Every finding on record at Kadima Rehabilitation & Nursing at New Castle

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the physician signs and dates all orders during each of his/her visits for six of 20 residents reviewed (Residents R7, R11, R23, R59, R60, and R61). Findings include: Resident R7's clinical record revealed an admission date of 8/16/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Dementia (loss of cognitive functioning affecting a persons memory and behaviors), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R7's clinical record revealed the last time his/her physician reviewed, signed, and dated his/her physician orders was on 10/21/24. Resident R11's clinical record revealed an admission date of 1/21/22, with diagnoses that included Diabetes, Epilepsy (a chronic brain disorder which a group of nerve cells or neurons will sometimes send wrong signals and cause a seizure which temporarily affects your consciousness, muscle control, and behavior) and Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning). Resident R11's clinical record revealed the last time his/her physician reviewed, signed and dated his/her physician orders was on 11/20/24. Resident R23's clinical record revealed an admission date of 11/24/22, with diagnoses that included Cerebral Palsy (a brain disorder that appears in infancy or early childhood, permanently affecting body movement and muscle coordination. It is caused by changes in the developing brain that disrupts its ability to control movement and maintain posture and balance), Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and COPD. Resident R23's clinical record revealed the last time his/her physician reviewed, signed and dated his/her physician orders was 1/7/25. Resident R59's clinical record revealed an admission date of 3/31/22, with diagnoses that included COPD, Schizoaffective Disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]), and Colon Cancer. Resident R59's clinical record revealed the last time his/her physician reviewed, signed, and dated his/her physician orders was 1/23/24. Resident R60's clinical record revealed an admission date of 3/4/26, with diagnoses that included Paraplegia (the loss of the ability to move, and sometimes to feel anything in the legs or lower body, typically caused by a spinal injury or disease), COPD, and GERD. Resident R60's clinical record lacked evidence of the last time his/her physician reviewed, signed, and dated his/her physician orders. Resident R61's clinical record revealed an admission date of 2/7/25, with diagnoses that included COPD, High Blood Pressure, and GERD. Resident R61's clinical record lacked evidence of the last time his/her physician reviewed, signed, and dated his/her physician orders. During an interview on 5/7/2026, at 2:20 p.m. the above information was discussed and reviewed with Director of Nursing and that the physician is required to sign and date all orders during their visits and Residents R7, R11, R23, R59, R60, and R61's clinical records lacked evidence of this being completed as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain that necessary resident information was communicated to the receiving healthcare provider upon transfer to the hospital for two of four residents reviewed for hospitalization (Residents R4 and R59) and that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for one of four residents reviewed for hospitalization (Closed Record Resident CR64). Findings include: Facility policy entitled Transfer and Discharge dated 12/17/25, revealed This facility will provide notice to its residents of the facility's bed-hold policies and readmission policies prior to transfer of a resident for hospitalization or therapeutic leave. Facility policy entitled Transfer Form Instructions dated 12/17/25, revealed Should it become necessary to transfer a resident from the facility, a Transfer Form will be executed and forwarded with the resident. Resident R4's clinical record revealed an admission date of 3/6/26, with diagnoses that included Idiopathic peripheral autonomic neuropathy (nerve damage to the peripheral nervous system with no identifiable cause despite medical evaluation causing numbness, tingling, burning in the feet or hands), generalized muscle weakness, abnormalities of gait immobility, needing assistance with personal care. Resident R4's progress notes revealed notes dated 1/23/26 and 2/8/26, indicating a transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R59's clinical record revealed an admission date of 3/31/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Schizoaffective Disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]), and Colon Cancer. Resident R59's progress notes revealed a note dated 1/9/26, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 5/8/26, at 11:00 a.m. the Director of Nursing (DON) confirmed that Residents R4 and R59's clinical records lacked evidence that the necessary clinical information was provided to the receiving health care provider. Resident CR64's clinical record revealed an admission date of 3/13/26, with diagnoses that included pneumonia, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Resident CR64 was transferred to the hospital on 4/14/26. The clinical record lacked documentation indicating that Resident CR64 and/or their representative were provided with a copy of the facility bed-hold policy. During an interview on 5/08/26, at 11:10 a.m. the Admissions and Social Services Coordinator confirmed that Resident CR64 and/or their representative were not provided with a copy of the facility bed-hold policy when transferred to the hospital on 4/14/26, and should have been provided to further explain how long his/her bed could be held during a leave of absence and the cost per day. 28 Pa. Code 201.18(e)(1) Management

