Every finding on record at Kinzua Nursing and Rehab

Based on review of facility policy, clinical records, and facility documents, and staff interview it was determined that the facility failed to provide care and treatment according to the resident's comprehensive person-centered care plan, and address provider recommendations for psychiatric medication changes for one of four residents reviewed (Resident R2).Findings include: Review of a facility policy entitled Consulting Physician/Practitioner Orders dated 12/09/25, indicated that the attending physician shall authenticate orders for the care and treatment of assigned residents. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will:Call the attending physician to verify the order.Document the verification order by entering the order, time, date, and signature on the physician order sheet.Resident R2's clinical record revealed an admission date of 4/03/26, with diagnoses that included major depressive disorder, alcohol abuse, and anxiety disorder. A care plan entitled at risk for adverse effects related to use of antipsychotic (work by changing how certain signals in your brain - called neurotransmitters - affect how you feel and act) and antidepressant medications dated 4/04/26, included an intervention to consult psychiatrist and follow-up as needed. Resident R2's current physician orders included: Seroquel (antipsychotic medication) 25 milligrams at bedtime. Review of Resident R2's departmental progress notes revealed frequent episodes of verbal and physical behaviors between 4/10/26, and 5/05/26. Further review of Resident R2's clinical record revealed a psychiatric evaluation dated 4/15/26, recommended to increase Resident R2's Seroquel at bedtime to 37.5 milligrams at bedtime. On 4/29/26, a psychiatric evaluation noted that the recommended dosage to increase Seroquel was not addressed by the facility. During an interview on 5/06/26, at 12:40 p.m. the Nursing Home Administrator confirmed the facility is unable to locate evidence that Resident R2's attending physician reviewed the psychiatric recommendations and acted upon the recommended change in medications. 28 Pa Code 211.12(d)(1)(5) Nursing services28 Pa Code 211.10(c) Resident care policies

Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility policies, facility job description, clinical records, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure admission medications are transcribed accurately for one of one residents reviewed (Resident R1). The facility's failure created a situation which placed the residents in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death for Resident R1.Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of facility policy entitled Medication and Treatment Orders dated 12/9/25, indicated Clarify the order and transcribe newly prescribed medications. on the Medication Administration Record (MAR). record or ensure the order is in the electronic MAR. and Written transfer orders (sent with a resident by hospital or other health care facility)-Implement a transfer order. unless the order is unclear or incomplete. the receiving nurse should verify the order with the current attending physician. Review of facility policy entitled Medication Errors dated 12/9/25, indicated the facility shall ensure medications will be administered. according to physician orders. Review of policy entitled Consult Pharmacist Reports dated 12/9/25, indicated Recommendations are acted upon and documented by the facility staff and/or prescriber. and Prescriber accepts and acts upon suggestion or rejects and provides and explanation for disagreeing. Review of facility Registered Nurse (RN) job description revealed The purpose of the Registered Nurse is to deliver care to residents utilizing the nursing process. while maintain all standards of professional nursing. Review of Resident R1's clinical record revealed an admission date of 1/8/26, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that causes impaired thinking process with episodes of extreme mood swings with emotional highs and emotional lows), Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and major depressive disorder (a serious mood disorder that causes feelings of sadness, loss of interest in daily activities, emotional and physical problems that impact daily life). Review of Resident R1's signed Consent to treat indicated I consent to receive care and services. as prescribed in the medical plan of care, and in accordance with applicable regulations, and professional and ethical standards. Review of Resident R1's transfer orders received upon admission revealed an order for lithium carbonate (psychotropic medication that affects the mind) 300 mg (milligram) tablet extended release orally with no stop date. Review of Resident R1's facility physician orders (orders that are transcribed by the facility into the resident's electronic medical record) dated 1/8/26, lacked evidence of an order for lithium 300 mg tablet extended release orally, therefore Resident R1 did not receive the lithium carbonate 300 mg from 1/8/26, through 2/8/26. Review of Resident R1's pharmacy admission medication review dated 1/8/26, indicated an alert that the pharmacy found a potential issue that actual or potential clinically significant irregularity had been identified. The review indicated under lithium carbonate capsule 150 mg that this dose falls below the recommended daily dose for this drug and is potentially subtherapeutic (too low of a dose). The pharmacy admission medication review lacked evidence that it was reviewed by the facility staff and/or physician. Review of Resident R1's MARs for the time period between 1/8/26, through 2/8/26, lacked evidence of an order for lithium carbonate 300 mg. Review of Resident R1's documentation from his/her last behavioral health visit dated 12/9/25, revealed active orders for lithium carbonate 150 mg every day and lithium carbonate 300 mg every day. Review of Resident R1's clinical record revealed progress notes:Progress note dated 1/30/26, at 4:19 a.m. indicating resident R1 was pacing, wandering, screaming, and yelling out. Progress note dated 1/30/26, at 6:39 a.m. indicated that resident R1 was being loud and vocal about being Christian and that this was out of the resident's usual behavior.Progress note dated 1/30/26, at 6:40 a.m. indicated that resident R1was hitting staff and talking about Jesus and seeing the light. Progress note dated 1/31/26, at 1:07 p.m. indicated the resident R1was really anxious and getting into arguments with other residents. Progress note dated 2/1/26, at 1:10 a.m. indicated that Resident R1was given an anti-anxiety medication for anxiety. Progress note dated 2/1/26, at 5:07 p.m. indicated that Resident R1was given anti-anxiety medication for anxiety. Progress note dated 2/2/26, at 7:57 a.m. indicated that resident R1was given anti-anxiety medication for anxiety. Progress note dated 2/2/26, at 7:17 p.m. indicated that Resident R1 asked for anxiety medication and he/she became frustrated because the nurse could not give the medication at that time. Progress note dated 2/3/26, 1:28 p.m. indicated that Resident R1 was in the day room being disruptive and was very anxious. Progress note dated 2/3/26, at 1:45 p.m. indicated that Resident R1 was given an anti-anxiety medication and he/she believed the medication was aspirin. Progress note dated 2/3/26, at 2:46 p.m. indicated that Resident R1was having increased agitation and anxiety he/she was being disruptive in the dining room. Progress note dated 2/4/26, at 7:46 p.m. indicated that Resident R1 appeared manic (showing uncontrolled excitement and energy) and argumentative. Progress note dated 2/5/26, at 3:08 a.m. indicated that Resident R1 had been up the majority of the shift wandering the halls and talking to him/herself. Progress note dated 2/5/26, at 7:43 a.m. indicated that the Resident R1 had not slept and was having flight of thoughts (a condition where a person's thoughts move quickly and jump between ideas) rambling about her past husbands and talking to her daughter who was not there. Progress note dated 2/5/26, at 10:32 a.m. indicated that Resident R1 appeared very agitated and having schizophrenic behaviors such as talking to self and to people not in the room. Progress note dated 2/5/26, at 11:09 p.m. indicated Resident R1 was very agitated, shaking and exhibiting flight of ideas. Progress note dated 2/6/26, at 