Every finding on record at Green Ridge Care Center

Based on select facility policy, clinical record review, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and competencies for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for two of 19 residents reviewed (Resident 8 and Resident 6). Findings include: A review of Pennsylvania Code Title 49, Professional and Vocational Standards, Department of State, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) indicate the LPN functions as a member of the health care team and administers medications and therapeutic treatments in accordance with established standards of safe nursing practice. Section 21.145(b) IV therapy curriculum requirements indicate an LPN may perform IV therapy functions only when the LPN has completed the required education and training and possesses the knowledge, skill, and ability to perform the procedure safely, and only under appropriate direction and supervision of a licensed professional nurse or other authorized health care provider. Permitted IV therapy functions include administration of IV medications and fluids, monitoring of the IV site, maintenance of IV access devices, and recognition and reporting of adverse reactions. Review of the facility policy entitled Administration of an Intermittent Infusion last reviewed October 1, 2026, indicated intermittent infusion of medications will be performed by licensed nurses according to state law and facility policy. The policy further revealed the nurses are responsible and accountable for obtaining and maintaining competence with infusion therapy within one's scope of practice and competency validation is documented. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included gram-negative sepsis (serious bloodstream infection caused by a specific group of bacteria called gram-negative bacteria) and Klebsiella pneumoniae (type of germ which may cause serious illness). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 9, 2026, revealed that Resident 8 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13–15 indicates an intact cognitive response with little to no impairment). A review of physician orders revealed an order dated April 29, 2026, for Ceftriaxone (antibiotic that fights bacterial infections) 2 grams (gm) intravenously one time via PICC line for osteomyelitis (bone infection). Review of the April 2026 MAR revealed the Ceftriaxone IV was administered by Employee 2 LPN (license practical nurse) on April 29, 2026. A review of physician orders revealed an order dated May 11, 2026, for Vancomycin 750 milligrams intravenously every day via PICC line (a thin, flexible tube put into a vein in your arm and guided to a large vein near your heart) for treatment of an infection. Review of the May 2026 Medication Administration Record (MAR) revealed the Vancomycin was administered by Employee 1 LPN on May 11 and May 12. The facility failed to ensure that a Registered Nurse (RN) or Licensed Practical Nurses with documented competencies demonstrate the ability to safely perform medication administration, flushes, and care to Resident 8 that had a PICC line. A clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses to have included sepsis (a serious medical emergency that occurs when the body's response to an infection becomes extreme, potentially leading to severe sepsis and septic shock that can harm essential organs and may result in death) and osteomyelitis (a bone infection). A review of the resident's quarterly Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status of 15, which indicated the resident was cognitive intact. A review of physician orders revealed an order dated June 21, 2026, at 5:39 PM, for cefazolin (an antibiotic for treating various bacterial infections), 2 grams (gm) reconstitution solution via PICC line give 2 gm every twelve hours for diagnosis of severe sepsis with septic shock. Flush PICC line with normal saline (sodium chloride 0.9%) with 10 milliliters (ml) before and after medication infusion and following with 10 units/ml heparin (anticoagulant medication used to prevent blood from clotting). Review Resident 6's Medication Administration Record (MAR) dated June 21, 2026, through July 7, 2026, revealed Employee 2, LPN, accessed the resident's PICC line to administer the ATB, cefazolin, and NSS flushes on June 22, 2026, June 28, 2026, July 1, 2026, July 6, 2026, and July 7, 2026. The MAR also revealed that Employee 3, LPN, accessed the resident's PICC line to administer NSS flushes on July 5, 2026. The facility failed to ensure that a Registered Nurse or Licensed Practical Nurses with documented competencies demonstrate the ability to safely perform medication administration, flushes, and care to Resident 6 that had a PICC line. The facility failed to produce evidence that Employees 1, 2, and 3 completed IV therapy education and training consistent with the requirements of Pennsylvania Code Title 49 21.145(b). The facility was unable to provide documentation of competency validation (process used to confirm staff have demonstrated the ability to safely perform a clinical skill), supervision documentation, or evidence of training specific to administration of IV medications through a PICC line for both Resident 6 and Resident 8. During an interview conducted on September 11, 2026, at 08:15 AM, the Director of Nursing (DON) was informed of the above findings of the facility's failure to provide documentation demonstrating the above LPNs completed the required IV therapy education or competency validation necessary to administer IV medications through a PICC line. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice for two of 19 residents reviewed (Residents 5 and Resident 6).Findings include: According to the Infusion Nurses Society (INS) (2024), Infusion Therapy Standards of Practice, the baseline circumference of an extremity with an intravenous catheter is measured upon insertion, noting location for future measurements to ensure consistent measurement. Facilities should assess circumference when edema or signs and symptoms of deep vein thrombosis (DVT) present, noting the location and characteristics of edema. A review of the facility titled Vascular Access Nurses, Licensed Nurses in the Post-Acute Care Facility last reviewed October 1, 2025 indicates licensed nurses will perform vascular access according to the state and facility policy. The policy further describes vascular services include peripheral inserted central catheters (PICCs). A clinical record review revealed Resident 8 was admitted to the facility on [DATE] with diagnoses that included gram-negative sepsis (serious bloodstream infection caused by a specific group of bacteria called gram-negative bacteria) and Klebsiella pneumoniae (type of germ which may cause serious illness). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 9, 2026, revealed that Resident 8 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates an intact cognitive response with little to no impairment) A clinical record review revealed written communication dated April 30, 2026 confirmed Resident 8 had a single lumen, 4 Fr, 45-centimeter (cm) catheter placed into the right arm (small, flexible tube was put into the right arm so medicines/ fluids can be given, stays in the arm for a longer time than a regular intravenous insertion site). The right arm circumference was 36 cm. The external length of the catheter was 38 cm. A physician's order dated April 30, 2026, indicated staff were to measure the exposed length of catheter and the right arm circumference weekly with the dressing change. A review of the May 2026 Medication Administration Record (MAR) revealed no documentation the facility staff completed catheter measurements or arm circumference measurements on May 22, 2026. A review of the June 2026 MAR revealed no documentation the facility staff completed catheter measurements or arm circumference measurements on Jun 5, 2026. Failure to measure the catheter length and arm circumference as ordered limited the facility's ability to identify potential catheter displacement (movement out of proper position) in a timely manner, placing residents at risk for complications. A clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses to have included sepsis (a serious medical emergency that occurs when the body's response to an infection becomes extreme, potentially leading to severe sepsis and septic shock that can harm essential organs and may result in death) and osteomyelitis (a bone infection). A review of the resident's quarterly Minimum Data Set, dated [DATE], revealed a Brief Interview for Mental Status of 15, which indicated the resident was cognitive intact. A clinical record review revealed written communication dated June 4, 2026, confirmed Resident 6 had a single lumen, 5 Fr, 24.5-centimeter (cm) catheter placed into the internal jugular (the largest vein in the neck that collects blood from the brain and face and returns it to the heart). A review of physician orders dated June 21, 2026, indicated for Resident 6's PICC line dressing to be changed on admission (may omit if dressing is clean, dry, intact and dated within the last 7-days) and then once per week or PRN (as needed) with special instructions to measure the arm circumference and external catheter length. Resident 6's clinical record failed to reveal that upon admission and weekly thereafter licensed nursing staff measured the jugular external catheter length to timely identify potential catheter displacement and deter complications. The facility could not provide documented evidence of licensed nursing staff obtaining external jugular catheter measurements upon admission or weekly thereafter. During an interview on September 11, 2026, at 9:03 AM, with the Director of Nursing (DON), the above findings were reviewed and acknowledged the facility failed to provide PICC line care and services in accordance with physician orders and professional standards of practice to Resident 8 and Resident 6. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on select facility policy, clinical record review, and staff interview, it was determined the facility failed to attempt non-pharmacological interventions and failed to evaluate the severity of pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one of 19 residents reviewed (Resident 8).Findings include:A review of the facility policy, Pain Management (last reviewed October 1, 2026), indicated the facility will ensure residents are assessed for pain or potential for pain to attain or maintain the highest practicable level of well-being. The policy further revealed the presence and severity of pain will be measured using an appropriate scale such as the numeric rating scale (a tool that asks a person to choose a number to show how strong or severe something feels), faces scale (a tool that uses pictures of faces, from a happy face to a very upset face, to help the resident show how much pain they are feeling), or verbal descriptor scale (a tool that asks the resident to choose a word or phrase that best describes how strong their pain or discomfort feels). According to the policy, non-pharmacological interventions (ways to help the resident manage pain without using medicine) will be attempted prior to the administration of PRN (as needed) pain medication. A clinical record review revealed Resident 8 was admitted to the facility on [DATE] with diagnoses that included gram-negative sepsis (serious bloodstream infection caused by a specific group of bacteria called gram-negative bacteria) and Klebsiella pneumoniae (type of germ which may cause serious illness).A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 9, 2026, revealed that Resident 8 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates an intact cognitive response with little to no impairment).Clinical record review revealed Resident 8 had a physician order dated July 8, 2026, for Oxycodone (a controlled substance, narcotic used to treat pain) 5 milligrams (mg) every six hours as needed for moderate to severe pain.A review of Resident 8's July medication administration record (MAR) revealed staff administered the pain medication on:July 8, 2026, at 6:26 PMJuly 9, 2026, at 5:01 PMJuly 10, 2026, at 00:02 AMJuly 10, 2026, at 8:46 PMJuly 13, 2026, at 2:06 AMJuly 13, 2026, at 6:05 PMJuly 14, 2026, at 0:20 AMJuly 14, 2026, at 06:23 AMJuly 14, 2026, at 0:20 AMJuly 14, 2026, at 02:07 PMJuly 14, 2026, at 08:44 PMJuly 16, 2026, at 01:44 AMJuly 17, 2026, at 00:15 AMJuly 17, 2026, at 06:45 AMDocumentation showed that non-pharmacological interventions were not attempted or documented prior to any of the 14 administrations, nor was the pain assessed using one of the pain scales mentioned in the facility policy.An interview with the Director of Nursing (DON) on September 10, 2026, at 1:30 PM confirmed the facility failed to follow the facility policy specifically regarding rating Resident 8's pain and using nonpharmacological interventions prior to administration of pain medication.28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f)(viii)(x) Medical records.

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure the attending physician acted upon and documented a clinical rationale regarding consultant pharmacist identified medication regimen irregularities for one of 5 residents reviewed (Resident 22). Findings include: A review of Resident 22's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a medical condition involving loss of cognitive functioning such as memory, thinking, and reasoning severe enough to interfere with daily activities). A review of the consultant pharmacist report titled Consultant Report dated March 16, 2026, an initial pharmacy consultation revealed the pharmacist identified that Resident 22 was recently admitted with a physician order for an antipsychotic medication Olanzapine 15 mg at bedtime. The consultant pharmacist advised that antipsychotics have a boxed warning for increased risk of mortality in older adults with psychosis related to dementia. The pharmacist recommended evaluated for a gradual dose reduction. The physician's response to the recommendation above was to decline the recommendation stating that the resident was new to the facility. A review of the consultant pharmacist report titled Consultation Report dated June 21, 2026, a monthly consultation revealed Resident 22 was still receiving the antipsychotic Olanzapine 15 mg at bedtime for dementia with psychosis. This report indicated that there were no psychiatric notes for the resident and the resident's antipsychotic was due for a gradual dose reduction. The physician's response to the recommendation above was to decline the recommendation indicating he would review at next visit. Review of resident's clinical record revealed that the physician did not review the resident's medication. As of end of survey September 11. 2026 the resident continued to receive Olanzapine 15 mg at bedtime During an interview on September 11, 2026, at 10:00 AM, the Director of Nursing confirmed the facility could not provide documentation showing the attending physician acted upon the consultant pharmacist's recommendation. 28 Pa. Code 211.2 (d)(3)(9) Medical director.28 Pa Code 211.5 (f)(vii) Medical records.28 Pa. Code 211.9 (k) Pharmacy services.