Based on review of facility policy and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to appropriately date and store medications in one of two nursing medication rooms (West).Findings include: Facility policy entitled Labeling of Medications dated [DATE], revealed Multi-does vial medications must be dated when opened for determination of discard date based on manufacturer's instructions. And Multiple dose vials must be dated at the time they are opened for use. Medications are considered expired from open date based on manufacturer's instructions. Manufacturer's guidelines revealed that a vial of Tubersol (a skin testing agent for tuberculosis) which has been entered and in use for 30 days should be discarded. Observation on [DATE], at 12:27 p.m. of [NAME] Wing Med Room, revealed an open vial of Tubersol without an open date marked on the vial. During an interview at the time of observation, Licensed Practical Nurse (LPN) Employee E1 confirmed that the open vial of Tubersol was opened and not dated, therefore they were unable to determine if the vial was in use for 30 days. LPN Employee E1 also confirmed that the Tubersol vial should have been dated when it was opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to send copies of notice of discharge to the representative of the Office of State Long-Term Care (LTC) Ombudsman for one of one residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 6/22/24, with diagnoses that included Type 2 Diabetes with a foot ulcer (A chronic condition in which the body either does not produce enough insulin or does not use insulin effectively with a open area caused by nerve damage and poor circulation), Human Immunodeficiency Virus (HIV, a virus that attacks the body's immune system), history of harm to self and post traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a traumatic event). Departmental notes indicated that Resident R1 was transferred to the hospital on [DATE], and given a letter of eviction on 10/22/25. There was no evidence that the Office of the State LTC Ombudsman was notified. During an interview on 1/8/25, at approximately 3:25 p.m. the Nursing Home Administrator confirmed that the facility failed to notify the Office of the State LTC Ombudsman of Resident R1's transfer and discharge from the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety for three of three kitchen refrigerators and four of four kitchen freezers and corresponding temperature logs reviewed. Findings include: A facility policy entitled, Equipment Temperature Logs dated 6/18/25, revealed, The Dining Services Manager will use the Refrigeration and Freezer Temperature Log to record the temperatures of all refrigerators and freezers on a daily basis. Review of the refrigeration and freezer temperature logs for the kitchen revealed two temperature log sheets, one for the main kitchen and one for the basement refrigeration. Review of the main kitchen log for the dates from August 1, 2025, through August 27, 2025, revealed that the main kitchen log had 216 opportunities (twice daily) to record temperatures for two refrigerators and two freezers and only had 104 refrigerator and freezer temperatures recorded, leaving 112 opportunites where temperatures were not recorded for monitoring. Review of the basement refrigeration temperature log for the dates of August 1, 2025, through August 27, 2025, revealed that there were two freezers and one refrigerator, and the temperature log from August 8, 2025, through August 27, 2025, had zero recorded temperatures for monitoring. During an interview on 8/28/25, at 10:00 a.m. the Dietary Manager confirmed that the refrigerator and freezer temperatures were not being recorded as required to monitor for morning and evening temperatures daily. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and resident council minutes, observations, and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for four of 19 residents interviewed (Residents R3, R24, R25, and R43). Findings include: Review of facility policy entitled Cell Phone/Camera Usage, with a policy review date of 5/01/25, revealed that Personal cell phones should not be used during work time. Review of grievances in January of 2025 revealed that there were concerns with staff members on their cell phones and education was provided by the Director of Nursing (DON). Review of resident council minutes over three months from February, March, and April of 2025, revealed the following: April 2025 resident council minutes revealed there were complaints of staff observed constantly on their phones; Most of the occurrences were on day and afternoon shift; Call bell wait times were 30 minutes or longer. Interviews during the resident council meeting on 5/28/25, between 11:00 a.m. and 11:45 a.m. revealed four of four alert and oriented residents in attendance had concerns related to staff not responding to their call bells timely. All residents in attendance revealed that staff are constantly on their telephones texting or having private conversations with other people. All residents in the resident coucil meeting stated that it delays their care response times and it makes residents upset. Resident R24 indicated that it could take 30-45 minutes for his/her call bell to be answered and staff are typically seen in the hallways, at the nurse's station, or in resident's rooms talking or on their phones having private conversations. Resident R3 indicated that he/she will wait for 30 minutes to 60 minutes to receive assistance to use the restroom after placing his/her call bell on and requires full assistance by staff. Residents R3, R24, R25, and R43 indicated they wait 30 minutes or longer when their call bell is placed on to be responded to by staff. All residents agreed that they observe staff on their phones and standing talking to one another during their shifts. During observations of two of two resident care areas during the week of the survey, from 5/27/25, to 5/30/25, there were observations of staff sitting at the nurses stations and in the hallway on their personal cell phones. During an interview with the DON and Assistant Director of Nursing on 5/30/25, at approximately 1:15 p.m. it was confirmed that residents do complain to administration about employees on their cell phones. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policies, dietary and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide daily menus, update menu changes, and notify residents of a change to the menu; and failed to provide a nutritionally adequate menu for one of one residents noted with a gluten free allergy (Resident R1). Findings include: A facility policy entitled Dietary Services Administration dated 5/01/25, revealed sufficient food will meet the nutritional needs of residents and shall be prepared as planned for each meal. Menus are followed. Menus are posted in all dining rooms and on all resident units. Special diets shall be prepared and served as ordered. A facility policy entitled Menu Item Substitution dated 5/01/25, revealed a resident shall receive a substitute food item of equal nutritive value when a scheduled menu item is not available. The substitute will be approved by the facility Dietitian. After the scheduled menu item has been determined to be unavailable, the Dining Services Manager in consultation with the Dietitian will select an appropriate substitute. A list of substitutable items for each menu category that has been approved and signed by the Dietitian will be available for changes needed in absence of the Dietitian. The day's menu sheet and diet extension will be revised to reflect the substitution. A facility provided foodservice invoice dated 5/02/25, revealed purchases of one case of gluten free pasta penne and one case of gluten free hamburger buns. The facility menu dated for week three, revealed Chicken Patty on Bun, French Fries, Mexicali Corn, Pudding, and a Choice of Beverage. Resident R10's clinical record revealed an admission date of 7/26/23, with diagnoses that included chronic respiratory failure with hypoxia (a condition where the lungs cannot deliver enough oxygen to the blood resulting in low oxygen in the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and affects the way a person breathes), diabetes mellitus (a disease that result in too much sugar in the blood), and cardiac heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should). During an interview on 5/27/25, at 1:00 p.m. Resident R10 indicated that alternatives are not always available for each meal and what is on the menu is not always available due to the kitchen runs out of food. Resident R10 further indicated that they are never told of food substitutions and no menu is provided. There was no menu observed in Resident R10's room. On 5/28/25, at 12:45 p.m. Resident R10 further indicated that the kitchen did not have hamburgers for the lunch meal. Resident R10 explained that a hamburger was what they chose instead of the chicken patty sandwich. When the Activity Assistant inquired about his lunch and dinner food choice that morning. Resident R10 stated, Sometimes you just get what you get, it's a surprise. During an interview and observation on 5/27/25, at 2:20 p.m. the Dietary Manager confirmed the facility failed to post the daily menus, including an alternate menu, on the dining room menu board for all residents and family members to view. The Dietary Manager further revealed the Activity Assistant reviews daily with each resident what is on the menu for lunch and dinner, including an alternative and if there is a food substitution, the Activity Assistant notifies the resident population. During an interview on 5/28/25, at 9:30 a.m. the Activity Assistant Employee E1 indicated he/she will meet with each resident every morning regarding their lunch and dinner food selection, then provides an accumulated list of the residents' food choices to the kitchen each morning prior to lunch. If a resident's food choice in unavailable due to insufficient food or other reasons, Activity Assistant Employee E1 indicated that they do not then notify each resident that their food choice is unavailable; the resident will learn his/her desired food choice is something different when the lunch meal and/or dinner meal arrive to them. Resident R1's clinical record revealed an admission date of 4/29/25, and discharge date of 5/24/25, with diagnoses that included COPD, muscle weakness, abnormalities of gait and mobility, and CHF. Review of Resident R1's physician progress note dated 5/01/25, revealed food allergies to gluten and wheat. An interview with the Dietary Manager on 5/29/25, at 11:30 a.m. revealed a facility provided invoice that included two gluten free food items for Resident R1. The Dietary Manager indicated that pasta, hamburgers, and hamburger buns were purchased for Resident R1's consumption related to their gluten free allergy. No bread, cereal, crackers, or other food items were purchased. The Dietary Manager confirmed that at times Resident R1 had limited food items and/or choices for each meal due to their gluten free allergy, and the menu could not be followed to its entirety due to insufficient gluten free food the facility had to offer. During an interview on 5/30/25, at 12:35 p.m. the Nursing Home Administrator (NHA) confirmed that the menu should be posted and followed daily for all residents and family members to readily view, and if the menu cannot be followed, the residents should be notified in a timely manner what the food substitution will be. The NHA further confirmed that Resident R1 had a gluten free allergy and there was an insufficient variety of food items to provide nutritionally adequate meals while Resident R1 resided at the facility from 4/29/25, through 5/24/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(a) Dietary Services 28 Pa. Code 211.10(c) Resident Care Policies

Based on review of resident rights, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to provide proper resident assistance during bathing that resulted in a fall with actual harm of a fracture of the right shoulder for one of 17 residents reviewed (Resident R41). Findings include: Review of Statement of Resident Rights revealed the resident has the right to a safe, clean, comfortable, homelike environment, including but not limited to: (a) receiving treatments and support for daily living safely; (d) ensuring that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, vascular dementia (brain damage cause by multiple strokes), history of transient ischemic attacks and cerebral infarction (temporary blockage of blood flow to the brain), altered mental status, other abnormalities of gait and mobility, and type one diabetes mellitus (a condition where the pancreas makes little to no insulin, leading to high blood sugar levels). Review of Resident R41's Activities of Daily Living (ADL) related care plan originally dated 10/12/2020 and last reviewed 3/19/2024, revealed resident has an ADL self-care performance deficit. Bathing required an assist of one staff member with bathing/showering. Review of R41's Minimal Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated February 21, 2024, revealed that Section GG0130 Self-care revealed Shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self, identified that Resident R41 required partial/moderate assistance; Section GG0170 FF: tub/shower transfer: the ability to get in and out of a tub/shower revealed that Resident R41 required partial/moderate