3:56 a.m. indicated Resident R1 was pacing, wandering, rummaging, and hitting others. Progress note dated 2/6/26, at 10:23 a.m. indicated Resident R1 was not making sense and became increasingly agitated with staff and other residents. Progress note dated 2/7/26, at 7:23 a.m. indicated Resident R1 was ambulating in the hallways most of the night and having delusional thoughts (false beliefs that seem real even when provided with evidence which can lead to emotional distress and difficulty in functioning in daily life). Progress note dated 2/8/26, at 4:41 p.m. indicated that Resident R1 was receiving one on one care due to mania and having a fall that shift. Progress note dated 2/8/26, at 10:11 p.m. indicated Resident R1 needing one on one due to mania. Progress note dated 2/9/26, at 10:08 a.m. indicated Resident R1 was found on the floor.Progress note dated 2/9/26, at 7:55 p.m. indicated Resident R1 was found on floor and was in a manic state not able to answer questions.Progress note dated 2/9/26, at 8:13 p.m. indicated that Resident R1continued to present with mania. Daughter came in to see resident and stated that she had not seen her parent like this since she was a little girl.Progress note dated 2/9/26, at 9:14 p.m. indicated Resident R1 was confused and disoriented. Progress note dated 2/10/26, at 12:12 p.m. indicated that Resident R1 was transported to neurology appointment and from the appointment resident was being admitted to geriatric psych for evaluation. Review of Resident R1's care plans revealed a care plan dated 1/8/26, for at risk for adverse effects related to antipsychotic. medication, and a goal that the resident will show no side effects . Another care plan dated 1/8/26, for at risk for behavior symptoms related to schizoaffective disorder with interventions to administer medications per physician order. Review of Resident R1's laboratory results dated [DATE], revealed lithium level reference range (normal range) of 0.60 - 1.20 MMOL/L (millimoles per liter), and his/her results were 0.14 MMOL/L. Review of a neurology progress note dated 2/10/26, revealed that Resident R1's lithium doses were not correctly dosed and that Resident R1was showing signs of active psychosis. During an interview on 2/25/26, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R1 was sent to an appointment on 2/10/26, and has not returned to the facility. During interviews on 2/25/26, between 11:35 a.m. and 12:55 p.m. the Director of Nursing (DON) confirmed that Resident R1 had been having flight of thoughts and increased behaviors. The DON confirmed that Resident R1's order for lithium carbonate 300 mg was not transcribed from his/her transfer orders into his/her facility medication record. He/she confirmed that Resident R1's pharmacy admission medication review dated 1/8/26, indicating a potential clinically significant irregularity for resident R1's lithium carbonate order was identified and not addressed by the facility staff and/or physician. He/she also confirmed that the lithium carbonate 300 mg order should have been clarified by the physician and transcribed into Resident R1's medication record, and that the pharmacy medication review should have been addressed by the facility and physician. On 2/25/26, at 2:37 p.m. the Nursing Home Administrator (NHA) and DON were made aware that Immediate Jeopardy (IJ) existed for in the facility and that a corrective action plan was required. The IJ template was provided to the NHA at that time. On 2/25/26, at 5:28 p.m. an acceptable immediate action plan was approved which included the following interventions: All Registered Nurses will receive education regarding the proper process for entering physician orders for new admissions. Which will include thorough review of hospital discharge orders, accurate entry of orders into the electronic health record, and the required process for transcription and clarification to ensure accuracy within the medical record. Nursing staff will utilize a standard Medication Transcription/Clarification Tool during the admission process to ensure all medication orders are completely and accurately transcribed. Any discrepancies identified will be clarified with the physician prior to implementation, and physicians will be notified promptly of any transcription error or clarification needs. Implementing a revised admission process requiring use of the Medication Transcription/Clarification Tool to validate that medication orders are accurately entered into electronic health record and appropriately populate in the electronic medication administration record. Director of Nursing or designee will audit the last 30 days of admissions as well as any new admissions moving forward within 48 hours to verify accuracy of order transcription and clarification. admission audits will be conducted three times a week until sustained compliance is achieved. Audit results will be reviewed at the Quality Assurance Performance Improvement meetings and additional corrective action or re-education will be implemented as indicated by audit findings. On 2/26/26, between 10:30 a.m. and 12:24 p.m. review of staff education, medication transcription/clarification tool, audits of physician orders for new admissions in the past 48 hours and past 30 days, and staff interviews confirmed the facility implemented the above stated action plan. On 2/26/26, at 12:53 p.m. NHA and DON were informed that the Immediate Jeopardy had been lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5)(3) Nursing services 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to prevent significant medication errors for one resident receiving a psychotic (mind altering) medication (Resident R1).Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice. Review of a facility policy entitled Medication and Treatment Orders dated 12/9/25, indicated Clarify the order and transcribe newly prescribed medications. on the Medication Administration Record (MAR). record or ensure the order is in the electronic MAR. and Written transfer orders (sent with a resident by hospital or other health care facility)-Implement a transfer order. unless the order is unclear or incomplete. the receiving nurse should verify the order with the current attending physician. Review of a facility policy entitled Medication Errors dated 12/9/25, indicated the facility shall ensure medications will be administered. according to physician orders. Review of Resident R1's clinical record revealed an admission date of 1/8/26, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that causes impaired thinking process with episodes of extreme mood swings with emotional highs and emotional lows), Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and major depressive disorder (a serious mood disorder that causes feelings of sadness, loss of interest in daily activities, emotional and physical problems that impact daily life). Review of Resident R1's facility physician orders (orders that are transcribed by the facility into the resident's electronic medical record) dated 1/8/26, lacked evidence of an order for lithium 300 mg tablet extended release orally, therefore Resident R1 did not receive the lithium carbonate 300 mg from 1/8/26, through 2/8/26. During an interview on 2/25/26, at 11:57 a.m. the Director of Nursing (DON) confirmed that Resident R1's order for lithium carbonate 300 mg was not transcribed from his/her transfer orders into his/her medication record and subsequently Resident R1 was not administered the ordered medication. He/she also confirmed that the lithium carbonate 300 mg order should have been clarified by the physician and transcribed into Resident R1's medication record to ensure administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that admission medications are transcribed accurately.Findings include: The job description for the NHA revealed that the NHA's primary purpose is to supervise clinical and administrative affairs of nursing homes and related facilities. Duties of the nursing home administrator include overseeing staff, personal, financial matters, medical care, medical supplies, and facilities. The job description for the DON revealed that the DON's primary purpose is to provide expert professional knowledge and skills necessary to plan, organize, develop, and direct the overall operations of the Clinical Department in accordance with all current regulatory standards to ensure the highest