Every finding on record at Julia Pound Care Center

Based on a review of facility policy and clinical record review, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for a urinalysis was completed timely for one of 15 residents reviewed (Resident 13) with symptoms of a urinary infection. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated July 23, 2026, revealed that the resident was cognitively impaired, required assistance with daily care needs and had diagnoses that included cholecystitis (gallbladder inflammation/infection). A Certified Nurse Practitioner note for Resident 13 dated July 10, 2026, at 1:00 a.m. revealed that the resident complained of urinary discomfort, and orders were received to obtain a UA flex to culture (diagnostic test that performs a standard urine analysis first and automatically orders a urine culture if specific indicators of infection are present) to rule out a urinary tract infection. Nurse's note for Resident 13 dated July 10, 2026, at 4:13 p.m. revealed that the urine was obtained by straight catheterization (invasive procedure in which a temporary tube is inserted into the bladder to obtain a urine sample); however, a nurse's note for Resident 13, dated July 11, 2026, at 12:33 p.m. revealed that the urine from July 10, 2026, was not sent to the lab and the resident had to be re catheterized to obtain another sample. Interview with the Assistant Director of Nursing on August 12, 2026, at 2:15 p.m. revealed that Resident 13's first urine was not sent to the laboratory timely and resulted in the resident receiving another catheterization to obtain the urinalysis per physician's orders. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician and treatments for pressure ulcers were provided as ordered by the physician for four of 30 residents reviewed (Resident 2, 45, 46, 58) who had pressure ulcers. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 18, 2026, revealed that the resident had severe cognitive impairment, required assistance from staff, had diagnoses that included dementia and other psychotic disorder, had a stage three pressure ulcer (tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible), and received hospice services. A wound consultant note for Resident 2, dated June 11, 2026, included the recommendation for a new wound treatment for staff to turn and reposition per pressure prevention protocol with a bed wedge. The wound measurement was 0.6 centimeters (cm) by 0.5 cm by 0.3 cm. A wound consultant note for Resident 2 dated June 18, 2026, included the recommendation for staff to turn and reposition per pressure prevention protocol with a bed wedge. The wound measurement was 0.9 cm by 0.5 cm by 0.3 cm. Physician's orders for Resident 2, dated June 18, 2026, included an order for the resident to have her coccyx cleansed with normal sterile saline (NSS-sterile salt water), apply silver gelling fiber (a highly absorbent wound, fibers transform into a cohesive soft gel) to the wound base and cover with bordered foam every day shift. Observations of Resident 2 on June 22, 2026, at 11:15 a.m. revealed that the resident was laying in bed and her blue bed wedge was observed in the corner of the room. A review of Resident 2's clinical record revealed that there was no documentation that the wound consultant's recommendations were reviewed with the physician. A review of the Treatment Administration Record (TAR) and Nurse Aide documentation in the task record for Resident 2 for June 2026 revealed no documented evidence that the wedge was used for turning and repositioning as recommended by the wound consultant. Interview with the Assistant Director of Nursing on June 25, 2026, at 1:52 a.m. confirmed that wound care recommendations were made by the wound nurse practitioner and the physician was to review the recommendations and accept or decline the recommendation. Staff received verbal orders from the physician to accept or decline the recommendations. There was no documented evidence that the physician reviewed the wound care notes or recommendations for approval or changes for Resident 2 on the above-mentioned dates. A significant change MDS assessment for Resident 45, dated April 9, 2026, revealed that the resident was cognitively impaired, required minimal assistance for daily care needs and had diagnoses that included hemiplegia (a form of paralysis that causes the severe or complete loss of motor function) and unstageable pressure ulcer coccyx. Physician's orders for Resident 45 dated May 24, 2026, included an order for the resident to have coccyx cleansed with normal sterile saline, apply Manuka hd (a sterile medical grade wound dressing impregnated with 100% active Manuka honey) to wound base and cover with dry dressing every day shift and as needed for soilage and dislodgement. Observations of treatment administration for Resident 45 on June 23, 2026, at 1:32 p.m. revealed that Licensed Practical Nurse 2 entered resident 45's room with supplies for ordered treatment. Resident 45 was positioned on his left side and did not have treatment in place to coccyx per physician's orders. Interview with Licensed Practical Nurse 2 June 23, 2026, at 1:35 p.m. confirmed that resident 45 did not have a have a treatment in place to coccyx per physician's orders. Review of the TAR for Resident 45 dated June 2026 indicated that the treatment was signed as being completed on June 22; however, there was no documented evidence in the clinical record to indicate that it became dislodged or was removed. Interview with the Assistant Director of Nursing on June 23, 2026, at 2:06 p.m. confirmed that Resident 45 should have had a treatment in place to coccyx per physician's orders. An admission Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated May 22, 2026, revealed that the resident was admitted to the facility on [DATE], was cognitively impaired, and had one unstageable pressure ulcer. Physician's orders for Resident 46 dated May 29, 2026, included an order for the resident to have her left heel wound cleansed with normal sterile saline (NSS-sterile salt water), apply calcium alginate (a highly absorbent wound dressing made from alginate, a natural polymer derived from the cell walls of brown seaweed) to the wound base, cover the wound with four by four and rolled gauze every day shift. Physician's orders for Resident 46 dated June 12, 2026, included an order for