Every finding on record at Heinz Transitional Rehabilitation Unit

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, resident interview, observation, and staff interview, it was determined the facility failed to accurately complete the Minimum Data Set (MDS) assessment for one of four residents reviewed (Resident 42).Findings include: Facility Resident Assessment Instrument (RAI) User's Manual (October 2026), which provides instructions for completing the Minimum Data Set (MDS, a federally required standardized assessment used to evaluate resident status and develop care plans), indicates the assessment must accurately reflect the resident's functional status and be completed with participation from appropriate health professionals. The RAI manual is the federally issued instruction manual that provides specific coding guidance for each item on the MDS. Facilities are required to code the MDS according to the specific instructions outlined in the RAI Manual to ensure accuracy, consistency, and regulatory compliance. Clinical record review revealed Resident 42 was admitted to the facility on [DATE], with diagnoses including infection and inflammatory reaction due to an internal right shoulder joint prosthesis (infection and inflammation involving an implanted artificial shoulder joint). A review of a admission MDS, dated [DATE] revealed that Resident 42 was cognitively intact with a BIMS score of 15 (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 no or very minimal cognitive impairment). A review of Section O (Special Treatments, Procedures, and Programs) of the admission Minimum Data Set (MDS), dated [DATE], documented that Resident 42 did not have intravenous access (a tube placed into a vein to deliver fluids or medications directly into the bloodstream), did not receive intravenous medications (medications administered directly into a vein), and did not receive supplemental oxygen (extra oxygen provided to help a person breathe more easily) during the Assessment Reference Date (ARD) look-back period. A review of the clinical record titled admission Evaluation - RN Assessment - V5, dated June 8, 2026, revealed Resident 42 was admitted with a central venous catheter (a long, flexible tube inserted into a large vein to provide reliable intravenous access for medications, fluids, or blood draws) in the left chest wall. A review of physician's orders dated June 8, 2026, revealed an order for Cefazolin 0.9 gram/100 milliliters intravenously every 12 hours for treatment of the infection involving the resident's right shoulder joint prosthesis. A review of the electronic Medication Administration Record (eMAR) documented Resident 42 received the ordered intravenous Cefazolin on June 8, June 9, June 10, and June 11, 2026, during the admission MDS Assessment Reference Date look-back period. Review of physician's orders revealed an order for oxygen at 2 liters per minute via nasal cannula (a soft tube with two small prongs that fit into the nostrils) at bedtime and as needed. The order directed staff to adjust the oxygen flow, as necessary, to maintain an oxygen saturation greater than 90 percent. A review of the electronic Treatment Administration Record (eTAR) documented staff administered oxygen at 2 liters per minute via nasal cannula during the admission MDS Assessment Reference Date look-back period of June 8 through June 11, 2026. During an interview on July 8, 2026, at 11:42 AM, Resident 42 stated he was admitted to the facility to receive intravenous antibiotics for an infection involving his right shoulder joint replacement and reported he used supplemental oxygen at home and while residing at the facility when needed. During an interview on July 9, 2026, at 10:30 AM, the Director of Nursing confirmed the admission MDS did not accurately reflect Resident 42's intravenous access, receipt of intravenous medications, or receipt of supplemental oxygen during the Assessment Reference Date look-back period. Despite documentation demonstrating that Resident 42 had intravenous access, received intravenous medications, and received supplemental oxygen during the Assessment Reference Date look-back period, the facility inaccurately coded Section O of the admission MDS. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, resident interview, and staff interview, it was determined the facility failed to review and revise a comprehensive person-centered care plan following a change in treatment and resident preference regarding the continued use of an indwelling urinary catheter for one of four residents reviewed (Resident 2).Findings include: A review of the facility policy titled Resident Comprehensive Care Plan, last reviewed November 5, 2025, indicated a comprehensive care plan will be initiated for each resident and will include measurable objectives based on the resident's assessed needs. According to the policy, the care plan will be reviewed and revised promptly if there is a change in the resident's physical or psychosocial wellbeing and with any change in resident's treatment regimen. Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including critical illness myopathy (a condition that develops in people who are critically ill and causes widespread muscle weakness). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 8, 2026 revealed Resident 2 was cognitively intact with a BIMS score of 15 (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 no or very minimal cognitive impairment). A clinical record review reveals a physician's orders dated June 26, 2026, to insert an indwelling urinary catheter (thin, flexible tube that's placed into the bladder and left there temporarily to drain urine continuously into a bag), provide catheter care every shift, and educate the resident and/or family regarding catheter care. An interview and observation with Resident 2 on July 8, 2026, at 11:15 AM confirmed the presence of an indwelling urinary catheter. Review of physician's orders revealed an order dated June 29, 2026, directing staff to remove the urinary catheter. Review of the Physician Progress Notes dated June 30, 2026, documented the catheter had originally been inserted to allow Resident 2 to attend an event outside the facility with family. The progress note documented Resident 2 declined removal of the catheter and elected to continue using it. Review of the Care Plan Report revealed a urinary elimination care plan initiated October 7, 2025, addressing urinary retention (inability to completely empty the bladder) and urinary incontinence (loss of bladder control resulting in urine leakage). The care plan documented the urinary catheter had been removed on March 6, 2026, and included goals for Resident 2 to urinate without difficulty and remain clean, dry, odor free, and without skin breakdown related to incontinence. The care plan was not reviewed or revised following the June 26, 2026, reinsertion of the indwelling urinary catheter and did not reflect the resident's continued catheter use, the physician's attempted catheter removal, or Resident 2's documented refusal to have the catheter removed and preference to continue catheter use. During an interview on July 8, 2026, at 2:00 PM, the Director of Nursing confirmed Resident 2's comprehensive care plan had not been revised to reflect the reinsertion and continued use of the indwelling urinary catheter or the resident's preference to continue catheter use. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(d)(3) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined the facility failed to provide care and services in accordance with professional standards and physician orders for the management and monitoring of a Peripherally Inserted Central Catheter (PICC) line for one resident out of 6 residents reviewed (Resident 68). Findings include: A review of nursing standards published by Lippincott Nursing Center (Picking Up on PICC Lines, Nursing Made Incredibly Easy) indicates that appropriate PICC line care (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart, used for intravenous fluids, including antibiotics) includes obtaining and documenting a baseline external catheter length (the portion of the catheter visible outside the body) and ongoing comparison of that measurement to identify catheter migration (movement of the catheter inward or outward from its original position). These standards further indicate that arm circumference (measurement around the arm where the catheter is inserted) should be obtained and trended to monitor for complications such as edema (swelling caused by fluid accumulation), phlebitis (inflammation of the vein), infiltration (leakage of fluid into surrounding tissue), or deep vein thrombosis (a blood clot in a deep vein). Without baseline measurements, nursing staff could not compare future assessments to identify catheter migration (movement of the catheter from its original position) or complications A review of clinical records revealed Resident 68 was admitted to the facility on [DATE], with diagnoses including a septic bacterial infection (a serious infection caused by bacteria) of the right knee requiring intravenous antibiotic therapy administered through a Peripherally Inserted Central Catheter (PICC) line. A review of the resident's Brief Interview for Mental Status (BIMS, a standardized assessment that is used to assess the resident's attention, orientation, and ability to register and recall new information) dated July 7, 2026, revealed a score of 15, indicating the resident was