degree of quality care. Based on the findings in this report that identified the facility failed to make certain that admission medications are transcribed accurately, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), electronic health record (EHR), and paper charts were consistent for two of 18 residents reviewed (Residents R9 and R52).Findings include: The facility policy entitled Advance Directives dated [DATE], indicated that The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.The Director of Nursing (DON) or designee will notify the Attending Physician of advance directives so that the appropriate orders can be documented in the resident's medical record and plan of care. Resident R9's clinical record revealed an admission date of [DATE], with diagnoses that included hemiplegia affecting the right dominant side (paralysis on one side of the body), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Resident R9's physician orders and EHR dated [DATE], revealed an order for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest)-Full code. Resident R9's paper chart revealed a Do Not Resuscitate (DNR) form dated [DATE], with a bright DNR sticker in the front of the paper chart and deeper within the paper chart a POLST dated [DATE], that revealed Resident R9 requested CPR/Attempt Resuscitation. Resident R52's clinical record revealed an admission date of [DATE], with diagnoses that included chronic obstructive pulmonary disease (progressive lung disease that blocks airflow, causing breathing difficulties), heart failure, and irregular heartrate. Resident R25's physician orders and EHR dated [DATE], revealed an order for CPR-Full code. Resident R25's paper chart revealed a POLST dated [DATE], that revealed Resident R25 requested DNR. During an interview on [DATE], at 11:15 a.m. the DON, confirmed Residents R9 and R52's, physician's orders, POLST, EHR, and paper charts information were not consistent with each other.28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(vii) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of two residents reviewed receiving hospice services (Resident R49).Findings include: Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Resident R49's clinical record revealed an admission date of 5/27/23, with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), hypertension (high blood pressure), and dysphagia (difficulty swallowing). Further review of clinical record revealed a hospice contract to admit Resident R49 to hospice services on 7/30/25. Review of Resident R49's MDS's lacked evidence that a significant change MDS with an ARD completed within 14-days from when Resident R49 was admitted to hospice care was completed. During an interview on 12/10/25, at 1:05 p.m. the Director of Nursing confirmed that the facility failed to complete a significant change MDS when Resident R49 admitted to hospice services within 14-days from effective date of the hospice election. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to utilize infection control practices regarding Enhanced Barrier Precautions (EBPs-additional infection control precautions put in place for individuals who have an increased risk of multi-drug resident organisms [MDROs] or who are colonized/infected with MDROs) for wound care for one of 18 residents reviewed (Resident R12). Findings include: Review of the facility policy entitled Enhanced Barrier Precautions dated 10/16/25, indicated EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO). It also indicated that gloves and gown are to be applied prior to performing the high contact resident care activities, which included wound care. Resident R12's clinical record revealed an admission date of 9/12/25, with diagnoses that included pressure ulcer of the sacral region stage 3 (wound involving full-thickness skin loss where the subcutaneous fat is visible), obstructive and reflux uropathy (complication with blocked urine flow and urine flowing backward from bladder to kidneys), and high blood pressure. Observations made prior to a pressure ulcer dressing change for Resident R12 on 12/10/25, at approximately 10:20 a.m. revealed a sign on the doorframe indicating EBPs in place, Licensed Practical Nurse (LPN) Employee E1 entered Resident R12's room without donning (putting on) a gown. During an interview on 12/10/25, at 10:35 a.m. LPN Employee E1 confirmed he/she did not don a gown prior to entering Resident R12's room. During an interview on 12/10/25, at 10:45 a.m. the Director of Nursing confirmed that EBPs were in place and employees should be wearing gloves and gowns when providing wound care 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for four of twelve residents reviewed (Residents R2, R3, R7 and R11) Findings include: Review of facility policy entitled Death of a Resident, Documentation, dated [DATE], indicated appropriate documentation shall be made in the clinical records concerning the death of a resident and that all information pertaining to a resident's death (i.e. date, time of death, name and title of individual pronouncing the resident dead, etc.) must be recorded in the nurse's notes. The policy further stated that the name of the mortician and person removing the deceased resident must be entered into the resident's medical record. Review of facility policy entitled Documentation of Wound Treatments, dated [DATE], indicated the facility completes accurate documentation of wound assessments and treatments and the wound treatments are documented at the time of each treatment. Resident R3's clinical record revealed an admission date of [DATE], with diagnoses that included brain cancer, cerebral edema (swelling of the brain), and pneumonia. Resident R3's clinical record revealed an expired / return not anticipated recapitulation form completed and signed by Resident R3's physician on [DATE], indicating Resident R3 passed away at the facility on [DATE]. Resident R3's clinical record progress notes lacked evidence of Resident R3's death including the date, time of death, name and title of individual pronouncing the resident, and name of person removing the deceased resident from the facility. During an interview on [DATE], at 1:23 p.m. the Director of Nursing (DON) confirmed that Resident R3's clinical record was incomplete and lacked evidence of Resident R3's death including the date, time of death, name and title of individual pronouncing the resident, and name of person removing the deceased resident from the facility. Resident R2's clinical record revealed an admission date of [DATE], with diagnoses that included acute osteomyelitis (bone infection) of left ankle and foot, stroke, diabetes, peripheral vascular disease and amputation of right leg below the knee. Review of Resident R2's August Treatment Administration Record revealed the following treatment orders: [DATE], for left plantar foot cleanse with wound cleanser, apply calcium alginate with silver ( type of wound treatment) to wound base and cover with border gauze every day and evening shift. Out of 41 opportunities to document completion of the treatment, 26 opportunities were documented as completed and 15 were left blank. [DATE], to cleanse wound base of stump with normal saline solution, pat dry and apply xerofoam and cover with optifoam dressing every day shift. Out of 26 opportunities to document completion of the treatment, 19 were documented as completed and seven were blank, Resident R7's clinical record revealed an admission date of [DATE], with diagnoses that included hemiplegia and hemiparesis following a stroke, diabetes and neuropathy. Review of Resident R7's August Treatment Administration Record revealed the following treatment orders: [DATE], Desitin Zinc oxide cream apply to buttocks/groin every shift for skin protection. Out of 76 opportunities to document completion, 60 were documented as completed and 16 were blank. [DATE], cleanse left buttock with wound cleanser pat dry and apply medihoney cover with border gauze. Out of 4 opportunities to document completion, one was documented as completed and three were blank. [DATE], cleanse bilateral buttocks apply a thin layer of triad (wound treatment) to areas of excoriation leave open to air every shift for wound healing. Out of 20 opportunities to document completion, 15 were documented as complete and five were blank. [DATE], left buttock cleanse wound pack tunnel with iodoform apply calcium alginate to entire open area cover with border gauze every day shift. Out of five opportunities to document completion, one was documented as completed and four were blank. Resident R11's clinical record revealed an admission date of [DATE], with diagnoses that included pressure ulcer right heel, adult failure to thrive, protein calorie malnutrition, and bipolar disorder. Review of Resident R11's August Treatment Administration Record revealed the following treatment orders: [DATE], coccyx pressure ulcer cleanse with wound wash apply medihoney and cover with optifoam dressing every day shift. Out of 27 opportunities to document completion, 16 were documented as completed and 11 were blank. [DATE], weekly weights for four weeks every day shift every seven days. Out of four opportunities to document completion, one was documented and three were blank. [DATE], treatment to right heel cleanse with wound cleanser cover with betadine gauze and cover with bordered gauze dressing every day shift. Out of 19 opportunities to document completion, 10 were documented as completed and nine were blank. During an interview on [DATE], at 1:25 p.m. the DON confirmed that Resident R2's, R7's and R11's clinical records were incomplete regarding treatment documentation. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical records, resident and staff interview, it was determined that the facility failed to provide a bath/shower per resident preference and failed to ensure that residents received assistance with bathing for two of 12 residents reviewed (Residents R3 and R4). Review of facility policy entitled Bed Bath, Shower/Tub dated 12/2/24, indicated The purpose of this procedure are to promote cleanliness, provide comfort to the resident. and Documentation 1. The date and time the shower/tub or bed bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub or bed bath. Review of Resident R3's clinical record revealed an admission date of 4/4/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow) and hypertension (high blood pressure). Review of Resident R3's physician's orders dated 4/8/25, revealed an order for shower every Wednesday and Saturday on evening shift. Review of Resident R3's task (an area where the nursing assistants document) for showers revealed he/she did not receive a shower on 7/5/25, and 7/19/25. Interview with Resident R3 on 7/23/25, at 10:30 a.m. revealed that he/she was very upset over not receiving their shower. He/she stated I want a shower, the staff told me I would get one this morning and its 10:30 a.m. Look at my hair it's greasy. Now it's almost lunch time and they will say they do not have the time to give me a shower. This is not the first time I waited a week to get a shower. Observations on 7/23/25, at 10:30 a.m. during the interview with Resident R3 revealed his/her hair appeared greasy and unkempt. Review of Resident R4's clinical record revealed an admission date of 1/9/24, with diagnoses that included Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat) and also identified their need for assistance with personal care. Review of Resident R4's physician's orders dated 4/24/25, revealed an order for shower every Tuesday and Friday on evening shift. Review of Resident R4's task for showers revealed he/she did not receive a shower on 7/11/25, 7/15/25, 7/18/25, and 7/22/25. Observations on 7/23/25, at 11:05 a.m. of Resident R4 revealed his/her hair appeared greasy and unkempt. During an interview on 7/23/25, at 1:00 p.m. the Director of Nursing (DON) confirmed that Residents R3 and R4 had not received showers as ordered and their hair appeared greasy and unkempt. The DON also confirmed that residents should receive their showers as ordered. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to take appropriate timely action to obtain a medication for one of 12 residents reviewed (Resident R1).Review of a facility policy entitled Administering Medication dated 12/2/24, indicated medications are administered in a safe and timely manner, as prescribed. Review of a facility policy entitled Medications Ordering and Receiving from Pharmacy dated 12/2/24, indicated medications and related products are received from the dispensing pharmacy on a timely basis. Review of facility policy entitled Medication orders dated 12/2/24, indicated a verbal prescription for a scheduled II medication may be called in to a pharmacist directly by the prescriber. The supply can be delivered from the pharmacy or may be available from the emergency kit. Review of Resident R1's clinical record revealed an admission date of 6/23/25, with diagnoses that included encounter for palliative care (care and comfort measures), hypertension (high blood pressure), and dementia (a disease that affects short term memory and the ability to think logically). Review of Resident R1's nursing documentation revealed that on 6/21/25, at 8:00 p.m. the facility staff called the hospital for an update on Resident R1. The hospital staff informed the facility that Resident R1 was placed under comfort measures only. Further review of nursing documentation revealed a note dated 6/23/35, at 3:54 p.m. that Resident R1 returned to the facility and upon return, Resident R1 was not responding to verbal or physical touch was having agonal (gasping and/or labored) breathing and received morphine before leaving the hospital. Review of Resident R1's clinical recorded revealed discharge orders from the hospital with an order for morphine 5-20 mg (milligrams) by mouth every 30 minutes for pain or dyspnea (difficulty breathing and/or shortness of breath). Review of Resident R1's facility physician's orders revealed an order dated 6/23/25, for morphine 20 mg per ml (milliliter) give 5 ml by mouth every 4 hours as needed. Review of Resident R1's admission/re-admission evaluation dated 6/23/25, revealed under the pain evaluation Does the patient have a diagnosis or disease condition that causes or is likely to cause pain or discomfort? The answer was marked as yes. Further review of Resident R1's admission/re-admission evaluation revealed a base line care plan for pain with an intervention to administer medication per physician's orders. Review of Resident R1's pain scale revealed on 6/23/25, at 10:51 p.m. a pain scale with advanced dementia (a pain scale where you observe signs of pain in a resident when they are unable to tell you their pain) was marked as 4 with details (observed signs of pain) of breathing score of a 2 for observations of noisy labored breathing, long period of hyperventilation, Cheyne-Stokes (an irregular breathing pattern) respiration and score of a 2 for observations of facial grimacing. Another pain scale with advanced dementia on 6/24/25, at 7:13 a.m. was marked as 4 with details of breathing score of a 2 for observations of noisy labored breathing, long period of hyperventilation, Cheyne-Stokes respiration and score of a 2 for observations of facial grimacing. Review of Resident R1's June 2025, medication administration record revealed that morphine was not given until 10:43 a.m. on 6/24/25. During an interview with Registered Nurse Employee E1, he/she revealed that it can take between 30 minutes to two hours to pull a controlled medication out of the facilities dispensing unit in the facility. He/she said that the process is to notify the physician and then the physician must speak to the pharmacist then the facility would receive a pull code (permission to remove a controlled medication from the dispensing unit). He/she expressed the time depends on the physician and pharmacist communication with each other. He/she also expressed that it may take longer depending on the day and/or time of day. During an interview on 7/25/25, at 1:00 p.m. with the Director of Nursing (DON) confirmed that the facility did not get a pull code for Resident R1's morphine until 6/24/25, at approximately 10:30 a.m. The DON confirmed that Resident R1 returned to the facility with an order for morphine on 6/23/25. The DON also confirmed that Resident R1 had a pain scale of four on two different occasions prior to the morphine being obtained and that an as needed medication should be available and administered per physician's orders. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical record review and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for one of 12 residents reviewed (Resident R2). Review of facility policy entitled Administering Medications dated 12/2/24, indicated Medications are administered in accordance with prescriber orders, including any required time frame. Review of facility policy entitled Medication Orders dated 12/2/24, indicated The prescriber is contacted by nursing for directions when delivery of a medication will be delayed, or the medication is not or will not be available. Review of Resident R2's clinical record revealed an admission date of 4/8/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), hypertension (high blood pressure), and Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R2's clinical record revealed a physician's order for caladryl external lotion 1-8% apply to rash topically two times a day for seven days dated 6/26/25. Review of his/her treatment record for the months of June and July 2025, lacked evidence that caladryl lotion was applied per physician's order. Review of nursing documentation revealed the facility was waiting delivery of the caladryl lotion from the pharmacy. During an interview on 7/25/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that there was no documented evidence that the caladryl lotion was received from the pharmacy or applied to Resident R2 per physician order. The DON also confirmed that the caladryl lotion should have been obtained from pharmacy and applied per physician order. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. code 211.12(d)(1)(3)(5) Nursing services

Based on review of employee credentials, and staff interviews, it was determined that the facility failed to ensure the employee designated as the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutritional professional, received frequently scheduled consultations from a qualified dietitian and/or failed to employ a full-time qualified dietitian since 1/7/25. Findings include: Review of the employee file/credentials the facility designated as the director of food and nutrition services revealed that he/she lacked the appropriate competencies and skills to function as the director to include any of the following: a certification for food service manager or a similar national certification for food service management and safety from a national certifying body or an associate's or higher degree in food service management or in hospitality or lacked two or more years experience in the position of food safety and completed a course study in food safety and management. There was no evidence that the facility had a dietitian functioning as a consultant for the employee designated as the director of food and nutrition services. During an interview with Director of Nursing (DON) on 3/17/25, at 10:05 a.m. the DON stated that since the company changed ownership they have not had a dietitian. During an interview with Nursing Home Administrator (NHA) on 3/18/25, at 10:50 a.m. the NHA stated that the facility has been without a dietitian on a full-time, part-time, or consulting basis since 1/7/25. 28 Pa Code 201.18(e)(1)(6) Management

Based on review of facility policy, job description, and clinical records, and staff interviews, it was determined that the facility failed to accurately and consistently assess a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment on a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for 27 of 85 Residents reviewed (Residents R1, R10, R11, R15, R20, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, and R43) Findings include: Review of facility policy dated 12/2/24, entitled Nutritional Management revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status (refers to the factors that reflect that an individual's nutritional status (includes both nutrition and hydration) is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values) in the context of his or her overall condition. The policy further stated that a comprehensive nutritional assessment will be completed by a dietitian within seven-two hours of admission, annually, and upon significant change in condition and that follow-up assessments will be completed as needed. The assessments may include, but are not limited to general appearance; height and weight; cognitive, physical, and medical conditions; food and fluid intake; evidence of fluid loos or retention; presence of persistent hunger, poor intake, or continued weight loss; review of medication list; and review of laboratory / diagnostic data. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Facility provided job description entitled Registered Dietitian Consultant revealed that he/she is responsible to ensure residents' clinical needs are provided by the food and nutrition service department. He/she will also review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan as well as assessing nutritional needs of each resident. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, pneumonia, and pressure ulcer (damage to the skin and/or underlying tissue that usually occurs over a bony prominence) to his/her right heel and sacrum that is unstageable (when the bottom of the pressure ulcer is covered in slough [debris that appears tan, yellow, green or brown in color] and/or eschar [hard plaque that's tan, brown, or black in color]. Resident R1's clinical record revealed the following weights: 1/09/25 - 149; 2/02/25 - 136.0; and 3/16/25 - 123.4. A significant weight loss of 9.26% in 17.18 % in two months. Resident R1's clinical record revealed a progress note dated 2/19/25, that indicated he/she had a new pressure ulcer located on the right heel and sacrum. Resident R1's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission, with development of a right heel and sacrum pressure ulcer, with continuous weight loss and/or throughout his/her stay at the facility at this time. Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R10's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors), flu, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Resident R11's clinical record revealed he/she was discharged to the hospital on 2/14/25, with return anticipated. Further review of Resident R11's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included osteomyelitis of the vertebra (infection of the bone), high blood pressure, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R15's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R20's clinical record revealed an admitted [DATE], with diagnoses that included metabolic encephalopathy (a condition where the brain function is disturbed temporarily or permanently due to various disease or toxins in the body), respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and high blood pressure. Resident R20's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R22's clinical record revealed an admitted [DATE], with diagnoses that included deep vein thrombosis (DVT - when a blood blot forms in a deep vein), urinary tract infection, and dementia. Resident R22's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R23's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia, COPD, and diabetes. Resident R23's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R24's clinical record revealed an admitted [DATE], with diagnoses that included dementia, high blood pressure, and anxiety. Resident R24's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, GERD, and alcohol induced cirrhosis of the liver. Resident R25's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included COPD, depression, and high blood pressure. Resident R26's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), COPD, and high blood pressure. Resident R27's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure and left side paralysis. Resident R28's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included fractured vertebra, diabetes, and anxiety. Resident R29's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included dementia, high blood pressure, and depression. Resident R30's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R31's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia, COPD, and diabetes. Resident R31's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, GERD, and depression. Resident R32's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R33's clinical record revealed an admitted [DATE], with diagnoses that included dementia, COPD, and Atrial Fibrillation (A-Fib - irregular and often rapid heart beat that can lead to stroke, heart failure, and other complications). Resident R33's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R34's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, kidney failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), glaucoma (a group of diseases that damage the optic nerve which could lead to vision loss) Resident R34's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R35's clinical record revealed an admitted [DATE], with diagnoses that included fractured vertebra, anxiety, high blood pressure. Resident R35's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident 36's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia, COPD, and anxiety. Resident R36's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included broken left hip, depression, and arthritis. Resident R37's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R38's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, COPD, and diabetes. Resident R38's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included heart attack, depression, and COPD. Resident R39's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R40's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, COPD, and diabetes. Resident R40's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included broken right leg, dementia, high blood pressure. Resident R41's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R42's clinical record revealed an admitted [DATE], with diagnoses that included kidney failure, dementia, A-Fib. Resident R42's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R43's clinical record revealed an admitted [DATE], with diagnoses that included A-Fib, diabetes, and COPD. Resident R43's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. During an interview on 3/17/25, at 10:05 a.m. the Director of Nursing stated that since the company changed ownership they have not had a dietitian. During an interview on 3/18/25, at 10:50 a.m. the Nursing Home Administrator (NHA) stated that the facility has been without a dietitian on a full-time, part-time, or consulting basis since 1/7/25. During an interview on 3/18/25, at 3:10 p.m. the NHA confirmed that there was no documented nutritional assessments for the above identified residents on admission or thereafter as required. The NHA further stated the facility has been without a dietitian since 1/07/25 and has not completed any nutritional assessments from 1/7/25 to the present on any residents. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (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 two of two residents reviewed for hospitalizations (Residents R11 and R12). Findings include: A facility policy entitled Bed-Holds and Return dated 12/2/24, indicated that prior to transfers and therapeutic leaves, that residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident R11's clinical record revealed an admission date of 1/31/25, with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors), flu, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Record review revealed that Resident R11 was transferred to the hospital on 2/14/25. The clinical record lacked evidence indicating that Resident R11 and/or their representative was provided with a copy of the facility bed-hold policy. Resident R12's clinical record revealed an admission date of 1/10/25, with diagnoses that included dementia, high blood pressure, and diabetes (condition of improper insulin/blood sugar levels) Record review revealed that Resident R12 was transferred to the hospital on 1/13/25. The clinical record lacked evidence indicating that Resident R12 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 3/17/25, at approximately 10:05 a.m. the Director of Nursing confirmed that there was no evidence to indicate that Residents R11 and R12 and/or their representatives were provided with a copy of the facility bed-hold policy upon transfers to the hospital. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 15 Residents reviewed (Resident R1). Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that a comprehensive assessment will be conducted to assist in developing person-centered care plans. It also indicated to identify current interventions and treatments and link these to problems and diagnosis they are to be treating. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, pneumonia, and pressure ulcer (damage to the skin and/or underlying tissue that usually occurs over a bony prominence) to his/her right heel and sacrum that is unstageable (when the bottom of the pressure ulcer is covered in slough [debris that appears tan, yellow, green or brown in color] and/or eschar [hard plaque that's tan, brown, or black in color]. Resident R1's clinical record revealed a progress noted dated 2/19/25, identifying pressure ulcers to his/her right heel and sacrum were discovered with physician orders dated for 2/19/25, to implement treatments to his/her right heel and sacrum. Progress notes also indicated that Resident R1 started seeing wound care consultant company on 2/28/25, for weekly wound assessments, measurements, and changes in treatments if applicable. Resident R1's clinical record lacked evidence that a care plan had been developed to address his/her actual skin integrity impairment and the presence of pressure ulcers to his/her right heel and sacrum. During an interview on 3/17/25, at 10:05 a.m. the Director of Nursing confirmed that a care plan had not been developed to address Resident R1's pressure ulcers to his/her right heel and sacrum. 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 interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 15 residents reviewed (Residents R9, R10, R8, R15, R16, R20, and R22). Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that comprehensive assessments, care planning, and the care delivery process involves collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and anxiety. Review of Resident R9's comprehensive care plan on 3/17/25, revealed that of the 39 care plans present, 37 had an outstanding target date of 2/28/25. The care plans included the problem categories of: skin breakdown related to rash, ADL [activities of daily living] care, anticoagulant therapy, aspirin therapy, adverse effected related to medications, elimination related to bowel and bladder, hydration, risk for skin integrity, risk for skin integrity related to diabetes and venous insufficiency, behaviors, coronavirus, falls, communication, pain, cardiac disease, mental status, dental, endocrine system, enhance barrier precautions, enhanced barrier precautions related to wounds, activities, paranoia, eye drops, GI distress, gastrointestinal, inappropriate behaviors, infection, hematology, adjustment, nutrition, discharge, leave of absence, advanced directive, steroid use, surgical wounds, pressure ulcers, and urinary incontinence. Review of Resident R9's comprehensive care plan on 3/17/25, revealed that of the 39 care plans present, two had no goals. The care plans included problem categories of: actual skin breakdown and safety. Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), diabetes, and high blood pressure. Review of Resident R10's comprehensive care plan on 3/17/25, revealed that of the 15 care plans present, 15 had an outstanding target date of 2/27/25. The care plans included the problem categories of: anticoagulant therapy, skin integrity, falls cardiac disease, discharge planning, diuretic use, vision, urinary incontinence, activities, nutrition, hearing, adjustment, communication, pain, and activities. During an interview on 3/17/25, at 10:50 a.m. the Director of Nursing confirmed that Residents R9 and R10's care plans were not reviewed and/or revised within the required timeframe and Resident R9's care plans lacked goals for all problem areas. Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), high blood pressure, and osteoporosis (a condition where bone strength weakens and is susceptible to breaking). Review of Resident R8's comprehensive care plan on 3/19/25, revealed that of the 30 care plans present, 30 had an outstanding target date of 2/19/25. The care plans included the problem categories of: pain, ADL's, coronavirus, falls, adverse effects, cardiac disease, urinary incontinence, bowel elimination, musculoskeletal, skin, nutrition, elopement, toileting, vision, gastrointestinal, hematological, cognitive, endocrine, activities, coping, dental, communication, mood, sleep, discharge potential, hydration, discharge planning, advanced directives, aspirin use, and respiratory. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included osteomyelitis of the vertebra (infection of the bone), high blood pressure, and anxiety. Review of Resident R15's comprehensive care plan on 3/19/25, revealed that of the 21 care plans present, 21 had an outstanding target date of 2/13/25. The care plans included the problem categories of: vision, infection of the skin, enhanced barrier precautions, skin integrity, skin breakdown, pain, indwelling catheter, falls, discharge plan, IV, activities, nutrition, aspirin use, ADL's, diuretic therapy, gastrointestinal distress, surgical wounds, side effects, cardiac disease, hydration/constipation, and risk for PI (pressure injury). Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included metabolic encephalopathy (a condition where the brain function is disturbed temporarily or permanently due to various disease or toxins in the body), pneumonia, and high blood pressure. Review of Resident R16's comprehensive care plan on 3/19/25, revealed that of the 33 care plans present, 29 had an outstanding target date of 2/5/25. The care plans included the problem categories of: skin integrity, endocrine, hematological, cardiac, urinary incontinence, pain, gastrointestinal distress, ADL's, nutrition, falls, potential for cavities, side effects from psychotropic's, elopement, cognitive loss, activities, bowels, anticoagulant, depression, communication, neurological, advances directives, falls, COVID, aspirin use, urinary tract infections, hydration, adverse effects from medications, skin integrity, and toileting. Review of Resident R16's comprehensive care plan on 3/19/25, revealed that of the 33 care plans present, four had no goals or interventions. The care plans included problem categories of: discharge potential, enhanced barrier precautions, infection - urinary tract, and safety related to hot liquids. Resident R20's clinical record revealed an admitted [DATE], with diagnoses that included metabolic encephalopathy, respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and high blood pressure. Review of Resident R20's comprehensive care plan on 3/19/25, revealed that of the 20 care plans present, 20 had an outstanding target date of 2/12/25. The care plans included the problem categories of: hearing, vision, anticoagulant, respiratory, diuretic use, cellulitis, risk for skin impairment, actual skin impairment, ADL's, discharge plan, cardiac, endocrine, steroid therapy, nutrition, advanced directive, side effects, hydration, falls, dental, and activities. Resident R22's clinical record revealed an admitted [DATE], with diagnoses that included deep vein thrombosis (DVT - when a blood blot forms in a deep vein), urinary tract infection, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Review of Resident R22's comprehensive care plan on 3/19/25, revealed that of the 15 care plans present, 15 had an outstanding target date of 3/13/25. The care plans included the problem categories of: safety, cardiac, side effects, toileting, falls, communication, enhanced barrier precautions, falls, cognitive loss, nutrition, vision, urinary incontinence, hydration, ADL's, and dental. Review of Resident R22's comprehensive care plan on 3/19/25, revealed that of the 15 care plans present, one had no interventions. The care plan included problem category of: enhanced barrier precautions. During an interview on 3/19/25, at 11:50 a.m. p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R8, R15, R16, R20, and R22's care plans were not reviewed and/or revised within the required timeframes, Resident R16's care plans lacked goals and interventions for all problem areas, and Resident R22's care plan lacked interventions for all problem areas. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, facility policies and documentation, and staff interview, it was determined that the facility failed to ensure adequate safety measures were implemented related to wheelchair transport and fall precautions for two of four residents reviewed for falls (Residents R13 and R14). Findings include: The facility was not able to provide a policy for staff to reference in the safe utilization of footrests while transporting residents via wheelchair. A facility policy entitled, Falls and Fall Risk, Managing, revised March 2018, indicated that Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included stroke, unsteady on feet, Parkinson's Disease (degenerative brain condition, meaning it causes parts of your brain to deteriorate, that causes slowed movements, tremors, balance problems and more), dysarthria and anarthria (motor speech disorder that makes it difficult to control the muscles used for speaking). Resident R13's Minimum Data Set (MDS- standardized assessment tool used to evaluate the health of nursing home residents) with an assessment reference date of 11/29/24, Section GG - Functional Abilities, GG0170S was coded as requiring partial/moderate assistance to propel his/her manual wheelchair 150 feet in a corridor or similar space. Resident R13's clinical record also revealed a departmental progress note dated 12/08/24, that indicated Resident R13 was being pushed in a wheelchair, lost his/her balance and hit right lower area of face and that the physician was notified and Resident R13 was transported to the acute hospital for evaluation and admitted . The facility investigation revealed an Interdisciplinary Team review of Resident R13's fall indicated the resident was being pushed in a wheelchair on ramp by staff and put his/her feet down and fell . During an interview on 1/07/25, at 8:39 a.m. the Nursing Home Administrator confirmed Resident R13 should have had footrests attached to his/her wheelchair while being pushed by staff. Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included prostate and bone cancer, cognitive communication deficit (condition that makes it difficult for someone to communicate due to issues with cognition), weakness, assistance with personal care, and abnormal gait and mobility. The clinical record revealed a physician's order dated 11/20/24, for a pressure alarm when in bed, a care plan intervention dated 11/20/24 for a pressure bed alarm, and a staff task to check placement and function of the bed alarm every shift and as needed, also dated 11/20/24. A departmental progress note dated 12/08/24, revealed that staff was alerted to Resident R14 falling to the floor, was bleeding out of his/her right head, and was unresponsive. It was noted that Resident R14 had a pressure alarm under him/her, but that it was not plugged in and did not alarm. Resident R14 was transported to the emergency department for evaluation. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(d)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to comprehensively address the formulation of advance directives (legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself-to include information provided oral and/or written instructions about future medical care in the event of becoming unable to express medical wishes) for two of 24 residents reviewed (Residents R4 and R36). Findings include: A facility policy entitled, Advanced Directives dated [DATE], indicated the following: -upon admission the resident and/or representative will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advanced Directive if he or she chooses to do so. - prior to or upon admission the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence of any written advanced directives. - the Social Services (or designee) will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. - the resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes to clarify and adhere to the resident's wishes. Resident R36's clinical record revealed an admitted [DATE], with diagnoses that included pervasive developmental disorder (developmental delay that affects social and communication skills), unspecified psychosis (diagnosis used when there isn't enough information to diagnose a specific psychotic disorder), difficulty speaking, and dementia with agitation. The clinical record also included a physician's order dated [DATE], that identified Resident R36 as a Full Code (medical directive that indicates that a patient wants to receive cardiopulmonary resuscitation [CPR] and all other medical treatment to save their life if their heart and lungs stop working). Further review of Resident R36's clinical record revealed that the facility failed to