and that the facility failed to provide adequate treatment and care for a PICC in accordance with professional standards of practice for one of three residents (Resident R84). 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R19).Findings include: Review of the facility Morning Care/AM Care policy last reviewed 4/1/25, revealed morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general well-being. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE], with diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration can't see things directly in front of them.), and muscle wasting. Review of Resident R19's MDS dated [DATE], revealed Section GG- Functional Abilities revealed the resident required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene and personal hygiene. The resident requires setup or clean-up assistance with eating. Review of Resident R19's care plan dated 8/15/25, indicated to provide assistance with meals as needed to encourage intake. Review of Resident R19's care plan dated 8/26/25, revealed the resident has limited ability to dress/undress self due to weakness. Interventions included to provide assistance for dressing. During an interview on 9/8/25, at 9:58 a.m. Resident R19 stated he was visually impaired and cannot see much. Resident R19 stated some staff can be unprofessional and they can be disrespectful. During an observation on 9/8/25, at 1:57 p.m. Resident R19 call light was on. During an observation on 9/8/25, at 1:59 p.m. Housekeeper, Employee E13 entered Resident R19's room. Resident R19 asked Housekeeper, Employee E13 if they were Nurse Aide (NA), Employee E14. Resident R19 stated I am legally blind, the nurse aide said I'll be back in ten minutes, that was at 11 a.m. During an interview on 9/8/25, at 2:00 p.m. Resident R19 indicated they put on their call light at 11 a.m. and at 11:20 a.m. NA, Employee E14 answered the call light and stated they would be back. A total of four hours ago. Resident R19 stated the facility is understaffed, and indicated I will need assistance to get on the toilet. During an interview and observation on 9/8/25, at 2:02 p.m. NA, Employee E14 entered Resident R19's room and confirmed they were aware Resident R19 needed assistance earlier in the morning around 11 a.m. NA, Employee E14 told the resident they would return. Resident R19 asked what happened, you told me ten minutes? NA, Employee E14 stated I kind of got caught up, I was on my break. NA, Employee E14 was observed to be argumentative with Resident R19. During an interview on 9/8/25, at 2:05 p.m The Director of Nursing was notified the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R19). During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated I don't know what I have, no one had told me. During an interview on 9/9/25, at 12:13 p.m. Registered Nurse, Employee E14 confirmed the facility failed to assist Resident R19 with meal set up. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(2.1) Management.

Based on review of clinical records, staff and interviews, it was determined that the facility failed to develop and implement a baseline care plan for one out of three residents (Resident R131).Findings include: Review of the facility's Interim/Baseline Care Planning Policy last reviewed 4/1/25, revealed the facility will develop a baseline care plan within 48 hours of admission. The baseline care plan will include the minimum healthcare information necessary to care for a resident. Review of the clinical record indicated Resident R131 was admitted to the facility on [DATE], with diagnoses of left femur fracture, severe protein-calorie malnutrition, and flaccid neuropathic bladder (a condition that disrupts normal bladder function due to nerve damage. This can lead to problems with bladder control, resulting in either an overactive bladder or difficulty emptying the bladder). Review of Resident R131's progress note dated 9/5/25, revealed on 9/4/25, Resident R131 was admitted to the facility with a new nasogastric tube placement. Review of Resident R131's clinical record revealed a Foley Catheter Justification assessment was completed on 9/5/25. The resident was assessed to have a foley catheter due to acute urinary retention or bladder outlet obstruction and the resident had a diagnosis of neurogenic bladder. It was indicated the catheter was maintained. During an interview on 9/11/25, at 10:55 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E11 confirmed the facility failed to ensure Resident R131's baseline care plan included their catheter and nasogastric tube. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical records, an observation and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of six residents (Resident R19).Findings include: Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's MDS dated [DATE], indicated diagnoses of depression, macular degeneration (an eye disease that affects central vision. This means that people with macular degeneration can't see things directly in front of them.), and muscle wasting. Section B100. Vision was entered as 0, which indicated Resident R19 ability to see in adequate light (with glasses or other visual appliances) was adequate (sees fine detail, such as regular print in newspapers/books.) During an interview on 9/8/25, at 9:58 a.m. Resident R19 stated he was visually impaired and cannot see much. During an observation on 9/9/25, at 12:12 p.m. Resident R19 was sitting in front of their lunch tray and stated I don't know what I have, no one had told me. During an interview on 9/10/25, at 11:13 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E11 confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for Resident R19. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records.