cognitively intact (a score of 13 through 15 indicates intact cognition). Hospital records, including the PICC Procedure Note dated July 6, 2026, documented placement of a double-lumen (two infusion channels and capable of withstanding high-pressure injections) PICC line in the resident's right upper arm for intravenous antibiotic therapy. The procedure note documented the catheter had a total length of 38 centimeters (cm) with an external catheter length of 0 cm at the insertion site. The physician's orders dated July 6, 2026, directed nursing staff to obtain and document the resident's arm circumference (measurement around the upper part of arm to monitor for potential complications like blood clots, swelling or other catheter-related complications) upon admission and every seven days thereafter, and to obtain and document the external catheter length (portion of the catheter remaining outside the body used to detect catheter migration) upon admission and every seven days thereafter to monitor for catheter migration and catheter-related complications. The physician's order further documented an external catheter measurement of 13 cm from the hub (the hard plastic connector where intravenous tubing attaches) to the tip (the insertion site where the catheter line enters the skin). A review of the facility's admission Evaluation dated July 6, 2026, incorrectly identified the PICC line as being located in the upper left arm, despite hospital documentation confirming placement in the right arm. In addition, the admission assessment failed to document either the baseline external catheter length or the baseline arm circumference as required by physician orders and accepted nursing standards. A review of Resident 68's Medication Administration Record, Treatment Administration, and nursing progress notes for July 2026, revealed no documented evidence that nursing staff measured or documented the resident's arm circumference or external catheter length upon admission as ordered. As a result, the facility failed to establish baseline measurements needed to compare future assessments and identify catheter migration or changes in arm circumference that could indicate complications such as swelling, vein inflammation, leakage of intravenous fluid into surrounding tissue, blood clots, or other PICC line complications. During an interview on July 9, 2026, at 9:19 AM the Director of Nursing confirmed there was no documentation demonstrating nursing staff obtained or documented the physician ordered arm circumference or external catheter length for Resident 68. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to fully implement enhanced barrier infection control procedures to prevent spread of infection for three of 14 sampled residents (Residents 13, 43, and 33). Findings include: According to the Centers for Disease Control (CDC) Enhanced Barrier Precautions (EBP) guidance focuses on gown and glove use and other important infection control measures for prevention of multi-drug-resistant organisms (MDRO type of bacteria or microorganism that has developed resistance to multiple classes of antibiotics, making infections harder to treat). EBP are recommended for residents with any of the following: infection or colonization with a MDRO, a wound, or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the facility Enhanced Barrier Precautions Policy last reviewed/revised November 1, 2024, indicated it is the facility policy to implement the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices including central lines (device inserted into a central vein for administration of medication or withdrawing blood), urinary catheters (plastic tube inserted and retained in the bladder for continuous drainage of urine into a closed system), feeding tubes, and tracheostomies (surgical procedure where a surgeon creates a hole through the neck and into the windpipe in order to deliver oxygen to the lungs safely. A tracheostomy tube is placed into the windpipe), regardless of MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The facility uses EBP in conjunction with standard precautions (set of infection control practices that are used for all patients regardless of their suspected or confirmed infection status, and are based on the principle that all body fluids should be treated as if they are infectious) and expands use of PPE (personal protective equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The procedure to implement includes that each resident's status will be reviewed in accordance with the latest CDC guidance and for those residents for whom EBP are indicated orders will be obtained and signage posted. These precautions will be employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. EBP are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. PPE and alcohol-based hand rub will be readily accessible with placement near or outside the resident's room. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which include osteomyelitis (a bone infection) of lumbar vertebrae region (the five bones that make up the lower part of the spinal column located between the chest and pelvis) and diabetes (chronic condition where the body does not produce or use insulin properly). A physician order dated August 25, 2025, noted an order for Cefazolin Sodium (an antibiotic used to treat bacterial infection) 2 grams intravenously every 8 hours via PICC (peripherally inserted central catheter- a type of central line, a long catheter introduced through a vein in the arm and passed to the larger vein in the heart) for staphylococcal lugdunensis bacteremia (type of bacteria that can cause infection in the blood, skin, bone, and joints) until September 29, 2025. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy. Observation on September 23, 2025, at 10:30 AM revealed no signage or evidence that EBP were implemented for Resident 13 based on the presence of a PICC line. A review of the clinical record revealed that Resident 43 was admitted on [DATE], with diagnoses which include atrial fibrillation (an irregular and often very rapid heart rhythm) and staph bacteremia (a bloodstream infection where Staphylococcus bacteria are present in the blood). A physician order dated September 23, 2025, noted an order for Vancomycin HCL (an antibiotic used to treat bacterial infection) 1250 mg intravenously once daily via PICC for bacteremia until October 3, 2025. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy. Observation on September 23, 2025, at 10:40 AM revealed no signage or evidence that EBP was implemented for Resident 43 based on the presence of a PICC line. A review of the clinical record revealed that Resident 33 was admitted on [DATE], with diagnoses which include congestive heart failure and benign prostatic hyperplasia (BPH- benign condition in which the gland surrounding the neck of the bladder in males is large than normal) with urinary obstruction (urine cannot drain through the urinary tract). A physician order dated August 27, 2025, noted an order for a Foley catheter (closed sterile system with a catheter and retention balloon that is inserted into the urethra to allow for bladder drainage) 18 Fr (French size, which is based upon measurement of the external diameter of the catheter tube) 10 cc (cubic centimeter, milliliter (ml) a measurement of volume in the metric system) balloon to straight bag gravity drainage for a diagnosis of urinary obstruction. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy for Resident 33's use of a Foley catheter. Observation on September 23, 2025, at 10:50 AM revealed that PPE was available in an over-the-door caddy on the entry door to Resident 33's room. However, signage for EBP was not posted as required per facility policy based on the presence of the Foley catheter. Interview with the director of nursing on September 23, 2025, at 11:00 AM confirmed that the facility failed to implement EBP as required for residents at higher risk for the development of infections based on facility policy and CDC Enhanced Barrier Precautions guidance. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of clinical records, facility policy, observation, and staff interview it was determined the facility failed to ensure the resident environment was free from potential hazards for one of 14 sampled residents (Resident 56).Findings included: A facility policy titled ‘Self-Administration of Medications', last reviewed on November 1, 2024, revealed the organization promotes the right to self-administer drugs unless the team has determined that the practice would be unsafe. The policy indicated if it is deemed safe and appropriate for a resident to self-administer medications, self-administration of medication is documented in the medical record and the care plan. A facility policy titled ‘Procedure for Medication Administration', last reviewed on November 1, 2024, indicated the purpose of the procedure is to guide safe medication administration. The policy further stated the licensed nurse will remain with the resident while he/she swallows oral medication, follow with a drink to clear the oral cavity if appropriate. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included a displaced intertrochanteric fracture of the right femur (a type of broken hip). According to the Brief Interview for Mental Status (BIMS-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) dated September 18, 2025, Resident 56 had a BIMS score of 15. A score of 13-15 indicates intact cognition. During an observation on September 23, 2025, at 10:22 AM, in the resident room of Resident 56 (window side), two circular, white tablets were observed on Resident 56's bedside table. Resident 56 was observed sitting on the side of the bed, near the table. A clinical record review did not include documented evidence that Resident 56 was assessed or deemed safe to self-administer medication. During an interview on September 24, 2025, at 9:51 AM, the Director of Nursing (DON) confirmed there was no documented evidence that Residents 56 was assessed or deemed safe and/or appropriate to self-administer medication. The DON confirmed that Residents 56 medication should not have been left at the bedside table as licensed nurses were to administer medications and medication on the bedside table was an accident hazard. The DON also provided a documented entitled ‘Staffing Coaching Education' (Dated September 23, 2025, at 3:52 PM). In summary, the ‘Staffing and Coaching Education' document cited the reason for education as the observation described above and confirmed Resident 56 received Tylenol two tablets in the morning. The ‘Staffing Coaching/ Education' document also included employee comments from Employee 1 acknowledging Employee 1 RN (registered nurse) had thought the resident did take all the meds A clinical review of the electronic medication record revealed a physician order for Acetaminophen Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablets by mouth two times a day for pain (Start Date-September 17, 2025). The electronic medication administration record (MAR) revealed Resident 56 receives the medication at 08:00 AM and again at 05:00 PM daily. The DON confirmed that it is the facility's responsibility to ensure the environment is free from potential accident hazards. The facility failed to maintain the residents' environment free of potential accident hazards by leaving medications accessible to anyone who enters the room and allows accidental consumption to those who the medication is not intended for. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that included management and refusal of a Wound Vacuum (a type of therapy to help wounds heal) for one resident out of 12 sampled (Resident 16). Findings include: A review of the clinical record revealed Resident 16 was admitted to the facility on [DATE], with diagnoses to include acquired absence of left toes, and end stage renal disease (a chronic kidney disease that occurs when the kidneys are permanently damaged and can no longer function) which required dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to function properly). A review of the clinical record revealed a physician order dated November 18, 2024, for continuous wound vac therapy to left medial foot with settings of 120 mmHg pressure intensity. Begin at 6 and decrease to 3 if resident is unable to tolerate (i.e. pain). A review of Resident 16's progress note dated November 21, 2024, revealed the resident refused to wear the wound vac when he needed to go out of the facility for dialysis, every Tuesday, Thursday, and Saturday. A review of Resident 16's care plan, last updated on October 24, 2024, revealed the care plan failed to address the resident's consistent refusals of the wound vac on his dialysis days and interventions on how to treat the wound when the resident left the facility. An interview with the Director of Nursing on December 4, 2024, at approximately 12:44 PM confirmed the facility failed to ensure that comprehensive care plans were developed to address this resident's specific needs. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records and staff interview, it was determined the facility failed to follow physician orders for administration of antibiotic and provide care to a PICC line as ordered for one resident out of 12 sampled. (Residents 18). Findings include: A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses which included intraspinal abscess and granuloma (a condition where a collection of pus forms within the spinal canal, alongside the development of a small inflammatory nodule [granuloma] both occurring within the spinal column), urinary tract infection, and heart disease. Further review of the resident's clinical record revealed Resident 18 was admitted with a PICC line (peripherally inserted central catheter inserted into a vein in the arm and threaded into a large vein above the heart) for intravenous (through a vein) antibiotic therapy. A review of Resident 18's physician orders dated November 3, 2024, revealed an order for Cefazolin (antibiotic) 1 GM (gram) use 2 GM intravenously every 8 hours for an epidural abscess until January 8, 2024. A review of the resident's Medication Administration Record (MAR) dated November 2024, revealed the Cefazolin was scheduled to be administered daily at 6:00 AM, 2:00 PM, and 10:00 PM. Further review of the MAR revealed there was no documented evidence the Cefazolin was administered on the following dates at 2:00 PM: November 9, 2024 November 15, 2024 November 19, 2024 November 20, 2024 November 23, 2024 November 29, 2024 A review of physician orders revealed an order dated November 4, 2024, to flush the intravenous catheter (PICC line) with Sodium Chloride Flush Solution 0.9% use 10 ml intravenously every shift to maintain patency. A review of the MAR dated November 2024 revealed there was no documented evidence that the PICC line was flushed as ordered on the dayshift on the following dates: November 9, 2024 November 15, 2024 November 19, 2024 November 20, 2024 November 23, 2024 November 29 , 2024 A review of physician orders revealed orders dated November 8, 2024, to change the PICC line dressing and change the end cap every 7 days on dayshift and as needed, and to measure the circumference of the arm 31cm above the insertion site initially and weekly thereafter and measure external catheter length on admission and weekly thereafter. Review of the MAR revealed there was no documented evidence the PICC line dressing was changed or that measurements were performed on November 15, 2024, November 22, 2024, or November 29, 2024. During an interview with the Director of Nursing on December 4, 2024, at approximately 1:30 PM it was confirmed the facility failed to provide documented evidence that nursing staff consistently followed physician orders as prescribed for Resident 18. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and select facility policy and protocol, and resident and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for the bowel protocol prescribed for three residents out of 13 sampled (Residents 21, 176 and 82) to promote normal bowel activity to the extent possible. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the facility policy titled Bowel Elimination Protocol, last reviewed by the facility on November 2, 2023, indicated that the facility will record bowel movements on each shift. The 11pm-7 am nurse will check the EMR (electronic medical record) each night. If no bowel movement is recorded, the nurse will check the previous documentation to determine the need for the bowel protocol. Bowel Protocol: 1. Any resident who has not had a bowel movement (BM) in three (3) days will be given Milk of Magnesia (MOM)/Lactulose on the 11pm-7 am shift (in the am of the 4th day). The nurse will assess bowel sounds and document accordingly. 2. If the resident has not had a bowel movement by the end of the day shift, Dulcolax Suppository will be given at the end of the shift. 3. If the Dulcolax suppository is not effective, a Fleets enema will be given by the 3pm-11pm shift. 4. If no results from the enema, bowel sounds will be assessed, and the physician informed. Nursing will document assessment and notification of physician in nursing notes as well as any new physician orders received for follow-up. A review of the clinical record revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses to include, diabetes, and acquired absence of the right leg below the knee (below the knee amputation). The resident had physician orders dated December 12, 2023, for the following bowel regimen: - Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days. - Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM. - Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective. Review of Resident 21 's report of bowel activity from the Documentation Survey Report v2 for the month of December 2023 and the Medication Administration Record (MAR) for December 2023, revealed the that the resident did not have a bowel movement on: - December 16, 2023 - day one without a bowel movement - December 17, 2023 - day two without a bowel movement - December 18, 2023 - day three without a bowel movement, 30 ml of Lactulose was ordered but no evidence that it was administered to the resident. - December 19, 2023 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered. - December 20, 2023 - day five without a bowel movement, Fleet enema was ordered but no evidence that it was administered. There was no documented evidence that the staff had notified the physician that the resident went five consecutive days, December 16, 17, 18, 19, and 20, 2023, without a bowel movement. A review of the clinical record revealed that Resident 176 was admitted to the facility on [DATE], with diagnoses to include, fracture of the pelvis, and difficulty in walking. The resident had physician orders dated December 27, 2023, for the following bowel regimen: - Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days. - Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM. - Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective. Review of Resident 176 's report of bowel activity from the Documentation Survey Report V2 for the month of December 2023 and the Medication Administration Record (MAR) for December 2023, revealed the that the resident did not have a bowel movement on: - December 27, 2023 - day one without a bowel movement - December 28, 2023 - day two without a bowel movement - December 29, 2023 - day three without a bowel movement, 30 ml of Lactulose was ordered and administered at 8:55 AM and documented as ineffective. - December 30, 2023 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered. - December 31, 2023 - day five without a bowel movement, Fleet enema was ordered but no evidence that it was administered. There was no documented evidence that the staff had notified the physician that the resident went five consecutive days, December 27, 28, 29, 30, and 31, 2023, without a bowel movement. A review of the clinical record revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors). The resident had physician orders dated December 28, 2023, for the following bowel regimen: - Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days. - Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM. - Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective. During interview with Resident 82 on January 3, 2024 at 11:30 AM the resident stated that he felt constipated. A physician order dated January 3, 2024, noted an order for Bisacodyl EC tablet delayed release 5 mg one tablet one time only for constipation. Review of Resident 82 's report of bowel activity from the Documentation Survey Report for the month of December 2023 though January 4, 2024 and the Medication Administration Record (MAR) for December 2023 though January 4, 2024, revealed the that the resident did not have a bowel movement on: - December 30, 2023 - day one without a bowel movement - December 31, 2023 - day two without a bowel movement - January 1, 2024 - day three without a bowel movement, 30 ml of Lactulose was administered as ordered. - January 2, 2024 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered. - January 3, 2024 - day five, Bisacodyl EC delayed release 5mg was administered as per physician order received on January 3, 2024, and a medium formed bowel movement at 9:43 PM was indicated on the resident's bowel activity survey documentation report. During an interview with the Director of Nursing (DON) on January 4, 2024, at 8:54 AM, the DON confirmed that staff failed to carry out the physician ordered bowel protocol prescribed for Residents 21, 176 and 82 to prevent constipation and promote normal bowel activity and was unable to provide documented evidence that the physician was notified of the five consecutive days without a bowel movement for Residents 21 and 176. 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.5(f) Medical records

Based on observation, review of select facility policy and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication (Lantus Insulin) for one of 13 residents reviewed (Resident 13). Findings include: A review of facility policy entitled Procedure for Medication Administration, and Self Administration of Medications, last reviewed by the facility November 2, 2023, indicated it is the policy to safely administer medications to the resident as ordered by the physician. Medications are not to be left bedside. It is the policy to promote the right of the resident to self administer drugs unless the interdisciplinary team (IDT) has determined that this practice would be unsafe. To assist in safe self administration the IDT will consider are the medications appropriate and safe for self administration, does the resident have the ability to ensure that the medications is stored safely and securely in a locked cabinet or drawer. If it is determined by the IDT that the resident is able to exercise this right, document in the medical record, nurse establish a plan to instruct the resident regarding his/her medications. This plan will be documented in the residents care plan. The resident may begin self administration after the instructions and understanding of the instructions has been demonstrated. This will be documented in the nursing notes. Medications must be locked in a cabinet or drawer. Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses to have included orthopedic aftercare, pneumonia, and diabetes. The resident was assessed as cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). The resident's care plan indicated that he is at risk for complications of blood sugar fluctuations related to diagnosis of diabetes date initiated on December 20, 2023, with a goal that the resident will not exhibit complications of Diabetes or signs/symptoms of hypoglycemia or hyperglycemia through next review, target Date of January 5, 2024. Interventions planned were to administer medications, assess and report to physician signs / symptoms of hypoglycemia or hyperglycemia as indicated by cold, clammy skin; sweating; lethargy; confusion, blood glucose monitoring, monitor lab tests, skin, especially feet, every shift and report any reddened or open areas to physician, and to provide diet per physician orders. The resident's care plan failed to identify the self-administration of medication, insulin (Lantus), nor the storage of the medication. A physician orders dated December 21, 2023, was noted for Lantus (diabetes medication) SoloStar subcutaneous solutions pen-injector 100 Unit/ML (Insulin Glargine), inject 42 unit subcutaneously two times a day for Diabetes Mellitus (DM) with scheduling details, that the Lantus is to be administered by a clinician at 0800 hrs (8:00 AM), and 2000 hrs (8:00 PM). During observation and interview with Resident 13, in his room on January 3, 2024, at approximately 10:33 AM, revealed an opened Lantus Solo Star insulin pen was observed on the resident's bedside table next to his personal items. During the interview with the resident, he stated staff leaves the insulin pen with him for him to self administer. A second observation of Resident 13 on January 3, 2024, at approximately 11:13 AM, revealed a Lantus Solo Star insulin pen remained on the resident's bedside table next to personal items. A third observation of the resident on January 3, 2024, at approximately 12:00 PM, in the presence of Employee 1 (Registered Nurse) confirmed that a Lantus Solo Star insulin pen was on the resident's bedside table next to personal items. Employee 1 confirmed that Resident 13 does self administer the Lantus insulin. During an interview on January 3, 2024, at approximately 12:05 PM, with Employee 1 (RN), Employee 1 confirmed that the resident's clinical record contained no physician order for Resident 13 to self-administer Lantus insulin, no self administration assessment of the resident's ability to self-administer, or care plan indicating that the resident does self administer the medication. Employee 1 further confirmed that the Lantus insulin pen was on the resident's bedside table and not securely stored During an interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, the DON confirmed that there was no self administration assessment of Resident 13, physician order for self-administration or care plan for the resident's self-administration and storage of the drug. Refer F 656 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to demonstrate that a resident was afforded the right to participate in care planning to meet the resident's nutritional needs and had incorporated the resident's personal preferences for weight loss and assure the resident received items included in the plan of care, to include snacks and additional protein, for one resident out of 13 sampled (Resident 13). Findings included: Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses of orthopedic aftercare, pneumonia, and diabetes. A review of an Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated December 26, 2023, indicated that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). The resident's care plan indicated that he was at risk for nutritional deficits related to a therapeutic diet initiated December 19, 2023, with a goal that the resident's weight will remain stable without significant changes through next review, target Date of January 5, 2024. Interventions planned were to honor food preferences and/or assist with menu completion, monitor weights, provide diet as ordered and monitor intake/tolerance, and provide education on therapeutic diet and/or food-drug interactions. A Nutritional assessment dated [DATE], indicated that the resident was on a carbohydrate (CHO) controlled regular diet and received a nutritional supplement, Glucerna, with breakfast and dinner. The assessment noted that the resident stated he would like snacks in-between his meals and supplements were added as snacks. Review of the resident's weight record revealed that the resident was 74.0 inches tall and his body mass index (BMI - a value derived from the weight and height of a person) was 31.8 (BMI of 30 and above indicates obesity). December 19, 2023 (2:38 PM) - 264.0 lbs December 20, 2023 (7:44 AM) - 264.0 lbs December 26, 2023 (6:35 AM) - 259.2 lbs - a 4.8 lbs weight loss (1.82 %) in 7 days. December 26, 2023 (6:47 AM) - 259.2 lbs January 2, 2024 (7:09 AM) - 248.0 lbs - a 16.0 lbs weight loss (6.06 %) in 14 days. The resident lost a total of 16.0 lbs or 6.06 % loss of body weight in 14 days (December 19, 2023 