comprehensively address the formulation of advance directives instructions regarding his/her preferences for medical care if he/she was unable to make decisions. During an interview on [DATE], at 11:31 a.m. Registered Nurse (RN) Employee E1 confirmed there was no evidence of a POLST (Physician Orders for Life Sustaining Treatment- document that provides a structure for conversations about end-of-life issues and patient preferences for treatment as the end of life nears) or an advance directive in Resident R36's clinical record. During interviews on [DATE], at 11:35 a.m. RN Employee E1, Licensed Practical Nurse (LPN) Employee E4, and LPN Employee E3 confirmed that they would prioritize following the instructions on a POLST or advance directive, and that the POLST should be in the resident's clinical record. During an interview on [DATE], at 8:45 a.m. RN Employee E5 confirmed there was no evidence of a POLST or advance directive in Resident R36's clinical record, no evidence that advance directives were reviewed and a signature obtained from the resident or responsible party, and also confirmed that each clinical record should have one. Review of Resident R4's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hyperlipidemia (high cholesterol), and chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow). Review of Resident R4's clinical record revealed an order for Do Not Resuscitate (DNR- medical directive that indicates that a patient does not want to receive CPR. Further review of Resident R4's clinical record revealed other than an order for a DNR, there was no evidence Resident R4 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event he/she could not make decisions regarding her health care. During an interview on [DATE], at 10:46 a.m. the Director of Nursing confirmed that the facility did not have evidence of written information on advance directives for Resident R4. He/she also confirmed that Resident R4 should have written information on advance directives in his/her clinical record. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of 24 residents reviewed (Residents R17, Resident R65, and Resident R69). Findings include: Resident R69's clinical record revealed an admitted [DATE], with diagnoses that included stroke, breast cancer, and high blood pressure. Resident R69's clinical record revealed a physician's order dated 10/31/24, for a left arm sling to be worn at all times except for hygiene purposes. There was also an order dated 11/20/24, for a soft cervical (neck) collar to be applied when out of bed, in wheelchair for cervical support and improved posture, may remove for eating. Observation of Resident R69 on 12/03/24, at approximately 10:47 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. Observation of Resident R69 on 12/04/24, at approximately 9:20 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. During an interview on 12/04/24, at 9:25 a.m. the Regional Nurse Consultant confirmed that Resident R69 was not utilizing a left arm sling or soft cervical collar as physician ordered. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and hyperlipidemia (high cholesterol). During an interview on 12/02/24, at 2:00 p.m. Resident R17 revealed that he/she was to have a dermatology appointment for his/her skin rash. He/she stated that the appointment was canceled due to COVID and he/she has yet to have an appointment with dermatology. Resident R17's clinical record revealed a physician's order dated 9/05/24, to schedule Telederm (a dermatology evaluation done remotely) appointment. Resident R17's clinical record lacked evidence that the appointment was scheduled or that Resident R17 has had a dermatology appointment. During an interview on 12/04/24, at 11:52 a.m. the Director of Nursing (DON) confirmed that the Telederm appointment was never scheduled. He/she also confirmed that the appointment should have been scheduled per physician orders. Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), and hypertension (high blood pressure). Resident R65's physician orders revealed, an order dated 5/20/24, for contracture boot application to right foot/ankle to be worn at all times except for general hygiene and regular skin checks. Resident R65's care plan revealed a care plan focus of ADL (Activities of Daily Living) Self Care: with an intervention of use assistive/adaptive equipment: contracture boot to right ankle/foot dated 5/20/24. Observation made on 12/02/24, at 3:10 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot to his/her right foot/ankle. Observation on 12/02/24, at 3:22 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot on his/her right foot/ankle. Observation on 12/02/24, at 4:00 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot to his/her right foot/ankle. Observation on 12/03/24, at 11:00 a.m. revealed Resident R65 lying in his/her bed without a boot to his/her right foot/ankle. Observation on 12/04/24, at 10:32 a.m. revealed Resident R65 lying in his/her bed without a boot to his/her right foot/ankle. During observations and interview on 12/04/24, at 11:59 a.m. with the DON, he/she confirmed that Resident R65 did not have a boot on his/her right foot/ankle. He/she also confirmed that Resident R65 should have a boot on his/her right ankle as ordered by the physician. 28 Pa. Code 211.5(f)(i) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decrease in range of motion for one of two residents reviewed for range of motion (Resident R65). Findings include: Review of Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat), and Hypertension (high blood pressure). Review of Resident R65's Occupational Therapy Discharge Summary dated 1/24/24, revealed a long term goal that include: patient will safely wear a resting hand splint on left hand for up to eight hours with minimal signs or symptoms of redness, swelling, discomfort or pain. Observation made on 12/02/24, at 3:10 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/02/24, at 3:22 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/02/24, at 4:00 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/03/24, at 11:00 a.m. revealed Resident R65 lying in his/her bed with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/04/24, at 10:32 a.m. revealed Resident R65 lying in his/her bed with no resting hand splint to his/her left hand. During all above observations there was a sign on the wall in Resident R65's room at the head of bed that read Resting hand splint on at all times during day (wake up to HS) (hour of sleep). During an interview on 12/03/24, at 11:00 a.m. with the Resident R65 and his/her significant other revealed that Resident R65 should have a hand splint applied to his/her left hand during the day. Resident R65 stated that he/she cannot remember the last time his/her hand splint was applied to his/her left hand. Resident R65's significant other stated that the hand splint was laying on Resident R65's nightstand in his/her room and that there was a sign above the head of Resident R65's bed that reminded staff to apply the hand splint. Significant other stated that Resident R65 has had three different room changes and the sign above Resident R65's bed has been placed above Resident R65's bed in all three rooms. Resident R65 and significant other further expressed that Resident R65's fingers push into his/her hand which causes his/her fingernails to push into his/her skin. Resident R65 stated that he/she wants the resting hand splint to be applied. Resident R65 stated that staff never applies the hand splint. During an interview with the Director of Rehab (DOR) on 12/05/24, at 8:57 a.m. he/she revealed that when Resident R65 discharged from therapy services he/she was discharged with a resting hand splint to be applied to Resident R65's left hand for eight hours a day. DOR expressed that the process to continue resident goals after a resident is discharged from therapy is that the resident's long term goals are e-mailed to the Director of Nursing (DON) and the DON inputs the goals into the plan of care for the nursing staff. During observations and interview on 12/04/24, at 11:59 a.m. with the DON, he/she confirmed that Resident R65 did not have a hand splint to his/her left hand and a sign was posted at the head of Resident R65's bed for the hand splint to be applied. The DON also confirmed that the hand splint should be applied every day. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services