Based on review of clinical records and staff interview it was determined the facility failed to develop and implement an individualized, person-centered comprehensive care plan that addressed ongoing behaviors and identified interventions to manage wandering and exit seeking behaviors for one of 18 residents reviewed (Resident 11). Findings include: A review of the clinical record revealed Resident 11 was admitted to the facility on [DATE], with diagnoses of Alzheimer's (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks) and delirium (a sudden and severe change in how the brain works, leading to acute confusion and trouble focusing). A review of Resident 11's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 15, 2026 revealed that Resident 11 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 to 12 indicates moderate cognitive impairment). The MDS revealed Resident 11 had no behaviors related to wandering. Review of nursing progress notes identified a pattern of ongoing behavioral concerns following admission. A progress note dated August 31, 2026, at 7:27PM documented Resident 11 was found wandering into another resident's room. The progress note documented Resident 11 was observed being agitated and yelling at staff and other residents. A progress note dated September 1, 2026, at 10:15PM documented resident 11 has been self-propelling in and out of other resident's rooms, seeking exit doors, and making statements to break out of the facility. The note documented redirection was not effective. A review of Resident 11's care plan revealed no documentation of the resident exit seeking or being at risk for elopement. Further the facility failed to develop and implement interventions for Resident 11's wandering or exit seeking behaviors. During an interview with the Director of Nursing on September 10, 2026, at 1:30 PM the above findings were reviewed and the facility acknowledged Resident 11's care plan failed to identify wandering and exit seeking behaviors. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of facility policies, clinical records, and staff interview, it was determined that the facility failed to ensure physician ordered medications were obtained and physicians were timely notified of unavailable medications and delayed treatment for 2 out of 19 residents reviewed (Resident 6 and Resident 30). Findings include: A review of a facility policy entitled Medication Shortages/Unavailable Medications, last reviewed by the facility on October 1, 2025, indicated that upon discovery that the facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the next available delivery causes delay or a missed dose in the resident's medication schedule, the facility should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, the facility should notify the pharmacy and arrange for a STAT (in a medical context refers to an order that must be carried out immediately, without delay for the next routine round of tests, medications, or procedures) delivery, if medically necessary. If the medication is unavailable after normal pharmacy hours, a facility nurse should obtain the ordered medication from the Emergency Medication Supply. However, if the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call the pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action and may include an emergency delivery from pharmacy or use of a back-up, third party pharmacy. If an emergency delivery is unavailable, the facility nurse should contact the attending physician to obtain new orders or directions for alternative administration. If the facility nurse is unable to obtain a timely response from the attending physician/prescriber in a timely manner, the facility nurse should notify the nursing supervisor and contact the facility's medical director for alternate orders/directions, ensuring to explain the circumstances of the medication shortage. When a missed dose is unavailable, the facility nurse should document the missed dose and explanation for the missed dose on the electronic Medication Administration Record (eMAR is the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) or Treatment Administration Record (TAR is the report that serves as a legal record of the treatments applied to a resident at the facility by a health care professional) and in the nurse's notes per facility policy. Such documentation should include a description of the circumstances of the medication shortage, description of pharmacy's response, and all addition actions taken. A clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses to have included sepsis (a serious medical emergency that occurs when the body's response to an infection becomes extreme, potentially leading to severe sepsis and septic shock that can harm essential organs and may result in death) and osteomyelitis (a bone infection). A review of Resident 6's hospital Discharge summary dated [DATE], at 3:17 PM, indicated that the resident was prescribed cefazolin, an antibiotic for treating various bacterial infections. The resident received a reconstitution solution of 2 grams via intravenous administration, to be given every twelve hours. The last dose before discharge was administered on June 21, 2026, at 8:53 AM, and the treatment was to continue at the facility. The resident had a physician order, dated June 21, 2026, at 5:39 PM, for cefazolin 2 gm reconstitution solution via IV, give 2 gm every twelve hours for diagnosis of severe sepsis with septic shock. A review of the electronic Medication Administration Record (eMAR) from June 21, 2026, to June 31, 2026, indicated that Resident 6 did not receive the cefazolin (ATB) PM dose on June 21, 2026, or the AM dose on June 22, 2026, as prescribed by the physician. A review of the facility's Emergency Medication Supply formulary revealed alternative cefazolin doses were available. The nurse's progress notes in Resident 6's clinical record did not provide evidence that licensed nursing staff attempted to follow facility pharmacy policies to obtain the physician-prescribed medications. Resident 6's clinical record did not include documentation indicating that the attending physician was notified of any missed doses of the prescribed antibiotic, cefazolin, used to treat severe sepsis with septic shock. During an interview with the Director of Nursing (DON) on September 11, 2026, at 8:15 AM, the above findings were reviewed. The DON confirmed that documentation could not be provided to demonstrate licensed nursing staff attempted to implement facility pharmacy policies to obtain Resident 6's prescribed ATB, cefazolin, or provide documentation that the attending physician was notified of missed doses of cefazolin. A clinical record review revealed Resident 30 was admitted to the facility on [DATE], with diagnoses that included displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing (break in the top part of the left thigh hip bone, and the bone pieces have shifted out of alignment). A review of Resident 30's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 8, 2026, revealed that Resident 30 is cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 means memory, orientation, and attention skills are almost completely intact-with minimal or no cognitive issues). A physician's order Lacosamide 50 milligrams (mg) (a medication used to prevent seizures) every 12 hours was initiated on August 3, 2026. A review of Resident 30's August 2026 medication administration record (MAR) revealed Resident 30 was not administered Lacosamide 50mg on August 3, 2026, at 09:00 PM and August 18, 2026, at 09:00 PM as ordered by the physician. The MAR indicated the medication was not available and provided no additional information. A clinical record review revealed no documented evidence facility staff notified the physician that Lacosamide 50mg was not administered to Resident 30.During an interview on September 11, 2026, at 8:15 AM the Director of Nursing (DON) confirmed Resident 30 did not receive Lacosamide 50mg in accordance with the physician's orders. The DON could not provide documented evidence the physician was notified that Resident 30's seizure medication was not administered on two occasions. 28 Pa Code 211.10 Resident care policies.28 Pa Code 211.5(f)(xi) Medical records.28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of select facility policy. controlled sub stance shift to shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records on three of three medication carts observed. Findings include: A review of facility policy entitled Inventory Control of Controlled Substances (a controlled substance is a medication regulated by federal or state law because it has a risk for abuse, diversion which is misuse for non-medical purposes, or addiction).last reviewed by the facility on October 21, 2025, revealed the facility is to maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. The policy further revealed that the facility should ensure the incoming and outgoing nurse count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift. A review of the facility Shift Verification of Controlled Substances Count record from the 500-unit medication cart revealed the following:August 27, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.August 31, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.August 31, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.September 1, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 1, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 1, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 2,2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 2, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.September 4, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 4, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 9, 2025, the night shift on coming nurse failed to sign that the narcotic count was completed and correct.September 9, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct.September 12, 2025, the night shift off going nurse failed to sign that the narcotic count was completed and correct.September 14, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 14, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 17, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 17, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 22, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.September 27, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 1, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.October 1, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.October 4, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.November 9, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.November 13, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.An interview completed on November 13, 2025, at 08:25AM with employee 4 (Licensed Practical Nurse) revealed she did not complete the shift-to-shift narcotic count with the off