Every finding on record at Lecom at Presque Isle, Inc

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding wound treatments and showers for five of five residents reviewed (Residents R1, R2, R3, R4, and R5). Findings include: Review of facility policy entitled Activities of Daily Living (ADL), Supporting dated 10/30/25, indicated Appropriate care and services are provided for residents who are unable to carry out ADLs independently. including appropriate support and assistance with: hygiene (bathing.). Review of facility policy entitled Charting and Documentation dated 10/30/25, indicated Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided. the signature and title of the individual documenting. Review of Resident R1's clinical record revealed an admission date of 8/30/24, with diagnoses that included cerebral palsy (a brain disorder that affects a person's movement and muscle coordination caused from abnormal development or damage to the brain), chronic respiratory failure (a condition where your lungs don't exchange air properly), and gastrostomy (a surgical opening in the abdomen into the stomach). Review of Resident R1's physician orders revealed an order for a wound dressing to Resident R1's right ischium to be completed every morning and again at bedtime dated 2/12/26. Review of Resident R1's treatment record for the month of March 2026, lacked documentation that a wound dressing was completed to his/her right ischium on 3/1/26, 3/2/26, 3/3/26, 3/5/26, 3/7/26, 3/9/26, 3/10/26, 3/13/26, 3/16/26, 3/18/26, 3/19/26, 3/20/26, 3/22/26, 3/23/26, 3/24/26, 3/26/26, 3/27/26, 3/28/26, and 3/29/26. Review of Resident R1's bathing task (an area in point of care where the nursing assistants document showers) revealed a task for bathing Wednesday and Sunday on the day shift. Review of his/her bathing task for the month of March 2026, lacked documentation that a bath was provided on 3/1/26, 3/4/26, and 3/8/26. Review of Resident R2's clinical record revealed an admission date of 10/14/25, with diagnoses that included hypertension (high blood pressure), chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), and fusion of spine lumbar region (surgical procedure on lower spine). Review of Resident R2's physician orders revealed an order for a wound dressing to Resident R2's coccyx to be completed every day shift dated 2/26/26. Review of Resident R2's treatment record for the month of March 2026, lacked documentation that a wound dressing was completed to his/her coccyx on 3/3/26, 3/6/26, 3/7/26, 3/8/26, 3/9/26, 3/10/26, 3/15/26, 3/16/26, 3/18/26, 3/19/26, 3/20/26, 3/22/26, 3/24/26, 3/25/26, 3/26/26, 3/28/26, and 3/29/26. Review of Resident R2's bathing task revealed a task for bathing Wednesday and Saturday on the evening shift. Review of his/her bathing task for the month of March 2026, lacked documentation that a bath was provided on 3/4/26, 3/11/26, and 3/18/26. Review of Resident R3's clinical record revealed an admission date of 6/18/24, with diagnoses that included chronic respiratory failure, multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction.), and hypertension. Review of Resident R3's bathing task revealed a task for bathing Wednesday and Saturday on the evening shift. Review of his/her bathing task for the month of March 2026, lacked documentation that a bath was provided on 3/13/26, 3/21/26, and 3/24/26. Review of Resident R4's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and quadriplegia (a condition where a person is paralyzed and unable to move their body from the neck down). Review of Resident R4's bathing task revealed a task for bathing Wednesday and Saturday on the evening shift. Review of his/her bathing task for the month of March 2026, lacked documentation that a bath was provided on 3/4/26, 3/11/26, 3/14/26, 3/18/26, and 3/21/26. Review of Resident R5's clinical record revealed an admission date of 12/27/24, with diagnoses that included spina bifida (a birth defect that occurs when the spine and spinal cord don't form properly), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes. Review of Resident R5's physician orders revealed an order for a wound dressings to resident R5's left ischium dated 3/14/26, and right sacrum dated 3/18/26 to be completed every day shift. Review of Resident R5's treatment record for the month of March 2026, lacked documentation that a wound dressing was completed to his/her left ischium on 3/16/26, 3/18/26, 3/19/26, 3/20/26, 3/23/26, 3/25/26, 3/26/26, and 3/28/26, and lacked documentation that a wound dressing was completed to his/her right sacrum on 3/19/26, 3/20/26, 3/23/26, 3/25/26, 3/26/26, and 3/28/26. During an interview on 3/30/26, at 2:10 p.m. the Nursing Home Administrator in training confirmed that Resident's R1, R2, R3, R4's and R5's clinical records did not have complete documentation regarding wound dressing changes and/or showers. He/she also confirmed that wound dressing changes and showers should be done as ordered/scheduled in the Resident's clinical record and documented when completed. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide enteral nutrition (a method for providing nutritional needs via tube feeding) and hydration in accordance with physician's orders for one of two residents reviewed (Resident R1).Findings include: Review of facility policy entitled Enteral Tube Feeding via Continuous Pump dated 10/30/25, indicated Check the enteral nutrition label against the order before administration. Check the following information: Rate of administration (mL/hour). Review of Resident R1's clinical record revealed an admission date of 8/30/24, with diagnoses that included cerebral palsy (a brain disorder that affects a person's movement and muscle coordination caused from abnormal development or damage to the brain), chronic respiratory failure (a condition where your lungs don't exchange air properly), and gastrostomy (a surgical opening in the abdomen into the stomach). Review of Resident R1's physician's orders revealed an order for Enteral Feed Order every shift for at risk malnutrition Enteral: Pump Feeding: Peptamen AF [feeding solution] at 55cc [cubic centimeters] /HR [hour] dated 12/31/25, and another order for Enteral Feeding Order every shift Enteral: Hydration Flush: 70cc/HR X [times] 24 hours day continuous dated 12/31/25. Observations on 3/23/26, at 10:30 a.m., 12:30 p.m., and 1:25 p.m. revealed Resident R1 was lying in his/her bed with his/her enteral feeding being administered through his/her gastrostomy tube (g-tube - a tube inserted through a small incision in the abdomen into the stomach, used for the administration of liquid nutrition and medications) with his/her feeding set at 50 cc/hr and his/her