betadine (an antiseptic used to treat and prevent skin infections) to be applied to the resident's left heel and left open to air every day shift. Physician's orders for Resident 46 dated June 19, 2026, included an order to cleanse the left heel with Dakins, cover the wound with calcium alginate and then cover with a foam border dressing every day shift. A wound consultant note for Resident 46, dated May 28, 2026, included a recommendation for the left heel wound to be cleansed with 0.25% Dakins solution (used to prevent and treat skin and tissue infections), apply silver alginate (an advanced medical wound dressing that combines highly absorbent, natural seaweed fibers (alginate) with antimicrobial silver) to the base of the wound, secure with a four by four and rolled gauze, and change daily and as needed. A wound consultant note for Resident 46, dated June 11, 2026, included a recommendation for the left heel wound to be cleansed with soap and water, pat dry, apple betadine to the base of the wound, and leave open to air twice per day. A wound consultant note for Resident 46, dated June 18, 2026, indicated that a new wound treatment recommendation was provided for the left heel wound that included cleanse the wound with 0.25% Dakins solution, apply silver alginate to the base of the wound, secure with a dry dressing, change daily and as needed and recommended an Xray to rule out osteomyelitis (an infection in a bone). A review of the Treatment Administration Record (TAR) for Resident 46 dated May 2026 and June 2026 revealed that on May 29, 2026, through June 9, 2026, the resident's left heel wound was cleansed with NSS, and calcium alginate was applied instead of the recommended cleanse with Dakins solution and apply silver alginate. A review of the TAR for Resident 46 dated June 2026 revealed that on June 12, 2026, through June 17, 2026, the resident's left heel wound had betadine applied once a day instead of the recommended twice per day. A review of the TAR for Resident 46 dated June 2026 revealed that on June 19, 2026, through June 23, 2026, the resident's left heel received calcium alginate instead of the recommended silver alginate. There was no documented evidence that an Xray to rule out osteomyelitis was ordered or completed. Interview with the Assistant Director of Nursing on June 23, 2026, at 2:19 p.m. confirmed that wound care recommendations were made by the wound nurse practitioner and the physician was to review the recommendations and accept or decline the recommendation. Staff received verbal orders from the physician to accept or decline the recommendations. There was no documented evidence that the physician reviewed the wound care notes or recommendations for approval or changes for Resident 46 on the above-mentioned dates. A significant change MDS assessment for Resident 58, dated March 17, 2026, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, had a diagnoses that included dementia, and had one Stage 3 pressure ulcer (a severe skin injury featuring full-thickness skin loss where the underlying fat is visible). Physician's orders for Resident 58 dated April 2, 2026, included for the resident to have her left buttocks wound cleansed with NSS, apply Bactroban (an antibiotic) to the wound base, cover with calcium alginate with silver, and apply a foam border dressing every day and evening shift. Physician's orders for Resident 58 dated May 22, 2026, included to cleanse the left buttocks with NSS, apply Manuka HD to the wound base, and cover with a gauze bordered dressing every day and evening shift and as needed. A wound consultant note for Resident 58, dated April 30, 2026, indicated that a wound treatment recommendation was provided for the left ischium pressure ulcer (a type of wound that develops on the skin and tissue over the ischial tuberosity (sitting bones) ) that included to cleanse the wound with NSS, apply Manuka HD Super Lite (a wound dressing that combines high-potency, medical-grade Manuka honey with a super-absorbent, cross-linked gelling mesh), Calcium Alginate with Silver to base of the wound, secure with bordered gauze, and change daily and as needed. A wound consultant note for Resident 58, dated May 21, 2026, indicated that a new wound treatment recommendation was provided for the left ischium wound that included to cleanse with NSS, apply Manuka HD Super Lite to base of the wound, and secure with Bordered gauze daily and as needed. A review of the TAR for Resident 58 dated April 2026 and May 2026 revealed that on April 30, 2026, through May 6, 2026, the resident's wound received Bactroban instead of the recommended Manuka HD Super Lite. A review of the TAR for Resident 58 dated May 2026 and June 22 revealed that on May 22, 2026, through June 22, 2026, the resident's wound treatment was completed every day and evening shift instead of the recommended once a day treatment. Interview with the Assistant Director of Nursing on June 24, 2026, at 10:46 a.m. confirmed that wound care recommendations were made by the wound nurse practitioner and the physician was to review the recommendations and accept or decline the recommendation. Staff received verbal orders from the physician to accept or decline the recommendations. There was no documented evidence that the physician reviewed the wound care notes or recommendations for approval or changes for Resident 58 on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety. Findings include: The facility's policy regarding general sanitization of the kitchen, dated June 10, 2026, indicated that the food and nutrition services staff will maintain the sanitation of then kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. The prep table shelves are scheduled to be cleaned 3 times a week.Observations in the main kitchen on June 25, 2026, at 9:20 a.m. revealed that the shelves under the food preparation tables where clean pots and baking trays were kept had dust, debris and a thick removable substance on them. The baking trays had and pink, removable substance around the edges.Interview with the Production Manager Assistant on June 25, 2026, at 9:25 a.m. confirmed that the shelves under the food preparation tables and the baking pans should be clean and free of debris and they were not. 28 Pa. Code 211.6(f) Dietary Services.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide dependent residents the necessary services to maintain nutritional status for one of 30 residents reviewed (Resident 45).Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 45, dated April 9, 2026, revealed that the resident was cognitively impaired, required minimal assistance for daily care needs and diagnoses that included hemiplegia (a form of paralysis that causes the severe or complete loss of motor function) and unstageable pressure ulcer coccyx. The resident's care plan, most recently reviewed June 7, 2026, indicated that she required extensive assistance with meals and snacks. Observations June 23, 2026, at 10:45 a.m. revealed that Resident 45 was being fed by her daughter. Resident 45's daughter revealed that when she entered the room at 10:30 a.m. breakfast was on the bedside table and was not touched, so she was feeding her mother breakfast, and the staff was supposed to be assisting her with her meals. Observations June 24, 2026, at 9:06 a.m. revealed that Resident 45 was feeding herself breakfast and was observed having difficulty lifting her cup and getting food into her mouth using utensils. There were no staff present to assist her. Interview with Occupational Therapist 1 on June 25, at 1:29 p.m. confirmed that Resident 45 does require extensive assistance with eating as documented on her Discharge summary dated [DATE]. Interview with Nursing Home Administrator on June 25, 2026, at 1:35 p.m. confirmed that Resident 45 should have extensive assistance from staff with meals and snacks. 42 CFR 483.24(a)(2) ADL Care Provided for Dependent Residents. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 30 residents reviewed (Resident 3 and 4). Findings include: A policy dated January 22, 2026, indicated that glucose meter checks are obtained per physician order or as needed if resident is displaying signs and symptoms of hypoglycemia or hyperglycemia. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 11, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnoses that included diabetes mellitus. A nursing note for Resident 3, dated May 28, 2026, at 11:01 p.m. revealed that the resident's blood glucose was 453 mg/dl. Physician's orders for Resident 3 dated April 26, 2026, included orders to monitor blood glucose two times a day and call physician if blood glucose levels were less than 70 mg/dl or greater than 450 mg/dl. A nursing note for Resident 3, dated May 28, 2026, at 11:59 p.m. revealed that the physician was notified of the resident's blood sugar of 453 mg/dl and gave an order to allow time for the resident's long-acting insulin to take effect and to recheck the residents blood sugar at 12:00 a.m. and contact the physician of the results. A review of Resident 3's clinical record revealed that there is no documentation that the residents' blood sugar was rechecked at 12:00 a.m. per physician orders. An interview with the Assistant Director of Nursing on June 24, 2026, at 10:03 a.m. confirmed that there was no documentation that Resident 3's blood sugar was rechecked per physician's orders. An annual MDS assessment for Resident 4, dated April 9, 2026, revealed that the resident was cognitively impaired, required minimal assistance for personal hygiene needs; and had diagnoses that included psychosis (a collection of symptoms that indicate a disconnection from reality) and mood disorder. Review of a psychiatric visit note for Resident 4, dated January 8, 2026, revealed that the resident was seen for a mental status exam that included a review of medications, behaviors and an order for the resident to follow up in one month. A review of Resident 4's clinical record revealed no documented evidence that Resident 4 had a follow up since January 8, 2026, per physician orders. Interview with the Assistant Director of Nursing on June 23, at 1:35 p.m. confirmed that Resident 4 should have had a psychiatric follow up visit one month after January 8, 2026, and she did not 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Service

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 30 residents reviewed (Resident 3).Findings include: A policy dated January 22, 2026, indicated that glucose meter checks are obtained per physician order or as needed if resident is displaying signs and symptoms of hypoglycemia or hyperglycemia. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 11, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had medical diagnoses that included diabetes mellitus. Physician's orders for Resident 3 dated March 31, 2026, included orders for the resident to receive 10 units of Novolog (fast-acting insulin) with meals and to hold if she does not eat. A review of Resident 3's clinical record on eating April through June 2026 revealed that on April 5 she ate 26-50% of lunch; April 16 she ate 26-50% of dinner; April 17 she ate 76-100% of dinner; April 19 she ate 76-100% of lunch and ate 76-1005 of dinner; April 22 she ate 76-100% of dinner; May 1 she ate 25-50% of breakfast; May 2 she at 76-100% of dinner; May 10 she ate 76-100% of breakfast; May 14 she ate 51-75% dinner; May 16 she ate 26-50% of breakfast and 26-50% of dinner; June 17 she ate 51-75% of breakfast; June 20 she ate 76-100% of lunch; and June 21 she ate 76-100% of breakfast. A review of Resident 3's Medication administration record April through June 2026 revealed that 10 units of Novolog was held on April 5; April 16; April 17; April 19; April 22; May 1; May 2; May 10; May 14; May 16; June 17; June 20; and June 21, 2026. An interview with the Assistant Director of Nursing on June 24, 2026, 10:03 a.m. confirmed that physician's orders for Resident 3 to receive 10 units of Novolog were not followed per order. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner and failed to provide a separately locked, permanently affixed compartment in the refrigerator for medication storage.Findings include: The facility's policy regarding storage of medication, dated June 10, 2026, medications and biologicals are stored safely, securely and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel and staff members lawfully authorized to administer medications. Observations on June 24, 2026, at 9:10 a.m. revealed that the medication cart for the Highlands unit was in the hall, unattended and unlocked. Licensed Practical Nurse 3 was observed walking out of a resident room. The medication cart was not in sight of the resident room. Interview with Licensed Practical Nurse 3 at that time confirmed that she left the medication cart unattended and not in sight to administer medications and that she should have locked the cart before walking away. Observations in the facility's medication room refrigerator in the Highlands unit on June 24, 2026, at 9:36 a.m. revealed a multidose injector pen of Ozempic (a medication used to improve blood sugar) inside a locked box attached to the refrigerator shelf. The shelf was not permanently affixed to the inside of the refrigerator. Interview with Licensed Practical Nurse 4 at that time revealed that Ozempic is supposed to be stored in a locked box in the refrigerator and the shelf that the box is attached to should be permanently affixed to the inside preventing it from being removed. Interview with Assistant Director of Nursing on June 24, 2026, at 10:04 a.m. revealed that medication carts should be locked when unattended and not in sight of the nurse and shelves that have locked boxes attached should be affixed to the inside of the refrigerator. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory services were obtained as ordered by the physician for one of 30 residents reviewed (Resident 43).Findings include: Facility policy for Laboratory Services dated January 22, 2026, indicated that the facility will provide or obtain laboratory services to meet the needs of the residents, and will promote practices to ensure the quality and timeliness of laboratory services. The day shift unit nurse will fill out and send laboratory requests for newly ordered laboratory tests. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated May 20, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs and had diagnoses that included diabetes mellitus. A Certified Nurse Practitioner note for Resident 43 dated May 15, 2026, at 1:00 a.m. revealed that the resident complained of urinary discomfort, and orders were received to obtain a UA flex to culture (diagnostic test that performs a standard urine analysis first, and automatically orders a urine culture if specific indicators of infection are present) to rule out a urinary tract infection. Nurse's note for Resident 43 dated May 16, 2026, at 7:46 p.m. revealed that the physician was notified of the urinalysis results and ordered 100 milligrams (mg) of Macrobid (an antibiotic) to be given every other day for five doses pending the culture and sensitivity (C&S- laboratory procedure that identifies infectious germs (culture) and determines the most effective antibiotic (sensitivity) to treat the infection) results. Review of Resident 43's lab results for May 2026 revealed no documented evidence that a C&S was obtained from the resident's urine sample on May 15, 2026, as ordered by the certified nurse practitioner. Interview with the Assistant Director of Nursing on June 23, 2026, at 12:40 p.m. revealed that a urine C&S was not obtained for Resident 43 as ordered and it should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for one of 30 residents reviewed (Residents 46).Findings include: The facility's pneumococcal vaccine policy, dated January 22, 2026, indicated that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or the resident's legal representative have the right to accept or refuse immunization. The resident's medical record includes documentation that indicates the following: a) The resident or the resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization on the Vaccine Informed Consent and Screening Form. b) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal on the Vaccine Informed Consent and Screening Form. An admission Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated May 22, 2026, revealed that the resident was admitted to the facility on [DATE]. The sections of the MDS assessment related to the resident's pneumococcal vaccination revealed that the resident's pneumococcal vaccination was not up to date due to not being offered. Pneumococcal Vaccine Authorization Release for Resident 46 dated May 16, 2026, revealed education was provided to the resident's responsible party and authorization to administer the pneumococcal vaccine was obtained. Physician's order for Resident 46 dated May 16, 2026, included that the resident may receive the pneumococcal vaccine. There was no documented evidence that the pneumococcal vaccine was administered. Interview with the Assistant Director of Nursing/Infection Control Nurse on June 23, 2026, at 12:40 p.m. confirmed that Resident 46's responsible representative signed consent for the pneumococcal vaccine on May 16, 2026, however, as of June 23, 2026, there was no documented evidence that it was administered. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that dietary staff wore appropriate hair coverings. Findings include: The facility's policy regarding personal hygiene, dated March 12, 2025, indicated that food is prepared, stored and distributed in a safe and sanitary manner preventing the spread of food borne illness. Observations in the 100-200 hall kitchenette during service for the lunch meal on June 2, 2025, at 11:48 a.m. revealed that Dietary Aide 3 was plating baked beans and hot dogs. Dietary Aide 3 had approximately three-inch tendrils of hair on each side of her head, and approximately two inches of loose hair on the nape of her neck that was not covered by her hairnet. Observations in the 100-200 hall kitchenette during service for the lunch meal on June 3, 2025, at 12:10 p.m. revealed that Dietary Aide 3 was plating hamburgers on a bun, and at the same time, she was standing over dishes of uncovered vanilla pudding. Dietary Aide 3 had approximately two inches of hair on each side of her head, and approximately two inches of loose hair on the nape of her neck that was not covered by her hairnet. Dietary Aide 4 was assisting the meal preparation by filling drinks and placing them on the trays. As she placed the drinks on the trays she passed over 13 dishes of uncovered pudding. Dietary Aide 4 had approximately three to four inches of hair on her bangs that was outside of her hairnet. Observations of Dietary Aide 5 revealed that she was assisting with plating hamburgers while standing over uncovered pudding dishes. Dietary Aide 5 had approximately two inches of hair on the nape of her neck that was not covered with a hairnet. Interview with the Dietary Manager on June 3, 2025, at 12:15 p.m. confirmed that Dietary Aides 3, 4, and 5 should have had their hair covered when plating and working around uncovered food in the 100-200 hall kitchenette. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for four of 33 residents reviewed (Residents 12, 18, 72, 81). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2024, indicated that Section B was to be completed for each resident to document the resident's ability to understand and communicate with others. Section B0700 was to be coded zero (0) if the resident was understood by others, one (1) for usually understood, two (2) for sometimes understood, and three (3) for rarely/never understood. Section C was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. A significant MDS assessment for Resident 12, dated March 19, 2025, revealed that Section B0700 was coded two (2), indicating that the resident was sometimes understood by others. However, Section C0100 was coded (0) No, indicating that the resident was rarely/never understood by others, and Sections C0200 through C0500 (the BIMS interview) were not completed. A quarterly MDS assessment for Resident 18, dated April 3, 2025, revealed that Section B0700 was coded zero (0), indicating that the resident was understood by others. However, Section C0100 was coded (0) No, indicating that the resident was rarely/never understood by others, and Sections C0200 through C0500 (the BIMS interview) were not completed. A quarterly MDS assessment for Resident 72, dated March 19, 2025, revealed that Section B0700 was coded two (2), indicating that the resident was sometimes understood by others. However, Section C0100 was coded (0) No, indicating that the resident was rarely/never understood by others, and Sections C0200 through C0500 (the BIMS interview) were not completed. Interview with the Social Worker on June 5, 2025, at 9:54 a.m. confirmed that Section C0100 was coded inaccurately on the above MDS assessments for Residents 12, 18, and 72. The RAI User's Manual, dated October 2024, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge. A nursing note for Resident 81, dated March 12, 2025, indicated that the resident was transferred to the local hospital where he was admitted for acute care. However, a discharge tracking MDS, dated [DATE], indicated that Resident 81 was discharged to a nursing home. An interview with the Registered Nurse Assessment Coordinator (registered nurse responsible for accurate reporting information) on June 5, 2025 at 10:44 a.m. confirmed that Resident 81 was discharged to the hospital and not to a nursing home. She confirmed that she entered the wrong discharge location on Resident 81's discharge tracking MDS. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 27, 60). Findings include: A facility policy regarding care plans, dated March 12, 2025, indicated that the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning. The care plan will be reviewed and evaluated for intervention effectiveness and updated electronically as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated May 20, 2025, indicated that the resident was cognitively intact, required assistance with care needs, had limited range of motion (the full movement potential of a joint) to her lower extremities on both sides, and had diagnoses that included muscular dystrophy (disease that causes progressive weakness and loss of muscle mass). A restorative care plan for the resident, dated February 25, 2025, included a program for restorative splint/brace assistance for bilateral PRAFO boots (used to help manage many ankle/foot abnormalities) with kickstand to the outside of the boots at all times as the resident tolerates with instructions to remove for hygiene, skin checks, and range of motion. Observations of Resident 27 on June 3, 2025, at 2:17 p.m.; June 4, 2025, at 12:52 p.m.; and June 5, 2025, at 9:06 a.m. revealed that the resident did not have PRAFO boots applied to her bilateral lower extremities. Interview with the resident on June 5, 2025, at 9:06 a.m. revealed that she stopped wearing those boots a long time ago because they hurt her feet and indicated that therapy had taken them away because she was not wearing them. Interview with the therapy manager on June 5, 2025, at 10:05 a.m. confirmed that Resident 27's PRAFO boots were discontinued about a month or two ago due to the resident declining to wear them. Interview with the Assistant Director of Nursing on June 5, 2025, at 12:01 p.m. confirmed that Resident 27's restorative care plan should have been revised to reflect that the resident was no longer using the PRAFO boots. A quarterly MDS assessment for Resident 60, dated May 12, 2025, indicated that the resident was cognitively intact, required maximum assistance from staff for care, and was always incontinent of urine. The resident's care plan, dated May 2, 2025, indicated that the resident had frequent urinary tract infections and that staff were to assess urinary output, record the amount, type, color, and odor. A nursing note for Resident 60, dated April 30, 2025, revealed that the resident no longer had an indwelling urinary catheter and that she was now incontinent of urine. There was no documented evidence that Resident 60's care plan was updated with revised and/or new urinary incontinence interventions after her indwelling urinary catheter was removed. Interview with the Director of Nursing on June 5, 2025, at 12:30 p.m. confirmed that Residents 60's care plan should not have indicated that the resident's urine output was to be monitored or recorded. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 33 residents reviewed (Resident 42, 72). Findings include: A facility policy for medication administration, dated March 12, 2025, indicated that the individual who administers the medication records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated May 15, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and was taking an opioid medication (medications with the potential to be abused used to treat pain). Physician's orders for Resident 42, dated October 23, 2024, included an order for the resident to receive two 50 milligrams (mg) tablets of Tramadol (a narcotic pain medication) to equal 100 mg every eight hours as needed for moderate to severe pain. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 42, dated April and May 2025, revealed that two 50 mg tablets of Tramadol were signed out on April 14 at 5:00 p.m.; May 10 at 5:15 a.m. and 4:20 p.m.; May 21 at 6:50 p.m.; May 25 at 1:50 a.m.; and May 31 at 12:19 a.m. However, there was no documented evidence in Resident 42's clinical record, including the MAR, that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Assistant Director of Nursing on June 5, 2025, at 10:34 a.m. confirmed that there was no documented evidence in Resident 42's clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. A quarterly MDS assessment for Resident 72, dated March 19, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and chronic pain syndrome. Physician's orders for Resident 72, dated February 25, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (a controlled pain medication) every 12 hours as needed for moderate pain. A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 72, dated April, May, and June 2025, that one 50 mg tablet of Tramadol was signed out for administration to the resident on April 10 at 11:32 p.m.; April 18 at 11:00 p.m.; May 9 at 5:00 a.m.; May 28 at 11:15 p.m.; May 31, at 11:40 p.m.; and June 1 at 12:05 a.m. However, there was no documented evidence in the resident's clinical record to indicate that the signed-out tablets of Oxycodone were administered to the resident on the above-mentioned dates and times. An interview with the Assistant Director of Nursing on June 5, 2025, at 12:21 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 72 on the dates mentioned above. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in two of three medication carts reviewed (Highlands 1 and Highlands 2), and failed to discard expired medical supplies in one of two medication rooms reviewed (Highlands). Findings include: The facility's policy regarding medication storage, dated [DATE], revealed that the facility would store medications and biologicals safely, securely and properly. In addition, when the original seal of the manufacturer's container is initially broken, a date opened and expired date sticker shall be placed on the container. Observations in Highlands medication cart 2 on [DATE], at 9:36 a.m. revealed that there were two containers of 1 percent diclofenac sodium (pain reliever) topical gel, one container of 0.1 percent triamcinolone (steroid used to decrease inflammation) cream, and two containers of 12 percent ammonium lactate (treats dry itchy skin) topical cream in use with the seal broken, that did not have the date opened and date expired sticker on them. Observations in the Highlands 100-200 hall medication room black storage box on [DATE], at 9:50 a.m. revealed that there was one unsealed 10 milliliter (ml) normal saline flush (a syringe filled with salt water solution to flush intravenous ports) that expired on [DATE]; one 3 cc syringe with a needle attached that expired [DATE]; twelve angiocaths (a thin plastic tube inserted into a vein using a needle, allowing for the administration of fluids and medications), including three 22 gauge angiocaths that expired on [DATE], and one that expired on [DATE]; four 24 gauge angiocaths that expired on [DATE], and five 24 gauge angiocaths that expired [DATE]. In addition, there were two culture and sensitivity test kits that expired [DATE]; two blood drawing needles and three claves (rubber needless connectors) that expired [DATE]; one 15 ml bottle of hemoccult developer that expired [DATE], and 32 hemoccult test screening cards that expired [DATE]. Interview with Licensed Practical Nurse 1 on [DATE], at 10:00 a.m. confirmed that the above listed gels and creams were in use with the seals broken; therefore, an open date and expiration date sticker should have been placed on them. Also, outdated medical equipment should be discarded and not in circulation. Observations in Highlands medication cart 1 on [DATE], at 9:43 a.m. revealed that there was one 30 gram container of 0.1 percent triamcinolone acetonide cream that was opened and not dated with the open date or expiration date. Interview with Licensed Practical Nurse 2 on [DATE], at 9:48 a.m. confirmed that the triamcinolone acetonide cream was in use with the seal broken and should have been marked with an opening date and expiration date, and it was not. Interview with the Director of Nursing on [DATE], at 2:43 p.m. confirmed that expired equipment should not be in circulation, and that opened medications should be properly labeled as per facility policy. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending July 11, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending June 5, 2025, identified repeated deficiencies related accuracy of assessments, care plan timing and revision, pharmacy services, and food safety. The facility's plan of correction for a deficiency regarding accuracy of assessments, cited during the survey ending July 11, 2024, revealed that accuracy of assessments would be monitored by QAPI. The results of the current survey, cited under F641, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding accuracy of assessments. The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending July 11, 2024, revealed that the care plan timing and revision would be monitored by QAPI. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding care plan timing and revision. The facility's plan of correction for a deficiency regarding pharmacy services, cited during the survey ending July 11, 2024, revealed that pharmacy services would be monitored by QAPI. The results of the current survey, cited under F755, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding pharmacy services. The facility's plan of correction for a deficiency regarding food safety, cited during the survey ending July 11, 2024, revealed that food safety would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with food safety. Refer to F641, F657, F755, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 33 residents reviewed (Resident 67). Findings include: Current CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their 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. The facility's policy regarding Enhanced Barrier Precautions (EBP), dated March 12, 2025, revealed that the required PPE during high contact resident activities included gloves and gown being donned (worn) with high-contact care activity (which includes wound care). An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated May 15, 2025, revealed that the resident was cognitively