Every finding on record at Julia Ribaudo Extended Care Center

Based on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's food and nutrition area. Findings include: A review of a policy for Freezers and Refrigerators, lase reviewed June 5, 2026, revealed the facility will ensure safe refrigerator and freezer maintenance and sanitation. The food and nutrition services director will inspect refrigerators and freezers monthly for gasket, fan condition, the presence of rust, excess condensation and any other damage or maintenance issues. Necessary repairs will be initiated immediately. A tour of the facility's main kitchen area on June 14, 2026, at approximately 9:30 AM revealed the walk in freezer with a large ice buildup on the ceiling, double exhaust fans, walls and floor. The pipe located under the exhaust fans (to remove the condensation/water from inside the unit to the outside of the building was missing, leaving an exposed hole in the freezer to the outside of the building. The freezer was located on an outside wall of the kitchen. The metal shelving unit located under the exhaust fans had two large plastic containers with individual ice cream cups encased in ice. These plastic containers were frozen to the metal shelves. There were multiple metal shelving units on either side of the freezer with wet cardboard boxes containing food. The cardboard boxes fell apart when moved. Several boxes of food, including two cakes, were noted to be freezer burned with ice on the food. A review of the freezer temperature logs at the time of the tour revealed the temperature inside the freezer was 9 degrees Fahrenheit. A review of a service order from the freezer repair company dated June 3, 2026 revealed that a technician was in the building on that date and inspected the freezer unit in the kitchen. He noted on the invoice that the walk in freezer needed a drain pipe, it was coming off the fan inside the unit. The technician left the building stating he needed to get parts to repair the unit. The service order noted that the technician was again in the building June 5, 2026, to make additional repairs to additional machines in the kitchen. The freezer was not repaired at that time. The repair company was contacted by the facility staff on June 14, 2026, after the survey team identified the issue with the walk in freezer. During an interview on June 15, 2026, at 10:00 AM, the Certified Dietary Manager (CDM) stated the pipe under the exhaust fans in the freezer had broken off two weeks ago. He stated the repair company was contacted and came out to the facility at that time but didn't have the needed part to fix the issue. As of the time of the start of the survey, June 14, 2026 the walk in freezer remained broken. An interview with the Nursing Home Administrator (NHA) on June 15, 2026, at 10:00 AM confirmed the facility failed to ensure that essential equipment was in safe operating condition. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.

Based on review of facility infection control records, clinical records, facility policy, and staff interview, it was determined that the facility failed to implement and maintain an antibiotic stewardship program and conduct and document antibiotic stewardship monitoring for eight of 8 months reviewed (November 2025 through June 2026) and failed to follow its antibiotic stewardship process for 1 of 20 residents reviewed (Resident 97).Findings include: A review of the facility policy titled Antimicrobial Stewardship Program, last updated June 5, 2026, revealed the program focuses on improving antimicrobial use by avoiding inappropriate or unnecessary antimicrobials. The policy stated antimicrobial use would be reviewed through monitoring and tracking of antimicrobial prescribing, use, and resistance to promote optimal antimicrobial use within the facility. The policy required the use of an antimicrobial tracking form or system to track and trend infections by site and organism. The policy also required monthly review of antimicrobial utilization reports from the pharmacy, including the type of drug prescribed, number of days of treatment, and number of new antimicrobial starts. The policy further required monthly antimicrobial use surveillance, including monitoring, tracking, and trending for patterns, trends, and clusters, and required clinical and diagnostic testing for specific infections.In addition, the policy required antimicrobial use protocols to address prescribing practices, documentation of the indication, dose, and duration of antimicrobial therapy, review of laboratory reports to determine whether antimicrobial therapy was indicated or required adjustment, completion of an infection assessment prior to prescribing, and monitoring of antimicrobial use through antimicrobial utilization reports, antimicrobial resistance reports, and current McGeer Criteria. McGeer Criteria are standardized surveillance definitions used in long-term care facilities to identify infections based on specific clinical signs, symptoms, and laboratory findings. The policy further stated that antibiotics would be prescribed and administered under the guidance of the facility's antibiotic stewardship program, which was established to monitor antibiotic use among residents. A review of the facility's infection control surveillance records from November 2025 through June 2026 revealed no documentation that antibiotic stewardship monitoring, tracking, trending, or utilization review activities had been completed during any of the eight months reviewed. A review of Resident 97's clinical record revealed the resident was admitted on [DATE], with diagnoses that included epilepsy (a neurological disorder characterized by recurrent seizures) and parkinsonism (a group of neurological disorders that cause symptoms such as tremors and slowed movement). A review of a physician's order dated April 27, 2026, revealed Macrobid 100 mg (an antibiotic used to treat urinary tract infections) was ordered twice daily for five days for a urinary tract infection (UTI, an infection involving the urinary system). A review of the April 2026 Medication Administration Record revealed Resident 97 received four doses of Macrobid. A review of Resident 97's clinical record revealed no documentation that a McGeer Criteria assessment had been completed prior to initiation of the antibiotic. Further review failed to identify documentation supporting the clinical signs or symptoms used to determine whether the resident met the facility's criteria for antibiotic treatment. A review of a urinalysis with culture report dated April 27, 2026, at 3:40 PM revealed minimal bacterial growth consisting of mixed normal urogenital flora (bacteria commonly found on the skin and surrounding areas that do not necessarily indicate infection). Documentation revealed the laboratory results were reviewed by the provider on April 30, 2026. Following review of the culture results, which did not identify evidence of a urinary tract infection, the antibiotic was discontinued. During an interview on June 15, 2026, at 11:00 AM, the Infection Preventionist stated Resident 97 met McGeer Criteria for antibiotic treatment. However, the facility was unable to provide documentation identifying the clinical findings that met the criteria or a completed McGeer Criteria assessment supporting initiation of the antibiotic. During an interview on June 16, 2026, at 1:00 PM, the Director of Nursing confirmed the facility had not completed antibiotic stewardship monitoring as required and acknowledged the facility's antibiotic stewardship process had not been followed. Cross refer F757 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary food storage, dishwashing, and ice machine sanitation practices in the food and nutrition services department. These failures had the potential to contaminate food and ice served to residents and increased the risk of foodborne illness.Findings include: Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During the initial tour of the food and nutrition services department on June 14, 2026, at 9:15 AM, in the presence of Employee 3, Cook/Dietary Aide observation revealed the following food storage concerns with the potential to increase the potential for food-borne illnesses: Cardboard food containers stored on metal shelving were wet and covered with freezer burn. A large accumulation of ice was observed on the ceiling, shelving beneath the exhaust fans, storage shelves, food containers, the floor, and the door threshold. At the time of the observation, the freezer temperature measured 9 degrees Fahrenheit. Commercial freezers are generally maintained at 0 degrees Fahrenheit or below to keep food frozen, preserve food quality, and minimize conditions that could contribute to food deterioration. Excessive ice accumulation and elevated freezer temperatures may indicate that the freezer is not functioning effectively and may compromise the safe storage of food. During the observation, the Certified Dietary Manager was unable to state whether the freezer had been consistently maintained at acceptable temperatures to ensure safe food storage or prevent the excessive ice accumulation observed throughout the freezer. Observation on June 14, 2026, at 9:15 AM revealed Employee 3, dietary aide, loaded soiled dishes into the dishwasher while wearing gloves that had contacted dirty dishware. After the wash cycle was completed, Employee 3 removed clean dishes from the dishwasher using the same gloves without removing the gloves or performing hand hygiene. The use of the same gloves for both dirty and clean dishware created the potential for cross-contamination by transferring microorganisms from soiled surfaces to cleaned and sanitized items. A second observation on June 15, 2026, at 9:30 AM revealed Employee 4, dietary aide, loaded soiled dishes into the dishwasher while wearing gloves and subsequently removed clean dishes from the dishwasher using the same gloves without changing gloves or performing hand hygiene. This practice also created the potential for cross-contamination between dirty and clean dishware. Observation of the ice machine located in the AB dining room/activity room on June 14, 2026, at 10:00 AM revealed a heavy accumulation of lint on the external filter. The exterior chrome surfaces contained dried liquid residue. The floor beneath and behind the machine contained paper debris, plastic debris, liquid stains, and dirt. The plastic drainpipe connected to the machine contained a large accumulation of brown sticky residue. The floor drain located two inches below the drainpipe contained a similar brown sticky substance. Additional plastic piping located at the rear of the machine near the floor contained numerous black spots throughout the length of the pipe. (Ice is considered food and must be protected from contamination during production, storage, and dispensing. Unsanitary conditions on and around ice machines and drainage systems may contribute to contamination of ice intended for resident consumption) Observation of the ice machine located in the CD dining room/activity room on June 14, 2026, at 10:30 AM revealed paper debris, plastic debris, liquid stains, and dirt on the floor beneath and behind the machine. The plastic drainpipe connected to the machine was then connected directly into the drainpipe. The drainpipe contained brown sticky residue, visible dirt, and staining. The surrounding floor area also contained brown residue, dirt, and liquid staining. Interview with the Nursing Home Administrator on June 15, 2026, at 12:00 PM confirmed the facility was expected to maintain safe food storage practices and sanitary conditions for equipment used in the preparation and service of food and ice. Cross refer F908 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Coe 211.6 (f) Dietary.