hydration flush set at 80 cc/hr. During an interview on 3/23/26, at 1:30 p.m. Registered Nurse (RN) Employee E1 confirmed Resident R1's enteral feeding was set at 50 cc/hr and his/her hydration flush was set at 80 cc/hr. RN Employee E1 confirmed that Resident R1's enteral feeding and hydration flush were not in accordance with Resident R1's physician orders, and that Resident R1's enteral feeding and hydration flush should be set per physician orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy, review of facility and clinical records, and staff interviews, it was determined that the facility failed to provide a weekly bath/shower for four of six residents reviewed (Residents R1, R2, R3, and R4). Findings include: Review of a facility policy entitled, Resident Self determination and Participation, dated 10/30/25, revealed Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or his interests, values, assessments and plans of care, including: a daily routine, such as sleeping and waking, eating, exercise and bathing schedules. Resident Council minutes dated 12/16/25, revealed new business resident concerns as Showers are not being offered as scheduled. Resident's R1's clinical record revealed an admission date of 4/06/24, with diagnoses that included lumbar spina bifida without hydrocephalus (a condition that occurs when the spine and spinal cord don't form properly during early fetal development), diarrhea, diabetes mellitus (a chronic condition where blood sugar levels are too high), and respiratory failure (a condition when the respiratory system cannot provide enough oxygen or take out carbon dioxide from the blood). Review of Resident R1's bath/shower documentation for 1/06/26, through 2/02/26, revealed no bath/shower was provided except on 1/11/26, 1/18/26, and 2/1/26, resulting in evidence of only three showers/baths provided during 28 day time-period. Resident's R2's clinical record revealed an admission date of 2/21/22, with diagnoses that included respiratory failure with hypoxia (.low oxygen in the blood), epilepsy (a brain disorder that causes seizure), hyponatremia (low sodium levels in the blood), and hypokalemia (low potassium levels in the blood). Review of Resident R2's bath/shower documentation for 1/06/26, through 2/02/26, revealed 1/10/26, Response not required. 1/16/26, as Bed bath.1/20/26, Response not required. 1/23/26, as Bed bath.1/24/26, as Shower.1/27/26, progress note stating shower provided.2/01/26, Response not required. 2/02/26, Response not required This resulted in evidence of only two showers/baths provided during 28 day time-period for Resident R2. Resident's R3's clinical record revealed an admission date of 5/01/24, with diagnoses that included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy [a group of neurological disorders affecting movement and muscle tone caused by abnormal brain development during fetal development or damage during or after birth] that affects the body's extremities and body), chronic respiratory failure, vitamin deficiency, and epilepsy. Review of Resident R3's bath/shower documentation for 1/06/26, through 2/02/26, revealed 1/07/26, as Bed bath.1/14/26, as Bed bath. 1/17/26, as Bed bath.1/21/26, as Bed bath.1/28/26, as Bed bath, This resulted in evidence of no showers/baths provided during 28 day time-period for Resident R3. Resident's R4's clinical record revealed an admission date of 8/30/24, with diagnoses that included cerebral palsy, chronic respiratory failure with hypoxia, asthma (a respiratory disease that causes the airways to narrow and swell resulting in shortness of breath or other respiratory symptoms), and myopathy (a disease of the skeletal muscles). Resident R4's bath/shower documentation for 1/07/26, through 2/02/26, revealed bed baths were provided, however no evidence that he/she received a bath/shower during 28 day time-period. During an interview on 2/05/26, at 11:54 a.m. the Nursing Home Administrator confirmed that the facility did not provide baths/showers according to residents' preference for the period of 1/06/26, through 2/02/26, for the above identified residents. 28 Pa. Code 211.10 (d) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for seven of 28 residents reviewed (Residents R4, R8, R11, R28, R37, R62, and R126). Findings include: A facility policy entitled Care Plans - Baseline dated 10/30/25, revealed The resident and/or representative are provided a written summary of the baseline care plan. Resident R4's clinical record revealed an admission date of 9/08/25, with diagnoses that included muscle wasting and atrophy (loss of muscle often due to inactivity or aging), elevated white blood count (increased infection fighting cells in your body that fight an infection and/or inflammation or a disorder of the white blood cells), dysphagia (difficulty swallowing), and hyperlipidemia (high level of fats like cholesterol in the blood). Resident R4's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R4 and/or his/her representative. Resident R8's clinical record revealed an admission date of 11/16/25, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia. Resident R8's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R8 and/or his/her representative. Resident R11's clinical record revealed an admission date of 11/4/25, with diagnoses that included depression, anxiety, and dysphagia. Resident R11's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R11 and/or his/her representative. Resident R28's clinical record revealed an admission date of 9/24/25, with diagnoses that included dependence on supplemental oxygen (uses oxygen on routine bases due to breathing), hypertension (high blood pressure). Resident R28's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R28 and/or his/her representative. Resident R37's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes mellitus (where the body either doesn't produce enough insulin or doesn't use the insulin efficiently), long term drug therapy, agranulocytosis (low levels of granulocytes which are a type of white blood cell, infection fighting cell), and asthma (a chronic lung disease caused by inflammation of the airways). Resident R37's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R37 and/or his/her representative. Resident R62's clinical record revealed an admission date of 11/1/25, with diagnoses that included muscle wasting and atrophy, pain, and restless legs syndrome. Resident R62's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R62 and/or his/her representative. Resident R126's clinical record revealed an admission date of 5/16/25, with diagnoses that included end stage renal disease (final stage of kidney disease where the kidney function has failed), hyperlipidemia, muscle wasting and atrophy, and diabetes mellitus. Resident R126's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R126 and/or his/her representative. During an interview on 1/07/26, at approximately 2:12 p.m. the Regional Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R4, R8, R11, R28, R37, R62, and R126 and/or their representatives. 