Every finding on record at Nightingale Nursing and Rehab Center

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure medications were administered in accordance with physician's orders for three of five residents reviewed (Residents R1, R2, and Closed Record Resident CR3). Findings include: Facility policy entitled, Administering Medications dated 2/09/26, revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Resident R1's clinical record revealed an admission date of 4/10/26, with diagnoses that included acute myeloblastic leukemia (occurs when immature white blood cells multiple uncontrollably), hypothyroidism (a condition where the thyroid does not make enough thyroid hormone to meet the body's needs ), anemia (a blood disorder which reduces blood cells to carry oxygen), and hyperlipidemia (high cholesterol in the blood). Resident R1's Medication Administration Record (MAR) for 7/01/26, through 7/31/26, and progress notes revealed the following medications were not administered: Resident R1 did not receive Donepezil HCL (hydrochloride) 10 mg (milligram) on 7/02/26, 7/03/26, 7/04/26, with progress notes indicating medication is awaiting arrival from pharmacy; Levothyroxine 75 mcg on 7/07/26, with progress notes indicating medication is unable to administer - on order with pharmacy; Terazosin HCL 2 mg on 7/02/26, 7/03/26, 7/04/26, 7/05/26, with progress notes indicating awaiting pharmacy; Levetiracetam 750 mg two tablets at bedtime on 7/02/26, with progress notes indicating none on hand from pharmacy; Ciprofloxacin HCL 500 mg at bedtime on 7/03/26; and Phenytoin Sodium Extended 100 mg two capsules at bedtime on 7/02/26. Resident R2's clinical record revealed an admission date of 2/19/22, with diagnoses that included atrial fibrillation (AFIB- when the upper chamber of the heart beats rapidly and in an uncoordinated manner), bradycardia (abnormal low heart rate), coronary artery disease (narrowing of blood vessels related to a buildup of cholesterol and other substances), and fatigue. Resident R2's MAR for 7/01/26, through 7/31/26, and progress notes revealed that Resident R2 did not receive Temazepam 15 mg at bedtime on 7/01/26, 7/03/26, 7/04/26, 7/05/26, and 7/06/26, with progress notes indicating that medication is on order. Resident CR3's clinical record revealed an admission date of 4/24/26, with diagnoses that included retinal detachment of left eye, morbid obesity (a serious weight-related condition involving a person generally weighing 100 or more over ideal weight), diabetes mellitus (a chronic disease when a person's blood sugar levels are persistently high), and muscle weakness. Resident CR3's MAR for 4/01/26, through 4/30/26, and progress notes revealed the following medications were not administered: Resident CR3 did not receive Pred Forte Ophthalmic suspension 1% four times a day on 4/25/26, and three times a day on 4/29/26, with 4/29/26 progress notes indicating that medication is on order; Lactobacillus two capsules on 4/29/26, with progress notes indicating that medication is not available; Calcium Carbonate 500 mg three times daily on 4/29/26, with progress notes indicating that medication is not available; and Atropine Sulfate Ophthalmic solution 1% two times a day on 4/25/26. An interview with the Director of Nursing (DON) on 7/09/26, at 11:35 a.m. confirmed the above medications were not administered in accordance with physician's orders for Resident R1, R2 and CR3. The DON further confirmed that all residents should have their medications administered in accordance with their physician's orders. 28 Pa. Code 211.9(a)(d) Pharmacy services28 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 the Resident and/or Resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for eight of eight residents reviewed (Residents R3, R9, R11, R14, R72, R95, R99, and R149).Findings include: Review of a facility policy entitled Transfer or Discharge, Facility-Initiated dated 2/9/26, indicated Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. And Information conveyed to receiving provider: Contact information of the practitioner responsible for the care of the residentResident representative information including contact informationAdvance directive informationAll other information necessary to meet the resident's needs.All special instructions or precautions for ongoing care.Comprehensive care plan goals.All other information necessary to meet the residents' needs, including but may not be limited to:Resident status.Diagnosis and allergiesMedicationsMost relevant labs. Review of Resident R3's clinical record revealed an admission date of 8/15/25, with diagnoses that included cerebral infarction (a blockage of blood vessels in the brain resulting in tissue death due to a lack of oxygen), muscle weakness, and dysphagia (difficulty swallowing). Review of Resident R3's progress notes revealed notes dated 8/16/25, 9/19/25, and 12/25/25, identified transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 8/16/25, 9/19/25, and 12/25/25. Review of Resident R9's clinical record revealed an admission date of 10/20/25, with diagnoses that included dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys cannot), atrial fibrillation (irregular heartbeat), and chronic pain. Review of Resident R9's progress notes revealed notes dated 11/3/25, 12/3/25, and 2/1/26, identified transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/3/25, 12/3/25, and 2/1/26. Review of Resident R11's clinical record revealed an admission date of 12/12/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R11's progress notes revealed notes dated 4/19/25, 6/6/25, 6/17/25, 6/29/25, 7/14/25, 7/17/25, 7/23/25, 8/9/25, 8/27/25, 12/8/25, and 12/20/25, identified transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 4/19/25, 6/6/25, 6/17/25, 6/29/25, 7/14/25, 7/17/25, 7/23/25, 8/9/25, 8/27/25, 12/8/25, and 12/20/25. Review of Resident R14's clinical record revealed an admission date of 08/23/21, with diagnoses that included spinal stenosis (the narrowing of the spinal canal, which compresses nerve roots or the spinal cord, leading to pain, numbness, or weakness in the neck, back, arms, or legs), osteoarthritis (a common degenerative, non-inflammatory joint disease, caused by the gradual breakdown of cartilage, leading to bone-on-bone friction, pain, stiffness, and reduced mobility.), and hypertension. Review of Resident R14's progress notes revealed notes dated 9/11/25, that identified a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/11/25. Review of Resident R72's clinical record revealed an admission date of 12/11/25, with diagnoses that included chronic diastolic heart failure (The stiffening of the heart muscle causing it to not be able to properly relax to fill with blood, despite normal pumping strength), type 2 diabetes (a chronic metabolic disorder where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond properly to insulin.), and morbid obesity (chronic life threatening disease defined as having a body mass index of 40 or higher or over 35 with severe obesity related health conditions such as diabetes). Review of Resident R72's progress notes revealed notes dated 11/10/25, and 12/26/25, identifying transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/10/25, and 12/26/25. Review of Resident R95's clinical record revealed an admission date of 10/31/25, with diagnoses that included chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes, and hypertension. Review of Resident R95's progress notes revealed notes dated 11/16/25, 12/9/25, and 12/28/25, identifying transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/16/25, 12/9/25, and 12/28/25. Review of Resident R99's clinical record revealed an admission date of 11/3/25, with diagnoses that included diabetes, dependence of renal dialysis, and hyperlipidemia (high cholesterol). Review of Resident R99's progress notes revealed notes dated 11/12/25, identifying a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/12/25. Review of Resident R149's clinical record revealed an admission date of 10/31/25, with diagnoses that included diabetes, sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R149's progress notes revealed notes dated 12/10/25, identifying a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 12/10/25. During an interview on 2/19/26, at 2:13 p.m. the Director of Nursing confirmed that Resident's R3, R9, R11, R14, R72, R95, R99 and R149's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and the clinical records lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer as required. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