assistance. Review of Resident R41's progress notes from 4/10/2024, at 2:24 p.m. revealed, resident was found on floor by aide. Resident slipped and fell getting out of tub. He fell on his right arm and now has limited range of motion. Resident assessed, no skin tears, bruises, or red marks noted to right arm. VSS [vital signs stable] recorded. Hoyer lift [type of mechanical lift] used to assist resident up into chair. Resident is his own POA [power of attorney]. Review of Resident R41's x-ray report of right shoulder dated 4/11/2024, revealed a comminuted (partial or complete break) fracture of the right shoulder. During an interview with the Director of Nursing (DON) on 6/6/2024, at approximately 1:30 p.m., it was confirmed that a physical therapist employee put the resident in the tub room, set him up by himself and left the resident unattended to take a bath. Review of a witness statement by Physical Therapist Assistant (PTA) Employee E1, stated On 4/10/2024, as I was exiting the tub room on west with another resident, [Resident R41], was waiting outside of the door clothes and body wash in hand. He asked to be let in to take his shower. Therapy documentation at this time reflects a set up status for ADL's, transfers, and ambulation so I let [Resident R41] into the shower room, as he has demonstrated good safety with set up. Review of a witness statement dated 4/10/2024, at 12:20 p.m. from Nurse Aide (NA) Employee E2, who found Resident R41 in the shower room on 4/10/2024, revealed, while waiting for trays, [Resident R41] asked to be let into the tub room but I told him to wait because therapy just went in with someone and lunch was coming. During the middle of lunch, the tub room call light went off and I was confused because I did not know anyone was in there. I went to go check and found [Resident R41] on his butt on the floor. I went to get his Nurse Aide and we went to assess him. After a few attempts to stand him up we used a Hoyer lift to get him into a sitting position and into a shower chair. During an interview on 6/7/2024, at 10:23 a.m. NA Employee E3 revealed that the nursing staff receives a list of residents that are to get showers each shift every day. They check and follow the resident care plan and tasks on set up and assistance with baths and transfers. NA Employee E3 revealed that residents are not left unmonitored in the shower regardless of their assist levels for safety purposes. An interview conducted with Registered Nurse (RN) Employee E4 on 6/7/2024, at 10:25 a.m. revealed that it is not the practice of the nursing staff to leave residents in the shower or tub room unattended. Staff should always be aware someone is in the tub room and close to watch or monitor resident for safety. Resident plans of care are reviewed for levels of assistance and care with baths. An interview with Licensed Practical Nurse (LPN) Employee E5 on 6/7/2024, at 10:30 a.m. revealed that care plans are reviewed for the levels of care and assistance with residents when taking a bath. LPN Employee E4 stated it is not safe practice to put a resident in the shower unattended. Staff are to be close to residents or monitoring residents for safety when in the tub room. An interview with RN Employee E6 on 6/7/2024, at 10:35 a.m. revealed that care plans are reviewed for assistance with showers or baths for residents who are on the shower schedule each day. It is not the practice of the nursing staff to leave residents unattended in the tub room. Staff is always close by or in the room assisting for resident safety in the tub room. An interview conducted with NA Employee E7 on 6/7/2024, at 10:40 a.m. revealed that residents' care plans are reviewed prior to the showers given so they have the correct number of staff to assist the resident safely. NA Employee E7 stated it is not the practice of the nursing staff to leave any resident unattended in the tub room for safety purposes. Staff is always close by or in the room assisting residents for safety purposes during baths or showers. During an interview with the DON and Nursing Home administrator on 6/7/2024, at approximately 11:30 a.m. it was confirmed that per investigation, Resident R41 was placed in the tub room unattended by PTA Employee E1 and was left unattended in the bathtub. The resident slipped and fell in the tub resulting in a right shoulder fracture. Resident R41's care plan at the time of the fall on 4/10/2024, revealed a ADL self-care deficit and bathing required assist of one staff member with bathing and showering. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to implement care and services identified on a comprehensive care plan regarding provision of care for activities of daily living (ADL) for one of 17 residents reviewed (Resident R41). Findings include: Review of Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, vascular dementia (brain damage cause by multiple strokes), history of transient ischemic attacks and cerebral infarction (temporary blockage of blood flow to the brain), altered mental status, other abnormalities of gait and mobility, and type one diabetes mellitus (a condition where the pancreas makes little to no insulin, leading to high blood sugar levels). Review of R41's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 2/21/2024, revealed that Section GG0130 Self-care revealed Shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self, identified that Resident R41 required partial/moderate assistance; Section GG0170 FF: tub/shower transfer: the ability to get in and out of a tub/shower revealed that Resident R41 required partial/moderate assistance. Review of Resident R41's ADL related care plan originally dated 10/12/2020 and last reviewed 3/19/2024, revealed resident has an ADL self-care performance deficit. Bathing required an assist of one staff member with bathing/showering. Review of an incident regarding Resident R41 revealed he/she was left unattended in the tub/shower area on 4/10/24, with subsequent fall with injury based on a physician's order dated 2/12/2021 for transfers independently. During an interview on 6/6/2024, at approximately 3:30 p.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the inconsistencies in Resident R41's clinical record and that the ADL care plan was not implemented accurately. Interviews conducted with facility staff members on 6/7/2024, between 10:25 am. and 10:40 a.m. revealed that prior to showering residents, the resident care plan for ADL's is to be reviewed to determine proper transfer/assistance level information to ensure resident safety. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of one residents reviewed (Resident R1). Findings include: Review of the facility's policy entitled Medication Administration, last revised 8/2016, revealed that medications are to be administered in accordance with written orders of attending physicians; residents are identified before medication is administered; medications ordered for one resident are never administered to another resident; prior to administration, the medication level is checked. Review of Resident R1's clinical record revealed physician's orders dated 11/3/2022, that included an order for the resident to receive Humalog (type of insulin) KwikPen solution pen-injector 100 Units/mL inject as per sliding scale to address blood glucose (sugar) levels if 141-180 milligrams (mg)/deciliter (dL) inject 1 unit; 181-220 mg/dL inject 2 units; 221-260 mg/dL inject 3 units; 261-300 mg/dL inject 4 units; 301-340 mg/dL inject 5 units; 341 mg/dL and over inject 6 units subcutaneously before meals as related to Type 2 diabetes with hyperglycemia (high blood sugar). Review of Resident R1's clinical record revealed a progress note, dated 11/15/2023, at 5:19 p.m. that Licensed Practical Nurse (LPN) Employee E1 reported to the Director of Nursing (DON) that Resident R1 was administered NovoLog 30 units instead of being administered Humalog 1 unit subcutaneously (SQ) per sliding scale for a blood glucose level of 149 mg/dL. During an interview on 12/13/2023, at 11:00 a.m. the Nursing Home Administrator and the DON confirmed that Resident R1's insulin was not administered in accordance with physician's orders and that Resident R1 was administered the wrong dose and the wrong medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for one of two resident neighborhoods (West Wing). Findings include: Observations between 7/18/23 and 7/19/23 revealed concerns of two resident wheelchairs. Resident R22's wheelchair was observed to be significantly soiled with dried liquid substances that also had dust, a buildup of food crumbs and debris substances on the wheelchair sides and frame. Resident R28's wheelchair was observed to have a damaged left armrest with the protective covering being cracked, peeling, and torn; all the outer edges of the protective covering were missing. During an interview with Resident R256, he/she mentioned that upon his/her arrival to the facility, he/she was provided with a very dirty wheelchair. Resident R256, stated he/she was so bothered by the condition of their wheelchair that he/she had their family bring in disinfectant wipes and they wiped and scrubbed the whole wheelchair down. During the interview, Resident R256 also disclosed pictures he/she had taken of the wheelchair with his/her phone to demonstrate the uncleanliness and unacceptable condition of the visibly soiled wheelchair provided. During an interview on 7/19/23, at 10:39 a.m. Registered Nurse (RN) Employee E1 confirmed that Resident R22's wheelchair was soiled with food crumbs and dried spillage down the side and on the frame of wheelchair. During an interview on 7/19/23, at 10:45 a.m. RN Employee E1 confirmed Resident R28's wheelchair had a damaged left armrest with cracked, peeling and torn protective covering and all edges of the protective covering were missing. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility documentation and facility policy and resident and staff interviews, it was determined that the facility failed to provide residents with access to their petty cash funds for two of eight residents that attended resident council (Residents R2 and R32) and one of 18 residents reviewed (Resident R3). Findings include: Review of the facility policy entitled, Resident Funds Distribution dated 4/19/22, stated that the facility will have sufficient funds to meet the needs of the residents. During a resident council meeting on 8/10/22, at 10:45 a.m. with eight alert and oriented residents, Resident R2 and R32 indicated that they have not received his/her Medicaid money of $45 a month for personal spending. In addition, during initial tour on 8/9/22 at 1:00 p.m., Resident R3 stated that he asked for his $45 on 8/9/22 at 8:00 a.m. and still has not received it. Upon observation of the bank statement for the residents' funds dated 8/11/22, Residents' R2, R32, and R3 have funds available for withdrawal. During an interview on 8/11/22, at 11:30 a.m. the Nursing Home Administer (NHA) revealed that the petty cash fund has a maximum of $200 and as residents' request money both on the weekdays and weekends, the balance decreases. In order to replenish petty cash, the NHA has to request it from Corporate and wait to receive the check and then go to the bank and cash it. During this period of waiting to replenish petty cash, if residents' want their money, they have to wait. The NHA confirmed this process on 8/11/22, at 11:48 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a)(d)(e) Resident Rights

Based on observations, review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to provide a bath/shower as per resident preference for three of 18 residents reviewed (Residents R20, R41, and R202). Findings include: Review of a facility policy entitled, Flow of Care, dated 4/19/22, revealed Residents are to have 2 baths/showers/week unless the resident states otherwise. Review of Resident R20's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R20 was alert and oriented with a BIMS (Brief Interview for Mental Status-a measure of cognitive status) score of 14/15. A review of facility documentation of a clipboard maintained in the bath/shower room for care givers to log resident bath/shower information such as date/time/resident name/temperature of water/employee signature revealed that Resident R20 received no baths/showers for the 30-day period of 7/12/22, through 8/09/22. No further clinical documentation of baths/showers was provided regarding Resident R20, for the past 30 day time-period 7/12/22 through 8/09/22. During an interview with Resident R20 on 8/09/22, at 1:10 p.m., he/she indicated he/she has not received his/her scheduled bath/shower on Wednesday and Saturday in the past several weeks. Resident R20 verbalized, I have not got a bath or shower in the past month or so. Resident R20 was observed with greasy hair during the