28 Pa. Code 211.10(c) Resident Care Plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of facility policy and facility records, observations, and resident and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature for one of one test trays completed. Findings include: A current facility policy entitled, Food And Nutritional Services revealed food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Resident Council and food committee minutes from 10/27/25, 11/20/25 and 12/18/25, all revealed that food was being served cold and frequently without the items that have been ordered by residents. Interviews conducted on 1/5/26, with Residents R1, R31, R62, and R111, revealed that the food is frequently served cold. Review of temperature logs completed by kitchen staff on 1/6/26, revealed the following lunch meal temperatures were obtained prior to the food leaving the kitchen: Pork 145 degrees Fahrenheit (F)Broccoli 169 degrees FNoodles 132 degrees F Observations on 1/6/26, at approximately 12:45 p.m. in the main kitchen revealed that the Northwest Hall Cart the kitchen was prepared with a test tray prepared last and placed on the cart. The Dietary Manager escorted the cart to the Northwest Hall. All the items including pork, broccoli, noodles, and milk were tasted from the test tray upon delivery to the Northwest Hall. The milk on the tray was warm to taste, the broccoli was a mushy texture, the noodles were dry and had crusty sections on them, and the pork had some hard pieces within the meat that did not have an appetizing feel to the texture. All food items at the time of the test tray were not palatable due to cool temperatures. Dietary Manager Employee E1 was present during the test tray and the results including the unacceptable temperatures and poor palatability at the time of the tray testing were discussed with the employee. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened; failed to ensure expired medications were discarded in a timely manner; and failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator in two of three medication carts reviewed and one of two medication rooms reviewed (Northwest Medication Cart, Southwest Medication Cart, and North Medication Room).Findings include: A facility policy entitled, Medication Labeling and Storage dated 10/30/2025, revealed, Controlled medications and other drugs subject to abuse are separately locked in permanently affixed compartments .Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Aspart insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened, vials and pre-filled pens should be discarded after 28 days. Observation on 1/5/26, at 3:00 p.m. of the Northwest Medication Cart revealed three open injector pens of Lantus and two open injector pens of Aspart without an open date, this was witnessed and confirmed at that time by Licensed Practical Nurse (LPN) Employee E3. Observation on 1/5/26, at 3:11 p.m. of the Southwest Medication Cart revealed an opened Humalog vial, an opened injector pen of Humalog, an opened injector pen of Lantus, and an opened injector pen of Aspart without an open date. Additionally, there was an opened injector pen of Lantus with an open date of 9/20/25, therefore the medication was expired. This was all witnessed and confirmed at that time by LPN Employee E4. Observation on 1/5/26, at 3:17 p.m. of the North Medication Room refrigerator revealed the separately locked container for controlled scheduled II-V medications was attached to a removeable shelf, therefore it was not permanently affixed to the refrigerator. This was witnessed and confirmed at that time by the Registered Nurse Supervisor Employee E5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of facility policies, job descriptions, clinical records, resident council minutes and grievances, observations, and resident and staff 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 13 of 28 residents reviewed (Residents R1, R8, R31, R36, R37, R62, R77, R86, R92, R101, R106, R107 and R111). Findings include: Review of facility policy entitled Answering the Call Light dated 10/30/25, revealed The purpose of this procedure is to ensure timely responses to the resident's request and needs. and Answer the resident call system immediately. Review of facility policy entitled Activities of Daily Living (ADL), Supporting dated 10/30/25, revealed appropriate care and services are provided for residents who are unable to carry out ADLs. including appropriate support and assistance with: bathing, dressing, grooming, transfer, ambulation, toileting, dining, and eating. Review of facility job descriptions for a Nursing Assistant (NA) revealed, The C.N.A. - Certified Nurse Aide provides resident centered care in accordance with policy and procedures. and addressing resident needs and concerns., Responds to call bells promptly., Assist residents with the activities of daily living including but not limited to; bathing, dressing, dining, transportation; Must show respect for residents., Must respect all resident rights. Interviews during the Resident Council meeting on 1/6/25, between 11:00 a.m. and 12:00 p.m., revealed five out of five alert and oriented residents R37, R77, R92, R101, and R106, in attendance all five stated that their call bells are not being answered in a timely manner, between 30 minutes to one and a half hours to be answered. All five residents stated when they request a snack they have waited hours to receive a snack if they get one at all. All five residents stated that their beds do not get made even after they have requested that their beds be made. All five stated that their meals being delivered are always late. All five residents stated that what they receive on their meal tray does not match their meal ticket. Review of Resident Council minutes over three months from October, November and December of 2025, revealed the following: October 2025 Resident Council minutes revealed nine residents in attendance stated that snacks are not being passed, and ice water is not being passed. November 2025 Resident Council minutes revealed seven residents in attendance stated that they are not receiving showers and snacks are not being passed. December 2025 Resident Council minutes revealed six residents in attendance stated that showers are not being given as scheduled. Review of the grievance logs from