Based on a review of scheduled facility mealtimes, facility policy, resident interviews, and staff interview, it was determined that the facility failed to consistently offer nourishing evening snacks when the scheduled time between dinner and breakfast exceeded 14 hours for residents residing on four nursing units. This deficient practice affected six of six residents who participated in a resident council interview (Residents 48, 95, 39, 33, 75, and 69).Findings include: A review of the facility policy titled Meal Times and Frequency Policy, last reviewed by the facility on June 5, 2026, revealed it is the facility policy that there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day; except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the following day if a resident group agrees to this meal span. A review of the facility's scheduled meal service times revealed that the time between dinner and breakfast exceeded 14 hours on all nursing units reviewed. Residents residing in North Nursing Unit Area 1 were scheduled to receive dinner at 4:40 PM and breakfast at 7:10 AM the following day, resulting in a meal interval of 14 hours and 30 minutes. Residents residing in North Nursing Unit Area 2 were scheduled to receive dinner at 5:00 PM and breakfast at 7:20 AM the following day, resulting in a meal interval of 14 hours and 20 minutes. Residents residing in South Nursing Unit Area 1 were scheduled to receive dinner at 4:50 PM and breakfast at 7:15 AM the following day, resulting in a meal interval of 14 hours and 25 minutes. Residents residing in South Nursing Unit Area 2 were scheduled to receive dinner at 5:15 PM and breakfast at 7:30 AM the following day, resulting in a meal interval of 14 hours and 15 minutes. During a resident council interview on June 15, 2026, at 10:00 AM, six of six residents interviewed (Residents 48, 95, 39, 33, 75, and 69) stated that evening snacks were not consistently offered. During an interview on June 15, 2026, at 2:00 PM, the Nursing Home Administrator (NHA) stated that it was the facility's practice to offer residents nourishing evening snacks. However, the NHA was unable to provide documentation or other evidence demonstrating that evening snacks were consistently offered to residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, facility policies, observations, and staff interviews, it was determined that the facility failed to implement procedures to maintain accurate records of controlled substances and ensure accountability for controlled drug administration for one resident (Resident 35), and failed to notify the physician when a prescribed medication could not be administered as ordered for one resident (Resident 98) out of 20 residents reviewed.Findings include: A review of the facility policy titled Routine Reconciliation of Controlled Substances, last reviewed by the facility on June 5, 2026, revealed that the facility will maintain separate controlled substance records for all Schedule II medications and other medications with a potential for abuse or diversion through the use of a Controlled Substance Declining Inventory Record. The policy further revealed that incoming nurses (the nurses beginning a shift and accepting responsibility for resident care and medication accountability) and outgoing nurses (the nurses ending a shift and transferring responsibility for resident care and medication accountability to the next shift) are responsible for jointly counting all Schedule II controlled substances and other medications at risk for abuse or diversion at each shift change and documenting that the count was verified as accurate. A review of the clinical record revealed Resident 35 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive decline in memory, thinking, and reasoning abilities that interferes with daily functioning) and chronic obstructive pulmonary disease (COPD, a chronic lung disease that restricts airflow and makes breathing difficult). A review of physician orders revealed an order dated February 9, 2026, for hydrocodone-acetaminophen 5/325 milligrams, a narcotic pain medication. A narcotic is a controlled substance. A controlled substance is a medication regulated by federal law because it has the potential for misuse, abuse, diversion, dependence, or addiction and therefore requires strict inventory controls and accurate recordkeeping. The order directed staff to administer the medication every six hours as needed for a pain scale of 4 through 10. A pain scale is a standardized tool used to measure the intensity of pain, typically on a scale from 0 to 10, with higher numbers indicating more severe pain. A review of facility records revealed the facility utilized a Controlled Substance Record to track the receipt, administration, and remaining inventory of controlled medications, including hydrocodone. A review of the Medication Administration Record (MAR) revealed the MAR documents the medication administered, date and time of administration, staff administering the medication, pain assessment, and reason for administration. A comparison of Resident 35's Controlled Substance Record and February 2026 MAR revealed discrepancies between the number of doses removed from controlled substance inventory and the number of doses documented as administered. The Controlled Substance Record indicated hydrocodone was removed from inventory on eight occasions. However, only four administrations were documented on the MAR. The MAR lacked documentation that the medication was administered on the following occasions despite the medication being removed from the controlled substance inventory:February 2, 2026, at 10:30 AM;February 7, 2026, at 12:33 PM;February 11, 2026, at 1:00 PM; andFebruary 12, 2026, at 9:30 PM. Observation of the A Hall medication cart on June 14, 2026, at 9:53 AM revealed the facility failed to consistently complete controlled substance shift count documentation used to verify the accuracy of controlled substance inventories at the change of shift. Specifically, the controlled substance count records lacked required signatures indicating that incoming and outgoing nurses verified the accuracy of the controlled substance count on the following dates:March 12, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.March 16, 2026, the incoming day shift nurse failed to sign that the controlled substance count was verified as accurate.March 17, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.March 18, 2026, the incoming day shift nurse failed to sign that the controlled substance count was verified as accurate.March 18, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.March 22, 2026, the incoming night shift nurse failed to sign that the controlled substance count was verified as accurate.March 23, 2026, the incoming nurse and outgoing nurse assigned to the day shift failed to sign that the controlled substance count was verified as accurate.March 25, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.April 1, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.April 2, 2026, the incoming day shift nurse failed to sign that the controlled substance count was verified as accurate.April 3, 2026, the outgoing night shift nurse failed to sign that the controlled substance count was verified as accurate.April 7, 2026, the outgoing night shift nurse failed to sign that the controlled substance count was verified as accurate.April 9, 2026, the outgoing night shift nurse failed to sign that the controlled substance count was verified as accurate.April 12, 2026, the incoming nurse and outgoing nurse assigned to the evening shift failed to sign that the controlled substance count was verified as accurate.April 13, 2026, the outgoing night shift nurse failed to sign that the controlled substance count was verified as accurate.April 13, 2026, the incoming day shift nurse failed to sign that the controlled substance count was verified as accurate.April 30, 2026, the incoming night shift nurse failed to sign that the controlled substance count was verified as accurate.May 5, 2026, the incoming evening shift nurse failed to sign that the controlled substance count was verified as accurate.May 7, 2026, the incoming day shift nurse failed to sign that the controlled substance count was verified as accurate.May 9, 2026, the outgoing evening shift nurse failed to sign that the controlled substance count was verified as accurate.May 14, 2026, the outgoing night shift nurse failed to sign that the controlled substance count was verified as accurate.May 31, 2026, the incoming evening shift nurse failed to sign that the controlled substance count was verified as accurate.June 6, 2026, the incoming night shift nurse failed to sign that the controlled substance count was verified as accurate.The observation conducted on June 14, 2026, at 9:53 AM revealed the incoming day shift nurse signed the controlled substance count record indicating the count was verified for both the incoming day shift and the outgoing 11:00 PM shift. The documentation reflected verification of the outgoing shift count before the end of that shift and prior to the actual shift change, creating inaccurate controlled substance accountability documentation. An interview conducted on June 16, 2026, at 1:00 PM with the Director of Nursing and Nursing Home Administrator reviewed the above findings related to the facility's failure to implement effective procedures to reconcile, monitor, and account for controlled substances administered to Resident 35. A review of the clinical record revealed Resident 98 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a degenerative joint disease caused by the breakdown of cartilage and changes in the underlying bone) and rheumatoid arthritis (an autoimmune disease in which the body's immune system attacks the joints, causing inflammation, pain, and joint damage). A review of Resident 98's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7, indicates severe cognitive impairment indicating significant difficulty with basic memory tasks, recognizing the date, or recalling recent information). A review of the facility policy, Medication Shortages/ Unavailable Medications, last reviewed June 5, 2026, indicates that upon discovery there is an inadequate supply of medication, the facility should immediately notify the pharmacy. If the medication is unavailable through the emergency medication supply, and an emergency delivery of the medication is not possible, the facility nurse should contact the attending physician to obtain new orders or directions for alternate administration. A review of the Resident 98's physician's orders includes an order for Prolia (denosumab, a medication that helps strengthen bones by slowing down the process that breaks them down), dated October 22, 2025. The order directed administration on the 22nd day of every sixth month. A review of nursing progress notes dated April 22, 2026, at 12:47 PM revealed the medication was unavailable and the pharmacy had been contacted. The note indicated the medication would be delivered with the next pharmacy delivery scheduled for April 25, 2026. This resulted in a three-day delay in administration of the medication ordered. The clinical record failed to reveal documentation that the attending physician was notified of the delay in medication administration or consulted regarding alternate treatment instructions as required by facility policy. During an interview on June 16, 2026, at 10:57 AM, the Nursing Home Administrator and Director of Nursing confirmed the pharmacy did not have the medication available, including within the emergency medication supply, and that the medication had to be ordered, resulting in a three-day delay in availability. The Nursing Home Administrator and Director of Nursing further confirmed it is the facility's responsibility to implement procedures that promote timely medication administration and physician notification when medications cannot be administered as ordered. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on observations and interview, it was determined the facility failed to maintain a clean, comfortable and homelike environment for residents on five of 5 resident units. (Units A,B,C,D and E )Findings include: An environmental tour conducted on June 14, 2026, at 9:30 AM revealed that the floor on all resident hallways (A,B,C,D and E) had a thick, yellow sticky substance around the perimeter to include in front of resident rooms and ancillary rooms. The high back upholstered chairs in the A,B activity/dining room had food and dried liquid stains on them. The floor was dirty with dirt and liquid stains. The floor under the ice machine had a black sticky substance on it as well as a large amount of dirt, paper and dried liquid stains. The C/D activity/dining room floor was dirty with dried food debris, dirt and dried liquid stains. The floor behind the ice machine was dirty with paper and plastic debris, dried liquid stains and visible dirt. The high back upholstered chairs had food and dried liquid stains on them. There was a large, uncovered bin with bagged dirty linen as well as a large, uncovered bin with bagged garbage on the patio outside the laundry area. During a Resident council meeting held June 15, 2026, at 10:00AM, revealed six out of 6 residents (Resident 33, 39, 48, 69, 75, and 95) complained of the shower rooms. Three out of 7 residents reported that the D Hall shower room has a mold like substance around the edges of the showers. Resident 75 and Resident 39 revealed the shower room was frequently full of wheelchairs, garbage cans, and other stored items, that limit the amount of room the residents have to take their showers. Six out of 6 residents revealed that staff do not clean the showers prior to showering residents, six out of 6 residents stated that when going to the shower there are dirty clothes, towels, and even dirty briefs, from the previous resident still present in the shower when they utilize it. Observation of the Hallway D shower room on June 15, 2026, at 11:40 AM revealed a presence of black mold along 3 out of 4 bottom edges of the shower walls. The fuzzy black mold was consistent along the bottom where the floor meets the wall, the mold was unable to be wiped clean with a paper towel. Observations of the A Hall shower room revealed 6 wheelchairs present in the shower room with a small walking path to the shower area. The small walking path was large enough to fit one wheelchair in the area. The shower room also revealed 3 garbage cans present, one filled with soiled linens. Observations of the B hall bathtub room revealed a bathtub full of equipment, including bed bolsters, two wheelchairs, and multiple garbage cans with lids present. The area revealed no walking path. The bathtub unable to be used. Interview with the Director of Nursing on June 16, 2026, at 1:00 PM reviewed the above findings of the facility's failure to ensure the facility was homelike, clean, and properly maintained. 