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 (Resident R11).Findings include: Review of a facility policy entitled Psychotropic Medication Use dated 2/9/26, indicated Non-pharmacological approaches are used to minimize the need for medications. Review of Resident R11's clinical record revealed an admission date of 12/12/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R11's physician's orders revealed an order for Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every 12 hours PRN for anxiety. Review of Resident R11's February 2026 medication administration record (MAR) revealed that the PRN Lorazepam was used on 2/1/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, and 2/18/26. The clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam for the 11 administrations. During an interview on 2/20/26, at 9:35 a.m. the Director of Nursing (DON) confirmed that Resident R11's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam. The DON also confirmed that non-pharmacological interventions should be attempted prior to administering psychotropic medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, 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 ensure medications were properly labeled with a resident name in one of three medication rooms reviewed and in one of three medication carts reviewed (D-North medication room and D-North medication cart). Findings include: Review of a facility policy entitled Medication Labeling and Storage dated 2/9/26, revealed that, .The medication label includes, at a minimum: resident's name.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 Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicate that vials which are entered and in use for 30 days should be discarded. Observation on 2/17/26, at 2:50 p.m. of the D-North medication room refrigerator revealed an opened vial of Tubersol PPD without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, the Director of Nursing confirmed that the opened Tubersol PPD vial lacked an open date, and staff were unable to determine the discard date. Observation on 2/17/26, at 3:02 p.m. of the D-North medication cart revealed an open Fluticasone Propionate inhaler (medication used for asthma or other conditions that cause difficulty with breathing) with instructions to discard 30 days after opening and with an open date of 1/9/26, therefore the medication was expired. There was also an open Trelegy inhaler (used for asthma or other conditions that cause difficulty with breathing) without a resident name. During an interview at that time, Licensed Practical Nurse Employee E1 confirmed that the Fluticasone Propionate inhaler with the open date of 1/9/26, was expired and should have been discarded and the Trelegy inhaler should have had a resident's name. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 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 ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one resident reviewed for dialysis (Resident R9).Findings include: Review of the facility policy Administering Medications, dated 2/9/26, revealed Medications are administered in accordance with prescriber orders, including any required time frame. Review of Resident R9's clinical record revealed an admission date of 10/20/25, with diagnoses that included dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys cannot), atrial fibrillation (irregular heartbeat), and chronic pain. Review of physician's orders revealed the following orders: change medications and treatment timing from facility's medication and treatment administration time to accommodate hemodialysis treatment; Carafate (medication used to treat stomach ulcers) one gram (GM) give one tablet by mouth before meals and at bedtime; Gabapentin (medication used to treat nerve pain) capsule 100 milligrams (mg) give one capsule by mouth three times a day; Hydralazine (medication used to treat high blood pressure) 10 mg give one tablet by mouth three times a day; Insulin Lispro routine (medication used to lower blood sugar) dose before meals; Insulin Lispro sliding scale (medication used to lower blood sugar, sliding scale determines amount administered based on blood glucose level) before meals; and Losartan (medication used to treat high blood pressure) 50 mg give one tablet by mouth in the afternoon. Review of Resident R9's progress notes and Medication Administration Records for November 2025, December 2025, January 2026, and February 2026 revealed Resident R9 did not receive the following medications as ordered on the following days:11/21/25 Carafate, Insulin Lispro, and Insulin Lispro sliding scale11/26/25 Insulin Lispro sliding scale12/15/25 Carafate, Hydralazine, Gabapentin, Insulin Lispro, and Insulin Lispro sliding scale12/31/25 Insulin Lispro, Insulin Lispro sliding sale, and Hydralazine 1/19/26 Losartan, Gabapentin, Hydralazine, and Carafate1/21/25 Gabapentin and Hydralazine1/26/26 Insulin Lispro sliding scale and Insulin Lispro2/13/26 Carafate, Hydralazine, and GabapentinThere was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R9 on dialysis days.During an interview on 2/19/26, at 2:54 p.m. the Director of Nursing confirmed that the above medications for Resident R9 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to follow professional standards of care with a lack of an immediate physician notification for one of seven closed records reviewed (Resident CR1) and failed to follow physician's orders for two of seven residents reviewed (Residents R2 and R3). Findings include: Review of a facility policy entitled, Change in a Resident's Condition or Status, dated 1/07/25, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Resident CR1' s clinical record revealed an admission date of 9/17/25, with diagnoses that included pneumonia (an infection of the lungs), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe), acute respiratory failure with hypoxia (a condition when the lungs can't release enough oxygen into your blood), and severe protein-calorie malnutrition (a condition a person does not consume enough protein and calories to meet their body's needs). Resident CR1's progress notes dated 9/28/25, 10:35 p.m. indicated the resident continued to remove oxygen. Oxygen (O2) saturation 55% on room air. Reapplied oxygen and recheck O2 saturation O2 saturation at 77%. Resident is confused and talking to people that are not visible. Resident refusing all meds and refused dinner. Resident did drink his milkshake. Registered Nurse (RN) supervisor made aware of oxygen saturation. Will continue to monitor. Further review of Resident CR1 ' s clinical record lacked evidence of physician notification related to low oxygen saturations and confusion. During an interview on 10/23/25, at 4:10 p.m. the Nursing Home Administrator (NHA) confirmed that Resident CR1's clinical record lacked evidence of physician notification for Resident CR1's change in condition of his/her oxygen saturation at 77 % with oxygen reapplied and confusion. Review of a facility policy entitled, Administering Medications, dated 1/07/25, revealed Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Resident R2's clinical record revealed an admission date of 10/17/25, with diagnoses that included end stage renal disease (kidneys have deteriorated and can no longer perform), dialysis dependent (when a person depends on a dialysis machine to filter waste and excess fluid from the blood due to kidneys not functioning), history of a fall, and diabetes mellitus type two (a chronic condition where blood sugar levels are not regulated due to ineffective use of insulin or not enough insulin produced). Resident R2's Medication Administration Record (MAR) revealed a physician's order dated 10/20/25, for Cefepime Hydrochloride (HCl) Intravenous (IV) Solution Reconstituted 2 gram (GM) (Cefepime HCl) Use 2 GM IV one time a day every Monday, Wednesday for infection until 11/22/25, post dialysis - Start Date 10/20/25, at 