October, November, and December of 2025, revealed grievances related to care, call bell response, not receiving showers, meals choices/concerns, getting out of bed, and receiving snacks. Interview with Resident R86 on 1/5/26, had concerns with not receiving what he/she had ordered on their meal tray and when Resident R86 asked to get what they had ordered it would take 30 to 45 minutes if he/she got it at all. Interview with Resident R107 on 1/5/26, had concerns with wanting to get up early in the morning. Resident R107 stated that the staff would tell him/her that they could not get them up. Resident R107 also had concerns with their call bell being answered timely. He/she stated that it can take between 30 to 45 minutes to be answered. Interview with Resident R31 on 1/5/26, had concerns with getting their shower on the scheduled day. Resident R31 stated that he/she had to wait until another day because staff would tell him/her they did not have time or a shower chair. Interview with Resident R8 on 1/5/26, had concerns with their call bell being answered timely. Resident R8 stated that he/she was on a bed pan for 40 minutes waiting for their call bell to be answered. Interview with Resident R1 on 1/5/26, had concerns with their call bell being answered timely. Resident R1 stated that it can take between one to two hours to be answered. Resident R1 also stated that when he/she receives their meal tray that the food is cold. Interview with Resident R62 on 1/5/26, had concerns with their call bell being answered timely. Resident R62 stated that it can take between one to two hours to be answered. He/she also stated that when they receive their meal tray that the food is cold. Interview with Resident R111 on 1/5/26, had concerns with his/her call bell being answered timely. Resident R111 stated that it can take between one to two hours to be answered. Interview with Resident R77 on 1/05/26, at 1:30 p.m. revealed concerns with their bed not made daily per his/her desire. Resident R77 at the time of interview was observed out of bed in their wheelchair and the bed without linen on the mattress. Further observations on 1/05/26, at 2:45 p.m. and 3:30 p.m. and 1/06/26, at 2:15 p.m. revealed no linen on Resident R77's mattress. Assistant Director of Nursing Employee E7 on 1/06/26, at 2:30 p.m. confirmed that Resident R77's bed was not made for two days, and the facility failed to provide sufficient services for the resident's physical and mental well-being. Interview with Resident R36 on 1/05/26, at 1:35 p.m. revealed concerns with call bell response times, receiving ice, water, and snacks daily, and having his/her bed made per their desire. Resident R36 was observed out of bed in his/her wheelchair awaiting the bed to be made on 1/05/26, at 1:35 p.m.; the bed was observed with no linen on the mattress. Resident R36 indicated that he/she had been waiting all day to get the bed made and just wanted to lay down. Resident R36 further indicated that at times, he/she waits over two hours to get assistance for incontinence care. Resident R36 also indicated that he/she requested to have ice water a few days earlier, and staff told him/her that the ice machine was broken, and there was no ice. Later that day, Resident R36 further indicated that a nurse gave him/her ice and said that the ice machine was never broken. Resident R36 also had concerns with staff providing a snack per their desire. Resident R36 indicated that staff at times will just say there are no snacks available if they don't want to get one for him/her, the same as with the ice. During an interview on 1/08/26, at approximately 10:30 a.m. the Nursing Home Administrator (NHA) confirmed that residents have concerns related to call bells, receiving snacks, beds being made, getting out of bed, receiving showers, and receiving meals late that are cold and not what is on the resident's meal ticket. The NHA also confirmed that all resident concerns should be addressed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding care for a foley catheter (a medical device that drains urine from the bladder) for one of two residents reviewed with foley catheters (Resident R111).Findings include: Review of a facility policy entitled Charting and Documentation dated 10/30/25, revealed, All services provided to the resident , progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Treatment or services performed. Resident R111's clinical record revealed an admission date of 5/23/25, with diagnoses that included paraplegia (paralysis affecting the lower half of the body), pain, and muscle wasting and atrophy. Review of Resident R111's physician's orders dated 11/29/25, revealed an order for foley catheter care every shift. Resident R111's Treatment Administration Record for December 2025, revealed the entire month 12/1/25, through 12/31/25, lacked documentation indicating the foley catheter care was completed per physician orders. During an interview on 1/7/26, at 2:18 p.m. the Regional Director of Nursing confirmed that Resident R111's treatment records did not have complete documentation regarding foley catheter care. 28 Pa. Code 211.5(f)(xiii)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of six residents reviewed (Residents R28 and R68).Findings include: Review of facility policy dated 10/30/25, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order. for oxygen administration. Review of facility policy dated 10/30/25, entitled Departmental (Respiratory Therapy) - Prevention of Infection indicated Wash filters from oxygen concentrators every seven days with soap and water. Review of Resident R28's clinical record revealed an admission date of 9/24/25, with diagnoses that included dependence on supplemental oxygen (uses oxygen on routine bases due to breathing), and hypertension (high blood pressure). Review of Resident R28's care plan revealed a care plan for altered respiratory status with an intervention for oxygen at 3L/min (liters per minute) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) continuously. Review of Resident R28's physician orders revealed an order dated 9/24/25, for oxygen at 3L/min via nasal cannula continuous. Observations on 1/5/26, at 2:00 p.m. and again on 1/6/26, at 8:53 a.m. revealed Resident R28 sitting in his/her wheelchair with supplemental oxygen in place and running. Observation of the concentrator filters to bilateral sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering bilateral filters. Review of Resident R68's clinical record revealed an admission date of 9/11/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), shortness of breath, and hypertension. Review of Resident R68's care plan revealed a care plan for respiratory