28 Pa Code 201.18(e)(2.1) Management.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications for two of two medication carts observed (A Hall and B Hall medication carts).Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals last reviewed by the facility [DATE], indicated that multi-use medication vials or bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on A hall unit on [DATE], at 8:56 AM, in the presence of Employee 2 RN (Registered Nurse) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin glargine (a long acting insulin medication used to lower blood sugar) and one (1) multi-dose pen of Insulin Aspart (a fast short acting insulin medication used to lower blood sugar), and one (1) Insulin Lispro (a fast acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened. Review of manufacturer safety information revealed the multi-dose pens of Insulin are to be discarded 28 days after opening and available for resident use. An interview with Employee 2 RN on [DATE], at 8:59 AM, confirmed all three (3) multi dose insulin pens, one (1) Insulin Aspart, one (1) Insulin Glargine and one (1) Insulin Lispro were opened, available for use, currently being used for administration, and not dated when initially opened. An observation of the medication cart located on B hall unit on [DATE], at 9: 53 AM, in the presence of Employee 1 LPN (Licensed Practical Nurse) revealed one (1) multi-dose insulin pen of SoloStar insulin (prefilled insulin pen containing a long-acting insulin that works steadily over 24 hours without big peaks or drops in effect) with an expiration date of [DATE] and one (1) vial of Insulin Lispro that had been opened and available for use, but not dated when initially opened. An interview with Employee 1 (LPN) on [DATE], at 9:55 AM, confirmed the one multi dose insulin pen of Solostar insulin was expired, and one (1) Insulin vial Lispro was not dated when initially opened. Both medications were being stored in the medication cart, and currently being used for administration. Interview with Director of Nursing and the Nursing Home Administrator on [DATE], at 01:00PM, reviewed the above findings of the facility's failure to ensure staff date each insulin when opened, to ensure the medication was not used passed the expiration date. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses administered medications in accordance with physician-ordered parameters for one of 20 residents reviewed (Resident 38).Findings include: A review of the facility policy titled Administering Medications last reviewed on June 5, 2026, revealed that medications are administered as prescribed in a safe, timely manner. Medications are administered in accordance with prescriber orders, and information is verified prior to administering medication including vital signs (measurements of basic body functions such as blood pressure, pulse, temperature, and breathing), are verified prior to administering medications when specific parameters are ordered. A review of the clinical record revealed Resident 38 was admitted to the facility on [DATE], with diagnoses to include hypotension (low blood pressure). A review of Resident 38's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 29, 2026, revealed that Resident 38 was moderately cognitively impaired with a BIMS score of 11 (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 8 through 12 indicates moderate cognitive impairment). A review of the physician's order dated January 26, 2026, directed staff to administer Midodrine HCl (medication used to treat low blood pressure) 5 milligrams (mg) orally three times a day. The physician's order specified to hold (not give) the medication if the systolic blood pressure (top number in a blood pressure reading, representing pressure when the heart contracts) was greater than 120 millimeters of mercury (mm/Hg). A review of the May 2026 and June 2026 Medication Administration Records (MARs), the legal documents used to record medication administration, revealed nursing staff administered Midodrine HCl on 15 occasions despite documented systolic blood pressure readings exceeding the physician-ordered hold parameter of 120 mm/Hg. These administrations included: May 15, 2026, at 12:00 PM, systolic blood pressure 150/80 mm/Hg;May 16, 2026, at 6:00 PM, systolic blood pressure 134/68 mm/Hg;May 17, 2026, at 12:00 PM, systolic blood pressure 144/76 mm/Hg;May 18, 2026, at 12:00 PM, systolic blood pressure 150/82 mm/Hg;May 21, 2026, at 12:00 PM, systolic blood pressure 142/68 mm/Hg;May 23, 2026, at 12:00 PM, systolic blood pressure 158/82 mm/Hg;May 24, 2026, at 12:00 PM, systolic blood pressure 146/76 mm/Hg;May 25, 2026, at 12:00 PM, systolic blood pressure 142/90 mm/Hg;May 27, 2026, at 12:00 PM, systolic blood pressure 126/80 mm/Hg;June 7, 2026, at 12:00 PM, systolic blood pressure 130/82 mm/Hg;June 10, 2026, at 12:00 PM, systolic blood pressure 130/82 mm/Hg;June 11, 2026, at 12:00 PM, systolic blood pressure 136/90 mm/Hg;June 12, 2026, at 6:00 AM, systolic blood pressure 126/68 mm/Hg;June 12, 2026, at 12:00 PM, systolic blood pressure 130/82 mm/Hg; andJune 13, 2026, at 6:00 AM, systolic blood pressure 137/80 mm/Hg. These records revealed nursing staff administered Midodrine HCl despite documented blood pressure readings that exceeded the physician's ordered parameter requiring the medication to be withheld. An interview with the Nursing Home Administrator and Director of Nursing on June 15, 2026, at 1:30 PM reviewed the above findings related to the facility's failure to ensure nursing staff administered blood pressure medications according to physician ordered parameters. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, medication administration records, and staff interview, it was determined the facility failed to document the use of non-pharmacological interventions prior to the administration of an as needed psychotropic medication and failed to obtain and document a clinical rationale to support continuation of the psychotropic medication beyond the federally permitted 14-day period for one of 20 residents reviewed (Resident 98).Findings include: Federal requirements for the use of psychotropic medications expect that psychotropic medications are used only when necessary to treat a specific, documented condition. A PRN (as needed) psychotropic medication order is limited to 14 days unless the prescribing practitioner documents the clinical rationale for extending the order and specifies the duration of the extension. Non-pharmacological interventions are approaches that do not involve medications, such as reassurance, redirection, environmental modifications, distraction techniques, or comfort measures. When clinically appropriate, these interventions should be attempted and documented prior to administering a PRN psychotropic medication. A review of the facility's policy titled Psychoactive Medication Policy reviewed June 5, 2026, indicated that all residents receiving psychoactive medications will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. The policy further revealed that individualized non-pharmacological approaches are provided as part of a supportive physical and psychological environment and are directed toward preventing, relieving, or accommodating a resident's distressed behavior. Clinical record review revealed Resident 98 was admitted on [DATE], with diagnoses including asthma (a chronic condition that causes inflammation and narrowing of the airways) and chronic obstructive pulmonary disease (COPD, a progressive lung disease that limits airflow and makes breathing difficult). A review of Resident 98's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment including significant difficulty with basic memory tasks, recognizing the date, or recalling recent information). Review of physician orders revealed an order dated September 29, 2025, for Lorazepam 0.25 milligrams (a psychotropic medication classified as an anti-anxiety medication used to reduce symptoms of anxiety or agitation) every six hours PRN for anxiety. Review of the Medication Administration Record (MAR) revealed 0.25mg was administered on the following dates and times: September 29, 2026, at 11:03 PMOctober 1, 2025, at 6:38 PMOctober 2, 2025, at 9:39 PMOctober 5, 2025, at 5:28 PMOctober 9, 2025, at 1:35 AMNovember 1, 2025, at 5:53 PMNovember 6, 2025, at 00:45 AM Review of the clinical record failed to identify documentation that non-pharmacological interventions were attempted or ineffective prior to administration of the PRN psychotropic medication on any of the seven occasions. As a result, the facility could not demonstrate that less restrictive interventions were considered before the medication was administered. A review of the clinical record failed to identify documentation from the prescribing practitioner providing a clinical rationale to support continuation of the PRN Lorazepam order beyond 14 days, nor did the record identify a documented duration for the extension of the order as required by federal regulations. During an interview on June 15, 2026, at 12:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the clinical record did not contain documentation of non-pharmacologic interventions prior to the administration of the psychotropic medication on the seven identified occasions and lacked documented clinical justification supporting continuation of the PRN psychotropic medication beyond 14 days. 28 Pa. Code 211.2(3) Medical director. 28 Pa. Code 211.5(ii)(xi) Clinical records. 28 Pa. Code 211.8(e) Use of restraints. 28 Pa. Code 211.9(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of 20 residents reviewed (Resident 84). Findings Include: Review of the clinical record revealed Resident 84 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. Hemiplegia is paralysis of one side of the body. Hemiparesis is weakness on one side of the body. A cerebral infarction is a stroke caused by an interruption of blood flow to an area of the brain. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 28, 2026, revealed that Resident 84 was severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates cognition is severely impaired). Review of Resident 84's Occupational Therapy (OT) evaluation dated May 12, 2026, revealed that OT observed a contracture (the permanent shortening or tightening of muscles, tendons, ligaments, or joints that restricts normal movement and range of motion) to the residents left hand during an assessment and believed a palm guard to the resident's left hand would prevent further contracture. Review of current physician orders revealed an order dated May 12, 2026, directing staff to apply a left palm guard in the morning and remove it in the evening. Review of the resident's current care plan revealed an intervention initiated May 12, 2026, directing staff to apply a left palm splint to prevent worsening contracture, remove the device in the evening, and perform skin checks each shift beneath the device. Observation of Resident 84 in the dining room on June 15, 2026, at 11:30 AM revealed the resident's left hand was positioned beneath her shirt. Upon request from the surveyor, Resident 84 removed her left hand from beneath her shirt. Observation revealed the physician-ordered left palm guard/splint was not in place. Resident 84 was able to partially open her left hand; however, observation revealed contracture of the left hand. Review of the resident's Point of Care History, which documents care and services provided to the resident, for May 2026 and June 2026, revealed repeated documentation indicating the splint intervention was not performed. Specifically, documentation revealed the following: On May 13, 2026, documentation indicated for the evening shift reflected not performed.On May 14, 2026, documentation indicated for the evening shift reflected not performed.On May 15, 2026, documentation indicated for the day shift reflected not performed.On May 18, 2026, documentation indicated for the day, and evening shift reflected not performed.On May 19, 2026, documentation indicated for the day, and evening shift reflected not performed.On May 20, 2026, documentation indicated for the day, and evening shift reflected not performed.On May 21, 2026, documentation indicated for the day, and evening shift reflected not performed.On May 24, 2026, documentation indicated for the day shift reflected not performed.On May 29, 2026, documentation indicated for the evening shift reflected not performed.On May 31, 2026, documentation indicated for the evening shift reflected not performed.On June 3, 2026, documentation indicated for the day, and evening shift reflected not performed.On June 6, 2026, documentation indicated for the day shift unanswered and evening shift reflected not performed.On June 8, 2026, documentation indicated for the day, and evening shift reflected not performed.On June 10, 2026, documentation indicated for the day, and evening shift reflected not performed.On June 12, 2026, documentation indicated for the evening shift reflected not performed.On June 14, 2026, documentation indicated for the day shift reflected not performed.On June 15, 2026, documentation indicated for the day shift reflected not performed. Review of the Point of Care History revealed incomplete and conflicting documentation regarding splint application, including blank entries and multiple entries indicating the intervention was not performed. On June 15, 2026, the same date the surveyor observed the resident without the splint in place, Point of Care documentation indicated the splint intervention was not performed during the day shift. During an interview on June 15, 2026, at 1:30 PM the Director of Nursing was unable to provide documented evidence demonstrating the physician-ordered palm guard intervention was consistently implemented as ordered. 28 Pa. Code: 211.5(f)(i)(ii) Medical records. 28 Pa Code 211.12 (c)(d)(5) Nursing services.