Based on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of two residents (Resident R84). Findings include: Review of facility policy Indwelling Urinary Catheter Care Procedure dated 6/1/24, indicated that clinical staff with demonstrated competence may provide urinary catheter care. Such care will help to prevent catheter association urinary infections and prolong the life of the catheter system. Ensure drainage bag is covered with a privacy-dignity cover. Review of Resident R84's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R84's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/25/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Section H-Bladder and Bowel indicated the utilization of a suprapubic catheter (a special catheter that drains urine from the bladder through a small incision in the lower abdomen into a bag). Review of the clinical record revealed that Resident R84 had a physician's order dated 8/16/24, for suprapubic catheter for neurogenic bladder (urinary bladder problem due to disease or injury of central nervous system or nerves in the control of urination). During an observation on 9/30/24, at 12:10 p.m. Resident R84 was observed sitting in his wheelchair beside his bed with his urinary catheter bag connected to his chair without a privacy-dignity bag. During an interview on 9/30/24, at 12:20 p.m. Registered Nurse Employee E1 confirmed that Resident R84 did not have a privacy-dignity bag on his catheter drainage bag. During an interview on 10/1/24, at 3:15 p.m. the Director of Nursing confirmed that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of two residents (Resident R84). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa code: 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care treatment for one of two residents (Resident R85). Findings include: The facility Admissions agreement: services of other providers policy dated 4/1/24, indicated that the facility will provide basic services. Routine personal hygeine services include nail hygiene services. The resident may receive services from outside providers in the facility, so long as the outside provider is properly licensed and certified under the law. Review of Resident R85's admission record indicated he was originally admitted on [DATE]. Review of Resident R85's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/5/24, indicated he had diagnoses that included sarcoidosis (an abnormal collection of cells in the lungs and lymph nodes), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), chronic pain syndrome, and history of urinary tract infection (infection in any part of the kidneys, bladder or urethra) . These are the most current diagnoses upon review. Review of Resident R85's care plan dated 8/29/24, indicated that Resident R85 was at risk of skin breakdown. Review of Resident R85's podiatry visit assessment dated [DATE], indicated Resident R85 had history of Onychomycosis (fungal infection to the nail bed) and skin on his feet was dry, scaly. Review of residents that received facility podiatry services from April 2024 to September of 2024 did not include Resident R85. Review of Resident R85's physician orders and treatments did not include any alternative treatment for Resident R85 feet. During an interview on 9/30/24, at 12:15 p.m. Resident R85 stated: I have a foot fungus. During observations on 9/30/24, at 12:15 p.m. Resident R85 left foot was observed and the left foot skin appeared dry and cracked. Left foot big toe nail appearing to need trimmed. During observations on 10/3/24, at 11:02 a.m. obervations of Resident R85's feet were found cracked, and dry. During an interview on 10/3/24, at 11:03 a.m. Resident R85 stated: I have not seen the podiatrist in three moths. I refused the antifungal pills. I take too many pills already. During an interview on 10/3/24, at 11:05 a.m. License Practical Nurse (LPN) Employee E9 stated that Resident R85 had no treatments for his feet and confirmed that the facility failed to provide adequate and timely podiatry care for Resident R85. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to properly assess pressure ulcers and update wound treatments for one of three sampled residents (Residents R30). Findings include: The facility Skin and wound management policy dated 9/19/24, indicated that skin care and pressure injury prevention includes providing routine skin care, conducting a full body assessment upon admission, offload heels for at risk residents, licensed nurse will complete a weekly skin check. Review of Resident R30's admission record indicated he was originally admitted on [DATE]. Review of Resident R30's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/20/24, indicated that he had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hyperlipidemia (elevated lipid levels within the blood). These diagnoses were the most recent upon review. Review of Resident R30's care plan dated 6/3/24, indicated he had a history of skin impairment, assess the pressure ulcer area (length, width, and depth), presence/absence of granulation tissue and condition of surrounding skin weekly. Review of Resident R30's physician orders dated 6/3/24, indicated to provide skin wipe to both heels. Review of Resident R30's wound assessment dated [DATE], indicated he had