distress requiring oxygen use with interventions for oxygen at 2L/min via nasal cannula as needed, and oxygen concentrator filter cleaning weekly. Review of Resident R68's physician orders revealed orders dated 8/15/25, for oxygen at 2L/min inhalation as needed, and oxygen concentrator filter cleaning weekly. Observations on 1/5/26, at 1:54 p.m., and again on 1/6/26, at 8:52 a.m. revealed Resident R68 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set a 4L/min. Further observation of the concentrator filters to bilateral sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering bilateral filters. During an interview on 1/6/26, at 1:11 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that Resident R68's oxygen concentrator was on and set at 4L/min and was not in accordance with the physician's order dated 8/15/25, for oxygen at 2L/min. LPN Employee E6 also confirmed that the filters to the bilateral sides of the oxygen concentrators for Residents R28 and R68 were covered in a gray fluffy substance, and the filters should be clean per physician orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records and resident and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 28 residents reviewed (Resident R37). Findings include: Review of a facility policy entitled Catheter Care, Urinary dated 10/30/25, revealed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Maintaining Unobstructed Urine Flow - Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Resident R37's clinical record revealed an admission date of 4/30/25, with diagnoses that included diabetes mellitus (where the body either doesn't produce enough insulin or doesn't use the insulin efficiently), long term drug therapy, agranulocytosis (low levels of granulocytes which are a type of white blood cell, infection fighting cell), and asthma (a chronic lung disease caused by inflammation of the airways). Resident R37's Treatment Administration Record (TAR) revealed a physician order dated 12/12/25, Irrigate Supra pubic cath (SP - catheter placed through a small incision in lower abdomen into the bladder to drain urine) daily with 60 cc [cubic centimeters] of normal saline - Instill and pull back everyday shift for maintenance care of SP cath. Resident R37's TAR lacked evidence that Resident R37's catheter was flushed daily between 12/01/25, and 12/31/25, 1/02/26, and 1/06/26. An interview with Resident R37 on 1/06/26, at 11:15 a.m. revealed that his/her SP catheter was not flushed daily per physician order. An interview with the Regional Director of Nursing on 1/07/26, at 3:00 p.m. confirmed that Resident R37's clinical record lacked evidence of his/her SP catheter being flushed daily per the physician order, and the facility failed to provide appropriate treatment and services regarding Resident R37's catheter. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R11). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 10/30/25, revealed non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Review of Resident R11's clinical record revealed an admission date of 11/4/25, with diagnoses that included depression, anxiety, and dysphagia (difficulty swallowing). The clinical record revealed that on 12/26/25, Resident R11's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.25 milliliters (ml) every 2 hours PRN for anxiety. Review of Resident R11's January 2026 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used on 1/1/26, 1/2/26, 1/3/26, and 1/5/26. Resident R11's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in January 2026. During an interview on 1/7/26, at 1:02 p.m. the Director of Nursing confirmed that Resident R11's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of five units observed (South Wing).Findings include: Review of facility policy entitled Cleaning and Disinfecting Residents' Rooms dated 10/30/25, indicated Clean curtains. when they are visibly soiled or dusty. Observations on 1/5/26, at 2:00 p.m., of the South Wing in room [ROOM NUMBER] revealed a privacy curtain pulled between the residents' beds. On the privacy curtain were several areas of a dark brown substance which appeared to be feces. Observations on 1/6/26, at 9:00 a.m. and again at 1:11 p.m. of room [ROOM NUMBER]'s privacy curtain revealed the dark brown substance remained on the curtain. During an interview on 1/6/26, at 1:15 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the privacy curtain in resident room [ROOM NUMBER] had several areas of a dark brown substance on it. LPN Employee E6 also confirmed that the privacy curtain should have been cleaned. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of the Resident Assessment Instrument (RAI) User's Manual (provides instructions and guidelines for completing required Minimum Data Set [MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care] assessments), dated October 2024, and clinical records, and staff interview, it was determined that the facility failed to make certain that MDS assessments were completed in the required time frame for four of sixteen residents reviewed (Resident R1, R2, R8, and R13). Findings include: Review of the Long-Term Care Facility RAI User's manual, revealed that for an admission MDS, the MDS completion date, and the Care Area Completion Date is to be completed no later than 14 calendar days following admission (admission date plus 13 calendar days), and the Care Plan Decision Date is to be the Care Area Completion Date plus 7 calendar days. The RAI manual further revealed that for a quarterly MDS, the MDS completion date is the Assessment Reference Date (ARD) plus 14 calendar days and for a discharge return anticipated MDS, the MDS completion date is the discharge date plus 14 calendar days. Resident R1 was admitted to the facility on [DATE], with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), traumatic brain injury - (TBI - brain injury cause by an outside force that may result in permanent or temporary impairment in physical and/or mental functioning), and Seizures. Resident R1 had an admission MDS with an ARD of 5/20/25. The MDS completion date and Care Area Completion date were due 5/27/25, and the Care Plan Decision date was due 6/2/25. The MDS completion date, Care Area Completion date, and Care Plan Decision date were all signed off as completed on 6/18/25, twenty-two and fifteen days after their due date, respectively. Resident R2 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), lung Cancer, and high blood pressure. Resident R2 had a quarterly MDS with an ARD of 5/19/25. The MDS completion date was due 6/2/25. The MDS completion date was signed off as completed on 6/18/25, sixteen days after the due date. Resident R8 was admitted to the