Based on clinical record review, observation, review of facility policy, and staff interview, it was determined that the facility failed to ensure oxygen was administered in accordance with physician orders for one of 20 residents reviewed (Resident 98).Findings include: A review of the facility policy titled Oxygen Administration, last reviewed by the facility on June 5, 2026, revealed it is the facility's policy to administer oxygen by the route and at the rate ordered by the provider. Clinical record review revealed Resident 98 was admitted to the facility on [DATE], with diagnoses that included asthma (a chronic condition in which the airways become inflamed and narrowed, making breathing difficult) and chronic obstructive pulmonary disease (COPD, a progressive lung disease that limits airflow and makes breathing difficult). A review of Resident 98's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 98 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment indicating significant difficulty with basic memory tasks, recognizing the date, or recalling recent information). Clinical record review revealed a physician order dated April 18, 2024, directing oxygen administration at two liters per minute (L/min) via nasal cannula (a device consisting of small prongs placed in the nostrils to deliver supplemental oxygen). Observation on June 14, 2026, at 9:43AM revealed Resident 98 was asleep in bed with oxygen in use through a nasal cannula. The oxygen tubing connected the nasal cannula to an oxygen concentrator (a machine that filters room air and delivers concentrated oxygen). Observation of the concentrator revealed the oxygen flow rate was set at 4.5 L/min. During an interview on June 14, 2026, at 11:16 a.m., Employee 1, Licensed Practical Nurse (LPN), confirmed Resident 98's physician order directed oxygen administration at 2 L/min. Employee 1 observed the oxygen concentrator setting and adjusted the flow rate from 4.5 L/min to 2 L/min. The above information was reviewed during an interview on June 15, 2026, at 12:30 PM, with the facility Director of Nursing and Nursing Home Administrator (NHA). 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, laboratory reports, facility policy, and staff interviews, it was determined the facility failed to ensure a resident was free from unnecessary medication by administering an antibiotic without documented clinical evidence supporting an active infection for one of 20 residents reviewed (Resident 97).Findings Include:A review of Resident 97's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included epilepsy (a chronic neurological disorder characterized by recurring seizures) and parkinsonism (a group of neurological disorders that cause movement problems such as tremors, stiffness, and slowed movement). A review of the facility policy titled Antimicrobial Stewardship Program Policy, last reviewed by the facility on June 6, 2026, revealed antibiotics should be prescribed only when clinical evidence supports the presence of an active infection. The policy further revealed appropriate indications for antibiotic use include meeting established clinical criteria for an active infection. The policy indicated that prescribers should provide complete antibiotic orders, including the medication name, dose, duration of treatment, and indication for use. The facility utilized McGeer's Criteria Checklist to determine whether residents met evidence-based criteria for the initiation of antibiotic therapy. McGeer's Criteria is a standardized surveillance tool used in long-term care facilities to identify signs and symptoms consistent with infection and to support appropriate antibiotic use. A review of a physician's order dated April 27, 2026, revealed an order for Macrobid 100 milligrams (an antibiotic medication) to be administered twice daily for five days for a urinary tract infection (UTI, an infection involving the urinary system). A review of Resident 97's clinical record failed to identify documentation of signs or symptoms supporting a urinary tract infection prior to the initiation of antibiotic therapy. Specifically, the clinical record failed to identify documented fever (an elevated body temperature that may indicate infection), dysuria (pain or burning during urination), urinary urgency (a sudden need to urinate), urinary frequency (urinating more often than usual), suprapubic pain (pain in the lower abdomen over the bladder), flank pain (pain in the side or back near the kidneys), rigors (episodes of shaking chills), acute mental status changes, or other documented clinical findings supporting the presence of an active urinary tract infection. A review of Resident 97's clinical record failed to identify a completed McGeer's Criteria Checklist or other documentation demonstrating the resident met the facility's established criteria for antibiotic treatment prior to the initiation of therapy. A review of Resident 97's April 2026 Medication Administration Record revealed the resident received four doses of Macrobid. A review of a urinalysis with culture report (a report used to check if a resident has an active infection, the culture report is a two-part test used to detect, identify, and determine the treatment for urinary tract infections.) dated April 27, 2026, at 3:40PM, revealed minimal bacterial growth consisting of mixed normal urogenital skin microbiota, which are bacteria commonly found on the skin and genital area and are generally not indicative of a urinary tract infection. Further review revealed the provider reviewed the urine culture results on April 30, 2026. The culture findings did not support the presence of a urinary tract infection, and the provider subsequently discontinued the antibiotic. During an interview on June 15, 2026, at 11:00 AM, the Infection Preventionist stated Resident 97 met McGeer's Criteria for antibiotic use. However, the facility was unable to provide documentation of signs or symptoms supporting an active urinary tract infection or documentation demonstrating the resident met McGeer's Criteria prior to the initiation of antibiotic therapy. The facility failed to ensure Resident 97 was free from unnecessary antibiotic use by initiating and administering an antibiotic without documented clinical evidence of an active infection and without documentation supporting that the resident met the facility's established criteria for antibiotic treatment prior to initiation of therapy. As a result, Resident 97 received four doses of an antibiotic before the urine culture results were reviewed and the medication was discontinued. During an interview on June 16, 2026, at 1:00 PM, the above findings were review with the Director of Nursing. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, Centers for Disease Control and Prevention (CDC) guidance, staff interviews, clinical record review, and direct observation, it was determined the facility failed to establish, maintain, and implement an effective infection prevention and control program to prevent the spread of infections regarding animal visitation and indwelling urinary catheter maintenance for 2 of 6 sampled residents. (Residents 1 and 2). Findings include: A review of the facility's policy titled Infection Control Policies and Practices, last reviewed February 12, 2025, revealed it is the policy of the facility to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors and contract healthcare workers. The policy indicated that employees support resident safety by adhering to all policies and procedures related to infection prevention. A review of a facility policy titled Animal Visitation Pet Policy reviewed March 31, 2025, revealed, the facility will allow residents to have pet visitation while attempting to provide a safe and infection free environment. Only dogs, cats, caged birds and small animals such as hamsters, gerbils, rabbits and fish are allowed as visitors to the facility. Prior arrangements must be made with the Life Enrichment (activity) department during the weekday prior to the pet visit. The policy required all medical vaccinations and check-ups must be up to date and a copy on file in the pet record binder maintained by the activity department. Pets shall not be permitted in the nurses' stations or in any areas where cleanliness and sanitary precautions are necessary to protect the health, comfort, safety and wellbeing of residents. Pets visiting the facility will be kept on a leash or in a safety cage throughout the visit. Small birds are required to have an annual exam, an annual fecal exam as well as wings clipped on a regular basis. An additional form entitled, Pet Protocol dated as reviewed March 31, 2025, revealed, all animals visiting the facility will have preventative care to ensure they do not pose a risk to the health, safety or rights of all residents. A review of Centers for Disease Control (CDC) documentation dated July 18, 2025, titled Healthy People, Healthy Pets: Backyard Poultry revealed that backyard poultry (including chickens, ducks, [NAME], [NAME] fowl, and turkeys) can carry germs that make people sick. The CDC identifies infections associated with poultry exposure to include:Avian influenza (bird flu), a viral infection that can infect humans.Campylobacter infection, a bacterial infection that can cause diarrhea and gastrointestinal illness.Escherichia coli (E. coli), bacteria found in the intestines of humans and animals that can cause serious foodborne illness.Histoplasmosis, a fungal infection that may cause flu-like respiratory symptoms.Salmonella infection, a bacterial infection that can cause diarrhea, fever, and abdominal cramps.Young children, older adults, and people with weakened immune systems are more likely to get sick from these germs. The CDC recommends that poultry and related equipment be kept outside and not permitted inside areas where people live, prepare food, or receive care. Don't eat or drink in areas where poultry live or roam. Stay outdoors when cleaning any equipment or materials used to raise or care for poultry. This includes cages or food and water containers The CDC further recommends routine veterinary care (to remain healthy and prevent the spread of disease) and hand hygiene after handling poultry or items in their environment.During an interview on February 12, 2026, at 9:05 AM Employee 1 (Licensed Practical Nurse) stated that in late October 2025, during a 7:00 AM to 3:00 PM shift, she brought a sick chicken into the facility in a small pet carrier at approximately 6:45 AM. She indicated she has about 40 chickens at home and this was one of those chickens. She stated she did not notify facility administration in advance and did not obtain veterinary evaluation to ensure the animal was safe for contact with residents, staff, or visitors. She stated the chicken was kept at the nurses' station on the floor. She further stated she removed the chicken from the carrier at the nurse's station to clean the cage, and to feed and hydrate the animal. She stated she carried the chicken in her arms within the facility and allowed residents to pet the animal. She stated the chicken remained in the facility for a few hours until a family member picked it up.An interview February 12, 2026, at 10:00 AM, the Director of Nursing (DON) confirmed that on October 22, 2025, Employee 1 (LPN) brought a chicken into the facility with her at the start of the 7:00 AM to 3:00 PM shift. He stated that Employee 1 (LPN) indicated that she brought the chicken into the facility because it was sick and she had no one to care for the sick bird at home while she worked. He stated that he became aware of the chicken in the facility at approximately 8:30 AM that morning and the animal stayed in the facility for a few hours until the employee's family member could pick it up. He did confirm that he was aware that the animal was sick during the time it was in the facility and that he was aware that Employee 1 (LPN) removed the chicken from its cage and allowed residents to pet the animal. He confirmed that Employee 1 (LPN) did not follow the facility pet protocol and was not in compliance with infection control protocols.A review of an in-service training record dated October 23, 2025, titled Animal Visitation Policy, revealed the presenter reviewed the facility's animal visitation policy and explained that chickens out of a crate are not allowed as part of visitation at the facility. Employee 1 (LPN) attended and signed the form as completed.The facility failed to demonstrate adherence to its infection control and animal visitation policies, failed to prevent introduction of a sick poultry animal into the facility, and failed to restrict the animal from resident contact and from the nurses' station area, which is a clinical care environment requiring sanitary precautions. This practice had the potential to expose residents, including those with advanced age and cognitive impairment, to zoonotic diseases (diseases transmitted from animals, such as birds, to humans). In addition, the facility failed to maintain proper infection control practices related to indwelling urinary catheter (a flexible tube used for draining urine from the bladder and having an inflatable part at the bladder end that allows the tube to be kept in place for variable time periods) care.A review of the facility policy titled Indwelling Urinary Catheter Care Procedure, last reviewed July 15, 2025, revealed that urinary drainage bags must be positioned below the level of the bladder to allow gravity drainage, but not placed directly on the floor. Improper handling or contamination of the drainage system increases the risk of a urinary tract infection (UTI), an infection involving the urinary system that may cause fever, pain, confusion, and in severe cases bloodstream infection (sepsis).Clinical record review revealed Resident 1 was admitted [DATE], with diagnoses including dementia (a progressive decline in memory and cognitive function) and urinary retention (inability to empty the bladder). A quarterly Minimum Data Set (MDS, a federally required standardized assessment used to evaluate and plan resident care), dated December 5, 2025, revealed the resident was severely cognitively impaired, required assistance with activities of daily living, and had an indwelling urinary catheter.A review of a care plan last reviewed June 2, 2025, revealed Resident 1 utilized a suprapubic catheter (a tube inserted through a small incision in the lower abdomen to drain urine directly from the bladder when normal urination is not possible). The goals to include, the resident will have appropriately managed catheter care as evidenced by not exhibiting obstruction or signs of infection. Interventions to include, provide full assistance for catheter care, observe for signs/symptoms of infection, report complications and keep the catheter system a closed system (catheter tubing and drainage bag remain sealed and are not disconnected to prevent bacteria from entering the urinary tract and causing infection) as possible. During observation on February 12, 2026, at 11:30 A.M., Resident 1 was in bed, and his urinary collection bag was observed resting directly on the floor. The observation was confirmed at the time by Employee 1 (LPN).Clinical record review revealed Resident 2 was admitted [DATE], with diagnoses including obstructive and reflux uropathy (conditions involving blockage and backward flow of urine that can damage the urinary system) and morbid obesity (a condition characterized by excessive body weight that increases health risks). An admission MDS dated [DATE], revealed she was moderately cognitively impaired, required assistance with activities of daily living and had an indwelling urinary catheter.A review of a care plan last reviewed January 7, 2026, for altered elimination related to indwelling catheter, the resident will remain free from infection. Interventions to include, catheter care per routine, position catheter collection bag and tubing below the level of the bladder and provide a privacy cover (a fabric bag used to cover the urine collection bag). During observation on February 12, 2026, at 11:40 AM, Resident 2 was seated in her wheelchair at the nurses' station, and her urinary collection bag was observed resting directly on the floor. The observation was confirmed at the time by Employee 1 (LPN). During interview on February 12, 2026, at 12:00 PM, the DON confirmed that urinary collection bags should be maintained off the floor. 28 Pa. Code 211.10 (a)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(5) Nursing services. 28 Pa. Code 211.17 (2)(5.1)(6)(7) Pet therapy