going night shift nurse. Employee 6 stated she forgot to sign the book, then proceeded to sign the shift-to-shift narcotic count sheet without completing a complete count of the controlled medications stored in 500 Hall Cart. A review of the facility Shift Verification of Controlled Substances Count record from the 500 Private Hall medication cart revealed the following:August 15, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.August 17, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.August 19, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.August 22, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.August 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.August 24, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.August 24, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.August 25, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct. August 25, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.August 30, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.August 30, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.September 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 2, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 4, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 6, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 7, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 8, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 8, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 12, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.September 12, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 15, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 15, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 16, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 16, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 16, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 23, 2025, the first shift on coming nurse failed to sign that the narcotic count was completed and correct.September 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.September 23, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 23, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.September 24, 2025, the third shift off going nurse failed to sign that the narcotic count was completed and correct.October 2, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 2, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 3, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 3, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 13, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 13, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 15, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 15, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 17, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 17, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 22, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.October 22, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 23, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.October 23, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 24, 2025, the first shift on coming nurse the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 25, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 25, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 28, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.October 28, 2025, the third shift on coming nurse failed to sign that the narcotic count was completed and correct.October 29, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.October 29, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.November 3, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.November 3, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct.November 7, 2025, the second shift on coming nurse failed to sign that the narcotic count was completed and correct.November 7, 2025, the second shift off going nurse failed to sign that the narcotic count was completed and correct. A review of the facility Shift Verification of Controlled Substances Count record from the 200-unit medication cart revealed the following:November 12, 2025, the first shift off going nurse failed to sign that the narcotic count was completed and correct.During an interview on November 13, 2025, at 08:05 AM, Employee 3 (Licensed Practical Nurse) confirmed that the count on the 200-unit cart for the above date was incomplete. On November 13, 2025, at 12:45 PM, the surveyor reviewed the above findings with the Nursing Home Administrator and the Director of Nursing.28 Pa Code 211.9 (c)(k) Pharmacy services28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service28 Pa Code 211.10 (c) Resident care policies.28 Pa Code 211.5(f)(x) Clinical records

Based on a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to conduct an investigation into an injury of an unknown source to rule out abuse and/or neglect and failed to implement corrective actions, and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of 18 residents reviewed (Resident 44). Findings included:A review of the facility's Pennsylvania Resident Abuse Policy last reviewed by the facility on October 21, 2025, indicated that it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. The facility classified an injury as an injury of an unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and if the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence over time. Further review of the facility's abuse policy indicated all allegations of abuse, neglect, injuries of an unknown source, etc. must be reported immediately to the Nursing Home Administrator (NHA), Director of Nursing (DON), and to the applicable State Agency. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Department of Health (DOH) immediately, but not later than two hours after the allegation is made. All serious incidents involving a resident will be reported to the DOH field office within twenty-four hours. Once the NHA and DON are notified, an investigation of the allegation or suspicion will be conducted, and the investigation must be completed within five working days from the alleged occurrence. Investigating injuries of an unknown source should include talking with both the shift on duty when the injury was discovered and prior shifts. Additionally, the investigation should include witness statements, obtain all medical reports and statements from physician and/or hospitals, and review the resident's record. Evidence of the investigation should be documented, and the final report will be submitted to the applicable State agency, after the investigation is completed, but no later than five working days from the occurrence. A review of Resident 44's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (a term that encompasses various neurological disorders characterized by cognitive decline, memory loss, and changes in behavior and mental health), unspecified fracture (a break in a bone) of lower end of left femur (thigh bone) with routine healing, left acute impact to left distal femur fracture, and presence of unspecified artificial knee joint. A review of Resident 44's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 26, 2025, the resident could not complete the BIMS (Brief Interview for Mental Status). The BIMS is a standardized interview used to assess memory and thinking skills. Because the resident was unable to participate in the interview, the BIMS was coded as 99, meaning the assessment could not be conducted. The MDS documented severe cognitive impairment and a need for total assistance of two or more staff for bed mobility and transfers. A progress note completed by Employee 1 (LPN) on April 8, 2025, at 6:45 AM, documented that the resident's left knee was noted to be swollen and painful during routine foot care. Vital signs were within normal limits, and the supervisor was notified. A progress note completed by Employee 2 (LPN) on April 8, 2025, at 12:35 PM, documented that the Certified Registered Nurse Practitioner (CRNP) assessed the resident and ordered an x-ray (medical imaging using radiation to create internal images) of the left knee. New orders included acetaminophen (a non-opioid pain reliever) 1000 mg orally every eight hours as needed for mild pain, and tramadol (an opioid pain reliever for moderate to severe pain) 50 mg orally twice daily for pain rated 7-10. The responsible party was notified.A progress note completed by Employee 2 (LPN) on April 8, 2025, at 12:35 PM, indicated that the Certified Registered Nurse Practitioner (CRNP) assessed the resident and ordered an x-ray (medical imaging using radiation to create internal images) of the left knee. New orders included acetaminophen (a non-opioid pain reliever) 1000 mg orally every eight hours as needed for mild pain, and tramadol (an opioid pain reliever for moderate to severe pain) 50 mg orally twice daily for pain rated 7-10 (pain scale ratings indicate 0 least amount of pain and 10 being worst amount of pain). The responsible party was notified. A review of the April 8, 2025, x-ray report, timed 10:19 AM, revealed a new but subacute angulated fracture (a bone break where it comes out of alignment, and tilts at an angle) of the distal left femur with partial healing. The report noted possible insufficiency fracture (a stress-related fracture occurring in weakened bone), moderate osteopenia (medical definition for bone density loss), degenerative joint disease (osteoarthritis most common type of arthritis and can occur in any joint, it usually affects the hands, knees, hips or spine), mild soft tissue swelling, and no significant joint effusion (joint swelling). Clinal correlation was suggested and follow up radiographs to confirm healing. The facility was unable to provide documentation that an investigation into this injury of unknown source was conducted, including interviews, review of shifts prior to discovery, or completion of the required investigation report. The facility was also unable to provide evidence that investigation results were submitted to the State Survey Agency within five working days as required by the facility's abuse policy.During an interview with the Director of Nursing on November 13, 2025, at 1:30 PM, it was stated that an investigation was not initiated because the facility's CRNP determined the swelling was related to an old fracture. During an interview with the Nursing Home Administrator on November 14, 2025, at 10:10 AM, the above information was reviewed. The Nursing Home Administrator indicated that an investigation should have been completed due to the presence of an injury of unknown source, in accordance with the facility's policy to rule out potential abuse or neglect.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(a)(c) Resident Rights.