interview. Review of Resident R41's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R41 was alert and oriented with a BIMS score of 14/15. A review of facility documentation of a clipboard maintained in the bath/shower room for care givers to log resident bath/shower information such as date/time/resident name/temperature of water/employee signature revealed that Resident R41 received one bath on 7/15/22. No further clinical documentation of baths/showers was provided for Resident R41, for the past 30 day, time-period 7/12/22 through 8/09/22. During an interview with Resident R41 on 8/09/22, at 1:00 p.m. he/she indicated he/she has not received the scheduled twice weekly showers in the past several weeks. Resident R41 verbalized, I haven't got a shower in the past several weeks or so. Resident R41 was observed with greasy hair during the interview. Review of Resident R202's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R202 was alert and oriented with a BIMS score of 14/15. A review of facility documentation of a clipboard maintained in the bath/shower room for care givers to log resident bath/shower information such as date/time/resident name/temperature of water/employee signature revealed that Resident R202 received no baths/showers for the 13-day period of 7/28/22, through 8/09/22. Clinical documentation in the facility electronic medical record system revealed one shower was provided on 8/02/22, which was the only bath/shower provided to Resident R202 since admission on 7/28/22. An interview with Resident R202 on 8/09/22, at 12:30 p.m. indicated that he/she only received one bath/shower since being admitted to the facility on [DATE]. Resident R202 verbalized, I have not been getting my bath or shower twice weekly since I've been here. Resident R202 was observed with greasy hair during the interview. An interview with the Director of Nursing on 8/10/22, at 11:50 a.m. confirmed that there was no evidence to indicate Resident R20, Resident R41, and Resident R202 received a bath/shower twice a week as preference to each resident and facility policy. 28 Pa. Code 201.4(a) Responsibility of licensee 28 Pa. Code 211.12 (d) (1)(3)(5) Nursing services

Based on review of facility policies, and resident and staff interviews, it was determined that the facility failed to meet resident needs regarding call bell response for three of 18 residents (Residents R12, R23, and R43), failed to provide a remote for his/her bed for one of 18 residents reviewed (Resident R35) and failed to provide fresh water every shift to residents for eight of eight residents reviewed during resident council (Residents R2, R8, R13, R16, R20, R23, R37, and R50). Findings include: Review of the facility policy entitled, Call Light Response dated 4/19/22, revealed that staff will answer call bells timely and listen to the residents' request; then staff will respond to the request and if needed, obtain assistance. Review of Resident R43's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with alert and oriented Resident R43 on 8/9/22 at 2:20 p.m. revealed that he/she asked to lie down in his/her bed at 1:05 p.m. and again at 2:05 p.m. and staff had not provided that assistance yet. Resident R43's roommate, Resident R25 who is alert and oriented, confirmed that Resident R43 asked to lie down at the above times and no staff member had assisted her. Additionally, Resident R25 stated that this happens all the time when Nurse Aide (NA) Employee E1 is assigned to Resident R43 and NA Employee E1 never puts the call bell next to Resident R43 so he/she can use it. Observation on 8/9/22, at 2:25 p.m. revealed that the call bell was tied to the far side of the bed and not within reach of Resident R43. Review of Resident R23's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/10/22, at 1:00 p.m. Resident R23, who is alert and oriented, stated that the staff have shut off her call bell at least two times in the past month without assisting her. Review of Resident R12's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/9/22, at 12:45 p.m. Resident R12, who is alert and oriented, stated that the staff shut off her call bell a lot without providing assistance for her. During an interview on 8/12/22, at 10:06 a.m. the Director of Nursing confirmed that staff need to answer the call bells and provide assistance with residents' needs timely. Review of the facility policy entitled, Maintenance Administration dated 4/19/22, revealed that the facility will maintain an electronic preventative maintenance system to report anything that needs repaired. Review of Resident R35's clinical record revealed an admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/9/22, at 12:30 p.m. Resident R35 stated that, I have not had a remote for my bed since I was admitted . An investigation by the Director of Nursing (DON) on 8/11/22 at 2:30 p.m., revealed that Resident R35 did have a remote upon admission. However, the remote stopped working soon after admission and a staff member removed the faulty remote without reporting the situation in the electronic preventative maintenance system. During an interview on 8/11/22, at 3:15 p.m. the DON confirmed that Resident R35 has not had a remote since shortly after their admission. Review of the facility policy entitled, Water Provision/Hydration dated 4/19/22, revealed that the facility will provide fluid rounds each shift which consists of filling the residents' water containers with ice and water. During resident council meeting on 8/10/22 at 10:40 a.m., all eight residents that were alert and oriented stated that they don't receive fresh ice and water every shift. During an interview on 8/11/22, at 10:05 a.m. the Director of Nursing confirmed that all residents should receive fresh ice and water each shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services 28 Pa. Code 201.29(j) Resident rights