facility on [DATE], with diagnoses that include dementia (loss of cognitive functioning affecting a persons memory and behaviors), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. Resident R8 had an admission MDS with an ARD of 5/14/25. The MDS completion date and Care Area Completion date were due 5/21/25, and the Care Plan Decision date was due 5/28/25. The MDS completion date, Care Area Completion date, and Care Plan Decision date were all signed off as completed on 6/18/25, twenty-eight and twenty-one days after their due date, respectively. Resident R13 was admitted to the facility on [DATE], with diagnoses that included COPD, 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 R13 had a discharge return anticipated MDS with an ARD of 5/20/25. The MDS completion date was due 6/3/25. The MDS completion date was signed off as completed on 6/18/25, or fifteen days after the due date. Resident R13 had another discharge return anticipated MDS with an ARD of 5/30/25. The MDS completion date was 6/13/25. The MDS completion date was signed off as completed on 6/18/25, or five days after the due date. During a telephone interview on 6/18/25, at 4:16 p.m. Nursing Home Administrator confirmed the facility failed to make certain that MDS assessments were completed within the required time frame for four of sixteen residents reviewed as identified above. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and in accordance with physician's orders for five of 23 residents reviewed (Residents R4, R40, R75, R95 and R205). Findings include: A facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen to breathe) dated 10/28/24, revealed to not run concentrator with a dusty filter. A facility policy entitled, Oxygen Therapy dated 10/28/24, revealed that humidification (process that adds moisture to oxygen therapy to prevent a dry, irritated respiratory tract) for patient comfort may be provided at any flow rate and whenever specifically ordered by the physician. A facility policy entitled, Oxygen Therapy via Nasal Cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) dated 10/28/24, revealed to verify physician's order, attach the humidifying device, if liter flow is 4 or greater or upon resident request, and change the prefilled bottle humidifier when low or at least weekly. Resident R4's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), heart disease, heart failure, myopathy (disease that affects the muscles that control voluntary movement). Resident R4's clinical record lacked evidence of a physician's order/treatment to provide humidification to his/her supplemental oxygen and clean the concentrator filter. Observation on 1/11/25, at 2:25 p.m. revealed Resident R4's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance and the prefilled humidifier bottle attached to the oxygen tubing and secured to the external surface of the concentrator was empty. Observation on 1/12/25, at 11:53 a.m. revealed Resident R4's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface and a full prefilled humidifier bottle was sitting on the floor. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around, and that the humidification bottle should not have been resting on the floor. During an interview on 1/12/25, at 1:56 p.m. the Regional Director of Nursing confirmed Resident R4's clinical record lacked evidence of a physician's order to provide humidification and an order on the Treatment Administration Record (TAR) for cleaning the oxygen concentrator filter was not identified. Resident R40's clinical record revealed an admitted [DATE], with diagnoses that included blood clots in the legs, dependence on supplemental oxygen, stroke with paralysis, pleural effusion (condition where too much fluid builds up in the area between the lungs and chest wall). Resident R40's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:00 p.m. revealed Resident R40's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:50 a.m. revealed Resident R40's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observtion on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R75's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, dependence on supplemental oxygen, blood clots in the legs, disorders of diaphragm (trauma, tumors, or other conditions that affect the diaphragm muscle and make it difficult to breathe). Resident R75's January 2025 TAR indicated that the oxygen concentrator was scheduled to be cleaned on 1/12/25, at 7:00 p.m. Observation on 1/11/25, at 3:10 p.m. revealed Resident R75's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:55 a.m. revealed Resident R75's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R95's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, dependence on supplemental oxygen, alcoholic cirrhosis of liver (severe form of liver disease that occurs when the liver is permanently scarred from excessive alcohol consumption), myopathy. Resident R95's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:20 p.m. revealed Resident R95's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:53 a.m. revealed Resident R95's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R205's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, heart disease, chronic obstructive pulmonary disease (COPD- ongoing lung disease limits airflow into and out of the lungs). Resident R205's TAR lacked evidence of a treatment to clean the concentrator filter. Observation on 1/11/25, at 2:30 p.m. revealed Resident R205's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:58 a.m. revealed Resident R205's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(i)(viii) Medical records

Based on observations, review of facility policy, and staff interview it was determined that the facility failed to maintain a clean, homelike environment for two of 12 residents reviewed (Residents R1 and R2). Findings include: Review of a facility policy entitled Daily Resident Room and Bathroom Cleaning dated 10/10/23, indicated, Check privacy curtains and spot clean as needed. Observations of Resident R1's room on 8/8/24, at approximately 12:50 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. Observations of Resident R2's room on 8/8/24, at approximately 12:55 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance. During an interview on 8/8/24, at 1:25 p.m. the Assistant Director of Nursing confirmed that the privacy curtains in Resident R1's and R2's rooms were heavily soiled with a brown colored substance and that the privacy curtains should have been cleaned or replaced. 