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on a review of clinical records, staff interview, facility policy, and the facility's infection assessment tool, it was determined the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use in accordance with the established infection prevention and control guidelines for two residents out of 19 sampled (Residents 34 and 71). Findings included: A review of a facility policy entitled Antibiotic Stewardship last reviewed December 2024, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy stated the facility will monitor and track new antibiotics start rates and antibiotic days of therapy monthly. It also required that antibiotic use protocols address prescribing practices, including documentation of the indication, dose, and duration of the antibiotic, review of laboratory reports to determine necessity, and completion of an infection assessment before prescribing. Additionally, the policy outlined monitoring procedures such as antibiotic use reports, antibiotic resistance reports, and the use of McGeer's criteria for determining the need for antibiotic therapy. A review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia and congestive heart failure (CHF - is a condition where the heart is unable to pump blood effectively). A review of the facility's infection tracker form, entitled Infection Control - Infection Tracker with McGeer's Criteria, dated December 6, 2024, and recorded on December 11, 2024, indicated that the form was initiated due to a suspected urinary tract infection (UTI). However, the completed assessment revealed that Resident 34 did not meet the McGeer's criteria to support the initiation of antibiotic therapy. Specifically, the resident did not have a fever, rigors, acute dysuria, leukocytosis, gross hematuria, or other signs and symptoms necessary to meet at least three criteria for a UTI diagnosis. Despite only meeting one criterion, a physician's order dated December 6, 2024, at 4:56 PM, prescribed Cefdinir 300 mg orally twice per day for seven days. A review of Resident 34's Medication Administration Record (MAR) for December 2024 revealed that the resident received 14 doses of Cefdinir without meeting the documented criteria for initiation of antibiotic therapy. The facility's failure to adhere to antibiotic stewardship protocols resulted in the unnecessary administration of antibiotics. A review of Resident 71's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included type II diabetes (a condition results from insufficient production of insulin, causing high blood sugar), dysphagia (difficulty swallowing), and cerebral infarction with weakness (is a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it and the lack of sufficient blood supply to brain cells deprives them of oxygen and critical nutrients, potentially leading to the death of brain cells). A nursing progress note dated November 15, 2024, at 9:35 PM, indicated that Resident 71 was catheterized ((is a medical procedure used to drain the bladder) to obtain a urine specimen. Orders were noted for STAT laboratory testing, including a complete blood count (CBC) and a basic metabolic panel (BMP), as well as an order to initiate Rocephin 1 gram intramuscularly daily for two days due to an elevated white blood cell (WBC) count. A review of the resident's laboratory results dated [DATE], at 8:27 AM, revealed that urinalysis results were unremarkable, the urine culture showed no growth, and WBC was elevated at 13.05 (reference range: 4.0 - 10.80). However, nursing progress notes from November 16, 2024, through November 18, 2024, documented that the resident's vital signs, including temperature, pulse, blood pressure, and respirations, remained within normal parameters. Despite the lack of clinical signs or symptoms of infection, the resident received two doses of Rocephin, indicating the facility's failure to ensure antibiotic therapy was supported by documented clinical necessity. During an interview with the facility's Infection Preventionist (IP) on January 30, 2025, at 11:20 AM, confirmed that the facility failed to implement antibiotic stewardship protocols for residents 34 and 71. This failure contributed to the initiation and continuation of antibiotic therapy without documented evidence of clinical necessity, inconsistent use of infection surveillance tools, and noncompliance with infection prevention and control guidelines. The facility failed to adhere to its established antibiotic stewardship program by allowing the initiation and continuation of antibiotic therapy without documented clinical indications. guidelines. Cross Refer F757 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide effective pain management, administer pain medication as prescribed by the physician, and attempt non-pharmacological interventions prior to administering narcotic pain medication prescribed on an as-needed (PRN) basis for one (1) of three (3) residents sampled for pain (Resident 18). Findings include: A review of the facility's policy titled Pain Management, with a policy review date of December 2024, indicated that an evaluation of pain presence and severity should occur using the appropriate pain scale (numeric pain rating scale, face rating scale, or verbal descriptor scale). The policy further stated that non-pharmacological interventions will be attempted prior to the administration of PRN (as needed) pain medications. If non-pharmacological interventions are ineffective, then when multiple PRN medications are available with corresponding intensity ratings, the resident will receive the medication prescribed for the corresponding pain rating. Documentation of medication administration and effectiveness is required in the electronic medication record (eMAR). A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include fibromyalgia (is a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances), rheumatoid arthritis ( a chronic inflammatory disorder affecting small joints in the hands and feet characterized by painful swelling in the affected areas) and complete rotator cuff tear of the right shoulder (a complete tear of the connecting muscle to bone of the shoulder, characterized by pain of the affected shoulder). A review of Resident 18's physician orders revealed the following PRN pain medication orders: Percocet 5/325mg (narcotic pain medication) one tablet by mouth every four hours as needed (PRN) for severe pain initially ordered on December 31, 2024, and discontinued January 2, 2025. Percocet 5mg (narcotic pain medication) one tablet by mouth every eight hours as needed (PRN) for severe pain initially ordered January 19, 2025, and discontinued January 20, 2025. A review of the resident's December 2024 and January 2025 Medication Administration Record (MAR) revealed the following: The PRN Percocet 5/325mg was administered two times in December: December 31, 2024, at 4:18 PM - medication administered for a pain scale of 3 (mild pain). December 31, 2024, at 9:04 PM - medication administered for a pain scale of 5 (moderate pain). The PRN Percocet 5/325mg was administered three times in January: January 1, 2025, at 9:04 AM - medication administered for a pain scale of 6 (moderate pain). January 1, 2025, at 5:42 PM - medication administered for a pain scale of 6 (moderate pain). January 6, 2025, at 9:36 AM - medication administered for a pain scale of 6 (moderate pain). The PRN Percocet 5mg was administered once in January: January 19, 2025, at 8:58 PM - medication administered for a pain scale of 3 (mild pain). A further review of the resident's January 2025 MAR revealed that the PRN Percocet was administered a total of four times in January. In all instances, no non-pharmacological interventions were attempted prior to administration. Additionally, three of the four doses were administered for pain levels of mild to moderate pain, despite the medication being prescribed only for severe pain. An interview with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at approximately 2:00 PM, confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and documented as ineffective prior to the administration of PRN pain medication. Additionally, they confirmed that the staff administered narcotic pain medication ordered for severe pain to Resident 18 when the resident's documented pain levels were only mild to moderate. The facility administered narcotic pain medication inappropriately for pain levels lower than the prescribed severity and failed to use alternative pain management strategies before resorting to medication. 28 Pa. Code 211.5(f)(vii) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source (Resident 23) out of 19 sampled residents. Findings include: Review of Resident 23's clinical record revealed admission to the facility on [DATE], and the resident's payor source was Medicaid. A review of nurses' progress notes in the resident's clinical record dated July 31, 2024, at 1:39 PM, revealed that the facility's contracted CRNP (certified registered nurse practitioner) in to see resident due to complaints of left sided facial pain. NON (new orders noted) for Clindamycin (is a medication used to treat a wide variety of bacterial infections) 300 mg PO (orally) every six hours for 7 days for parotitis (is a serious gum infection that damages the soft tissue around teeth). Further review of Resident 23's clinical record failed to reveal that the facility offered dental services from November 16, 2022, until October 20, 2024. During an interview with the Director of Nursing (DON)on November 30, 2025, at 9:20 AM, confirmed that the facility failed to assure that Resident 23 was annually offered routine dental services. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 19 residents reviewed (Resident 3) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses to include atrial fibrillation (an irregular and often very rapid heart rhythm). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 15, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating she was cognitively intact. A review of Resident 3's social service notes, revealed a note dated August 28, 2024, indicating the resident would like to be discharged home when able. The next social service notes regarding discharge from the facility were not until November 18, 2024, indicating the resident was to be discharged home on December 13, 2024. During the survery ending January 31, 2025 there was no further documentation regarding discharge to home and no documentation regarding the reason the resident did not discharge home on December 13, 2024. A review of the resident's comprehensive care plan, reviewed during the survey ending January 31, 2025, revealed no documented evidence that an individualized discharge plan was revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. During an interview with the Nursing Home Administrator on January 30, 2025, at 12:00 PM confirmed there was no documented evidence of a current discharge goal and plan for this resident. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29 (a) Resident rights.