Based on a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an environment that promotes each resident's quality of life by ensuring residents' personal space was free from intrusions by other residents (Residents 16 and 19), including experiences reported by two residents out of the 25 residents sampled (Residents 3 and 29) and experiences reported by six out of the eight residents during a resident group interview (Residents 26, 28, 32, 49, 69, and 90). Findings include:A review of resident council meeting minutes dated May 27, 2025, revealed residents in attendance had concerns regarding one resident wandering into resident rooms. A review of the meeting minutes failed to determine if this concern was resolved. A review of resident council meeting minutes dated June 26, 2025, revealed residents in attendance had concerns regarding wandering residents. The minutes indicated the concerns for wandering residents were better. A review of the meeting minutes failed to determine if this concern was resolved. A review of resident council meeting minutes dated July 29, 2025, revealed residents in attendance had concerns regarding wandering residents. The meeting minutes indicated the issue of wandering residents is better; however, it was indicated that one resident continues to wander through resident room doorways. Further review of the meeting minutes failed to determine if this concern was resolved or if any further actions were taken to resolve the issue. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of an admission Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 13, 2025, revealed that Resident 3 was cognitively intact with a BIMS score of 13 (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 cognition is intact). A clinical record review revealed Resident 29 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of a quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 29 was moderately cognitively impaired with a BIMS score of 12 a score of 08-12 indicates cognition is moderately impaired. A clinical record review revealed Resident 16 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a significant change in status Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 16 is severely cognitively impaired with a BIMS score of 4 a score of 00-07 indicates cognition is severely impaired. A clinical record review revealed Resident 19 was admitted to the facility on [DATE], with diagnoses that included dementia. A review of a significant change in status Minimum Data Set assessment (MDS)dated May 19, 2025, Section C100 Cognitive Patterns, revealed Resident 19 had short-term and long-term memory problems, inattention, and severe cognitive impairment to make decisions. During an interview on August 12, 2025, at 9:55 AM, Resident 29 explained that she is upset because Resident 16 continues to enter her room uninvited. She indicated that Resident 16 wanders into her room, rummages through her belongings, and has eaten her snacks. Resident 29 explained this has been an ongoing issue, and she has reported it to the facility, but Resident 16 continues to enter her room uninvited. Resident 29 indicated she has to hide her food so Resident 16 doesn't wander in and steal it. During an interview on August 12, 2025, at 10:05 AM, Resident 3 explained she is frustrated because Resident 16 continues to enter her room uninvited. She indicated Resident 16 wanders into her room, sits on her bed, and has tried to pull the covers off of her bed. Resident 3 explained that she is angry and does not want Resident 16 in her room. She indicated she has to yell for staff to have the resident removed from her room. During a resident council interview on August 13, 2025, at 10:00 AM, six out of eight residents reported ongoing concerns with resident(s) wandering into their rooms (Residents 26, 28, 32, 49, 69, and 90). The six residents described ongoing concerns with intrusions from multiple residents, including Residents 16 and 19. The residents in attendance explained they have informed the facility about these issues over the last several weeks, but residents wandering into their rooms remains a problem for them at the facility. During an interview on August 14, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed resident wandering has been a concern residents have expressed during resident council meetings. The NHA indicated residents have expressed fewer episodes of resident intrusions into other residents' rooms but confirmed resident wandering has been an ongoing focus for the facility. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on resident council meeting minutes, resident and staff interviews, and observations it was determined the facility failed to maintain an adequate supply of clean linens to meet the needs of residents for 2 of 4 resident care units observed (E Hallway and A Hallway). Finding include: Review of the Resident Council meeting minutes dated July 29, 2025, revealed residents expressed concerns regarding the availability of linens. The minutes further documented that the Nursing Home Administrator identified nurse aides were discarding washcloths, and the Administrator noted that a lot of linen had been ordered for staff to utilize while providing care to residents. Observations conducted on August 12, 2025, at approximately 11:00 AM in the E Hallway revealed one washcloth available for resident care. Additional observation of the A Hallway at approximately 11:15 AM on the same day revealed a linen cart containing only three bath towels and three washcloths available for resident care. Observations conducted on August 13, 2025, at 8:15 AM in the E Hallway revealed no washcloths and only four bath towels available for resident care. On August 14, 2025, at 10:00 AM, observation of the A Hallway revealed only two bath towels and two washcloths available for resident care. An interview conducted with Employee 10 (Nurse Aide) on August 14, 2025, revealed the staff frequently experienced difficulty finding clean washcloths and towels. The staff member reported that clean linens were not delivered to the floor until after 9:00 AM, despite care being provided prior to that time, resulting in a shortage of available linens. Observation conducted on August 14, 2025, at approximately 11:00 AM of the facility laundry room revealed no additional linens available for staff use. Further observation of the linen closet located outside the E Hallway revealed 12 washcloths and 10 bath towels in storage. An interview with the Nursing Home Administrator on August 14, 2025, at approximately 1:00 PM revealed the facility had previously identified an issue with linens being sent out to be laundered and not returned. The Administrator was unable to provide further information to confirm that the facility maintained an adequate number of linens to meet residents' daily needs. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 205.74 Linen.

Based on a review of scheduled facility mealtimes, select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents, including experiences reported by four out of eight residents during a group interview (Residents 28, 32, 69, and 90). Findings include: A review of the facility policy titled Meal Times and Frequency Policy, last reviewed by the facility on February 1, 2025, revealed that it is the facility policy that there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day; except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the following day if a resident group agrees to this meal span. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours. Specifically, residents residing in the North Nursing Unit Area 1 are scheduled to receive dinner at 4:40 PM and receive breakfast at 7:10 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 30 minutes. Residents residing in the North Nursing Unit Area 2 are scheduled to receive dinner at 5:00 PM and receive breakfast at 7:20 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 20 minutes. Residents residing in the South Nursing Unit Area 1 are scheduled to receive dinner at 4:50 PM and receive breakfast at 7:15 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 25 minutes. Residents residing in the South Nursing Unit Area 2 are scheduled to receive dinner at 5:15 PM and receive breakfast at 7:30 AM. The scheduled time between dinner and breakfast the next day is 14 hours and 15 minutes. During a resident council interview on August 13, 2025, at 10:00 AM, four out of eight residents (Residents 28, 32, 69, and 90) indicated that a snack is not consistently offered in the evenings. Resident 69 explained that on occasion she is offered a snack, but it does not happen often. Residents 28, 32, and 90 reported not being offered an evening snack. During an interview on August 14, 2025, at approximately 2:00 PM, the Nursing Home Administrator (NHA) provided a list of the rotating available snacks for residents. The NHA was not able to provide documented evidence that snacks were consistently offered to residents in the evening. The NHA confirmed it is the facility's policy to offer residents nourishing snacks in the evening. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on observations, a review of facility-provided documents, and resident and staff interviews, it was determined the facility failed to maintain an effective pest control program on two of two nursing units (South Nursing B Hall and North Nursing D Hall) and in the North Nursing Resident Dining/Lounge area. In addition, two residents out of twenty-five sampled (Residents 62 and 81) and six residents out of eight during a resident group interview (Residents 26, 28, 32, 49, 69, and 90) reported ongoing problems with small black flies, gnats, or ants in resident rooms and common areas.Findings include: A review of a facility policy entitled Pest Control Policy that was last reviewed on February 1, 2025, indicated routine pest control procedures will be in place to prevent pest infiltration and contracted pest services will document all visits along with actions taken. A review of the facility's current contract with the pest management contractor signed and dated August 12, 2019, revealed year-round protection against pests (except for gnats, outdoor pests and other free flying insects such as mosquitos, lawn insects and pests) and an inspection and report with each visit. A review of Resident Council Meeting minutes dated June 26, 2025, and July 29, 2025, indicated that residents reported observations of small black flies/gnats and ants were observed in their rooms and resident common areas. During a resident council interview on August 13, 2025, at 10:00 AM, six out of eight residents (Residents 26, 28, 32, 49, 69, and 90) reported ongoing concerns with gnats, flies, or ants in their rooms or resident common areas throughout the facility. The six residents described seeing multiple flying insects or pests throughout the day. During an interview with Resident 81 on August 12, 2025, at 10:25 AM, small black flies were reported and observed during the interview flying in the resident's room. Resident 81 reported the facility was made aware and a few weeks ago, the bug guy was here to spray for insects but they were still observed. Additionally, the resident pointed out the bug light that was placed on the dresser and reported family bought it to help get rid of the black flies. An observation on August 12, 2025, at 2:15 PM revealed small flying insects in the B nursing hallway. An observation on August 12, 2025, at 2:20 PM revealed several small black flying insects on a white shower chair in the B hallway. An observation in Resident 62's room on August 13, 2025, at 12:15 PM, revealed several small black flies flying around the room and the resident reported the facility was aware. The resident indicated the flies and ants were on-going over the last few months despite the facility being informed. Observation of the North Nursing Unit resident pantry area on August 13, 2025, at 12:30 PM, revealed several small black flies/gnats flying around the garbage can and ice machine. A review of facility-provided pest control invoices revealed the following:Invoice #667 (May 24, 2025): Documented two pesticide treatments but no description of services performed.Invoice #680 (June 26, 2025): Noted drain flies in the kitchen and hallways and indicated need to really clean all restroom floors and check on pipe in kitchen and documented two pesticide treatments.Invoice #700 (July 31, 2025): Documented service to all rooms, restrooms, dining areas, and the kitchen, including baseboard spraying and bait station checks, with two pesticide treatments applied.The facility was unable to provide additional documentation demonstrating consistent pest control follow-up, detailed treatment outcomes, or contractor recommendations for resolving persistent pest issues. During an interview with the Nursing Home Administrator on August 15, 2025, at 10:00 AM, the above findings were reviewed. The Administrator acknowledged that the facility continued to experience pest control issues despite treatments and was considering contracting with a different pest control company. 28 Pa. Code 201.18 (e) (2.1) Management.