through January 2, 2024). A nutrition update note dated December 23, 2023, at 1:39 PM, indicated that the resident requested to speak with dietary staff. He informed staff that he has been diabetic since 2006, and he stated being hungry between meals and at hour of sleep (HS). The entry noted that Glucerna was provided twice daily. The resident requested additional protein. The resident's care plan was not updated to identify the additional protein portions with meals, when reviewed at the time of the survey ending January 5, 2024. A Nutrition update note dated December 30, 2023, at 1:45 PM indicated that the resident again requested to speak with someone from the kitchen. The resident complained that he gets his snacks a few days a week but has not received them since Tuesday and said his blood sugar was low today around breakfast. The entry noted that the dietary staff reviewed requested food items, and would discuss with kitchen staff. Interview with Resident 13 on January 3, 2024, at approximately 10:33 AM, and again at 11:55 AM, indicated he was dissatisfied with his current weight loss, stating I didn't come here to lose weight. The resident stated that he knew he lost weight by the way he felt and by the way his clothing fit. The resident stated he frequently did not receive the additional protein, and or snacks requested, stating it all depended on who worked in the kitchen, and whether it's a weekend or weekday. The resident stated he got tired of speaking with staff regarding his hunger and dietary concerns. A review of a nursing progress note dated January 3, 2024, at 5:45 PM, revealed the resident was discharged home. Interview with the Director of Nursing (DON) on January 5, 2024, at approximately 8:50 AM, confirmed Resident 13 had a significant weight loss and his care plan failed to identify the additional protein portions with meals the resident requested. 28 Pa. Code 201.29 (a) Resident rights

Based on observation, clinical record review and staff and resident interviews, it was determined that the facility failed to develop person-centered care plans that included individual resident needs and preferences for self-administration of medication and potential for pain for two residents out of 13 sampled (Resident 13 and 3). Findings include: A review of the clinical record revealed Resident 3 was admitted to the facility December 11, 2023, for orthopedic aftercare. An Nursing Admission Evaluation dated December 11, 2023, revealed the admission diagnosis as failure of recalled total hip arthroplasty hardware. Hospital discharge instructions dated December 11, 2023, prior to the resident's admission to the skilled nursing facility, indicated that had been hospitalized for a left hip arthroplasty because of a left hip hardware failure. A Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 18, 2023, revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 15. The MDS assessment noted that the resident has had pain or was hurting in the last 5 days. A facility pain evaluation dated December 24, 2023, indicated that the resident has experienced pain at the left surgical hip. Interview with Resident 3, in her room on January 3, 2024, at approximately 10:40 AM, revealed that currently she does experience pain A review of Resident 3's care plan conducted during the survey ending January 5, 2024, revealed that the resident's comprehensive care plan did not include the resident's potential for pain or actual pain. Interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of potential for pain, and pain management needs, on Resident 3's care plan. Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses to have included orthopedic aftercare, pneumonia, and diabetes. A review of the clinical record indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). The resident's care plan indicated that the resident was at risk for complications of blood sugar fluctuations related to diagnosis of diabetes initiated December 20, 2023, with a goal that the resident will not exhibit complications of Diabetes or signs/symptoms of hypoglycemia or hyperglycemia through next review as of the target Date of January 5, 2024. Interventions planned were to administer medications, assess and report to physician signs/symptoms of hypoglycemia or hyperglycemia as indicated by cold, clammy skin; sweating; lethargy; confusion, blood glucose monitoring, monitor lab tests, skin, especially feet, every shift and report any reddened or open areas to physician, and to provide diet per physician orders. The resident had current physician orders dated December 21, 2023, Lantus (diabetes medication) SoloStar subcutaneous solutions pen-injector 100 Unit/ML (Insulin Glargine), inject 42 unit subcutaneously two times a day for Diabetes Mellitus (DM). Observation and interview with Resident 13, in his room on January 3, 2024, at approximately 10:33 AM, revealed an opened Lantus Solo Star insulin pen on the resident's bedside table next to his personal items. During the interview with the resident, he stated that staff leaves the insulin pen in his room for him to self-administer his insulin. A second observation of Resident 13 on January 3, 2024, at approximately 11:13 AM, revealed the Lantus Solo Star insulin pen remained on the resident's bedside table next to his personal items. A third observation of the resident on January 3, 2024, at approximately 12:00 PM, in the presence of Employee 1 (Registered Nurse) confirmed the Lantus Solo Star insulin pen on the resident's bedside table next to personal items. Employee 1 confirmed that resident 13 does self administer the Lantus insulin. During an interview on January 3, 2024, at approximately 12:05 PM, with employee 1 (RN), a review of resident 13's clinical record confirmed the resident's comprehensive care plan failed to identify the resident's self administration of insulin. During an interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of medication (Lantus) self administration on Resident 13's care plan. Refer F554 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of clinical records and resident and staff interview, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 13 sampled (Resident 127) Findings include: A review of the clinical record revealed that Resident 127 was admitted to the facility on [DATE], with diagnoses to include left tibia fracture, diabetes, and depression. The resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental, {BIMS} which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The resident's care plan indicated that she was at risk for adverse reactions and behavior problems not easily altered related to current psychoactive medication date initiated on [DATE]. The goal was that the resident will be educated to use of medication and recognition of adverse reactions, along with interventions if adverse reaction occurs through next review, target Date of [DATE]. Interventions planned were to monitor the resident's mood and/or behavioral changes, and to offer ongoing support and encouragement with plan of care. A review of a nursing progress note dated [DATE], 2:13 PM indicated that the resident was very tearful and missing her husband. The resident stated he always helped her when she was here last time. The entry noted that nursing provided support. Interview with the administrator during the survey ending [DATE], revealed that the resident's husband was deceased . A nursing progress note dated [DATE], 7:42 AM indicated that the resident having breakfast at nurse's station. The entry noted that the resident was continuously crying and was inconsolable at this time. Nursing noted that the resident wants her husband. Nursing noted support was provided on [DATE], but there was no evidence of further supportive therapeutic social service interventions implemented to assist the resident with her emotional distress regarding wanting her husband. The resident's care plan failed to identify the known episodes of crying/tearfulness, and missing her husband and, did not include interventions for staff to implement when the resident was experiencing this distress and assist in coping with her grief. A review of a nursing progress note dated [DATE], 6:21 AM indicated that the resident displayed occasional tearful episodes and that nursing staff provided 1:1 emotional support, which was effective for short intervals. There was no documented evidence of the provision of therapeutic social services developed and planned to assist the resident with her emotional distress and coping. Interview with Resident 127, on [DATE], at approximately 10:45 AM found her in her room tearful. The resident stated that she was lonely. Interview with Employee 2, Social Worker, on [DATE], at approximately 1:20 PM revealed she had not followed up, or conversed with Resident 127 in response to the resident's episodes of tearfulness and crying due to missing her husband. During an interview on [DATE], at approximately 1:55 PM, the Nursing Home Administrator was unable to provide evidence that the facility consistently provided the necessary therapeutic social services to assist and support this resident in dealing with her emotional distress (crying/tearful) and coping with her grief regarding the absence of her husband. The NHA confirmed that the resident's care plan had failed to identify the resident's emotional distress as evidenced by the episodes of crying/tearfulness, and missing her husband and, did not include interventions for staff to implement when the resident was experiencing this psychosocial distress. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of select facility policy and clinical records, and resident and staff interviews it was determined that the facility failed to provide a physician ordered nutritional supplement prescribed to one out of four sampled residents sampled (Resident 77). Findings include: Review of the clinical record revealed that Resident 77 was admitted to the facility on [DATE], with diagnoses which included left femur fracture (break in the thigh bone) with left hip hemiarthroplasty (surgical procedure similar to total hip replacement but only ball point of the hip joint is replaced). A physician order dated January 2, 2024, was noted for Juven (a powdered nutritional supplement mixed with water or juice to support wound healing and maintain lean body mass) with meals for supplement, but failed to indicate the amount of Juven to be provided to the resident at each meal. A clarification physician order dated January 4, 2024, noted an order for Juven 8 ounce with each meal. Further review of the clinical record revealed no documented evidence that the physician ordered nutritional supplement was being provided. Interview with Resident 77 on January 4, 2024, at 12:45 PM confirmed that he was not yet receiving Juven with his meals. Interview with the director of nursing (DON) on January 4, 2024, at 1:15 PM confirmed that the physician's order for Juven was not timely implemented and provided to the resident as prescribed. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on review of select facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to provide care and services consistent with standards of practice for management of pain and opioid dependence related to a resident's daily use of an opioid pain medication prescribed as needed (PRN) and to ensure accurate administration of pain medication based on an established pain scale to meet the resident's pain management goals for one resident (Resident 5) out of three residents sampled for pain management. Findings include: According to US Department of Health and Human Services, Interagency Task Force, Executive Summary Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: o An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. o Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. o A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. These include the following five broad treatment categories -Medications: Various classes of medications, including non-opioids and opioids, should be considered for use. The choice of medication should be based on the pain diagnosis, the mechanisms of pain, and related co-morbidities following a thorough history, physical exam, other relevant diagnostic procedures and a risk-benefit assessment that demonstrates the benefits of a medication outweighs the risks. The goal is to limit adverse outcomes while ensuring that patients have access to medication-based treatment that can enable a better quality of life and function. Ensuring safe medication storage and appropriate disposal of excess medications is important to ensure best clinical outcomes and to protect the public health. o Restorative Therapies including those implemented by physical therapists and occupational therapists (e.g., physiotherapy, therapeutic exercise, and other movement modalities) are valuable components of multidisciplinary, multimodal acute and chronic pain care. o Interventional Approaches including image-guided and minimally invasive procedures are available as diagnostic and therapeutic treatment modalities for acute, acute on chronic, and chronic pain when clinically indicated. A list of various types of procedures including trigger point injections, radiofrequency ablation, cryoneuroablation, neuro-modulation and other procedures are reviewed. o Behavioral Health Approaches for psychological, cognitive, emotional, behavioral, and social aspects of pain can have a significant impact on treatment outcomes. Patients with pain and behavioral health comorbidities face challenges that can exacerbate painful conditions as well as function, QOL, and ADLs. o Complementary and Integrative Health, including treatment modalities such as acupuncture, massage, movement therapies (e.g., yoga, tai chi), spirituality, among others, should be considered when clinically indicated. o Effective multidisciplinary management of the potentially complex aspects of acute and chronic pain should be based A review of facility policy entitled, Pain Management Process, last reviewed by the facility October 6, 2022, indicated that the policy is to provide compassionate, appropriate assessment and interventions to control resident's pain via an interdisciplinary approach using non-pharmacological and pharmacological methods. The resident's descriptive words regarding the quality, duration and location of pain will be used to evaluate pain and to identify changes in pain. The pain scale indicated that 0 is no pain, 1 - 4 is mild pain, 5 - 7 is moderate pain, and 8 - 10 is severe pain. A review of Resident 5's clinical record revealed admission to the facility on [DATE], with diagnoses of osteomyelitis (inflammation or swelling that occurs in a bone), diabetes, clostridium difficile (inflammation of the colon C-diff), gout, non-pressure chronic ulcer left foot, gas -gangrene (bacteria gather in an injury or surgical wound that has no blood supply), vascular implants/grafts, surgical amputations - acquired absence of left great toe, and other right toe(s). An Admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated January 25, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess the resident's cognition - a score of 13-15 equates to being cognitively Intact) According to the MDS the resident has had pain or was hurting within the last 5 days. A review of Resident 5's plan of care dated January 18, 2023, revealed a focused area of the potential for pain, related to neuropathy, surgical/incisional pain related to left toe, and metatarsal amputation. Planned interventions for pain management were for staff to administer pain medication as ordered by the physician and document the effectiveness. Physician orders dated January 18, 2023, were noted for Gabapentin Capsule 300 MG Give 300 mg by mouth three times a day for neuropathy (medication used to treat neuropathic pain caused by diabetic neuropathy, postherpetic neuralgia, and central pain). Physician orders dated January 18, 2023, also included the non-narcotic analgesic, Acetaminophen Tablet 325 MG, give 650 mg by mouth every 4 hours as needed (prn) for mild pain. Do not exceed 3 GM per 24 hours and to use non - pharmacological interventions. On January 30, 2023, the physician also ordered for Lidocaine Patch 4 % Apply to low back topically one time a day for pain management and remove per schedule (a local anesthetic that works by causing a temporary loss of feeling in the area where you apply the patch). The resident also had a physician order dated January 18, 2023, for Hydrocodone - Acetaminophen (an opioid - narcotic pain medication), Tablet, 5 - 325 mg, give 1 tablet by mouth every 4 hours, as needed for pain rated from 4 - 10, do not to exceed 3 gm Acetaminophen in 24 hours. On January 19, 2023, the physician order was changed to Hydrocodone - Acetaminophen, Tablet, 5 - 325 mg, give 1 tablet by mouth every 6 hours, prn for pain rated 4 - 10, do not to exceed 3 gm in 24 hours. A review of the resident's January 2023, Medication Administration Record (MAR), revealed that nursing administered the PRN opioid pain medication to the resident daily, multiple times a day, a total of 25 doses, from January 18th thru January 31, 2023. A review of the resident's February 2023, Medication Administration Record (MAR), as of February 3, 2023, revealed that nursing administered the prn opioid pain medication to the resident daily, four doses as of the day shift of duty on February 3, 2023. Interview with alert and oriented Resident 5 on February 2, 2023, at approximately 11:32 AM revealed that the resident stated that he needs to ask nursing staff to give him the as needed hydrocodone - acetaminophen every day in order to get thru the day, stating that I am absolutely dependent on it (the opioid pain medication). Interview with the Director of Nursing (DON) on February 3, 2023, at approximately 11:05 AM, confirmed that Resident 5 requests the opioid-narcotic pain medication every day, and on many occasions, multiple times a day. The DON also verified that the current physician order for the Hydrocodone - Acetaminophen (an opioid - narcotic pain medication), Tablet, 5 - 325 mg, for pain 4 - 10, as prescribed, included pain levels of mild, moderate, and severe, which was not consistent with facility policy or standards of practice for pain management. The facility failed to clarify a physician's order, (Hydrocodone - Acetaminophen, for pain 4 - 10), which as written, was to be used for mild, moderate, and severe pain as needed. The resident's care plan failed to address the resident's dependence on the opioid pain medication and failed to include an individualized assessment of the resident for the development of multi-modal approaches to the resident's pain in an attempt to effectively manage the resident's pain while attempting to decrease the resident's dependence on the opioid pain medication to the extent practicable for the management of the resident's acute pain condition, which was confirmed during interview with the DON on February 3, 2023, at approximately 11:30 AM. 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.2 (a) Physician services