intact and had pressure ulcers. A physician's order for Resident 67, dated June 2, 2025, included an order for the resident to have Enhanced Barrier Precaution isolation. Observations of wound care for Resident 67 on June 4, 2025, at 11:15 a.m. revealed that there was no signage posted outside the resident's door to alert staff of the need for EBP. Licensed Practical Nurse 6 entered the room and completed wound care on Resident 67 without donning a gown per the EBP requirements. Interview with Registered Nurse Supervisor 7 on June 4, 2025, at 12:20 p.m. confirmed that Resident 67 should have had EBP signage at his door to alert staff of the necessary PPE when performing care on his pressure ulcer. Interview with the Assistant Director of Nursing on June 4, 2025, at 12:50 p.m. confirmed that Resident 67 should have had a sign outside his room indicating that he was on EBP and that Licensed Practical Nurse 6 should have worn a gown when performing wound care. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to provide care in a safe manner for one of three residents reviewed (Resident 1) resulting in a fall with fractures. This deficiency was cited as past non-compliance. Findings include: A facility policy related to fall management, dated March 12, 2025, indicated that each resident is provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The facility will ensure the resident environment remains as free of accident hazards as possible. Resident falls are analyzed and trended through the Performance Review process to maintain a safe environment. A facility policy related to reclining lift chairs, dated March 12, 2025, indicated that residents are evaluated to ensure they are capable to safely utilize a reclining lift chair. When a resident/family voices an interest in utilizing a reclining lift chair, therapy will be notified to complete a screen/evaluation of the resident's ability to safely use the reclining lift chair. The determination of safe or not safe will be included in the resident's care plan. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 13, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, had a fracture of the body of the sternum (long flat bone located in the central part of the chest connected to the ribs) and had a diagnosis of dementia. A care plan for Resident 1, dated December 22, 2023, indicated that the resident was not safe to sit in a recliner chair. A therapy recommendation for Resident 1, dated September 17, 2024, indicated that the resident was not safe to sit in a recliner chair. A nursing note for Resident 1, dated April 4, 2025, revealed that the resident had fallen and was observed lying on her back in front of a recliner chair in the TV room. The resident had complaints of severe pain under her right arm and chest/sternal pain. The physician was notified, and the resident was sent to the hospital for an evaluation. An x-ray report from the hospital, dated April 4, 2025, revealed that the resident had a sternal fracture. Information submitted to the Department of Health, dated April 4, 2025, indicated that Nurse Aide 1 was placed on administrative leave at that time pending investigation. A PB22 for Resident 1 was initiated April 4, 2025. The investigation revealed that the resident had fallen in the common area and was lying directly beneath the recliner chair that she had been transferred into by Nurse Aide 1 less than five minutes prior to the fall. Resident 1's care plan had reflected that she was not safe to sit in a recliner. A written statement by Nurse Aide 1, dated April 4, 2025, revealed that she transferred Resident 1 into a brown recliner by the living room TV. A written statement by Nurse Aide 1, dated April 7, 2025, revealed that she was not aware that Resident 1 was not safe to be in a recliner and would not have put her in the recliner if she was aware that she was not safe to be in it. An interview with the Assistant Director of Nursing on April 22, 2025, at 2:40 p.m. confirmed that Nurse Aide 1 failed to follow Resident 1's care plan related to her not being safe to be in a recliner; however, she indicated that upon further investigation, it was determined that the care plan intervention related to the resident not being safe in a recliner was not linked to the nurse aide charting so that Nurse Aide 1 could see it. Interview with the Nursing Home Administrator on April 22, 2025, at 2:46 p.m. confirmed that abuse/neglect was able to be substantiated for Resident 1; however, there was no fault found with Nurse Aide 1 as the intervention was not linked to the nurse aide charting, and she was unaware that the resident was not safe to be in a recliner chair. Following the incident on April 4, 2025, the facility initiated a plan of correction and the facility's corrective actions included: Resident 1 was admitted to the hospital on [DATE], and the recliner intervention had been linked to the nurse aide electronic charting system. Current residents were evaluated by occupational therapy for recliner safety by April 9, 2025. An audit for current residents is in process and to be completed by the RNAC or designee to ensure that appropriate recliner interventions are linked to the electronic charting system if appropriate by April 11, 2025. Current nursing staff were provided re-education on the process to review individual care plan interventions by the Assistant Director of Nursing or designee by April 12, 2025, and on the facility abuse/neglect and exploitation policy by April 12, 2025. Current licensed nursing staff were provided education on the recliner/lift chair evaluation policy on linking individualized interventions to the nurse aide electronic charting system by the RNAC or designee by April 12, 2025. Current occupational therapy and physical therapy staff were provided with education on the recliner/lift chair evaluation policy by the Nursing Home Administrator or designee by April 12, 2025. Current nurse aides were provided education on reviewing and adhering to individualized interventions that have been linked to the electronic nurse aide charting system by April 12, 2025. An audit of five random residents will be completed to ensure that any recliner interventions are linked to the electronic charting system by the Director of Nursing or designee weekly for four weeks and then monthly for two months to ensure that recliner interventions are linked to the nurse aide electronic charting system. The results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on April 12, 2025. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of six residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had diagnosis which included diabetes and dementia. Physician's orders for Resident 3, dated November 1, 2024, included for the resident to have her blood glucose (amount of sugar in the blood) level checked before meals and at bedtime, receive 25 units of Lantus Solostar (long-acting insulin used to treat high blood sugar) twice a day, and 6 units of insulin lispro (fast acting insulin used to treat high blood sugar) three times a day. Physician's orders, dated November 1, 2024, also included for the resident to receive 2 units of insulin lispro if her blood sugar was between 150 milligrams per deciliter (mg/dL) and 199 mg/dl; 4 units of insulin lispro if her blood sugar was between 200 mg/dL and 249 mg/dL; 6 units of insulin lispro if her blood sugar was between 250 mg/dL and 299 mg/dL; 8 units of insulin lispro if her blood sugar was between 300 mg/dL and 349 mg/dL; 10 units of insulin lispro if her blood sugar was between 350 mg/dL and 399 mg/dL; and 12 units of insulin lispro if her blood sugar was between 400 mg/dL and 450 mg/dL. Review of the Medication Administration Record (MAR) for Resident 3, dated November 2024 and December 2024, revealed no documented evidence that the resident received 25 units of Lantus Solostar insulin at bedtime as ordered on December 13. There was no documented evidence that the resident received 6 units of insulin lispro at breakfast time as ordered on November 13, 17, 21, 22, and 28, and December 12; no documented evidence that the resident received 6 units of insulin lispro at lunch time as ordered on November 17, 21, 22, and 28, and December 4, 10, and 12; and no documented evidence that the resident received 6 units of insulin lispro at suppertime as ordered on November 28 and December 10. Review of the MAR revealed that there was no documented evidence that the resident's blood sugar was checked before breakfast on November 13, 21, and 28 and December 12, and at bedtime on December 13, and no sliding scale insulin coverage was provided. Review of the MAR revealed that the resident's blood glucose before lunch on November 17 was 172 mg/dL, requiring 2 units of insulin lispro; however, there was no documented evidence that it was administered to the resident. The resident's blood glucose before lunch on November 28 was 164 mg/dL, requiring 2 units of insulin lispro; however, there was no documented evidence that it was administered to the resident. The resident's blood glucose before supper on November 28 was 361 mg/dL, requiring 10 units of insulin lispro; however, there was no documented evidence that it was administered to the resident. The resident's blood glucose before supper on December 10 was 244 mg/dL, requiring 4 units of insulin lispro; however, there was no documented evidence that it was administered to the resident. Interview with the Director of Nursing on December 16, 2024, at 4:20 p.m. confirmed that there was no documented evidence that the resident received blood glucose checks and insulin as ordered on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of five residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had diagnoses that included diabetes and dementia. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 5 milligrams (mg) of olanzapine (used to treat the symptoms of schizophrenia) at bedtime. Review of Resident 3's Medication Administration Record (MAR), dated November 2024, revealed that there was no documented evidence that the resident received this medication on November 11, 2024, or on November 29, 2024. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive two 325 mg tablets of Tylenol at bedtime. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 250 mg probiotic (supplements intended to maintain or improve the good bacteria in the body) capsule at bedtime. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 15 mg tablets of buspirone (antianxiety medication) twice a day. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received the nighttime dose of this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 30 mg tablets of duloxetine (used to treat depression and anxiety) twice a day. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received the nighttime dose of this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 15 mg of mirtazapine (antidepressant) at bedtime. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 1, 2024, included that the resident receive 20 mg of rosuvastatin (used to treat high cholesterol) once a day. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received this medication on November 17, 2024, or on December 13, 2024, as ordered. Physician's orders for Resident 3, dated November 3, 2024, included that the resident receive two 10 milliequivalent (mEq) capsules of potassium chloride (medication used to prevent or to treat low blood levels of potassium) twice a day. Review of the resident's MAR, dated November 2024 and December 2024, revealed that there was no documented evidence that the resident received the nighttime dose of this medication on November 17, 2024, or on December 13, 2024, as ordered. Interview with the Director of Nursing on December 16, 2024, at 4:20 p.m. confirmed that there was no documented evidence that the resident received the above-mentioned medications as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of five residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated November 14, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had a diagnosis which included diabetes and dementia. Review of nurse aide documentation, dated December 3, 2024, revealed that the resident ate 100 percent of her lunch meal. Review of a grievance investigation related to Resident 3, dated December 3, 2024, revealed that Resident 3's lunch tray was removed from her room at 3:45 p.m. by the Director of Nursing, and the resident did not eat anything on that tray. Interview with the Director of Nursing on December 16, 2024, at 4:20 p.m. confirmed that nurse aide documentation of the resident's lunch meal on December 3, 2024, was documented incorrectly. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(5) Nursing Services.