9:00 a.m. Resident R2's clinical record, including MAR, lacked evidence that he/she received the Cefepime IV antibiotic for infection on Monday, 10/20/25. Resident R3's clinical record revealed an admission date of 10/17/25, with diagnoses of subarachnoid hemorrhage (bleeding between the brain and membranes covering the brain), seizures, pressure ulcer of sacral region stage 4 (skin breakdown extending into muscle, tendon, ligament, cartilage or bone- involvement of the triangular bone in the lower back), and osteomyelitis (infection of bone). Resident R3's MAR revealed a physician's order dated 10/18/2025, for Daptomycin IV Solution Reconstituted Use 725 milligrams (mg) IV in the afternoon for Daptomycin in Normal Saline (NS) 50 milliliter (ml) IV piggyback (IVPB) until 10/31/25, 23:59 Infuse 725 mg at 129 ml/hour over 30 minutes - Start Date-10/18/25, 2:00 p.m Resident R3's clinical record, including MAR, lacked evidence that he/she received the Daptomycin per physician's order on 10/18/25, 10/19/25, and 10/20/25 at 2:00 p.m. During an interview on 10/23/25, at 4:05 p.m. the Director of Nursing (DON) confirmed that physician's orders were not followed for Resident R2 and R3 related to Cefepime and Daptomycin IV antibiotic medication administration respectively. The DON further confirmed that Resident R2 and R3's clinical record lacked evidence that Residents R2 and R3 received the IV antibiotics as prescribed by their physician. 28 Pa. Code 211.12(d)(1)(5)Nursing services

Based on review of facility policy and clinical and facility records, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to a resident's change of status for one of two closed records reviewed (Resident CR1). Findings include: Review of facility policy entitled Charting and Documentation dated 1/07/25, 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 medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident CR1' s clinical record revealed an admission date of 9/17/25, with diagnoses that included pneumonia (an infection of the lungs), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe), acute respiratory failure with hypoxia (a condition when the lungs can't release enough oxygen into your blood), and severe protein-calorie malnutrition (a condition where a person does not consume enough protein and calories to meet their body's needs). Resident CR1's progress notes dated 9/28/25, 10:35 p.m. revealed resident continues to remove oxygen. Oxygen (O2) saturation 55% on room air. Reapplied oxygen and recheck O2 saturation O2 saturation at 77%. Resident is confused and talking to people that are not visible. Resident refusing all meds and refused dinner. Resident did drink his milkshake. Registered Nurse (RN) supervisor made aware of oxygen saturation. Will continue to monitor. Further review of Resident CR1 ' s clinical record lacked evidence of further documentation of resident progress, nursing follow-up care and treatment, and physician notification related to low oxygen saturations and confusion. Review of facility provided nursing documentation, a nurse's written statement provided by the Nursing Home Administrator (NHA), for Resident CR1's care and treatment on 9/28/25, indicated per report resident non-compliant with oxygen therapy, oxygen low all day. After report, resident vital signs obtained by this writer. RN aware. Throughout shift resident assessed multiple times oxygen reapplied and education provided. Overnight shift resident restless and removing oxygen, as needed medications offered at time refused. This writer 1:1 resident in room [ROOM NUMBER]:00 a.m.-3:30 a.m. incontinence care provided by nursing assistant at 0330 this writer returned to desk 4:15 a.m. resident reassessed oxygen reapplied resident restless. During an interview on 10/23/25, at 4:10 p.m. the NHA confirmed that the facility provided nursing documentation for Resident CR1's care and treatment provided 9/28/25, was not part of Resident CR1's permanent clinical record. The NHA further confirmed that Resident CR1's clinical record lacked evidence of the nursing response to Resident CR1's change in condition including resident's progress, changes, and communication between the interdisciplinary team regarding the resident's condition and response to care. 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 policy and 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 a PRN (as needed) psychotropic (affecting the mind) medication for one of four residents reviewed for unnecessary medications (Closed Record Resident CR2)Findings include: Facility policy entitled Psychotropic Medication Use, dated 1/7/2025, indicated that Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Resident CR2's clinical record revealed an admission date of 9/20/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and High Blood Pressure. Resident CR2's clinical record revealed a physician's order dated 9/20/25, for Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth every eight hours PRN for anxiety and a physician's order dated 9/25/25, for Lorazepam 0.5 mg by mouth routinely at bedtime and every eight hours PRN for anxiety. Resident CR2's September 2025 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used six times (9/21/25 two times, 9/22/25, 9/23/25, 9/24/25, and 9/26/25). Review of September MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam six of the six times it was used. During a telephone interview on 11/19/25, at 9:24 a.m. Nursing Home Administrator confirmed that the facility lacked evidence of non-pharmacological interventions being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. for Resident CR2. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vial with the date it was opened and discard an expired multi-dose insulin vial; and failed to prevent the opportunity for unauthorized access to medications in three of five medication carts (Unit D North, Unit E, and Unit C South); and failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in two of five medication rooms (Unit C North and Unit D South). Findings include: A facility policy entitled, Security of Medication Cart dated, [DATE], revealed that medication carts must be securely locked at all times when out of the nurse's view. A facility policy entitled, Storage of Medications dated, [DATE], revealed that unlocked medication carts are not left unattended, and Schedule II-V controlled medications are stored in separately locked permanently affixed compartments. A facility policy entitled, Insulin Administration dated, [DATE], revealed to check expiration date, if drawing from an opened multi-dose vial; if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). Observation on [DATE], at 8:52 a.m. of the Unit D North medication cart revealed one multi-dose vial of Lantus (long-acting insulin) labeled with an opened date of [DATE], (36 calendar days prior) and a pharmacy label that indicated to discard after 28 days opened. During an interview at that time, Licensed Practical Nurse (LPN) Employee E6 confirmed that the multi-dose vial was expired and should have been discarded. Observation on [DATE], at 10:13 a.m. of the Unit E medication cart revealed one opened multi-dose vial of insulin glargine (long-acting type of insulin) and lacked an opened date. During an interview at that time, Registered Nurse Employee E3 confirmed that the vial should contain an opened date and that he/she was unable to determine a discard date. Observation on [DATE], at 1:26 p.m. of the Unit C North medication refrigerator rack contained a locked compartment with two boxes of injectable lorazepam (controlled substance used to treat anxiety disorders). The rack of the refrigerator was not permanently affixed. During an interview at that time, the Assistant Director of Nursing confirmed that the refrigerator rack was not permanently affixed. Observation on [DATE], at 1:37 p.m. of the Unit S South medication refrigerator rack contained a locked compartment with one box of injectable lorazepam. The rack of the refrigerator was not permanently affixed. During an interview at that time, LPN Employee E1 confirmed that the refrigerator rack was not permanently affixed. Observation on [DATE], at 11:04 a.m. revealed the Unit C South medication cart was unsecured and unattended outside of a resident room (approximately 25 feet from nurse's station and was unable to be seen from nurse's station). Several staff and residents walked by the unsecured cart, and LPN Employee E4 approached the medication cart from nurse's station area. During an interview at that time, LPN Employee E4 confirmed that the medication cart should have been locked. During an interview on [DATE], at 11:35 a.m. the Director of Nursing confirmed the medication cart should have been locked when not attended to and/or in view. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, and facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure medications were administered appropriately and residents were assessed and treated in a timely manner for one of 24 residents reviewed (Resident R108). Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.145. Functions of the Licensed Practical Nurse (LPN), (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. Review of the facility job description for an LPN included: prepare and administer medication as ordered by the physician; be knowledgeable of nursing and medical practices and procedures, as well as, laws, regulations, and guidelines; must possess the ability to make independent decisions when circumstances warrant such action; implement and maintain established nursing objectives and standards; administer professional services; and monitor seriously ill residents as necessary. A facility policy entitled, Administering Oral Medications dated 1/07/25, included verifying the physician's medication order, and instructing the resident to place sublingual (situated beneath the tongue) medications under the tongue and allow the drug to dissolve. A facility policy entitled, Assessment of Chest Pain dated 1/07/25, revealed that assessing a resident experiencing chest pain in a skilled nursing facility requires prompt and systematic action to ensure resident safety, and included the following: 1. Immediate assessment and monitoring: pain evaluation- quickly assess the characteristics of the chest pain; vital signs monitoring- measure and document vital signs. 2. Medication administration: administer medications as per standing orders, and resident's care plan. Resident R108's clinical record revealed an admitted [DATE], with diagnoses that included heart disease, heart failure, and anxiety. The clinical record revealed a physician's order dated 1/07/25, to give Nitrostat (nitroglycerin- prevents and treats chest pain by relaxing your blood vessels) 0.4 milligram tablet sublingual every five minutes as needed for chest pain every five minutes up to three doses. The clinical record revealed a care plan entitled Altered cardiovascular status with interventions including assess for chest pain, administer medications as ordered and monitor for side effects and effectiveness. Observations on 2/27/25 revealed the following: -At 2:09 p.m. female voice heard yelling help, nurse from behind a closed door. Resident R108 stated, Please help. I am having chest pain. Resident R108's right leg was over the side of bed, his/her oxygen tubing was laying on bed, and the call bell was under the bed. Licensed Practical Nurse (LPN) Employee E4 was observed seated at the nurse's station and was notified of Resident R108's report of chest pain, and responded Three people have already been in there and remained seated at nurse's station. -At 2:10 p.m. the Director of Nursing inquired of Resident R108's as needed medications, and was informed by LPN Employee E3 of the available nitroglycerin. -At 2:15 p.m. LPN Employee E3 sat at nurse's station with an amber plastic pharmacy bag containing nitroglycerin. -At 2:33 p.m. LPN Employee E3 entered Resident R108's room, administered one tablet of nitroglycerin with water to Resident R108 to swallow, and then returned to the nurse's station. -At 2:41 p.m. LPN Employee E3 remained at the nurse's station and was notified by the Assistant Director of Nursing that Resident R108 required another administration of nitroglycerin. -At 2:44 p.m. LPN Employee E3 entered Resident R108's room, administered one tablet of nitroglycerin with water to Resident R108 to swallow, and then returned to the nurse's station. -At 2:59 p.m. Emergency Medical Services arrived on the unit to transport Resident R108 to the hospital and LPN Employee E3 was observed seated at the nurse's station. LPN Employee E3 entered Resident R108's room twice to administer nitroglycerin with water and failed to assess Resident R108's medical condition and/or monitor for changes in condition. During an interview on 2/27/25, at approximately 3:05 p.m. the Director of Nursing confirmed that the Nitrostat should have been given sublingual and that having the resident swallow the medication was inappropriate. The Director of Nursing also confirmed that LPN Employee E3 failed to act within his/her professional standards in response to Resident R108's calling out about chest pain and possible medical condition. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

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 for one of one residents reviewed for respiratory services (Resident R7). Findings include: Review of facility policy dated 1/25/24, entitled Oxygen Administration indicated that Oxygen will be administered as per MD order to aid in breathing. Review of Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive lung disease that results in shortness of breath and difficulty breathing), diabetes (condition of improper blood sugar control), and high blood pressure. Review of Resident R7's clinical record revealed a physician's order dated 2/14/24, for Oxygen via Nasal Cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) 2 lpm (liters per minute) every shift for shortness of breath. Observation on 2/26/24, at 2:50 p.m. revealed Resident R7 sitting in his /her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at 3 lpm. Observation on 2/28/24, at 1:38 p.m. revealed Resident R7 sitting in his/her wheelchair with supplemental oxygen in place via portable oxygen tank and set at 2.5 lpm. Oxygen concentrator was also noted to be on and set at 3 lpm. During an interview on 2/28/24, at 1:48 p.m. Licensed Practical Nurse Employee E1 confirmed that Resident R7's oxygen concentrator was on and set at 3 lpm and his/her portable oxygen was on, in use and set at 2.5 lpm and was not in accordance with the physician's order dated 2/14/24, for oxygen at 2 lpm every shift. 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 record, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of 22 residents reviewed (Resident R61). Findings include: A facility policy entitled Notification of Changes last reviewed in June 2023, indicated that the facility must inform the resident's representative, or family member when there is a Clinical Complication an example of which was the development of Stage 2 (partial-thickness skin loss) skin breakdown. Resident R61's clinical record revealed an admitted [DATE], with diagnoses that included Dementia, Type II Diabetes (condition of improper blood sugar control), Chronic Kidney Disease and Pain. A progress note dated 12/13/23, documented that Resident R61 had newly developed two Stage 2 open areas around the buttocks area. There was no further documentation to indicate that Resident R61's responsible party was notified of these areas of skin breakdown. During an interview on 2/28/24, at approximately 10:20 a.m. the Director of Nursing confirmed that Resident R61's responsible party was not notified of the areas of skin breakdown as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation related to bowel movements for three of three residents reviewed (Residents R1, R2, and R3) Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and constipation. Review of Resident R1's bowel elimination flow sheet for the time period between 2/23/23, and 3/11/23, lacked documentation to indicate if Resident R1 had a bowel movement 23 of the 50 (46%) documentation opportunities. Review of Nurse Practitioner's progress note dated 3/2/23, indicated Resident R1 had a small bowel movement last night (3/1/23) and review of order administration note dated 3/2/23, indicated that the Milk of Magnesia that was administered earlier in the day was effective. There was no documented evidence on the bowel elimination flow sheet that Resident R1 had a bowel movement on 3/1/23, or 3/2/23. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and dementia. Review of Resident R2's bowel elimination flow sheet for the time period between 2/28/23, and 3/31/23, lacked documentation to indicate if Resident R2 had a bowel movement 32 of the 95 (34%) documentation opportunities. Review Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included arthritis, constipation, and chronic obstructive pulmonary disease (respiratory disease that results in difficulty breathing). Review of Resident R3's bowel elimination flow sheet for the time period between 3/21/23, and 3/31/23, lacked documentation to indicate if Resident R3 had a bowel movement 13 of the 33 (39%) documentation opportunities. During an interview on 5/2/23, at 1:53 p.m. the Assistant to the Nursing Home Administrator confirmed that bowel documentation was not accurately completed for Residents R1, R2, and R3, and not only should it be completed every shift to identify if resident had a bowel movement or not, but should also reflect accurate information. 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately transcribe and act upon a physician's order to promote normal bowel regimen and/or prevent constipation for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and constipation. Review of a physician's progress note dated 2/27/23, at 9:13 a.m. revealed that the resident's appetite was not great, and he/she felt constipated. Physician's action / plan was to add Miralax (laxative) and Senokot-S (stool softener). Review of orders written by Resident R1's physician and signed and dated for 2/27/23, revealed orders for Miralax 17 grams (gm) by mouth every day and Senokot-S take two by mouth every day. Further review of the written order revealed that the nurse indicated that he/she noted (observed and initiated) the order for both the Miralax and Senokot on 3/1/23, or two days later. Review of Resident R1's medication administration record (MAR) revealed he/she received the first dose of Miralax at 8:00 a.m. on 3/2/23, and the first does of Senokot-S at 6:00 p.m. on 3/2/23. During an interview on 5/2/23, at 1:00 p.m. Director of Nursing confirmed that the 2/27/23, physician's order for Miralax and Senokot-S should have been noted on 2/27/23, and not two days later that delayed the administration of both medications. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records, facility policy and protocol, facility documentation, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), and resident/resident family and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the well-being for 21 of 21 residents interviewed (Residents R3, R15, R23, R26, R27, R31, R33, R35, R41, R44, R51, R77, R86, R88, R89, R91, R100, R102, R259, R306, and R309). Findings include: Review of the RAI manual instructions for Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severly impaired. Review of facility policy entitled Staffing with a policy review date of 2/15/23, revealed that the facility provides sufficient numbers of staff with skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Review of facility protocol entitled, Lift/Transfer Education stated, [NAME] lift/Sit to stand lift always use 2 people and Hoyer [mechanical lift] Lift 2 person assist. During a resident group meeting on 3/29/23, at 11:00 a.m. with Residents R27, R33, R86, R88, and R89, all residents in attendance concurred that the facility was understaffed, call bells took over a half hour to be answered on a consistent basis because of the facility being understaffed. Calls bells would be turned off by a staff member, and the resident would be told they would be back, and nobody would come back for over a half hour. Resident R33 stated that staff sometimes use one person when using lifts that require two staff to assist because they cannot find another staff member for assistance. During an interview on 3/29/23, at 10:45 a.m. Resident R33 (BIMS score of 15) stated, They do not always have two people when using lifts, they often do it with one person because they are short and cannot find anyone to help. During an interview on 3/29/23, at 1:39 p.m. Resident R95 (BIMS score of 13) stated They usually have two when using my lift, but sometimes if they are short there is just one. I feel safe though, I have been doing this for a while. During an interview on 3/28/23, at 2:30 p.m. Resident R91 (BIMS score of 13) stated that he/she has to wait a long time for the nursing staff to answer his/her call light and provide needed assistance. The resident recalled one instance he/she had to wait three hours for nursing staff to clean him/her after he/she had an incontinence episode while in bed. During an interview on 3/29/23 at 9:30 a.m. Resident R41 (BIMS score of 13) stated that he/she has to wait a long time for the nursing staff to answer his/her call light and provide needed assistance. The staff do the best they can, but need more help. Resident R41 also stated that medications are given late a lot of times, and one occasion his/her morning medications were not given until 12:00 p.m. During an interview on 3/29/23, at 10:15 a.m. Resident R23 (BIMS score of 14) stated that he/she has to wait a long time for the nursing staff to answer his/her call light and provide needed assistance. Resident R23 also stated that sometimes there are only two nursing assistants for the whole floor and they are extremely busy. During an interview on 3/29/23, at 2:00 p.m. Resident R44 (BIMS score of 14) stated that he/she has to wait a long time for the nursing staff to answer his/her call light and provide needed assistance. When the staff do answer the call bell, they respond that they are sorry, they are short staffed today. During an interview on 3/30/23, at 9:30 a.m. Resident R51 (BIMS score of 15) stated that he/she has to wait a long time for the nursing staff to answer his/her call light and provide needed assistance. Frequently, call bell wait times are over 30 minutes long. He/she claimed that call bells are turned off and the staff member leaves because they are working with someone else, and you have to wait longer for staff to return because they are busy. He/she stated that his/her shower schedule is Mondays and Thursdays every week, and he/she frequently gets told they cannot give his/her shower on time due to lack of staff. He/she stated that he/she also gets his/her medications administered late or has to wait sometimes because they are understaffed. During interviews on 3/28/23, and 3/29/23 with Resident R35 (BIMS score of 14), R100 (BIMS score of 15), R102 (BIMS score of 13), and family members of Resident R26 (BIMS score of 3), and Resident R259 (BIMS score of 3), it was revealed call bells were not responded to in a timely manner with a range of response times from 30 minutes to two hours. These residents also verbalized that their call bell lights would be turned off by staff with the resident's need not addressed, staff verbalizing they would be right back, then staff would not return. The residents indicated that they would turn the call bell on again and continue the wait process all over again. Residents R35, R100, R102, and family member of Resident R26 all indicated their food is delivered cold for all meals due to not enough staff on each floor to get it to them soon enough after the dietary department delivered the trays. During an interview with Resident R26's spouse on 3/28/23, at approximately 1:30 p.m. it was disclosed that he/she would come into facility and find Resident R26 laying in linen that appeared wet with urine and several rings of dried urine surrounding his/her body. He/she indicated that there are just not enough staff to do everything needed for the residents, such as appropriate incontinence care. During an interview on 3/29/23, at approximately 9:00 a.m. Resident R35 indicated that he/she does not receive his/her showers twice weekly in the evening due to lack of nursing staff. Resident R35 disclosed that the Nurse Aide (NA), the night before came into his/her room at 8:00 p.m. and asked if he/she would like a shower, and the resident verbalized yes, absolutely. The NA left the room for what Resident R35 thought was to get the shower