Based on clinical record and staff interview, it was determined the facility failed to assure the presence of documented evidence of clinical necessity for administration of an antibiotic drug for two residents out of five sampled residents for unnecessary medication prescribing practices (Residents 34 and 71). Findings included: A review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia and congestive heart failure (CHF - is a condition where the heart is unable to pump blood effectively). A review of a facility documentation entitled Infection Control - Infection Tracker with McGeer's Criteria 2024 assessment (an algorithm that uses criteria to make an empiric diagnosis of UTI in nursing home residents. For resident's that do not have an indwelling urinary catheter and with at least three of the following signs and symptoms must be present prior to a practitioner prescribing antibiotic therapy include a fever (temperature of at least 38 C [100.4 F]), new or increased frequency, urgency, or burning on urination, new flank or suprapubic pain or tenderness, change in character of urine, and worsening of mental or functional status) dated December 6, 2024, at 3:59 PM, and recorded on December 11, 2024, at 3:59 PM, revealed that the form was initiated due to a suspected UTI. Further review of the completed infection tracker McGeer's Criteria form revealed that Resident 34 did not have a fever, rigors (feeling cold or having chills), or new on-set hypotension (low blood pressure), without alternate site of infection, no acute dysuria (burning sensation when urinating), no leukocytosis (is the presence of more white blood cells than normal, which can indicate infection, inflammation, injury or immune system disorders), and no gross hematuria (presence of red blood cells in the urine), increased incontinence (involuntary loss of large or small amounts of urine), increased urgency (need to urinate), or increased frequency). A review of Resident 34's clinical record revealed a nurses' progress note dated December 4, 2024, at 2:17 PM, revealed the facility's contracted CRNP (certified registered nurse practitioner) was in the facility to assess the resident and ordered a urine analysis (UA an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection)with a culture and sensitivity ( C & S a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection). Further review of nurses' progress notes dated December 6, 2024, at 2:07 PM, revealed urine culture results showed a result of greater than 100, 000 colonies/ml (significant number of bacteria in the urine that may cause an infection) A review of physician's orders dated December 6, 2024, at 4:56 PM, revealed orders for Cefdinir (antibiotics) 300 mg twice per day for seven days related to UTI (urinary tract infection). The resident lacked essential clinical indicators such as fever, dysuria, leukocytosis, or gross hematuria. The only criterion met was a urine culture with >100,000 CFU/mL of a single organism, which alone was insufficient to justify antibiotic therapy. As a result, the resident received fourteen doses of an unnecessary antibiotic. During an interview with the facility's Infection Preventionist (IP) on January 30, 2025, at 11:20 AM, confirmed that Resident 34 did not meet the requirements for antibiotic treatment. A review of Resident 71's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included type II diabetes (a condition results from insufficient production of insulin, causing high blood sugar), dysphagia (difficulty swallowing), and cerebral infarction with weakness (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it and the lack of sufficient blood supply to brain cells deprives them of oxygen and critical nutrients, potentially leading to the death of brain cells). A review of nurses' progress notes in Resident 71's clinical record dated November 15, 2024, at 9:35 PM, revealed the resident was catheterized (is a medical procedure used to drain the bladder) to obtain urine specimen (refers to a sample of urine collection from a patient for diagnostic tests).A CBC (complete blood count that checks different arts of the blood such as the white blood cells to identify infection). A physician's order for Rocephin (antibiotic) IM (intramuscular injection that delivers medication deep into muscle tissue, allowing rapid absorption). A review of the resident's laboratory results dated [DATE], at 8:27 AM, revealed the urinalysis results were unremarkable, urine culture showed no growth, and WBC (white blood cells measures the number of white blood cells in your blood, which are part of your immune system) elevated at 13.05 (reference range for normal parameters 4.0 - 10.80). Additionally, nursing progress notes dated November 16, 2024, through November 18, 2024, documented that the Resident 71's vital signs (temperature, pulse, blood pressure, and respirations) were documented within normal parameters. Rocephin was administered for two days without meeting McGeer's Criteria or having laboratory evidence of an infection During an interview with the facility's Director of Nursing (DON) on January 30, 2025, at 1:15 PM, reported that prior to initiating an antibiotic and as a part of the facility's antibiotic stewardship program licensed nursing staff did not complete the required Infection Tracker form with McGeer's Criteria - 2024 to clinically justify the use of an antibiotic. Additionally, the DON reported that staff did not complete the form as per the antibiotic stewardship program and confirmed that Resident 71's prescribing physician was aware that his signs and symptoms did not meet McGeer's protocol for prescribing an antibiotic. The DON confirmed the facility failed to assure that Resident 71's medication regimen was free from unnecessary medications, Rocephin, and failed to meet antibiotic prescribing practices. 28 Pa. Code 211.2 (3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3) Nursing Services

Based on review of clinical records and select facility policy and incident reports, and staff interviews it was revealed that the facility failed to assure that one of 18 residents reviewed was free of a significant medication error (Resident 81), which compromised the resident's clinical condition and required corrective treatment to reverse the effects of the error. Findings include: A review of the facility's current pharmacy policy and procedures last reviewed January 2024, revealed that facility staff should only prepare medications for one resident at a time. Staff should verify each time a medication is administered that it is the correct medication at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. A review of the clinical record revealed that Resident 81 was admitted to the facility on [DATE], with diagnosis to include rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in the blood) and acute kidney failure. A review of an admission MDS assessment dated [DATE], (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed that the resident was moderately cognitively impaired. A facility incident report dated January 10, 2024, at 8 AM , revealed that Employee 1 (LPN) erroneously administered the following medications to Resident 81, which were prescribed for Resident 10: Cymbalta 30mg two tablets (antidepressant medication) Iron 325 mg one tablet (mineral supplement) Metoprolol Succinate ER 25 mg half tablet hold for systolic blood pressure is less then 100 or heart rate less than 60 (blood pressure medication) Procardia XL 30 mg one tablet (blood pressure medication) Senna-S 8.6 mg one tablet (stool softener) Ativan 0.5mg one tablet (anti-anxiety medication that can cause drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision) Buspirone HCL 7.5 mg one tablet hold if lethargic (anti-anxiety medication) Memantine HCL 5mg one tablet (dementia medication) Oxycodone HCL 5 mg one tablet (opioid narcotic pain medication that can cause confusion, shallow breathing, and slowed heart rate) Seroquel 75 mg one tablet (anti-psychotic medication which can cause drowsiness, dizziness, and lightheadedness) These medications were not prescribed for Resident 81 during the resident's stay, to date, at the facility. A review of a nursing note dated January 10, 2024, at 9:07 AM revealed that Resident 81 was lethargic, sleepy, and only arousable with tactile stimuli (physical touch e.g., sternal rub { firm rub on someone's sternum is a method used when testing an unconscious person's responsiveness}). The resident's blood pressure was 65/36 mm/Hg (a blood pressure of 65/36 is considered a dangerously low blood pressure that can reduce the blood flow to the brain and other organs in the body). The Certified Registered Nurse Practitioner was notified at that time and new orders were obtained. A review of the resident's blood pressures after the medication error on January 10, 2024 were as follows: 9:05 AM - 65/36 mm/Hg 9:22 AM - 70/42 mm/Hg 9:45 AM - 80/46 mm/Hg 9:55 AM - 84/60 mm/Hg 10:00 AM - 80/64 mm/Hg 10:10 AM - 92/40 mm/Hg A review of the Resident 81's January 2024 Medication Administration Report (MAR) revealed that on January 10, 2024, the resident required, and was administered Narcan 0.4 mg/ML (an emergency medication used to treat an opioid overdose) intravenously (through the veins) one time for sedation and Sodium Chloride 0.9% 100 ml intravenously every hour for 2 hours then 60 ml every hour. The facility's investigation report indicated at 8:00 AM on January 10, 2024 Employee 1 entered Resident 81's room to obtain vital signs then exited the room to obtain the resident's medications. While Employee 1 was preparing the resident's medications, other staff entered the room to get Resident 81 out of bed to take her to the dining room. Once Employee 1 had prepared all the medications, she decided not to administer the medications to Resident 81 until the staff were finished getting the resident up out of bed. Employee 1 placed Resident 81's medications off to the side of the med cart to later administration. Employee 1 prepared Resident 10's medications. Once Resident 10's medications were prepared, Employee 1 placed the cup of medications intended for Resident 10 to the side. At approximately 8:10 AM staff brought Resident 81 out of her room. Employee 1 stopped the resident in the hall and grabbed Resident 10's medications and administered Resident 10's medications to Resident 81. Employee 1 realized the error and notified Employee 2, RN (registered nurse) Supervisor. Instead of awaiting further instruction or notifying the physician, Employee 1 then administered Resident 81's prescribed Lasix 40 mg tablet and Potassium 2 0 meq tablet to Resident 81 without identifying if any of these medications may interact with the other medications Employee 1 had erroneously administered to the resident. At approximately 8:30 AM Employee 2 went to the dining room to assess Resident 81 but was met in the hallway by staff, returning Resident 81 to the unit due to a sudden change in condition. A review of a witness statement from Employee 1 dated the following day, January 11, 2024, revealed that this nurse stated that other staff came into Resident 81's room to provide care to the resident while she was preparing the resident's medications. The employee stated she labeled the medication cup with the resident's pre poured medications and began preparing Resident 10's medications. Employee 1 indicated that staff brought the resident out of her room to go to the dining room. Employee 1 stated that she stopped the resident grabbed the wrong medication cup, that was poured for Resident 10 and administered the wrong medications to Resident 81. Employee 1 indicated that when the nursing supervisor went to assess the resident, he was met in the hall with by staff returning the resident to her room. Employee 1 stated that Resident 81 at that time was extremely lethargic (sluggish, extremely fatigued, lack of energy). An interview with the Nursing Home Administrator and Director of Nursing on February 2, 2024 at approximately 2:00 PM confirmed that Employee 1 administered the incorrect medications to Resident 81 on January 10, 2024, failing to ensure the resident was free from significant medication errors. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued use of multiple psychoactive medications, including antipsychotic and duplicate drug therapy for anxiety disorder, prescribed for one resident out of five sampled residents (Resident 73). Findings include: A review of Resident 73's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included anxiety, dementia with behavioral disturbance, Lewy body dementia [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], osteoarthritis [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], and repeated falls. A review of the resident's clinical record physician's orders revealed the following orders: November 9, 2023, Pimavanserin Tartrate Oral Capsule 34 MG [Nuplazid is in the drug class of antipsychotics that is used to treat the symptoms of a certain mental/mood disorder (psychosis) that might occur with Parkinson's disease.] Give 1 capsule by mouth one time a day related to unspecified dementia with behavioral disturbance. November 11, 2023, Sertraline HCL (antidepressant used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to unspecified anxiety disorder. December 12, 2023, Buspirone HCL (anti-anxiety medicine) Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to anxiety disorder. December 13, 2023, Seroquel Oral (antipsychotic used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) Tablet 25 MG Give 1 tablet by mouth at bedtime related to neurocognitive disorder with Lewy bodies. December 16, 2023, Ativan (an antianxiety medication used to treat anxiety) Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to unspecified anxiety disorder and December 30, 2023, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed (PRN) for increased anxiety/agitation related to unspecified anxiety disorder. A review of the facility's consultant pharmacist's consultation report dated January 3, 2024, identified that Resident 73 had experienced multiple falls that occurred on 11/22/2023, 11/23/2023, and 12/20/2023. A comprehensive review of the medical record was conducted and identified that the following medications may contribute to falls: Two (2) antipsychotics: Nuplazid 34 mg daily and Seroquel 25 mg twice per day for Lewy Body dementia. Ativan 0.5 mg once daily and every eight (8) PRN for anxiety (PRN dose not administered prior to any fall). Sertraline 25 mg daily for anxiety, and Buspar 5 mg three times per day for anxiety. The pharmacist requested that the attending physician evaluate these medications as possibly causing or contributing to falls, deducing/discontinuing as appropriate and that if the therapy was to continue it would be recommended that the prescriber document an assessment of risk versus benefits, indicating that the medication is not believed to be contributing to falls in Resident 73; b) the facility interdisciplinary team ensures ongoing effectiveness and potential adverse consequences. A review of the attending physician's progress notes dated January 6, 2024, noted that Resident 73 was receiving Sertraline (Zoloft) and buspirone (Buspar) and Seroquel for the resident's mood. There was no documented evidence that attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder. A review of the physician's response dated January 16, 2024, revealed that a physician extender, a certified registered nurse practitioner, and the resident's attending physician) addressed the pharmacist's recommendations and decreased the resident's dose of the antipsychotic drug Seroquel dose to 25 mg at bedtime and increased the resident's antidepressant Zoloft to 50 mg oral daily. Through survey ending February 2, 2024, there was no documented evidence provided that the resident's attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder and that the physcian had thoroughly evaluated the combination of these medications and their potential side effects that may be negatively affecting the resident. Interview with the Director of Nursing (DON) on February 2, 2024, at 10:24 AM, confirmed that Resident 73's attending physician failed to document an evaluation of potential adverse consequences, including an assessment of the resident's condition and documented the clinical necessity of each psychoactive drug, including antipsychotics and duplicate drug therapy for anxiety disorder, in maintaining or improving the resident's function and abilities. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.2 (d)(3) Medical Director. 28 Pa. Code 211.5(f) Medical records.