an unstageable deep tissue injury to his right heel measuring 4 c.m. x 3.5 c.m. x 0 c.m. Review of Resident R30's clinical nurse notes dated 6/5/24, indicated Resident R30 had blood in urine and complaints of abdominal pain. Physician called and ordered he be sent to the emergency room . Review of Resident R30's clinical nurse notes dated 6/7/24, indicated that Resident R30 returned from the hospital. Review of Resident R30's physican orders did not include continued wound treatments for the right heel wound until 6/19/24. Review of Resident R30's wound assessments, clinical nurse progress notes, and physician notes did not include measurements of the right heel wound for the week of 6/12/24. During an interview on 10/3/24, at 10:39 a.m. Registered Nurse (RN) Employee E10 stated that there was a wound consultant for the facility, and she did not see wound assessment for the week of 6/12/24. During an interview on 10/4/24, at 11:22 a.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E11 stated the following: he came back around June 2024. Before discharge, there was a right heel treatment order in on 6/5/24 and then there is a right heel treatment dated 6/19/24. During an interview on 10/4/24, at 11:40 a.m. the Director of Nursing (DON) confirmed that the facility failed to properly assess pressure ulcers weekly and update wound treatments for Resident R30 as required. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose), for two of four sampled residents (Residents R30 and R63). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. The facility Diabetes protocol policy dated 4/1/24, indicated the provider and staff will work together and give appropriate treatment to manage diabetes. The staff will identify and report complications such as foot infections, pressure injury, increased thirst, or hypoglycemia. The facility Hypoglycemia Policy policy dated 4/1/24, indicated once acute hypoglycemia has resolved, notify the provider and document in resident's medical record. Review of Resident R30's admission record indicated he was originally admitted on [DATE]. Review of Resident R30's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/20/24, indicated that he had diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hyperlipidemia (elevated lipid levels within the blood). These diagnoses were the most recent upon review. Review of Resident R30's care plan dated 6/2/24, indicated he had a history of hypoglycemia. Review of Resident R30's physician orders dated 6/7/24, indicated to administer insulin (lispro) subcutaneously with blood glucose monitoring, provide medication when meal is in front of resident/hold if meal is missed, and provide insulin three times per the following protocol: 0-70= call doctor 71-150 = 0 units 151-200 = 1 units 201-250 =2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 6 units if greater than 400= 10 units and call MD Review of Resident R30's vitals records from June 2024 to July 2024, indicated the following blood glucose measurements: 6/13/24= 468 mg/dl 7/20/24= 443 mg/dl Review of Resident R30's clinical records and physician documents did not include notifications to the physician as ordered related to the abnormal blood glucose levels on 6/13/24 and 7/20/24. During an interview on 10/3/24, at 10:27 a.m. the Assistant Director of Nursing (ADON) Employee E5 failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order for Resident R30 as required. Review of Resident R63's admission record indicated he was originally admitted on [DATE]. Review of Resident R63's MDS assessment dated [DATE], indicated diagnoses that included anemia (low iron in the blood), diabetes (high sugar in the blood), and hypertension (high blood pressure). Review of Resident R63's care plan dated 9/26/24, indicated resident has impaired glucose tolerance related to diabetes. Review of R63's physician orders dated 7/20/24, indicate Insulin (lispro) subcutaneous insulin pen amount per sliding scale before meals and at bedtime: Blood Sugar is 151 to 200, give 2 Units. Blood Sugar is 201 to 250, give 4 Units. Blood Sugar is 251 to 300, give 6 Units. Blood Sugar is 301 to 350, give 8 Units. Blood Sugar is 351 to 500, give 10 Units. If Blood Sugar is greater than 500, call MD. Review of Resident R63's clinical record indicated on 8/28/24, a glucometer check was completed at 6:07 a.m. reading 63. Review of Resident R63's clinical records and physician documents did not include clinical interventions and notification to the physician related to the abnormal blood glucose levels of 63 on 8/24/24. During an interview completed on 10/02/24, at 2:04 p.m. Licensed Practical Nurse (LPN) Employee E2 stated low blood sugar is not included in the order parameter for to call physician, over 500 would be high, the order is only built to address the hyperglycemia. We know to call if less than 70. During an interview completed on 10/02/24 at 2:16 p.m. Registered Nurse (RN) Employee E3 stated some are on straight standard orders they are maintained, everybody that has the sliding scale if below or above would call the doctor, every nurse knows to call the doctor. During an interview on 10/03/24, at 10:14 a.m. the ADON Employee E5 stated It depends on the order or if they are symptomatic example if they are over 500, we have an order, there is not always order for hypoglycemia it depends on the symptoms if they are having an issue, if below 70 are considered hypoglycemic. Nurses report to the supervisors. I would have to look it up in the policy. Not everyone has orders for hypoglycemia we use the ongoing education, I think it's in the Relias training. Residents who have hyperglycemia have orders; hypoglycemia are treated as a nursing measure. It should be documented along with the interventions, anything under 70. ADON Employee E5 confirmed the facility failed to document appropriate interventions for a resident with hypoglycemia and failed to notify physicians of a decreased Capillary Blood Glucose (CBG) levels for Resident R63 as required. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two medication carts (3 South medication cart). Findings include: A review of the state operations manual dated 8/8/24, Resident Rights section S483.10(h) Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A review of the facility policy General Dose Preparation and Medication Administration dated 4/1/24, indicates observe each resident's privacy and rights in accordance with applicable law (e.g. knocking before entering, pulling the privacy curtains, informing resident what is to occur before administration, blocking unnecessary access to the MAR). During an observation on 10/1/24, at 9:01 a.m. the medication cart outside of resident room [ROOM NUMBER], in the corridor, was left unattended with a resident listing with identifiable and personal information so any passer by could see. During an interview on 10/1/24, at 10:05 a.m. Registered Nurse (RN) Employee E1 confirmed the facility failed to maintain the confidentiality of residents identifiable and personal information on one of two medication carts (3 South medication cart). 28 Pa. code: 211.5(b) Clinical records 28 Pa. Code: 201.29(i) Resident Rights 28 Pa. Code: 211.12(d)(3) Nursing Services

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R16 and R46). Findings include: Review of facility policy Oxygen Administration dated 4/1/24, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by the provider. Verify provider order. Cleaning: Change oxygen tubing weekly and document accordingly to facility policy. Review of facility policy Non-Invasive Positive Pressure Policy dated 4/1/24, indicated the facility will provide the machines. A licensed clinician trained in the proper setup procedure will make noninvasive positive pressure ventilation setting adjustments and provide ongoing assessment and documentation of the patient ' s condition. Cleaning: Cleanse hose weekly with soap and tap water-air dry. Wash mask with soap and water after each use, let air dry. Once dry store mask in a plastic bag to keep it clean. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/8/24, indicated diagnoses of hypertension (high blood pressure), depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section O0100, Oxygen therapy was marked. Review of a physician's active orders dated 8/6/24, indicated to administer oxygen via nasal cannula (a medical device that provides supplemental oxygen to patients through two prongs inserted into the nostrils) continuously at 3 liters per minute. Change oxygen tubing every seven days. Review of physician's active orders dated 8/6/24, indicated to administer Ipratropium-albuterol solution (used to help control the symptoms of lung disease via nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) every four hours, as needed, for chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of physician's active orders dated 9/5/24, indicated Continuous Positive Airway Pressure (CPAP) at bedtime, pressure 20. Special instructions: put distilled water in the chamber and start machine. During an observation on 9/30/24, at 12:20 p.m. Resident R16 was laying in her bed receiving 3 liters per minute of oxygen via nasal cannula. No date was present on the oxygen nasal cannula. The nebulizer hose and mouthpiece that is connected to the nebulizer machine and CPAP mask was laying on the bedside nightstand and failed to be stored in a bag, when not in use. During an interview on 9/30/24, at 12:25 p.m. Registered Nurse (RN) Employee E1 confirmed that no date was present on Resident 16 ' s nasal cannula tubing and that nebulizer equipment and CPAP mask was not properly stored in a bag, when not in use. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's MDS dated [DATE], indicated diagnoses of shortness of breath, COPD, and respiratory failure (inadequate gas exchange by the respiratory system). Section O0100, Oxygen therapy was marked. Review of a physician's active orders dated 9/13/24, indicated to administer oxygen via nasal cannula continuously at 4 liters per minute. During an observation on 9/30/24, at 12:22 p.m. Resident R46 was laying in her bed receiving 4 liters per minute of oxygen via nasal cannula. No date was present on the oxygen nasal cannula. During an interview on 9/30/24, at 12:27 p.m. RN Employee E1 confirmed that no date was present on R46's nasal cannula tubing. During an interview on 9/30/24, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for two of two residents (Resident R16 and R46). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services.