28 Pa. Code 201.18 5(e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and facility documents, and staff and resident interviews, it was determined that the facility failed to ensure that the residents were offered snacks at bedtime daily for four of four nursing units. Findings include: Review of facility policy entitled Resident Nourishments, with a policy review date of 10/30/2023, revealed Nourishments will be provided in addition to regular meals in order to promote high levels of nutritional intake. These items are located in the pantries. At any time, residents can request food from the kitchen or direct care staff. When kitchen staff are not available, the direct care staff can access food if it is not in the pantry. Review of meal times revealed that breakfast is delivered to the first hallway at 7:35 a.m. and dinner delivered to the first hallway at 4:35 p.m., which is fifteen hours between meals. The facility must provide meals within 14 hours unless a nourishing snack is served. During a resident council meeting held on 2/14/2024, at 1:00 p.m. there were seven cognitively intact residents that regularly attend resident council meetings. The residents were asked if the facility offers them snacks in the evening. The residents responded that the kitchen area is stocked with snacks after dinner, you have to get what you want right away or else they are out of snacks. If you try to request a snack, staff are either too busy or you have to wait long periods of time to get what you want. Sometimes they forget and you don't get anything. Residents who can't request a snack do not get one. Observation of the snack cabinets on 2/15/24, at 9:30 a.m. in the dining area revealed snacks were available for resident consumption. It was observed that the pantry doors were unlocked, and snacks were available for residents to take when they wanted. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), on 2/15/2024, at 8:45 a.m. they confirmed that the facility does supply and stock snacks to residents in the kitchen area. Residents have to obtain them themselves if they are able to go to the kitchen area, or wait for staff assistance to request a snack from staff members. It was confirmed that snacks are not offered or delivered to all residents by staff members routinely. Residents unable to request or obtain a snack themselves do not get snacks. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (North medication room) and one of five medication carts (South medication cart). Findings include: Observation on 2/14/2024, at 9:45 a.m. in the North medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded. At the time of the observation, the Registered Nurse Supervisor Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing (DON) confirmed on 2/15/2024, at 9:45 a.m. the PPD vial should have been identified with an open date to indicate after 30 days of use, the vial would be discarded. Observation on 2/14/2024, at 3:10 p.m. of the South medication cart, revealed an opened Humalog insulin pen without an open date marked on the pen. A review of the drug manufacturer leaflet indicated a Humalog insulin pen which has been entered and in use for 28 days should be discarded. At the time of the observation, the Licensed Practical Nurse Employee E2 confirmed the insulin pen was opened, undated and not dated to indicate when the medication should be discarded. The DON confirmed on 2/15/2024, at 9:45 a.m. the insulin pen should have been identified with an open date to indicate after 28 days of use, the insulin pen would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, and staff interviews, it was determined that the facility failed to reorder medications in a timely manner for one of three residents reviewed for medication administration (Resident R61). Findings include: Review of Resident R61's clinical record revealed an admitted [DATE], with diagnoses that included acute respiratory failure, cognitive communication deficit, Alzheimer's disease, dementia, major depressive disorder, anxiety disorder, undue concern and preoccupation with stressful events, and age related physical debility. Review of Resident R61's clinical record revealed a physician's order with a start date of [DATE], for Lorazepam tablet 0.5 milligrams (mg) give 1 tablet by mouth three times a day for anxiety disorder for 180 days. This order expired on Monday [DATE], and was not reordered until [DATE], at 8:00 p.m. for Ativan tablet 0.5 mg (Lorazepam) give 1 tablet by mouth three times a day for related anxiety for 180 days. Resident R61 missed six doses of the medication. The facility could not produce a policy regarding timeliness of reordering expired medication orders. During an interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed that Resident R61 missed six doses of the medication Ativan for anxiety between [DATE] and [DATE]. The medications were not reordered in a timely manner after the order expired. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 201.18 (d)(3) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide medication administration in a manner that enhanced resident dignity for one of eight residents observed (Resident R61). Findings include: Review of the facility policy entitled, Resident Privacy dated as last reviewed 1/2/23, indicated that all residents will be examined and treated in the privacy of their own room or a private examination room. No residents will be assessed in a public space. Observation of medication pass on 3/14/23, at 4:20 p.m. revealed that Resident R61 received medications from Licensed Practical Nurse (LPN) Employee E1, in the hallway while sitting in a wheelchair by the nurses station. While Resident R61 was trying to take the medications he/she was having trouble swallowing them and needed multiple sips of water. Another resident passing by assisted Resident R61 with a drink to help with swallowing the medications. After the medications were administered, an interview was conducted on 3/14/23, at 4:28 p.m. with LPN Employee E1 who confirmed that it would have been more appropriate to administer the medications for Resident R61 in his/her room or a private area to ensure resident dignity. During an interview on 3/16/23, at 1:00 p.m. the Director of Nursing confirmed that Resident R61 should not have had his/her medications administered in the middle of a busy hallway with other residents and passers by present to observe and that residents should receive medications and care in a private area to maintain dignity and respect. 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.10 (c) (d) Resident care policies 28 Pa. Code 2121.12 (d) (3) (5) Nursing services