ready, but the NA never returned. Resident R35 then revealed, he/she will ask the dayshift nurse to give him/her a shower. After he/she is done with his/her shift, he/she gives me one when this happens. Resident R35 indicated he/she believes there just are not enough staff on afternoons to get showers done. Resident R35 also indicated he/she has to wait for extended periods of time for their as needed (prn) pain medication. Resident R35 indicated there is not enough staff on the unit and they are just too busy. A review of Resident R35's physician's orders revealed that he/she does have pain medication dated 2/22/23, ordered every six hours prn. During an interview with Resident R100 on 3/28/23, at approximately 2:15 p.m. he/she indicated he/she has to wait for extended periods of time for prn pain medication. Resident R100 verbalized he/she has to typically wait until dayshift nursing staff comes to work for pain medication due to not enough nurses on the night shifts. Resident R100 indicated he/she will request pain medication, but the nurse never brings it due to the nurse being so busy. A review of Resident R100's physician's orders revealed that he/she does have pain medication dated 3/17/23, ordered every four hours prn. During an interview with Resident R259's spouse on 3/29/23, at approximately 11:00 a.m., it was indicated that he/she would have to go out into the hallway and holler for staff to help with Resident R259's needs. He/she indicated there is just not enough staff to take of these residents. During interviews conducted on 3/28/23 and 3/29/23 with Residents R3 (BIMS score of 12), R33 (BIMS score of 15), R14 (BIMS score of 9), R31 (BIMS score of 15), R309 (BIMS score of 15), R15 (BIMS score of 12), and R306's family member, all revealed that they wait a very long time for call bell response, all stated 30 plus minutes. During interviews conducted on 3/29/23 with Residents R31(BIMS score of 15) and R15 (BIMS score of 12) revealed that they were left saturated with urine in their incontinence brief for the entire nightshift. During interviews on 3/28/23 and 3/29/23 with Residents R77 (BIMS score of 15) and R306's family member revealed that meals are often cold when they arrive. During an interview with Licensed Practical Nurse Employee E4 he/she stated, what the residents are telling you is true, staffing is a concern. During an interview with the Nursing Home Administrator on 3/31/23 at 10:30 a.m. it was confirmed that staffing is a concern and that the facilities mechanical lifts do require an assist of two employees. 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, observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to care and treatment of residents with catheters (a tube inserted into the bladder to facilitate urine drainage) for two of five residents observed with catheters (Residents R8 and R257). Findings include: Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included prostate cancer, obstructive and reflux uropathy (a condition in which the kidneys are damaged by the obstruction and backward flow of urine into the kidneys). Review of Resident R8's clinical record revealed physician's order summary sheet with orders for Cipro (antibiotic) to treat a urinary tract infection (UTI). Observation on 3/29/23, at 10:16 a.m. revealed Resident R8 seated in a recliner chair with his/her catheter drainage bag and tubing extended out and lying on the floor next to the chair. There was no cover over the catheter bag that was directly on the floor. Observation on 3/30/23, at 10:46 a.m. revealed Resident R8 seated in a recliner chair with his/her catheter drainage bag and tubing extended out and lying on the floor next to the chair. There was no cover over the catheter bag that was directly on the floor. Observation on 3/30/23, at 12:36 p.m. revealed Resident R8 seated in a recliner chair with his/her catheter drainage bag and tubing extended out and lying on the floor next to the chair. There was no cover over the catheter bag that was directly on the floor. Nurse Aide Employee E6 confirmed that the catheter drainage bag and tubing was laying on the floor without a covering on 3/30/23, at 12:40 p.m. and that the catheter bag and tubing should not be laying on the floor or touching an unclean surface. Review of Resident R257's clinical record revealed an admitted [DATE], with diagnoses that included, but not limited to, retention of urine (involves the inability to empty urine from the bladder), seizure disorder, fracture of right lower extremity, and anxiety disorder. Observation on 3/30/23, at 11:20 a.m. revealed Resident R257's catheter drainage bag and tubing extended out and laying on the floor beside the bed. The catheter bag was without a covering. Licensed Practical Nurse Employee E1 confirmed that the catheter drainage bag and tubing was laying on the floor on 3/30/23, at 11:25 a.m. and that the catheter bag and tubing should not be laying on the floor or touching an unclean surface. During an interview on 3/30/23, at 3:15 p.m. the Nursing Home Administrator confirmed that catheter bags should not be lying on the floor and should have a covering over the catheter drainage bag. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and resident and staff interviews, it was determined that the facility failed to offer evening snacks for five of 24 residents reviewed (Residents R27, R33, R86, R88 and R89) Findings include: Review of the facility policy entitled, Food and Nutrition Services with a policy review date of 2/15/23, indicated that suitable, nourishing alternative meals and snacks will be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times. During a resident group interview, held on 3/29/23, at 11:00 a.m. five of five residents (Residents R27, R33, R86, R88, and R89) all indicated that they or other residents were never offered and did not receive an evening snack. They disclosed that they have never seen a snack cart and have never been offered a snack by any staff member. During an interview on 3/30/23, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that snacks are not passed in the evening and not offered by staff. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that monthly pharmacy drug regimen reviews were completed for five of 24 residents reviewed (Residents R34, R71, R36, R100 and R62). Findings include: Resident R34's clinical record revealed an admitted [DATE]. with a diagnosis Pick's Disease (a type of dementia that affects the frontal part of the brain), post-traumatic stress, and anxiety. The clinical record lacked evidence of a pharmacist monthly drug regimen review. Resident R71's clinical record revealed an admitted [DATE], with a diagnosis of dementia, high blood pressure and diabetes. The clinical record lacked evidence of a pharmacist monthly drug regimen review. Resident R36's clinical record revealed an admitted [DATE], with a diagnosis of dementia, major depression and chronic obstructive pulmonary disease (difficulty breathing). The clinical record lacked evidence of a pharmacist monthly drug regimen review. Resident R100's clinical record revealed an admitted [DATE], with a diagnosis of muscle weakness, high blood pressure, diabetes and muscle tremors. The clinical record lacked evidence of a pharmacist monthly drug regimen review. Resident R62's clinical record revealed an admitted [DATE], with a diagnosis of chronic pain, major depression and hypertension (high blood pressure) with heart failure. The clinical record lacked evidence of a pharmacist monthly drug regimen review. During an interview on 3/31/23, at 10:40 a.m. the Nursing Home Administrator (NHA) confirmed that the clinical records for Residents R34, R71, R36, R100, and R62 lacked evidence of monthly pharmacist drug regimen reviews. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of drug manufacturer instructions, and staff interview, it was determined that the facility failed to appropriately date and store medications on two of three nursing units ([NAME] and Third floor). Findings include: Observation on 3/29/23, at 10:30 a.m. of the [NAME] Unit medication room revealed an opened vial of Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an opened date marked on the vial and verified by Registered Nurse Employee E5, who stated that the opened vial did not have the required date opened marked on the vial. Observation on 3/29/23, at 1:15 p.m. of the Third floor medication room, revealed an opened vial of PPD without an opened date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol which had been entered and in use for 30 days should be discarded. At the time of the observation, the Director of Nursing (DON) confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The DON confirmed on 3/29/23, at 1:16 p.m. the PPD vial should have been noted with an opened date to indicate after 30 days of use, the vial would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to appropriately maintain, promote cleanliness and prevent the spread of infection regarding respiratory care equipment according to physician orders for two of 23 residents reviewed (Residents R31 and R257). Findings include: Review of Resident R31's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), morbid obesity, and obstructive sleep apnea (breathing issues during sleep). The clinical record also revealed a physician's order for change O2 [oxygen] tubing every night shift every Sun [Sunday]. Observation on 3/29/23, at 12:45 p.m. revealed Resident R31's nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) had a piece of tape wrapped around the oxygen tubing dated 2/13. It was also noted that the oxygen tubing extender was not dated. During an interview on 3/29/23, at 2:35 p.m. Licensed Practical Nurse (LPN) Employee E3 confirmed that the oxygen tubing was dated 2/13, and that the oxygen tubing is to be changed weekly and dated when it is changed. Additional observation on 3/30/23, at 5:00 p.m. revealed Resident R31's nasal cannula remained the same with the piece of tape wrapped around the oxygen tubing dated 2/13. The oxygen tubing extender remained undated. During an interview on 3/30/23, at 5:10 p.m. LPN Employee E1 confirmed that the oxygen tubing was dated 2/13, that the oxygen tubing is to be changed weekly and dated when it is changed. Review of Resident R257's clinical record revealed an admitted [DATE], with diagnoses that included fracture of the left arm, repeated falls, blood clots of veins in left leg, respiratory failure, muscle weakness and unsteadiness on feet. Review of R257's clinical record revealed physician's orders dated 3/6/23, to change oxygen tubing every night shift every Sunday. In addition, a physician's order dated, 3/07/23, indicated to keep and titrate oxygen above 90 percent. Observations on 3/28/23, at 1:00 p.m. and 3/29/23, at 1:25 p.m. revealed Resident 257 with nasal cannula tubing and a humidification bottle without a date. Further observations on 3/29/23, at 1:27 p.m. with Registered Nurse Unit Manager Employee E2 revealed he/she could not locate a date on oxygen tubing and humidification and confirmed tubing should be dated to acknowledge when it was changed. 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility policies and procedures, hospital records, and interviews with facility and medical staff, it was determined that the facility failed to ensure that one of three residents (Resident R1) sustaining a fall with injury, received treatment and care in accordance with professional standards of practice resulting in actual harm of a cervical (neck) injury, blood loss associated with a nasal fracture and laceration requiring blood [CONDITION(S)], and admission to the intensive care unit for treatment and monitoring. Findings include: The 4/06/2020, facility policy entitled Incident Reporting indicated that falls involving the head or neck require neuro checks and sensory exam to be completed until resident is stable or until neuro condition no longer warrants frequent monitoring. Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Manufacturers' Safety Information indicated that taking the medication causes an increased risk of bleeding which can be serious and lead to death. The information further directs those utilizing the medication to call the doctor or get medical help right away if you develop unexpected bleeding, bleeding that lasts a long time, is severe or that you cannot control. Interdisciplinary Progress Notes (IDPN) dated 1/16/21, revealed that staff identified a change in Resident R1's condition at 5:35 p.m. marked by increased weakness with transfers. Vitals signs were obtained as follows: temperature 97.4, pulse 83, respirations of 18 and blood pressure 118/60, blood oxygen saturation 97 percent on two liters of oxygen and a blood sugar of 167. The note indicated staff were made aware and that the resident would be monitored. At 9:16 p.m. on 1/16/21, an IDPN indicated that Resident R1 remained lethargic (sleepy), was more difficult to arouse and unable to verify his/her date of birth, or location, and displayed jerking movement to the upper extremity. The on-call Physician Assistant (PA) Employee E1 was contacted and an order received to send Resident R1 to the emergency room for evaluation, if the family was in agreement, and if not to obtain designated lab studies. Upon family notification at 9:23 p.m. the family declined to have Resident R1 transferred to the emergency room or have lab studies completed but indicated to call back if there was a further decline in Resident R1's condition. An IDPN, dated 1/17/21, at 1:17 a.m. indicated that Resident R1 was discovered on the bathroom floor laying in front of the toilet on his/her face, laceration noted on the left nose and to forehead, 3 centimeters . [MEDICATION(S)] (a dressing product that absorbs liquid) put on resident nose for bleeding caused by fall. The note indicated Resident R1 was alert and oriented to person, place and time and that vital signs were as follows: Temperature 97.5, pulse 82, blood pressure 90/50, and oxygen saturation 93% on 2.5 liters of oxygen. An IDPN summarizing the events surrounding Resident R1's fall, dated 1/17/21, written at 6:30 a.m. indicated that Resident R1 was found on the bathroom floor, lying face down at 12:10 a.m. having been observed ten minutes prior to the fall sitting on the edge of the bed. There was a large amount of blood on the floor and staff attempted to stop the bleeding from the nose documented as squirting out from the laceration to the left side of the bridge of nose by utilizing pressure and [MEDICATION(S)] pieces. The note indicated several pieces of [MEDICATION(S)] were saturated through before the bleeding appeared to slow down at 1:30 a.m. (an hour and 20 minutes after the fall). Documentation indicated that staff continued to periodically check on resident. The clinical record, however, reflected only the original set of vital signs obtained at 1:00 a.m. documented on a Neurological Checklist with the columns related to level of consciousness, pupil assessment and hand grasps blank and no further documentation to support that Resident R1 was assessed again following the fall at 12:10 a.m. The IDPN note indicated that at 3:00 a.m. a nursing assistant reported that Resident R1 was discovered with a large amount of blood on his/her bedding. The family and PA Employee E1 were notified and Resident R1 was transferred to the emergency room at 4:00 a.m. (three hours and 50 minutes after the fall). There were no documented vital signs, neurological assessment or reference to Resident R1's condition in the clinical record when discovered at 3:00 a.m. or prior to transfer to the emergency room at 4:00 a.m. Hospital records dated 1/17/21, at 8:33 a.m. revealed that Resident R1 was examined in the emergency room following an unwitnessed fall at the nursing facility. The attending emergency room physician's note indicated that Resident R1 was anticoagulated (blood clotting process slowed due to medication) and was reportedly bleeding from a facial laceration for some time prior to admission. The note indicated that Resident R1 was hypotensive (low blood pressure) during transport to the hospital, the systolic blood pressure (pressure within the arteries exerted by the heart's contractures) being 88 in the emergency room , which required a transfusion of whole blood and an intravenous infusion of [MEDICATION(S)] (fluids containing blood clotting factors) to promote blood clotting. Resident R1 experienced a second drop in blood pressure during the emergency room stay, the