Based on a review of clinical records, and staff interview, it was determined that the facility failed to act upon identified declines in bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 36). Findings include: A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and muscle weakness. A review of Resident 36's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2023, revealed that the resident was occasionally incontinent of bladder and always continent of bowel. A review of Resident 55's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was now frequently incontinent of bladder and occasionally incontinent of bowel. There was no documented evidence at the time of the survey ending February 2, 2024, that the facility had acted upon the decline in the resident's bowel and bladder continence and developed and implemented an individualized plan to decrease episodes of incontinency and restore normal function to the extent practicable for this resident. Interview with the Nursing Home Administrator on February 2, 2024, at approximately 2:00 PM confirmed that the facility failed to address the resident's increase in incontinency with an individualized plan to improve the resident's function and prevent further decline. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for one resident (Resident 1) out of seven reviewed. Findings included: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses of alcohol use and repeated falls. A review of Resident 1's Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 25, 2023, revealed that the resident's cognition was moderately impaired. A review of an Admission Elopement assessment dated [DATE], revealed that the resident was assessed to be at high risk for eloping from the facility. A progress note dated June 6, 2023, at 1:29 PM revealed that the facility's director of maintenance saw the resident coming out of the building from the exit near the staff time clock. The resident stated he wanted to go outside and followed the staff in front of him from the time clock. An incident report dated June 6, 2023, at 1:16 PM revealed the Employee 1, the Maintenance Director, witnessed Resident 1 exiting the building. Nursing staff brought the resident back into the facility and assessed for injuries at that time. Further it was indicated the resident exited the facility through a door Employee 2 Housekeeping had just exited out of due to the door not closing all the way shut. Employee 1 followed the resident while Employee 2 went to get nursing staff to help him back into the building. Employee 1's witness statement dated June 6, 2023, indicated that Employee 1 watched the resident walk out of the time clock exit door and started walking down the sidewalk towards the rear of dietary. Employee 1 stated she followed the resident around the building where he had stopped, talking to dietary workers. A written witness statement from Employee 2 dated June 6, 2023, revealed that Employee 2 stated that after she left the building from the time clock door and got into her car, she noticed Resident 1 was outside the facility and went to get staff inside the facility to help bring him back inside. A written witness statement from Employee 3 LPN (license practical nurse) dated June 6, 2023, indicated that dietary staff approached her to inform her that Resident 1 was outside the building. Employee 3 went outside and brought the resident back into the facility. The facility staff failed to ensure the doors at the staff time clock were secured when staff exited the facility and failed to ensure awareness that a resident with a known risk for elopement was behind them exiting the facility when they were leaving. An interview with the Director of Nursing on September 8, 2023, at approximately 1:00 PM confirmed the facility failed to provide adequate safety measures and supervision of a resident with known high elopement risk placing the resident at risk for accidents and injury. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The resident was brought back into the facility. A head to toe assessment was completed with no injuries noted. The resident will be offered to go to the courtyard daily. He was placed on 15 minute checks for 72 hours. A head count was completed to ensure all residents were in the facility. All doors were checked for functioning and locking. All windows were checked to ensure proper functioning. 2. To identify like residents that have the potential to be affected the DON or designee will complete new elopement assessments on all residents. If a resident is at risk for elopement care plans will be updated along with the elopement risk book. To identify like residents that have the potential to be affected the maintenance director or designee will complete door checks for functioning and window checks to ensure no other residents could elope. 3. To prevent this from reoccurring the DON or designee will educate current staff on the elopement policy and to ensure doors are firmly closed when exiting locked doors. When new staff members are hired, they will be educated on the elopement policy. Elopement drills will be held every shift to ensure staff members are aware of what to do in case of an elopement. 4. To monitor and maintain ongoing compliance the nursing home administrator or designee will hold and elopement drill monthly for three months. To monitor and maintain ongoing compliance the nursing home administrator or designee will interview five staff weekly for four weeks then monthly for two months to ensure comprehension of elopement policy and education. To monitor and maintain ongoing compliance the maintenance director or designee will complete an audit weekly for four weeks and then monthly for two months to ensure all doors and windows are locked and functioning appropriately. 5. These results of the audits will be forwarded to the facilities QAPI committee for further review and recommendations. The facility's plan of correction was completed on June 7, 2023 28 Pa Code: 201.18 (e)(1) Management 28 Pa. Code: 211.12 (d)(3)(5) Nursing Services

Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to ensure the pharmacist conducted drug regimen reviews at least monthly for one resident out of 18 sampled (Resident 74), Findings include: Review of Resident 74's clinical record revealed that she was initially admitted to the facility on [DATE], with diagnoses to have included Alzheimer's disease [is a generally progressive disorder that is a type of brain disorder that causes problems with memory, thinking and behavior], anxiety and depression. Review of Resident 74's clinical record revealed no documented evidence that the licensed pharmacist conducted drug regimen reviews for irregularities with the resident's medication regimen during the months of July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, and February 2023. Interview with the Director of Nursing (DON) on March 3, 2023, at 11:00 AM, verified that there was no documented evidence that the pharmacist had conducted drug regimen reviews of Resident 74's medication regimen at least monthly. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services.

Based on a review of employee files and the facility's abuse prohibition policy and staff interviews, it was determined that the facility failed to implement abuse prohibition procedures for fully screening one potential employee out of five reviewed to ensure that they were eligible for employment in a long-term care nursing facility. Findings include: A review of the facility's policy Pennsylvania Resident Abuse last reviewed by the facility in January 2023, revealed that under the area of employee screening, the facility will generally attempt to obtain references from 2 prior employers for an applicant. A review of the personnel files of newly hired employees, revealed that Employee 1 (Housekeeping) was hired January 12, 2023. On the employee's application for employment, he indicated that he had one previous employer. There was no indication that the facility contacted the previous employer to screen the employee for employment in a long-term care nursing facility. Interview with the Employee 2, Human Resources on March 2, 2023, at approximately 11:00 AM., confirmed that the facility had failed to contact the former employer of one newly hired employee to screen the employees for employment in the facility. 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to identify use by/discard dates for multidose insulin pens on one of two medication carts sampled (Residents 3 and 7). Findings include: A review of the facility's policy and procedure entitled Storage and Expiration Dating of Medications and Biologicals last revised January 2023 revealed if a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that open vial. An observation of the 500 Hall Medication Cart on March 2, 2023, at approximately 9:30 AM revealed Resident 3's Lispro Insulin Pen 100 units/ml (milliliters) was dated January 29, 2023. Further observation revealed Resident 7's Lispro Insulin Pen 100 units/ml was dated January 27, 2023. An interview with Employee 3, LPN (license practical nurse), on March 2, 2023, at the time of the observation confirmed that the insulin pens located in the medication cart were past the use by date and should have been discarded after 28 days of opening. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.9(k)(1)(2) Pharmacy services