Based on observations, review of facility policies, and staff interviews, it was determined that the facility failed to maintain food safety requirements in the main kitchen and the main resident pantry refrigerator. Findings include: Review of the facility policy entitled Sanitation dated 4/19/22, indicated that all kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Review of the facility policy entitled, Pantry Refrigerator Cleaning Policy dated 4/19/22, revealed that the pantry refrigerator should be deep cleaned weekly by the Dietary Department. During a tour of the main kitchen on 8/9/22, between 11:30 a.m. and 12:15 p.m. revealed that the hand washing station, coffee machine, and silverware container had excessive brownish/blackish areas on/in them, the freezers and cold storage units had excessive food particles on the bottom shelf, and the floors throughout the kitchen had blackish areas on them and in the corners there was a build-up of dirt. Observation of the main kitchen on 8/9/22, between 11:30 a.m. and 12:15 p.m. also revealed that the air conditioner in the kitchen had blackish areas in the inside of it, there was a frozen rag with blackish areas on it in the freezer next to the bread sticks, and there was an employee water bottle half empty in the cold storage unit. Review of kitchen cleaning schedules revealed that there were areas not marked as completed. During an interview on 8/9/22, at 12:11 p.m. the Dietary Manager confirmed the above observations and additionally the cleaning tasks not being marked as completed. Observations on 8/10/22, at 12:15 p.m. revealed that the resident pantry refrigerator had two areas with brownish sticky substances on the shelves and food particles on the bottom and sides of the refrigerator. During an interview on 8/10/22, at 12:18 p.m. the Corporate Dietary Manager confirmed the above observations. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.6(f) Dietary services

Based on review of clinical records and facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for two of 18 residents reviewed related to incontinence care (Residents R1 and R202). Findings include: Review of a facility policy entitled, Call Light Response, dated 4/19/22, revealed Staff will respond to the call bell in a timely manner. Listen to resident's request. Never make the resident feel that you are too busy to help. Offer further services before leaving resident's room. Resident R1's clincal record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1 was alert and oriented with a BIMS (Brief Interview for Mental Status-a measure for cognitive status) score of 15/15. During an interview on 8/10/22, at 10 a.m. Resident R1 indicated that he/she typically has a bowel movement between 10:00 a.m. and 12:00 p.m. daily. Resident R1 indicated there have been numerous occasions when he/she was expected to eat his/her lunch while sitting in his/her feces due to nursing staff telling him/her that he/she would have to wait. Resident R202's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R202 was alert and oriented with a BIMS score of 14/15. Observations on 8/09/22, at 12:25 p.m. revealed Resident R202 self propelling down the hallway from his/her room to the nurses' station. Resident R202 verbalized at that time, in an upset tone, I need help. My call bell was turned off and I was transferred to my wheelchair from my bed and expected to eat my lunch. I told them I needed changed and that I had an accident. How do they expect me to eat a meal when I covered in my feces and sitting in it? How would they like it? They just put me in my chair, turned off my call light, and gave me my lunch tray then left. Nursing Assistant (NA) Employee E1 then assisted Resident R202 with incontinence care after being alerted of Resident R202's concerns. NA Employee E1 verbalized after providing care, He/She was covered. Resident R202's clothing was observed being taken to be laundered due to being covered. During an interview on 8/12/22, at 11:15 a.m. the Director of Nursing confirmed that staff did not protect Resident R1 and Resident R202's dignity by leaving each resident sit in their feces expecting them to eat a meal in that condition. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of clinical records, and staff interviews, it was determined that the facility failed to update a resident care plan to ensure safety while transferring for one of 18 residents reviewed (Resident R6). Findings include: Review of Resident R6's clinical record revealed an initial admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R6's clinical record revealed that on 8/6/22, Resident R6 fell from a mechanical lift when he transferred his weight to his right side while in the lift causing the sling to tip. Review of statements and interviews, revealed that there were two trained staff members present during use of the lift. Observations of Resident R6 during the week revealed that when sitting in a broda chair, he does transfer weight and lean to one side. An observation of Resident R6 in the lift was conducted on 8/10/22, at 12:30 p.m. with a demonstration of how staff use the lift. Transfer was completed from chair to bed. it was observed that Resident R6 does tend to lean to one side while in the lift. Two nursing assistants were present during the transfer. Review of Resident R6's care plan revealed that he had falls on 4/28/22, 6/8/22, 7/28/22, and 8/6/22. There was no evidence that the care plan was updated to reflect the staff assistance needed to ensure safety while being transferred in the mechanical lift. During an interview on 8/11/22, at 1:30 p.m. the Director of Nursing confirmed that the care plan needs to be updated to reflect the assistance of staff members to prevent resident from tipping or transferring weight while operating the mechanical lift and review and implement with staff. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and facility policies, and resident and staff interviews, it was determined that the facility failed to obtain a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy entitled, Physician Services dated 4/19/22, revealed that the physician will prescribe new therapies. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/10/22, at 11:00 a.m. Resident R8 revealed that he/she had on a left hand splint. Review of Resident R8's clinical record revealed there was no physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/11/22, at 3:15 p.m. the Therapy Director indicated that Resident R8 was going to occupational therapy during June and near the beginning of June he/she received a left hand splint. An additional interview on 8/11/22, at 4:15 p.m. with the Therapy Director, verified there was no physician's order written for the continued use of the use of the left hand splint for Resident R8. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to develop a comprehensive, individualized discharge care plan for three of three closed record residents discharged to the community (Residents CR1, CR2 and CR3). Findings include: Review of the facility policy entitled MDS (Minimum Data Set - periodic assessment of resident care needs)/RAI (Resident Assessment Instrument - guidelines for completion of the MDS)/Care Planning dated 11/20/21, revealed that a written, individualized plan of care would be developed for every resident which identifies through an assessment process his/her strengths and needs. Review of Resident CR1's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident CR1's clinical record revealed that upon admission, Resident CR1 planned to remain in the facility for long term care. August 2021, Social Service (SS) Notes revealed efforts, per Resident CR1's request, to be transferred to another facility. October 2021, SS Notes indicated arrangements to obtain a primary care physician, pain clinic and apartment in Resident CR1's prior community. November 2021, SS Notes revealed a consult for home health, physical and occupational therapy services, which Resident CR1 declined; testing for oxygen use at home; and discharge arrangements for an apartment in Resident CR1's prior community and discharge on 11/10/21. Resident CR1's clinical record lacked an individualized, comprehensive discharge care plan with a goal, interventions taken/planned by the facility to arrange for Resident CR1's discharge to the community and updates/changes to the discharge goal from long term placement to discharge to the community. Review of Resident CR2 's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of October 2021, SS Notes indicated that on admission Resident CR2's case worker requested involvement in care plan meetings and the discharge planning process and that Resident CR2's group home was in contact with the facility related to the discharge plan. An 11/23/21, SS Note indicated that Resident CR2 was discharged to a group home with a follow-up physician appointment and Nursing, Physical Therapy and Occupational Therapy consults in place. Resident CR2's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR2's discharge to the community. Review of Resident CR3's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of SS Notes, dated 11/15/21, indicated that Resident CR3's discharge plan was for a short term stay. SS Notes, dated 11/16/21, and 11/17/21, revealed arrangements for physical therapy, occupational therapy and nursing services following discharge, and a physician follow-up appointment scheduled on 11/22/21. SS notes reflected Resident CR3 was discharged home with family on 11/18/21. Resident CR3's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR3's discharge to the community. During an interview on 12/02/21, at 1:15 p.m. the Director of Nursing confirmed that all residents should have an individualized plan of care related to discharge that reflects the resident's discharge goal and interventions to meet that goal. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

rBased on review of clinical records and facility policies and staff interviews, it was determined that the facility failed to administer medications per physician's order for one of three closed record residents discharged to the community (Resident CR1). Findings include: Review of the facility policy entitled Medication Administration dated 11/20/21, indicated that medications are administered in accordance with physician's orders and within 60 minutes before or after the scheduled times. The policy also indicated that medication times may be changed in response to resident preference, or to enhance compliance, unless therapeutically contraindicated. Review of Resident CR1's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed that Resident CR1 was scheduled to be discharged from the facility to a private apartment, a four hour trip from the facility, on 11/10/21 at 7:00 a.m., with medications and personal belongings. Documentation further revealed that Resident CR1 didn't leave the facility until 10:30 a.m. Resident CR1's physician ordered medications, current at the time of discharge, included the following medications to be administered in the morning: [MEDICATION(S)] (a medication to lower fat levels in the blood) 10 milligrams (mg) daily at 8 a.m.; [MEDICATION(S)] (an allergy medication) 10 mg daily at 8 a.m.; [MEDICATION(S)] (a stool softener) 100 mg daily at 9:00 a.m.; [MEDICATION(S)] Extended Release (ER - a medication for high blood pressure or irregular heart rhythm) 120 mg daily at 9:00 a.m.; [MEDICATION(S)] (relieves wheezing and shortness of breath) Handihaler 18 microgram (mcg) capsule, two separate inhalations, daily at 9:00 a.m.; [MEDICATION(S)] (slows blood clotting) 5 mg twice daily, first dose at 8:00 a.m.; Budesonide (an allergy medication) Aerosol Powder Breath Activated, 180 mcg per activation, 1 puff twice daily, first dose at 8:00 a.m.; [MEDICATION(S)] (for muscle spasms) 10 mg twice daily, first dose at 9:00 a.m.; [MEDICATION(S)] (for [CONDITION(S)]) 0.4 mg, twice daily, first dose at 9:00 a.m.; Mucinex ER (thins respiratory secretions) 600 mg twice daily, first dose at 9:00 a.m.; [MEDICATION(S)] (for gastric reflux) 20 mg twice daily, first dose at 8:00 a.m.; [MEDICATION(S)] (for seizures and neurological pain) 900 mg three times daily, first dose at 9:00 a.m.; and [MEDICATION(S)] (for nasal allergies) 137 mcg, two sprays each nostril twice daily, first dose at 8:00 a.m. Resident CR1's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/30/21, at 11:30 a.m. Social Worker (SW) Employee E1 revealed that Resident CR1 was scheduled for discharge on 11/10/21, at 7:00 a.m., via transportation arranged by a Nursing Home Transition Coordinator associated with Resident CR1's insurance provider. SW Employee E1 indicated the transport was delayed and did not arrive until 10:30 a.m. During an interview on 11/30/21 at 11:50 a.m. the Director of Nursing confirmed that Resident CR1 was prepared and awaiting transport for a four hour transport to his/her new home on 11/10/21, at 7:00 a.m.; that arrangements were not made for administration of Resident CR1's morning medications (due to be given while in transport) prior to discharge; or that the morning medications were administered when it was identified that Resident CR1 was not going to leave the facility until after the medications' scheduled administration times. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1)(6) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services