Based on clinical record review, staff interviews, and resident interviews, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan that addressed the resident's individualized needs and interventions for safe transfers for one out of 25 residents sampled (Resident 22). Findings include: A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning). A physician's order indicated Resident 22 required the assistance of two staff members for transfers using the standing lift (mechanical device used to help a resident who has some weight bearing ability but cannot safely stand or transfer without assistance) initiated on January 14, 2025. A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2025, revealed that Resident 22 is moderately cognitively impaired with a BIMS score of 08 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08-12 indicates moderate cognitive impairment). A progress note dated August 11, 2025, at 10:45 PM documented that Resident 22 bit a nurse aide during a transfer to bed performed by two staff members. The note indicated Resident 22 stated, Yes, I bit you, and that the nursing supervisor was informed of the incident. During an interview on August 13, 2025, at 9:30 AM, Resident 22 explained she was upset by the way she was transferred to bed earlier this week. Resident 22 indicated that two staff manually transferred her to bed without the use of the standing lift as normally performed, which frightened her and caused distress. Following inquiries conducted during the survey week, Resident 22's care plan was updated on August 14, 2025, to include that she experienced severe anxiety regarding transfers with the standing lift. The updated intervention specified the standing lift as the primary transfer method; however, staff could use a manual two-person assist, when necessary, due to the resident's anxiety or behavioral responses. During an interview on August 14, 2025, at 9:25 AM, Employee 2, Director of Rehabilitation Services, confirmed that the standing lift with two staff was the ordered method for Resident 22's transfers and that staff were expected to follow physician orders and the individualized plan of care. Employee 2 indicated the care plan was updated on August 14, 2025, after learning of Resident 22's anxiety during transfers. During an interview on August 14, 2025, at 11:35 AM, Employee 3, Nurse Aide (NA), stated that on August 11, 2025, at approximately 9:45 PM, she and Employee 4, NA, manually transferred Resident 22 into bed. Employee 3 indicated Resident 22 became anxious and bit her during the transfer. Employee 3 reported this incident to the therapy department on August 12, 2025. Employee 4, NA, was not available for interview on August 14, 2025. During an interview on August 14, 2025, at approximately 2:00 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Through this review, it was established that staff are expected to follow physician orders and implement each resident's individualized plan of care. It was further confirmed during the review that Resident 22's plan of care did not identify her anxiety regarding transfers, nor did it include the option for a manual two-person assist until updates were made on August 14, 2025, following surveyor inquiries. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3) Nursing services.

Based on observations, a review of clinical records, documentation provided by the facility, and resident and staff interviews, it was determined that the facility failed to implement adequate safety measures to prevent accidents for two out of 25 residents sampled (Resident 62 and 63). Findings include: A review of facility policy titled Self-Administration of Medications, last revised June 2024, revealed the interdisciplinary team should assess and determine with respect to each resident whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. The policy indicates that if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan, the facility should routinely assess the residents cognitive, physical and visual ability to carry out this responsibility, and the resident should have a locked medication storage compartment in their room so that another resident is not is not able to access the medications. A clinical record review revealed Resident 62 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (a disease that restricts airflow to the lungs and causes breathing problems). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 19, 2025, revealed that Resident 62 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). A review of the clinical record revealed a document labeled Self-Administration of Medications dated for December 15,2024, indicated the resident did not want to self-administer medications. During an observation on August 12, 2025, at 11:15AM, in Resident 62's room, a bottle of Pepto Bismol (over the counter antacid/antidiarrheal medication) was noted in a basket on the resident's bedside. During an interview with the resident during this observation, the resident stated her nephew usually brings her snacks, and adult briefs and other things she needs. She stated the Pepto Bismol was brought in by her nephew. During an interview on August 13,2025, at 12:00 PM with Resident 62, the resident opened her bedside table drawer, and two inhalers were noted to be inside the drawer: A Trelegy Ellipta inhaler (prescription therapy inhaler for long term maintenance of COPD) with the date of 6-22 written on it, as well as a Combivent inhaler (prescription inhaler for COPD) with no date observed to be on it. During the interview the resident stated that the drawer does not lock, and she keeps them there in the event she becomes short of breath. When asked how the resident obtained the inhalers, she stated, one of the nurses gave them to me. She was unable to recall which nurse provided her the inhalers, nor was she able to recall how long she had them in the bedside table drawer. During this interview, the basket with the bottle of Pepto Bismol was noted to be on the resident's bed.An interview was conducted on August 14, 2025, at approximately 2:00 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to discuss the above findings related to the facility's failure to maintain the residents' environment free of potential accident hazards by leaving medications accessible to residents at their bedside which allows accidental consumption to other residents. A clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of a quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 63 has moderate cognitive impairment with a BIMS score of 10; a score of 08-12 indicates cognition is moderately impaired. A review of Resident 63's care plan revealed he has a problem with noncompliance related to refusal to participate in restorative programs, refusal of medication, and attempts to go behind the front desk and push a button to allow visitors or staff to enter the building, initiated on July 1, 2025. Interventions implemented, including a gate, will be used to prevent entry behind the front desk when not attended by staff, and Resident 63 will be provided with education related to compliance and negative outcomes related to noncompliance. An observation on August 12, 2025, at approximately 8:15 AM revealed Resident 63 behind the front desk. Resident 63 pressed and activated the mechanism to allow the survey team to gain entrance to the facility. Upon entering the facility, Resident 63 indicated to the survey team not to tell anyone, because he is not allowed to go behind the front desk. During an interview on August 12, 2025, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed the facility failed to ensure adequate safety measures were in place to prevent possible accidents. The NHA confirmed the facility failed to ensure adequate safety measures were implemented to prevent Resident 63 from gaining access to the area behind the front desk. A follow-up observation on August 12, 2025, at approximately 2:30 PM revealed a plastic lock covering installed at the front desk preventing access to the door unlocking mechanism. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, observations, and staff and resident interviews, it was determined the facility failed to ensure oxygen therapy was administered and maintained in accordance with physician orders and facility policy, including requirements for equipment labeling, dating, and routine maintenance, in a manner that minimized the risk for infection for two residents out of twenty-five sampled (Residents 3 and 62). Findings include: A review of the facility policy titled Oxygen Administration Policy, last reviewed by the facility on February 1, 2025, revealed it is the facility's policy that licensed clinicians with demonstrated competence will administer oxygen by way of the specified route as ordered by a provider. The policy indicates changing the humidifier bottle (containers attached to an oxygen concentrator to add moisture to the oxygen being delivered) when empty; length of use is dependent upon the liter flow setting (a measurement describing the amount of oxygen delivered in liters per minute, abbreviated as L/min). A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lungs that blocks airflow and makes it hard to breathe). A physician's order dated July 12, 2025, directed staff to administer oxygen (O ) via nasal cannula (a thin tube delivering oxygen through the nostrils) continuously at 3 liters per minute (3 L/min), with humidification added for comfort if needed. Staff were further directed to check the oxygen concentrator for proper function, verify oxygen saturation (the amount of oxygen in the blood), and maintain humidification as appropriate. Additional orders instructed staff to clean the oxygen concentrator and filter, wipe down equipment, air-dry the filter, and change tubing weekly (every seven days). An observation on August 12, 2025, at 10:01 AM, revealed Resident 3 was in her bedroom receiving oxygen by way of the nasal cannula. The plastic oxygen humidification bottle was observed sitting directly on the floor (storing medical equipment on the floor creates a risk of contamination because the floor surface cannot be considered a clean or sanitary area for equipment that delivers oxygen directly to a resident) with a clear plastic bag next to it. The humidification bottle and tubing were not dated. The humidification bottle appeared empty. A follow-up observation on August 13, 2025, at approximately 9:30 AM, revealed Resident 3 was in her bedroom receiving oxygen by way of the nasal cannula. The plastic oxygen humidification bottle was attached to the oxygen concentrator. The humidification bottle and tubing were still not dated and empty. An interview conducted with Employee 1, Registered Nurse (RN), at 9:30 AM on August 13, 2025, confirmed the humidification bottle and tubing for Resident 3 were not dated and the bottle was empty. A review of Resident 62's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). A physician's order dated August 12, 2025, directed staff to administer oxygen at 2 L/min via nasal cannula continuously, adding humidification if oxygen exceeded 4 L/min or for comfort if needed. Staff were also instructed to clean the concentrator, change the tubing weekly, and clean the filter. An observation August 12,2025, at approximately 11:15 AM revealed a clear plastic bag attached to the oxygen concentrator with 7/23 (date) written on it. The bag appeared intended to store the nasal cannula when not in use; however, the nasal cannula and oxygen tubing were observed laying across the length of the bed with the nasal cannula on the floor. The oxygen humidification bottle was observed sitting on the floor with the attachment straps broken, preventing it from being secured to the concentrator. The humidification bottle was not dated. An observation on August 13, 2025, at 12:00 PM revealed the oxygen humidification bottle remained on the floor with the attachment straps still broken, preventing it from being secured to the concentrator. The humidification bottle was not dated. During an interview at 12:07 PM, Employee 11 confirmed the humidification bottle was on the floor, the straps were broken, and the bottle was not dated. During an interview with the Nursing Home Administrator (NHA) on August 14, 2025, at 1:30 PM, the above observations and findings were reviewed with the NHA and confirmed the humidification bottles should not be stored directly on the ground. The NHA indicated that bags should be placed around the bottles and dated when the bottles were last changed. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and information submitted by the facility and staff interviews, it was determined that the facility failed to utilize safe technique, the required assistance devices and sufficient level of staff assistance, during transfers to prevent an accident resulting in severe injury, a fractured lower leg, to one resident (Resident 11) out of 18 residents reviewed. Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, muscle weakness, and dementia (the loss of memory and other mental abilities severe enough to interfere with normal activities of daily living - ADLs - everyday tasks that include bathing, eating, dressing). A physician's order dated September 4, 2020, indicated that staff were to use a mechanical lift (an assistive device that is utilized in nursing homes to transfer patients between a bed and a chair or other similar resting places) with the assist of two staff when transferring the resident. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 10, 2020, revealed that the resident's cognition was severely impaired and that she required extensive assistance with two persons for bed mobility (how the resident moves to and from lying position, turns side to side and positions their body while in bed or alternate sleep furniture) and for transfers between surfaces including to/or from: bed, chair, wheelchair and/or standing position. A review of an incident report dated June 26, 2020, revealed that the resident began complaining of pain in the right lower extremity during the evening of June 25, 2020. A nurses' note dated June 26, 2020, at 10:25 a.m. revealed that Resident 11 continued to have pain in the right lower extremity. CRNP assessed Resident 11 and ordered a venous Doppler and an x-ray. Results from the x-ray dated June 26, 2020, at 7:30 p.m. revealed a metaphyseal fracture of the distal tibia (broken lower part of the shin bone). A review of a Pennsylvania Department of Aging, Act 13 Mandatory Abuse Report, (a state mandated report form for investigation of alleged abuse) dated June 27, 2020, and documentation submitted by the facility also dated June 27, 2020, revealed that on June 25, 2020, at approximately 7:30 PM Employee 1 (NA-nurse aide) transferred Resident 11 from the wheelchair to the bed by herself and without the use of a mechanical lift. The nurse aide stated that the resident's foot got caught under the bed during transfer; Employee 1 laid the resident down in the bed, stating at that time that the resident didn't complain of pain. Further review of the two aforementioned reports revealed the resident is an assist of 2 for bed mobility per physician's orders, her plan of care and facility policy. The reports also indicated that the employee (Employee 1) did not follow the resident's care plan by using the mechanical lift and having another person assist her with the resident's care, resulting in this resident's fracture. Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 1 on June 30, 2020, revealed that the nurse aide stated I transferred her by myself, put resident in bed when transferring her foot got caught under the bed, I layed (sic) her down she wasn't complaining of her leg and finished care. An interview with the Nursing Home Administrator on March 11, 2021, at approximately 2:00 PM confirmed that nursing staff failed to use safe nursing technique when transferring the resident to her bed. The nurse aide transferred the resident, without additional staff assistance and without the use of the mechanical lift as required during the provision of personal care, and the resident sustained a fracture. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, the Director of Nursing /designee interviewed residents requiring transfer assistance and completed skin assessments on residents requiring transfer assistance that were non interviewable. 4 residents were identified, and therapy screens completed To prevent this from recurring the Director of Nursing /designee educated nursing staff to ensure they follow individualized POC (plan of care) for each resident. Mechanical lift competencies completed on nursing staff. To monitor and maintain ongoing compliance the Director of Nursing /Designee will audit 10 residents weekly, 5 interviewable and 5 non interviewable will complete skin assessment x 4 then monthly x 2. The facility's immediate corrective action plan was completed July 2, 2020. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, select resident incident\accident reports and facility policy and procedures, and staff interview it was determined that the facility failed to thoroughly evaluate an identified pressure ulcer to ensure interventions were in place to prevent the worsening of the pressure ulcer for one resident (Resident 38) out of 18 sampled. Findings include: Review of the facility's Skin Assessment Prior To Discharge/Transfer/LOA (leave of absence) policy last reviewed by the facility August 11, 2015, revealed that the nurse will complete a full body skin assessment prior to a resident's discharge to the hospital, transfer to appointment, and prior to a leave of absence. Upon the resident's return to the facility, the nurse will complete the Skin Assessment upon return from Transfer/LOA on the form. In the event a newly identified skin issue is identified the nurse will notify the director of nursing and/or designee immediately upon the resident's return to the facility (there was no mention of what the director of nursing and/or designee will do once notified). Interview with the administrator on November 13, 2015, at 9:30 a.m., failed to provide documented evidence of the facility's procedures or protocols in place designed specifically for preventing the development and worsening of pressure ulcers. A review of the clinical record revealed that Resident 38 had diagnoses, which included [MEDICAL CONDITION] (stroke) with right [MEDICAL CONDITION] (paralysis), muscle weakness and diabetes mellitus. A quarterly Minimum Data Set assessment (MDS - a standardized assessment completed at periodic intervals to identify resident care needs) dated September 3, 2015, indicated that the resident required staff assistance for all activities of daily living, had functional limitation in range of motion, was at risk for developing pressure ulcers, had an identified Stage IV pressure ulcer (full thickness tissue loss with exposed bone, muscle, or tendon and often includes tunneling), which was non-facility acquired. The resident had a pressure reducing device for the bed, was on a turning/repositioning program and was receiving pressure ulcer care. A nurses noted dated October 25, 2015, indicated that the resident was admitted to the hospital. A nurses note dated November 7, 2015, at 5:40 p.m., indicated that the resident was readmitted to the facility on this date from the hospital. Upon readmission the resident was noted to have a 0.5 cm circular area noted at the coccygeal area (located at the bottom of the spine). A Non-pressure Skin Condition Record dated November 7, 2015, noted that the area was 0.5 cm by 0.5 cm with a depth of 0 cm. The area was described as partial thickness with serous scant exudate (small amount of thin clear watery drainage); a pink, pale tissue wound bed; normal surrounding skin; and no pain. A treatment of [REDACTED]. Review of the resident's November 2015 Treatment Administration Record revealed that nursing staff signed once each shift indicating that the resident was turned and repositioned every two hours and as needed. Further review of the resident's clinical record failed to indicate that the resident's repositioning was evaluated for adequacy and to determine if every two hour side and back positioning was most beneficial for the resident based on the presence of skin impairment on the coccyx. Review of a Wound Care Specialist Evaluation dated November 11, 2015, revealed that the resident had a Stage III (full thickness tissue loss) wound of the lower sacrum (coccygeal area) of at least one day duration. The wound size was noted as 1.5 cm by 3.5 cm by 0.1 cm (upon readmission the area was noted as 0.5 cm by 0.5 cm). A light serous exudate with no pain associated with the wound was noted. The wound was noted as hospital acquired. The Wound Care Specialist recommended to off-load the wound (provide pressure relief) and reposition the resident per facility protocol. A treatment order for Hydrogel (promotes healing of wounds) once daily with a dry protective dressing once daily was also noted. Further review of the resident's clinical record failed to provide documented evidence that the facility identified the worsening of the resident's pressure ulcer prior to the Wound Care Specialist's visit on November 11, 2015. Review of the resident's November 2015 Treatment Administration Record following the Wound Care Specialist recommendation to off-load the wound revealed no documented evidence that any changes in the resident's repositioning were made to ensure off-loading of the pressure ulcer. Interview with the administrator and compliance nurse on November 13, 2015, at 9:30 a.m., failed to provide documented evidence that the facility promptly implemented and/or evaluated the adequacy of existing interventions to prevent the worsening of a skin impairment (identified upon readmission from the hospital) to a Stage III pressure ulcer. 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 12/12/14 28 Pa. Code 211.10 (a)(d) Resident care policies Previously cited 12/12/14 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/12/14

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to provide necessary services to promote adequate hydration of one resident out of 24 sampled (Resident 2) Findings include: The facility policy for hydration, reviewed by the facility July 2013, revealed that the registered dietitian shall evaluate each resident's hydration needs based on the residents clinical condition and risk factor. Individuals at risk for dehydration will be identified, assessed, and provided sufficient fluids to encourage optimum health. Risk factors which may lead to dehydration include: infectious processes (including urinary tract infections)and the use of certain medications, including diuretics (water pills) and limited fluid intake. The interdisciplinary team shall work together to determine the resident's response to nutrition and hydration interventions. Revised interventions will be implemented as needed to facilitate adequate hydration and health. A review of the facility policy for intake and output reviewed by the facility July 2013 revealed that residents being treated for [REDACTED]. The procedure noted that when a resident meets the criteria for tracking output, the nurse will record the amount of urine output for their shift. The licensed nurse will enter the amount of intake and or output on the intake/output (I&O) record. At the end of the 24 hour period, the licensed nurse will total the intake/output record. Signs and or symptoms of decreased fluid intake and when variance identifies intake exceeds output the physician will be notified. The Intake and Output form tracks a 7 day period. Once the form is completed for the 7 days, the nurse will complete the summary at the bottom of the form; evaluate the intake and output measurement to determine accuracy. The nurse will notify the physician if inadequate intake or if output exceeds intake. A review of the clinical record revealed that Resident 2 had [DIAGNOSES REDACTED]. Physician's orders dated February 27, 2013 prescribed [MEDICATION NAME] (a diuretic) 40 mg