systolic reading in the 50's, and a second unit of whole blood was administered in addition to a dose of [MEDICATION(S)] (a medication for high-risk bleeding conditions to control bleeding after an injury). The note indicated that Resident R1 would be admitted to the trauma neuro-intensive care unit for management of the hemorrhagic shock (low blood pressure) from blood loss related to an open nasal fracture; for management of the resident's volume status (amount of fluid circulating in the blood vessels) due to a history of heart failure; for management of kidney function due to a history of chronic kidney failure that will likely worsen due to the hemorrhagic shock and for follow up care related to the nasal fracture/laceration and the cervical spine injury. During an interview on 1/27/21, at 11:40 a.m. PA Employee E1 confirmed that he/she was not called regarding Resident R1's fall when it occurred, but would expect to be called/notified regarding a resident sustaining a fall with injury, especially one taking an anticoagulant. PA Employee E1 also indicated that he/she, if called at the time of the fall, would have recommended transfer to the hospital and would expect Resident R1 be closely monitored and neurological checks completed per facility policy. During an interview on 1/27/21, at 3:40 a.m. the Nursing Home Administrator and Director of Nursing confirmed that Resident R1 was not appropriately assessed and monitored following a fall with a head injury and associated blood loss resulting in harm and the resident's transfer to the hospital for emergent treatment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, facility policies and procedures, hospital records, and interviews with facility and medical staff, it was determined that the facility failed to notify the physician and the resident's responsible party in a timely manner of changes in one of three residents' (Resident R1) condition following a fall with injury, resulting in actual harm to the resident who experienced a delay in treatment and subsequent admission to the hospital with a cervical (neck) injury, nasal fracture, a nasal laceration with associated blood loss requiring blood [CONDITION(S)]. Findings include: The 4/06/2020, facility policy entitled Physician Notification, indicated that a resident's physician will be notified in a timely manner of a change in condition so that the physician may order interventions and/or treatments. Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Manufacturers' Safety Information indicated that taking the medication causes and increased risk of bleeding which can be serious and lead to death. The information further directs those utilizing the medication to call the doctor or get medical help right away if you develop unexpected bleeding or bleeding that lasts a long time, is severe or that you cannot control. Interdisciplinary Progress Notes (IDPN) dated 1/16/21, revealed that staff identified a change in Resident R1's condition at 5:35 p.m. marked by increased weakness with transfers. Vitals signs were obtained as follows: temperature 97.4, pulse 83, respirations of 18 and blood pressure 118/60, blood oxygen saturation 97 percent on two liters of oxygen and a blood sugar of 167. The note indicated staff were made aware and that the resident would be monitored. At 9:16 p.m., on 1/16/21, an IDPN indicated that Resident R1 remained lethargic (sleepy), was more difficult to arouse and unable to verify his/her date of birth, or location, and displayed jerking movement to the upper extremity. The on-call Physician Assistant (PA) Employee E1 was contacted and an order received to send Resident R1 to the emergency room for evaluation, if the family was in agreement, and if not to obtain designated lab studies. Upon family notification at 9:23 p.m. the family declined to have Resident R1 transferred to the emergency room or have lab studies completed but indicated to call back if there was a further decline in Resident R1's condition. An IDPN, dated 1/17/21, at 1:17 a.m. indicated that Resident R1 was discovered on the bathroom floor laying in front of the toilet on his/her face, laceration noted on the left nose and to forehead, 3 centimeters . [MEDICATION(S)] (a dressing product that absorbs liquid) put on resident nose for bleeding caused by fall. The note indicated Resident R1 was alert and oriented to person, place and time and that vital signs were as follows: Temperature 97.5, pulse 82, blood pressure 90/50, and oxygen saturation 93% on 2.5 liters of oxygen. The note lacked evidence that the resident's family was notified of the change as requested or that the physician was notified of the fall with injury. An IDPN summarizing the events surrounding Resident R1's fall, dated 1/17/21, written at 6:30 a.m. indicated that Resident R1 was found on the bathroom floor, lying face down at 12:10 a.m. having been observed ten minutes prior to the fall sitting on the edge of the bed. There was a large amount of blood on the floor and staff attempted to stop the bleeding from the nose documented as squirting out from the laceration to the left side of the bridge of nose by utilizing pressure and [MEDICATION(S)] pieces. The note indicated several pieces of [MEDICATION(S)] were saturated through before the bleeding appeared to slow down at 1:30 a.m. (One hour and 20 minutes after the fall). The IDPN indicated that at 3:00 a.m. a nursing assistant reported that Resident R1 was discovered with a large amount of blood on his/her bedding. The family and physician were then notified (two hours and 50 minutes after the initial fall) of the fall with injury and Resident R1 was transferred to the emergency room at 4:00 a.m. Hospital records dated 1/17/21, at 8:33 a.m. revealed that Resident R1 was examined in the emergency room following an unwitnessed fall. The emergency physician note indicated that Resident R1 was anticoagulated (blood clotting process slowed due to medication) and was reportedly bleeding from a facial laceration for some time prior to admission. The note indicated that Resident R1 was hypotensive (low blood pressure) during transport to the hospital, the systolic blood pressure (pressure within the arteries exerted by the heart's contractures) dropping to the 90's, which required a transfusion of whole blood to stabilize following arrival. Resident R1 then received [MEDICATION(S)] (an IV infusion of clotting factors) to promote blood clotting. Resident R1 experienced a second drop in blood pressure, the systolic reading in the 50's, and a second unit of whole blood was administered and a dose of [MEDICATION(S)] (a medication for high-risk bleeding conditions to control bleeding after an injury) for concerns related to ongoing bleeding. The note indicated that Resident R1 would be admitted to the trauma neuro-intensive care unit for management of the hemorrhagic shock (low blood pressure) from blood loss related to an open nasal fracture; for management of the resident's volume status (amount of fluid circulating in the blood vessels) due to a history of heart failure; for management of kidney function due to a history of chronic kidney failure that will likely worsen due to the hemorrhagic shock and for follow up care related to the nasal fracture/laceration and the cervical spine injury. During an interview on 1/27/21, at 11:40 a.m. PA Employee E1 confirmed that he/she was not initially notified of Resident R1's fall, or issues with bleeding from the nasal laceration until 3:00 a.m., when Resident R1 experienced further bleeding. PA Employee E1 indicated that he/she would expect to be called/notified regarding a resident sustaining a fall with injury, especially one taking an anticoagulant and that he/she would have recommended timely transfer to the emergency room to receive treatment. During an interview on 1/27/21, at 3:40 a.m. the Nursing Home Administrator and Director of Nursing confirmed that medical staff and family were not notified in a timely manner of Resident R1's fall and injuries resulting in harm from a delay in treatment to the fractures, laceration and associated blood loss occurring as a result of the fall. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 211.5(f)(g) Clinical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services