Based on clinical record review and staff interview, it was determined that the facility failed to accurately and consistently monitor fluid consumption to ensure adequate hydration status of a resident on a physician prescribed fluid restriction for one resident out of five residents sampled (Resident 72). Findings include: A review of the clinical record revealed that Resident 72 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a weakness of the heart that leads to a build-up of fluid in the lungs and surrounding body tissues). A physician order dated January 17, 2023, was noted for a fluid restriction of 1800 cc fluid per day for a diagnosis of acute congestive heart failure. Dietary will provide the resident 480 cc breakfast, 450 cc lunch, 450 cc dinner, 120 cc snack and nursing would provide 300 cc per day to total 1800 cc/day. Review of Resident 72's nutritional assessment dated [DATE], indicated that the resident's fluid needs were 1800 cc fluid/day. Review of Resident 72's Treatment Administration Records (TAR) for January 17, 2023, through January 31, 2023 February 1, 2023, through February 2, 2023 TAR revealed that on January 18th and January 19th on the first shift and on January 26th and January 31st on the second shift, staff failed to record the resident's fluid intake for the shift. Further review of the clinical record revealed no documented evidence that the total daily intake was calculated to evaluate adherence to the fluid restriction and the provision of adequate fluids to maintain hydration. The resident's documented intake per shift fluid intake from January 17th through January 31, 2023 and February 1st through February 2, 2023, varied from 540 ccs to 1290 cc's of fluid per day. The facility failed to demonstrate consistent and accurate monitoring of the resident's fluid intake to timely identify if the resident repeatedly exceeded the physician ordered fluid restriction or if the resident's fluid intake was consistently sufficient to meet the resident's needs for adequate hydration status. Interview with the director of nursing (DON) on February 2, 2023 at 1:30 PM confirmed that a resident's actual fluid intake varied. The DON also confirmed, that for a resident prescribed a fluid restriction, nursing staff is to record the resident's total daily fluid intake each shift on the resident's Treatment Administration Record. The DON verified that the daily fluid intake is to be totaled at the end of each day to ensure hydration needs are being met and evaluate adherence to the physician prescribed fluid restriction. The DON verified that the facility was unable to demonstrate that Resident 72's total actual daily fluid intake was being monitored to ensure the physician prescribed fluid restriction was being followed and the resident's hydration needs were being met. 28 Pa Code 211.6(c)(d) Dietary services 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on a review of facility policy, the facility's COVID-19 testing records and standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of one resident exhibiting signs and symptoms of COVID-19 out of 13 sampled residents. (Resident 8) Findings include: According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020, and revised on September 10, 2021, residents either vaccinated or unvaccinated who exhibit signs and symptoms of COVID-19 must be tested for COVID-19. A review of facility policy entitled COVID 19 Plan last reviewed on October 6, 2022, indicated that section E, SARS -CoV-2 Vital testing, anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. Interview with the facility's Nursing Home Administrator (NHA) and Director of Nursing (DON) during entrance conference on January 31, 2023, at approximately 8:50 AM revealed that the facility currently had an outbreak of COVID 19 among its residents and staff. A review of the county level testing transmission data, as provided by the facility, revealed that the rate for the county in which the facility maintains occupancy is Luzerne County. The facility provided COVID 19 transmission log, indicated that the weeks ending January 2, 9, 16, 23, and 30, 2023, the transmission rate was high. Resident 8's clinical record revealed COVID 19 daily screen - V 2 dated January 26, and 27, 2023, indicated that the daily screener indicated a positive screen for COVID symptoms as the resident had a cough. However, the resident was not tested for COVID until January 28, 2023. A review of Resident 8's clinical record, nursing progress note, dated January 28, 2023, at 6:16 PM, revealed all parties notified of positive covid swab on January 28, 2023. A continued review of Resident 8's clinical record, respiratory therapy note, dated January 28, 2023, at 6:54 PM, revealed nasal antigen covid swab done with positive results. RN and resident are aware of results. The facility failed to timely conduct testing of one resident exhibiting signs and symptoms of COVID-19 on January 26, and 27, 2023, and on the 3rd day. The resident was tested on [DATE], and was positive for COVID - 19. Interview with the Director of Nursing (DON) on February 3, 2023, at approximately 11:20 AM, confirmed that the facility failed to timely perform COVID-19 testing despite exhibiting signs and symptoms. 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code: 211.12 (a)(c)(1)(5) Nursing services. 28 Pa. Code 211.5 (h) Clinical records

Based on observation, clinical record review, and staff interview it was determined that the facility failed to provide services necessary to maintain sanitary oxygen delivery systems for one of three sampled residents (Resident 10). Findings include: Review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses, which included chronic [CONDITION(S)] with [CONDITION(S)] (condition in which the blood does not have enough oxygen). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on March 8, 2022, at 11:30 AM revealed that Resident 10 was receiving oxygen at 3 liters/minute via nasal cannula. The oxygen tubing and humidifier bottle attached to the concentrator were not dated when placed into use. The observation was confirmed by employee 1 (registered nurse). Interview with the director of nursing on March 8, 2022 at 12:30 PM confirmed the oxygen tubing and humidifier bottle were to be dated to assure consistent and timely changes. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on March 8, 2022, at 9:30 a.m., in resident room 218 revealed deep gouges in the walls of the resident bathroom. The gouges were particularly deep on the wall behind the bathroom door. Further observation of the exterior of nurses station across from resident room 218, revealed large cracks and chipped paint on one exterior wall of the nurses station. An observation on March 9, 2022, at approximately 12:00 p.m., revealed an accummulation of a thick black substance on the end of the hose of the ice machine. During an interview March 10, 2022 at approximately 10:00 a.m, the Director of Nursing observed the above and confirmed the observations and the facility's failure to maintain a clean and safe environment. 28 Pa Code 207.2 (a) Administrators responsibility

Based on a review of clinical records and the facility's infection assessment tool and staff interview it was determined that the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use for two residents out of 12 sampled. (Resident 10 and 162) Findings included: Review of the facility McGeer Criteria for Long Term Surveillance Definitions for Infection Updated 2012 indicated that for a resident without a catheter (tube inserted into the bladder to drain urine) to be considered to have a urinary tract infection ([CONDITION(S)]- condition in which bacteria invade and grow in the urinary tract) which would warrant the use of an antibiotic Criteria 1 AND 2 must be present. Criteria 1 noted the following would be met: acute dysuria OR fever OR leukocytosis (elevated white blood cells which may indicate infection) AND gross hematuria (blood in the urine), new or marked increase in incontinence, new or marked increase in urgency, OR new or marked increase in frequency. Criteria 2 noted the following would be met: at least 100,000 cfu/ml of no more than two species of microorganisms in a voided urine sample OR 100 cfu/ml of any number of organisms in a specimen collected by in-and-out catheter. A review of Resident 10's clinical record revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses note dated March 1, 2022, indicated that the resident had some slight confusion and was yelling out for her daughter in the hallway and asking questions with confused meanings. The physician was notified and a new order for a urinalysis (a test of your urine used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease, and diabetes) with C & S (culture and sensitivity- microscopic study of the urine culture performed to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection) was obtained. Little frequency noted per resident. Responsible party and resident made aware. A review of the resident's urinalysis laboratory test results dated March 2, 2022 revealed abnormal results which included a slightly cloudy urine, moderate esterase (reference range negative; may be indicative of [CONDITION(S)] if present in urine), WBC (white blood cells) 50+/HPF (reference range 0-2; may be indicative of [CONDITION(S)] if elevated). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's urinalysis C&S report dated March 4, 2022 revealed 10,000 to 100,000 colonies/ml Escherichia coli (a bacteria) susceptible to [MEDICATION(S)]. Further review of the clinical record revealed no documented evidence of the how the urine sample was obtained (voided urine sample or in-and-out catheter). There was no documented clinical rationale for the initiation of the [MEDICATION(S)] Monohyd on March 2, 2022, prior to receiving the results of the urinalysis C&S report. There was no documented evidence that the facility McGeer Assessment Tool for a Urinary Tract Infection was applied to Resident 10 to prevent use of an unnecessary antibiotic and ensure the antibiotic was clinically justified and appropriate. An interview with the infection Preventionist on March 10, 2022 at 11:00 AM failed to provide documented evidence that the facility's chosen McGeer Assessment Tool for a Urinary Tract Infection was used to ensure the administration of [MEDICATION(S)] Monahyd was clinically indicated and the clinical necessity of initiating the antibiotic prior to, and based on the urinalysis C&S results. Review of Resident 162's clinical record revealed that she was admitted from the hospital on February 25, 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated March 1, 2022, at 12:42 PM, indicated that the resident's husband was aware about the change in antibiotics as he had received a call from the hospital. The resident's antibiotic was changed based on the culture report received by the hospital on February 28, 2022, after the discharge. Review of Resident 162's hospital record conducted on March 9, 2022, revealed that upon discharge from the hospital on February 25, 2022, there was no culture and sensitivity report available to determine that the resident had received the appropriate antibiotic therapy to treat her urinary tract infection. There was no documented evidence that the facility had reviewed Resident 162's clinical status and findings upon admission for the presence of the urine culture report to ensure that appropriate and effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the facility's Infection Preventionist on March 10, 2022, at 10:30 AM confirmed that the resident's clinical record was not reviewed upon admission for receipt of culture reports to ensure appropriate and effective antibiotic therapy was prescribed as part of the facility's antibiotic stewardship procedures to monitor antibiotic use. 28 Pa Code 211.2 (a) Physician Services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies

Based on clinical record reviews and staff interviews, it was determined the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and residents' responsible party for three of three residents reviewed (Residents 16, 21 and 123). Findings include: A review of the facility's written transfer/discharge notice revealed it did not include the reason for the transfer (in a manner and language they understand), a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request and For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. A review of the clinical record revealed that Resident 16 was transferred to the hospital and admitted on [DATE]. The facility's transfer discharge notice did not include the reason for transfer, but solely noted a check box next to which was noted that Resident has experienced a change in condition and transfer/discharge to the hospital is necessary for the resident's welfare; resident's needs cannot be met at the facility. It also did not include the aforementioned information as required. The facility was unable to provide evidence that a notice was also sent to the resident's responsible party. A review of the clinical record revealed that Resident 21 was transferred to the hospital on May 5, 2021. The facility's transfer discharge notice did not include the reason for transfer, but only a check box indicating that Resident has experienced a change in condition and transfer/discharge to the hospital is necessary for the resident's welfare; resident's needs cannot be met at the facility. The notice did not include the required information. The facility was unable to provide evidence that the notice was also sent to the resident's responsible party. A review of the clinical record revealed that Resident 123 was transferred to the hospital on April 15, 2021. The facility's transfer discharge notice did not include the reason for transfer. The document was incomplete and lacked required information. The facility was unable to provide evidence that a written notice of transfer was also sent to the resident's responsible party. Interview with the Nursing Home Administrator (NHA) on May 6, 2021 at 1:00 PM confirmed the transfer forms did not include the required information as required and that there was no evidence that the written notices were provided to the residents' representatives. 28 Pa. Code 201.29(h) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to implement measures to prevent development and worsening of pressure sores, failed to timely identify skin breakdown, and effectively implement prescribed treatments to promote the healing of a pressure sore for one resident out of two residents sampled with pressure sores (Resident CRA1). Findings include: Resident CRA1 was admitted to the facility on [DATE], for the purpose of receiving skilled rehabilitation services due to a [MEDICAL CONDITION] femur (non-surgical repair). Physician orders on admission (May 3, 2010), directed that a left lower leg immobilizer, was to be worn at all times, but that it could be removed for bathing and skin care only. The resident was not to bear weight on the left leg. A plan of care developed on admission (May 3, 2010) identified that the resident was at risk to develop pressure areas due to non-weight bearing status on the left leg and the left lower leg immobilizer use. Interventions included daily shift skin assessments by licensed nurses with treatments conducted per MD orders. A review of the facility's policy for 'Knee Immobilizers',(not dated), revealed that only licensed staff are instructed in the application of the knee immobilizer. A review of daily nursing documentation revealed that skin integrity was to be documented daily by every shift if a resident had [MEDICAL CONDITION], rashes or any type of skin irritation or injury. The 7 AM -3:30 PM, May 3, 2010, nursing documentation, under skin integrity on the admission assessment, revealed that the resident had slight [MEDICAL CONDITION] in the left knee area and had multiple ecchymotic areas on the left lower leg. Nursing documentation for all nursing shifts subsequent to the note dated May 3, 2010, 7 AM to 3:30 PM, and from May 4, 2010 through My 8, 2010, revealed that all shifts for documentation regarding skin integrity, documented that the left leg immobilizer was intact. There was no further written documentation revealing any evidence of the actual skin integrity beneath the left lower leg immobilizer, despite nursing documentation on the initial assessment of May 3, 2010, revealing that there were multiple bruises on the left lower extremity and swelling in the left knee area that had the potential for causing increased pressure on the lower leg from the immobilizer. During an interview with the Director of Nursing Services (DON) on September 23, 2010, at approximately 1 PM, the DON relayed that interviews with both licensed nursing staff and caregivers, that had cared for the resident from May 3, 2010 through May 8, 2010, failed to identify any staff member that had visually inspected the resident's skin beneath the immobilizer. Documentation revealed that on May 9, 2010, when a caregiver removed the left lower leg immobilizer to prepare the resident for the first shower since admission, an open area on the left lower leg was observed and the licensed nurse was summoned. An open area was identified on the resident's on the lateral left leg, described as a Stage II pressure ulcer, measuring 6 centimeters (cms) in length, 3 cms and 2 cms in width and a depth of less than 0.1 cms. The pressure ulcer was draining serosanguinous (bloody) drainage. A review of the physician's progress note dated May 10, 2010 revealed that the resident had developed the pressure ulcer directly related to the pressure on the skin from the immobilizer. Physician orders for wound care obtained subsequent to an office visit conducted on June 15, 2010, revealed that the resident's tendon was exposed in the pressure ulcer. The physician directed that only the gauze dressing, above the [MEDICATION NAME] dressing that was applied at the office visit, was to be changed daily and as needed, with all other wound care orders discontinued. Nursing documentation on June 16, 2010 revealed that due to a nurse transcription error, the [MEDICATION NAME] dressing had been removed on June 16, 2010, during the treatment that day. During an interview with the DON on September 23, 2010, at approximately 1 PM it was relayed that the physician had performed a graft to the area which is why the [MEDICATION NAME] dressing was not to be removed. Physician orders obtained on June 17, 2010 revealed that a graft was again scheduled at the physician's wound clinic for June 22, 2010. The resident was discharged to home on June 18, 2010. 28 Pa Code 211.12 (a)(c)(d) (1)(5) Nursing services Previously cited 12/11/2008, 12/11/2009, 2/16/2010 28 Pa Code 211.10 (a)(d) Resident care policies 28 Pa Code 211.11 (a)(b) Resident care plan