twice a day. A review of the resident's hydration risk evaluation dated March 2013, June 2013, September 2013 and October 2013 revealed that Resident 2 was at risk for dehydration. A review of a medical nutrition therapy assessment dated [DATE] revealed Resident 2's BUN (Blood urea nitrogen, a high BUN level can be an indicator of dehydration) was 27 MG/DL ( normal 7-25 MG/DL) and her daily estimated fluid needs were 1950 ml in 24 hours. A review of a lab result record dated July 1, 2013 revealed that Resident 2 chloride level was 104 mmol/l (normal 98-107 mmol/l), BUN 28 (normal 7-25 mg/dl) and creatinine level 1.0 mg/dl (normal 0.6-1.3 mg/dl). A review of the resident's fluid intake for July 2013 revealed that this resident was close to meeting her estimated fluid needs on most days. A review of fluid intakes for August 2013 through October 2013, however, revealed this resident never met her recorded estimated fluid needs. A review of nurses notes dated August 31, 2013, at 11 AM revealed that the resident presented with increased confusion and was leaning foreword in the wheelchair. A urine for culture and sensitivity was collected and sent to the lab and an antibiotic was initiated for 7 days for a urinary tract infection. The resident's weight was noted as 182.6 lbs on August 5, 2013. A review of lab study results dated August 31, 2013 revealed a urine culture positive for > CFU/ml 100,000 Escherichia coli and > 100,000 CFU/ml gram negative Bacilli. Antibiotic therapy was prescribed. There was no evidence that the facility completed intake or output monitoring according to their policy. There was no evidence of increased fluids planned and provided for this resident at this time based on her urinary tract infection, which increased her need for hydration A nurses note dated September 6, 2013 at 2 PM revealed that the resident was still confused and that fluids were "encouraged." Lab studies dated September 10, 2013 revealed chloride 108 MMOL/L ( 98-107 MMOL/L), BUN 48 ( normal 7-25 MG/DL), and creatinine 1.95 MG/DL ( 0.6-1.3 MG/DL). The physician ordered that the resident's [MEDICATION NAME] and potassium be held on September 11 and 12, 2013. On September 12, 2013 at 3:30 PM and again at 10 PM nurses notes documented that the resident's urine was dark amber in color. The resident's weight was noted as 180 lbs on September 4, 2013. Lab work dated September 13, 2013, revealed that the resident's chloride 110 MMOL/L (high level), BUN 41 MG/DL ( high level ) and creatinine 1.39 (high level). A dietary note dated September 13, 2013 revealed that the resident's BUN and creatinine were elevated and that the staff reports that the resident pushes food away at times. The resident was moved to the supervised dining room recently where she receives encouragement. The plan also included beginning fortified foods. The note indicated that the resident had a recent UTI with antibiotic, which may be contributing to decreased intakes. It was noted to continue with supplements given decreased meal intakes. The entry did not reference the resident's increased fluid needs or that she was not meeting her estimated daily fluid needs, although hydration related lab values were noted to be elevated. Resident 2's weight on October 4, 2013 had declined to 171.6 lbs; an 8.4 lb, 4.6# weight loss in 30 days. A re-weight on October 7, 2013 revealed a 170.8 lbs; another 0.8 lb loss. A nurses note dated October 5, 2013 revealed that the resident had developed an open area on her coccyx. The physician was notified and a treatment was started. A dietary note dated October 9, 2013, noted a 5.1% weight loss in one month. The resident's meal intakes were noted to be 50% overall. The note further stated "Made aware by nursing that resident has skin breakdown, BUN and creatinine up. Will re-consult speech therapy given weight loss and decreased meal intakes. Will follow labs and weights. Fortified foods were discontinued and Juvin supplement ( a protein supplement) was ordered to promote wound healing." This entry also failed to evaluate the adequacy of the resident's hydration status, reference the resident's increased fluid needs or that the resident was not meeting her estimated daily fluid needs. After a dysphagia ( difficulty swallowing) evaluation on October 10, 2013, the resident's diet was downgraded to puree consistency on October 11, 2013. The resident's meal intakes from October 4 through 11, 2013 were listed as fair (50 to 74% ) for most meals with her estimated fluid needs not met for any day in this time period. Nurses notes dated October 11, 2013 at 8 AM revealed that the resident displayed decreased level of consciousness, was difficult to arouse, and a sternal rub was used at breakfast. The resident wakes but goes back to sleep. The nurse aides put her back to bed and the resident did not eat breakfast. Lab studies were ordered, including a urine culture and sensitivity and an antibiotic started after obtaining the urine sample. There was no evidence of intake or output monitoring completed as per the facility policy. There was no evidence of increased fluids provided to this resident at this time or that alternate forms of hydration were assessed for appropriateness or necessity. A review of lab results dated October 12, 2013, revealed that the resident again had a urinary tract infection and her chloride was 112 MMOL/L ( high), BUN 33 MG/DL (high) and Creatnine 1.05 MG/DL. The residents weight on October 14, 2013 was 168.8' a 2 pound weight loss. The resident's meal consumption continued to decline, but there was no assessment of the adequacy of the resident's fluid consumption. A review of lab results dated October 14, 2013, revealed that the resident's sodium increased to 147 MMOL\L, chloride to 113 MMOL\L and BUN to 42 MG\DL. A nurses note dated October 17, 2013 at 2 PM revealed that the resident was very lethargic, consumed 25% of breakfast and lunch, and was in bed that afternoon. A nurses note dated October 19, 2013 at 3:15 PM revealed that the resident was very lethargic. The next nurse's note dated October 19, 2013 (no time noted) revealed that the resident remained lethargic throughout the shift. The resident refused dinner. Medications were taken with sips of water. A review of the ADL tracking form and the meal intake form indicated that from October 16, 2013 through October 22, 2013 revealed that the resident's fluid intake declined without evidence that the facility had evaluated the resident's hydration status and potential need for care and services to provide fluids. A nurses note dated October 20, 2013 at 8 AM revealed that the resident was in bed and lethargic. She responded to tactile stimuli. The resident was assisted to sit up and responded verbally when spoken to. A nurse's note note at 9 AM on October 20, 2013, revealed that a call was placed to physician regarding resident's condition and a new order was received for lab studies for that date. A physician's order dated October 20, 2013 , (no time noted) prescribed D5W at 100 cc per hour times one liter then D4W at 80 cc per hour intravenously ( intravenous fluids) for this resident. However, there was no documented evidence at the time of the survey that Resident 2 received any intravenous fluids on October 20, 2013. A nurses note dated October 20, 2013 at 9:50 PM revealed that a call was placed to the "on call" physician and a message left to page him. The nursing staff at the facility was unable to start an intravenous line. The resident's 24 hour fluid intake for October 19, 2013 was 360 ccs, October 20, 2013 was 360 ccs and October 21, 2013 was documented as 1000 ccs. All three days totals were markedly below the documented daily estimated fluid needs for Resident 2. A review of a lab work dated October 20, 2013 revealed that her sodium now increased to 155 (normal 136-145 MMOL\L) chloride 120, which was noted as critical, BUN 46 MG\DL. A nurses note dated October 21, 2013 at 11:40 AM revealed that the critical chloride level called to physician. These lab values were dated October 20, 2013, and were noted as printed and sent to the facility on [DATE] at 4:41 PM, but the physician was not informed until October 21, 2013, at 11:40 AM The next nurses note dated October 21, 2013 at 12:20 PM documented as a late entry for October 20, 2013, at 6:30 PM revealed "labs called to covering physician, critical values, fluids offered, water taken without difficulty. Team LPN regarding ^ fluid intake." A nurses note dated October 21, 2013 at 2:40 PM revealed that the resident's attending physician had called. A new order was noted to hold the resident's [MEDICATION NAME] and potassium, encourage and give by mouth fluids and labs to be drawn October 22, 2013. A nurses note dated October 21, 2013 at 9 PM revealed that the resident remained lethargic, refused supper and intake was poor. A review of lab work dated October 21, 2013 revealed sodium 157 MMOL\L, chloride 120 MMOL\L, still at a critical level, BUN at 39 MG\DL and calcium 8.5 (8.6-10.3 MG\DL). A nurses note dated October 22, 2013 at 2:30 PM revealed that the resident was lethargic most of the AM, easily awakened but falls back to sleep quickly. A review of lab work dated October 22, 2013 revealed sodium 154 MMOL\L, chloride 131 MMOL\L (critical level), BUN 38 MG\DL, and calcium 8.1 MG\DL. The resident's weight was documented as 161.2 lbs on October 22, 2013. This represents a 10.4# weight loss (6.06%) in 18 days. A review of intake and output records revealed that the intake and output was started on October 21, 2013, and the resident was hospitalized the next day secondary to urine culture and increased renal studies. A review of monthly physician progress notes [REDACTED]. A physician's progress note dated November 1, 2013, revealed that the resident was status [REDACTED]. A review of a hospital discharge summary dated October 31, 2013, revealed both admission and discharge [DIAGNOSES REDACTED]. Hospital treatment course included intravenous fluids, culture in urine and sacral wound infected with e-coli (a bacteria found in feces), treated with antibiotics and placement of a PEG tube ( a tube placed into the stomach for liquid nutrition. Hospital labs noted October 24, 2013 revealed sodium 155 MMOL\L, potassium 3.7 MMOL\L, chloride 122 MMOL\L and BUN 32 MG\DL. Her labs noted in the hospital dated October 28, 2013 revealed a steady improvement in electrolytes following IV fluids: October 28, 2013 noted, sodium 144 MMOL\L, potassium 4.2 MMOL\L, chloride 113 MMOL and BUN 10 MG\DL. Upon return to the nursing facility, November 11, 2013, revealed her sodium, potassium and chloride within normal limits and her BUN 26 MG\DL. A review of a nursing care plan for at risk for shortness of breath, chest pains, [MEDICAL CONDITION] (swelling) or high blood pressure due to [DIAGNOSES REDACTED]. Approaches included, monitor for signs and symptoms of dehydration. A care plan for the resident's nutritional risk dated April 12, 2012 revealed approaches to include offer fluids at and between meals. An approach dated October 21, 2013, revealed the plan to encourage by mouth fluids, urinary tract infection. A review of facility 24-hour nursing report sheets dated from September 1, 2013 through October 21, 2013, revealed multiple daily notations of Resident 2's UTIs with antibiotics, but no mention that the resident was not meeting fluid needs or of dietitian or physician notification of this inadequate fluid intake. During an interview November 21, 2013 at 1 PM the facility's dietitian confirmed that nursing did not communicate to her that Resident 2 was not meeting her daily fluid needs. She did confirm that daily fluid needs were not addressed on the resident's nutritional care plan. The dietitian stated that the resident's nutritional issues are discussed daily at morning meeting, but she was not made aware of this resident not meeting her fluid needs. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services previously cited 10/12/12 28 Pa Code 211.10 (a) Resident care policies previously cited 10/12/12 28 Pa. Code 211.6(d) Dietary services