Based on observations, a review of facility policy, clinical records, and staffing schedules, and resident, family, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 14 of 20 North Hall residents reviewed. Findings include: A review of facility policy entitled Use of Call Bell System dated 1/01/22, stated Answer all call bells in a timely and courteous manner. NEVER make the resident feel you are too busy to give assistance, offer further assistance before you leave room. A review of Resident Council minutes dated 5/20/22, and 6/16/22, stated, Residents expressed that they are waiting a long time for call bells to be answered. Residents noticed several of staff are working extra and are tired and crabby towards the residents. Residents notice that there are not enough nurses, nurse aides and respiratory therapists to cover all the shifts (specifically second and third shift). One resident expressed that she notices the attitudes of the nurses and nurse aides change when there is a call off, they become rude. During resident and family interviews on the North Hall on 8/18/22, from 12:00 p.m. through 3:00 p.m., alert and oriented residents with a [CONDITION(S)] ([CONDITION(S)]-opening in the front of the neck for a tube to be inserted to help breathing) verbalized that call bell response times were a concern with wait times of half hour or more which was scary and frustrating. One resident verbalized that he/she cannot cough on his/her own. Both residents verbalized that when nursing staff suction their [CONDITION(S)], it sometimes hurts them due to the nurses are always in a hurry due to lack of staff. Residents verbalized it was common to wait for long periods of time especially on afternoon and midnight shifts. Interviews with family of residents on the North Hall indicated there is not enough nursing staff to meet the complex needs such as [CONDITION(S)] care, mechanical ventilators (machines to move air in and out of the lungs), feeding tubes, urinary catheters, vascular access (intravenous lines providing hydration and medicine), and wound management including wound vacs (a vacuum assisted closure of a wound that is a type of therapy to help wounds heal). During the family interviews, it was revealed that families feel resident's medications are late, [CONDITION(S)] care is late, especially when a Respiratory Therapist (RT) is not scheduled, and the residents who are non-verbal typically are not ever prioritized. During an interview on 8/18/22, at 11:30 a.m. Registered Nurse Employee E1 confirmed it was extremely difficult to meet the needs of the residents that rely on a mechanical ventilator or with a [CONDITION(S)] and cover the rest of the resident population when an RT is not working in the facility and sometimes even when an RT is working and there is only one nurse on that hallway working. Observations on 8/18/22, between 11:35 a.m. and 3:00 p.m. of nursing staff on the North Hall revealed one LPN working. A review of facility documentation and clinical records for the North Hall resident population, including the facility matrix dated 8/18/22, and wound report dated 8/22/22, revealed fourteen residents have tracheostomies, four residents need a mechanical ventilator to breathe 24-hours daily, five residents require a mechanical ventilator at hours of sleep, eleven residents require a feeding tube for nutrition, and seven residents have major wounds (one resident noted with 8 wounds, four stage four pressure areas, one stage three pressure area and three other wounds). Further clinical record review revealed wound vac therapy utilized for management of the resident's wounds on the North Hall, as well as eleven of the fourteen residents with tracheostomies are transferred with a mechanical lift, which requires a two person assist. A review of the staffing deployment sheet dated 8/18/22, identified one LPN to work the North Hall for twenty residents which allowed one nurse to provide complex resident care which included medication administration, treatment administration, management of tracheostomies, feeding tubes, foley catheters, assistance with meals, transfers, call light response, all required daily care and activities of daily living. 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(3) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide comfort to ease the anxiety for one of eight residents reviewed (Resident CR1). The findings include: The admission face sheet indicated that Resident CR1 was admitted to the facility on [DATE]. The history and physical, dated [DATE], revealed [DIAGNOSES REDACTED]. The Hospice (a provider of end of life care) Discharge Summary, dated [DATE], indicated that hospice care for Resident CR1 began [DATE]. The nursing notes, dated [DATE], at 10:30 p.m., indicated that Resident CR1 was noted to be restless in the wheelchair, frequently taking off clothes and difficult to re-direct. On [DATE], at 11:30 p.m., Resident CR1 was in bed, combative with care and refused care. A physician's orders [REDACTED]. Resident CR1's Plan of Care, dated [DATE], and reviewed [DATE], lacked identification of anxiety as a problem and lacked interventions or approaches related to anxiety. The nursing notes, dated [DATE], at 6:40 a.m., indicated that Resident CR1 experienced increased anxiety throughout the night. Licensed Practical Nurse (LPN), Employee E2, documented on [DATE], at 6:40 a.m., "author has call in to pharmacy" and "supervisor has call in to physician". The Hospice nursing notes, dated [DATE], indicated that there was, "difficulty getting the [MEDICATION NAME] here from the pharmacy," that the [MEDICATION NAME], "finally arrived" on [DATE], at 12:30 p.m., and was given at that time (over 12 hours after the medication order for the [MEDICATION NAME] (ordered to relieve Resident CR1's anxiety) was transcribed) and that following the administration of the [MEDICATION NAME], Resident CR1's anxiety subsided and the resident ceased to breath at 1:25 p.m. The Hospice Discharge Summary, Summary of Care nursing note, dated [DATE], indicated that "On ,[DATE], (Resident CR1) had a very scared look on her face and died the next day. She had one dose of [MEDICATION NAME], then she was turned to change her and she passed that quickly." During an interview on [DATE], at 9:00 a.m., the Director of Nursing stated that the [MEDICATION NAME] was not administered in a timely manner and that documentation was not available to indicate that nursing staff attempted to obtain an alternative medication or intervention to address Resident CR1's anxiety. CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited [DATE], [DATE]. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE]. 28 Pa. Code: 201.18(b)(1) Management. Previously cited [DATE]. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited [DATE]. 28 Pa. Code: 211.12 (b)(c) Nursing services. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE].