Every finding on record at Nursing and Rehabilitation at the Mansion

Based on a review of the facility's arbitration agreements and staff interview, it was determined that the facility's arbitration agreements failed to ensure a neutral and fair arbitration process by ensuring the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 13 and 50).Findings include: Review of an Addendum XIII: Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial), signed by Resident 13's responsible party on March 20, 2025, revealed that the document stipulated that, By signing this Arbitration Agreement, the parties hereby agree that if the parties cannot agree on a neutral arbitrator after thirty days, then (name of arbitrator services company, which the facility utilized), will serve as neutral arbitrator in accordance with the (name of arbitrator services company, which the facility utilized) Rules of Procedure. The agreement afforded the facility the selection of the arbitrator (third-party decision-maker contracted to resolve a dispute) if the parties (Resident 13/Resident 13's responsible party and the facility) could not reach an agreement on a neutral arbitration service within 30 days. Review of an Addendum XIII: Arbitration Agreement, signed by Resident 50 (via an, X) on September 13, 2024, revealed that the document stipulated that, By signing this Arbitration Agreement, the parties hereby agree that if the parties cannot agree on a neutral arbitrator after thirty days, then (name of arbitrator services company, which the facility utilized), will serve as neutral arbitrator in accordance with the (name of arbitrator services company, which the facility utilized) Rules of Procedure. The agreement afforded the facility the selection of the arbitrator if the parties (Resident 50/Resident 50's responsible party and the facility) could not reach an agreement on a neutral arbitration service within 30 days. Interview with Employee 4 (social services, staff the Nursing Home Administrator identified as the person who reviews the arbitration agreement process with residents) on December 18, 2025, at 10:33 AM confirmed the above verbiage in the arbitration agreements in effect for Residents 13 and 50. The surveyor reviewed the above concerns regarding Resident 13's and Resident 50's arbitration agreements during an interview with the Nursing Home Administrator and the Director of Nursing on December 18, 2025, at 2:00 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident rights

Based on observation and staff interview, it was determined that the facility failed to prepare and store food items in a safe and sanitary manner in the facility's main kitchen.Findings included: Observation of the facility's main kitchen on December 16, 2025, at 8:00 AM revealed the following: There was an accumulation of dust on the stainless-steel hood over the stove. The dry goods storage area contained a white colored heating/cooling unit on the wall near the ceiling. The unit had a build-up of a blackish colored substance on the vents of the unit. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 17, 2025, at 2:00 PM. A review of the facility policy titled Temperature, last reviewed on May 7, 2025, revealed that the temperatures of the food items will be taken and properly recorded for each meal. Observation of the plating service during the tray line in the facility's main kitchen on December 19, 2025, at 11:50 AM revealed that staff were plating the lunchtime meal food trays and placing them in delivery carts so they could be taken to the residents. Seven entrees were observed already prepared on trays that were placed in the meal carts. The surveyor requested documentation of lunch food temperatures taken prior to plating the resident meals and was given a food temperature binder that contained documentation for recorded food temperatures for breakfast, lunch, and dinner services. The last temperatures recorded in the binder were dated December 18, 2025. An interview with Employee 5, dietary services, on December 19, 2025, at 11:50 AM revealed that Employee 5 did not measure temperatures for the breakfast meal and temperatures for the lunch time service were not written down yet. Continued observation of the lunch meal service revealed that Employee 5 stopped plating meals from the tray line and started taking food temperatures. The above information regarding food temperatures was reviewed with the Nursing Home Administrator on December 19, 2025, at 12:20 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and resident and staff interview, it was determined that the facility failed to invite residents to their care plan meetings for one of 16 residents reviewed (Resident 9) and failed to revise a resident's comprehensive care plan for one of 16 residents reviewed (Resident 20).Findings include: The SOM Appendix PP states that Residents and their representative(s) must be afforded the opportunity to participate in their care planning process. During an interview with Resident 9 on [DATE], at 9:52 AM he stated that he had never been invited to his care plan meetings. Resident 9 has a BIMS score (Brief Interview for Mental Status, used to evaluate aspects of cognition such as attention, orientation, and memory recall) of 15 out of 15, indicating normal thinking and memory, no cognitive issues. Clinical record review of Resident 9's chart revealed no documentation of the resident being invited to his care plan meetings. The Nursing Home Administrator and the Director of Nursing were made aware of the above findings on [DATE], at 2:05 PM. During an interview with the Director of Nursing on [DATE], at 8:30 AM she stated that the resident's responsible party was receiving invitations to the care plan meetings. The Director of Nursing could not find evidence that a care plan invitation was provided to Resident 9, and due to the residents' high BIMS score, he should have received an invite. Clinical record review for Resident 20 revealed a current physician's order that noted DNR (Do Not Resuscitate; a DNR is no cardiopulmonary resuscitation when the resident has no pulse and is not breathing) that was dated [DATE]. The banner section in the electronic health record for Resident 20 revealed that the resident was a DNR. The POLST (Pennsylvania Orders for Life-Sustaining Treatment) for Resident 20 signed and dated on [DATE], by the resident's responsible party indicated the resident was a DNR. The current care plan for Resident 20 initiated [DATE], revealed the resident has an advance directive of Full Code (attempt resuscitation and CPR when the person has no pulse and is not breathing). An intervention included CPR (cardiopulmonary resuscitation) will be performed as needed. The above information for Resident 20 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:00 PM. A follow-up interview regarding Resident 20 with the Director of Nursing on [DATE], at 12:00 PM revealed that the care plan was not updated. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, resident and staff interview, and clinical record review, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 16 residents reviewed (Residents 37 and 2).Findings include: Interview with Resident 37 on December 17, 2025, at 10:45 AM revealed that he experienced range of motion (ROM) limitations of his bilateral arms and shoulders due to arthritis (swelling and tenderness of one or more joints, main symptoms are joint pain and stiffness), and he was not participating in any exercise programs or therapy related to range of motion exercises. Observation of Resident 37 on the date and time of the interview revealed that his range of motion limited him to raise his arms only to midway between his waist and head. Clinical record review for Resident 37 revealed diagnoses that included primary osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time) of left and right shoulders since April 1, 2025. An occupational therapy Discharge summary dated [DATE], noted that Resident 37's diagnoses included pain in both right and left shoulders. Resident 37 demonstrated decreased bilateral upper extremity strength (score of two plus out of five) without change from his baseline performance of upper body activities of daily living (ADLs), which was dependent on staff assistance. Resident 37 was unable to don/doff a shirt without assistance due to his limited ROM with bilateral upper extremities. Resident 37 had reached his highest level of independence with ADLs. Due to Resident 37's medical complexities, decreased ROM/strength/endurance and increased pain/resistiveness, he continued to require increased physical assistance with ADLs. Resident 37 was assessed as very limited to what he could do for himself due to the limited ROM at bilateral shoulders and elbows. A plan of care initiated by the facility on September 3, 2025, noted Resident 37 had an ADL self-care performance deficit related to osteoarthritis. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 31, 2024; and quarterly MDS assessments dated February 4, 2025, May 7, 2025, August 20, 2025, and November 20, 2025, assessed Resident 37 as having no functional impairment/limit with ROM of his bilateral upper extremities. The surveyor reviewed the discrepancies of the MDS assessments related to Resident 37's interview, observation, and occupational therapy documentation during an interview with the Nursing Home Administrator and the Director of Nursing on December 18, 2025, at 2:00 PM. Interview with Resident 2 on December 17, 2025, at 9:19 AM revealed that her teeth have broken over several years from medications used most of her life. Resident 2 stated that she had missing and broken teeth. Observation of Resident 2 on the date and time of the interview revealed missing teeth. Resident 2 stated that she would be interested in receiving professional dental services in the facility. Review of an admission MDS assessment dated [DATE], revealed that staff assessed Resident 2 as having no dental concerns (no obvious broken teeth or cavities). A significant change MDS dated [DATE], continued to assess Resident 2 as having no dental concerns. The surveyor reviewed the above concerns regarding Resident 2's MDS accuracy during interviews with the Nursing Home Administrator on December 19, 2025, at 11:20 AM and 1:00 PM. Interview with Employee 1 (registered nurse assessment coordinator) on December 19, 2025, at 1:05 PM confirmed the above MDS coding regarding Resident 2's dental condition were errors, and she submitted modifications to correct the MDS assessments and initiated a plan of care to address Resident 2's dental concerns. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview it was determined that the facility failed to ensure a resident's rights to secure and confidential personal and medical information in the facility (Main Lobby Area) for one of 16 residents reviewed (Resident 74). Findings include: Observation of the main lobby of the facility on December 18, 2025, at 11:01 AM revealed a binder titled Department of Health Survey Results. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binder revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder. Further review of the binder revealed a complaint deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a complaint investigation completed on December 27, 2024. The letter noted the name and associated specific resident identifier for Resident 74. The facility failed to ensure Resident 74's right to privacy of their personal and medical information. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 18, 2025, at 11:19 AM. 28 Pa. Code: 201.18(e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of four residents reviewed for advance directives concerns (Resident 11).Findings include: Review of Resident 11's electronic medical record (EMR) revealed social services documentation dated October 1, 2025, at 1:37 PM that the interdisciplinary team met with Resident 11's two sons and reviewed her POLST (Physician Orders for Life Sustaining Treatment, a binding medical order that instructs healthcare providers the specific types of medical treatment a resident wishes to receive at the end of life) form that instructed staff to not use artificial hydration and nutrition by tube. Review of Resident 11's physical chart revealed a POLST document signed by Resident 11's son/responsible party on November 12, 2025, that Resident 11 was not to receive hydration or nutrition by tube. Review of Resident 11's active physician orders dated August 12, 2025, revealed instructions to trial nutrition and/or hydration via tube. The surveyor reviewed the discrepancy between the POLST document and active physician orders with the Nursing Home Administrator and the Director of Nursing on December 17, 2025, at 2:00 PM. The facility provided a revised physician order (changed after the surveyor's questioning, dated December 17, 2025) that now stipulated Resident 11 was not to have nutrition or hydration via tube. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services consistent with professional standards of practice and the resident's comprehensive care plan related to dialysis access care for one of one resident reviewed for dialysis concerns (Resident 6).Findings include: Interview with Resident 6 on December 16, 2025, at 10:45 AM revealed that she leaves the facility three times a week for hemodialysis treatment (due to the inability of the kidneys to filter blood, blood is circulated from the resident, through a machine, for the purpose of removing excess fluids and waste products). Observation of Resident 6 during the interview revealed intravenous access tubing from a dressing on her right upper chest. Resident 6 stated that she needed to have the fistula (shunt, a connection surgically created between an artery and a vein that is used for hemodialysis treatment) in her left arm revised due to a failure to function; and the dialysis center was temporarily using the site to her right upper chest for her treatments. A sign above Resident 6's bed instructed staff to not utilize Resident 6's left arm for blood pressure assessments or blood draws for laboratory testing. Clinical record review of a plan of care developed by the facility to address Resident 6's need for hemodialysis (initiated August 14, 2025) revealed interventions that included no venipuncture/blood pressures in extremity with shunt. Review of a plan of care developed by the facility to address Resident 6's .tunneled right central venous catheter (a special type of intravenous line when a long, thin, flexible tube is tunneled under the skin and placed into a large vein in your chest) to complete dialysis (initiated December 8, 2025), revealed interventions that included, No blood draws or blood pressure to right upper extremity. A physician's order started May 20, 2025, instructed staff to complete a weekly skin review and blood pressure assessment for Resident 6 every Tuesday. Review of a treatment administration record (TAR, electronic documentation of the completion of treatments) dated December 2025 revealed that Employee 2 (licensed practical nurse) obtained the blood pressure assessment for Resident 6 on Tuesday, December 9, 2025. Interview with Employee 2 on December 18, 2025, at 1:35 PM revealed that she obtained the blood pressure assessment on the arm opposite (right arm) the one with the fistula. Further interview with Employee 2 confirmed that Resident 6 had a fistula in her left arm, but she also had a central line access device in her right upper chest. Employee 2 denied knowledge that she was to avoid use of the right arm. Review of the binder at the nurses' station that contained communication forms to/from the dialysis center and the facility revealed no reference to the bilateral limb restrictions. Interview with Employee 3 (registered nurse) on December 18, 2025, at 1:35 PM with Employee 2 confirmed that blood pressure assessments are obtained from Resident 6's right arm despite the care plan intervention, No blood draws or blood pressure to right upper extremity. The interview indicated that neither staff could refer to clinical record evidence that facility staff sought clarification from Resident 6's physician or the dialysis center practitioner regarding bilateral limb restrictions and the need to obtain blood pressure assessments and/or venipuncture for laboratory testing. Nursing documentation by Employee 3 dated December 18, 2025, at 1:51 PM (following the surveyor's questioning) revealed that the staff called the dialysis provider to seek clarification of bilateral upper extremity restrictions. Interview with the Director of Nursing on December 18, 2025, at 2:00 PM confirmed that the facility had no evidence that staff reviewed bilateral upper limb restrictions with Resident 6's primary care physician or dialysis provider to develop a plan to obtain blood pressure assessments (e.g., use of lower extremity or removal of one upper extremity limb restrictions) before the surveyor's questioning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain a complete and accurate accounting of a controlled medication for one of three closed resident records reviewed (Resident 71). Findings include: Clinical record review for Resident 71 revealed that the resident was admitted to the facility on [DATE], and discharged due to expiring on October 29, 2025. Review of the Medication Administration Record (MAR) for Resident 71 revealed the resident had orders for morphine sulfate (a controlled substance; a narcotic medication used to relieve pain), which included the following: Morphine sulfate (concentrate) oral solution 20 milligrams (mg) per milliliter (ml) give 0.25 ml by mouth four times a day for generalized pain for five days dated October 21, 2025, at 6:00 PM. Morphine sulfate (concentrate) oral solution 20 mg/ml give 0.25 ml by mouth every two hours as needed for pain / shortness of breath dated October 21, 2025, at 5:15 PM and discontinued on October 28, 2025, at 1:15 PM. Morphine sulfate (concentrate) oral solution 20 mg/ml give 0.25 ml by mouth every one hour as needed for pain / shortness of breath dated October 28, 2025, at 1:15 PM. Facility documentation titled, Controlled Drug Accountability Sheet for Resident 71 revealed a tracking sheet (that documented the date, time, quantity dispensed, amount administered, quantity destroyed/wasted, remaining quantity, signature of staff, and witness signature of staff if destruction or waste) utilized by staff to keep track of Resident 71's controlled medication. The medication/drug was listed as morphine sulfate with a concentration of 100 mg in five ml. Directions handwritten on the document instructed to give 0.25 ml by mouth four times a day; and 0.25 ml every two hours as needed. Further review of the documentation revealed there was no nurse signature on the controlled drug accountability sheet for the following medication administration dates/times: October 21, 2025, at 6:20 PM; 8:21 PM; 10:28 PM October 22, 2025, at 12:00 AM; 2:30 AM; 6:00 AM, 10:55 AM; 12:45 PM, 3:10 PM, 5:25 PM, 6:00 PM October 23, 2025, at 12:00 PM The Controlled Drug Accountability Sheet documentation further noted that 0.25 ml of morphine was marked as dispensed and administered on October 22, 2025, at 6:00 AM with no medication waste or destruction. The remaining quantity was marked as 28.5 ml. The next line of documentation dated October 22, 2025, at 10:55 AM documented 0.25 ml of morphine dispensed and administered with no waste or destruction. The remaining amount of medication was documented as 28.0 ml. There was no documentation provided by the facility to indicate what occurred with the additional 0.25 ml dose (i.e., was it wasted, administered, or destroyed by staff). The Controlled Drug Accountability Sheet revealed staff documented on October 28, 2025, at 4:10 AM that a 0.25 ml dose of morphine was dispensed and administered with no waste or destruction. The remaining quantity was documented by staff as 21.0 ml. Documentation on page two dated October 28, 2025, at 6:26 AM revealed that 0.25 ml of morphine was documented as dispensed and administered with a remaining quantity of 19.75 ml. There were no doses documented between these two administrations as wasted, administered, or destroyed by staff. The Controlled Drug Accountability Sheet revealed that the last administration documented by staff was 0.25 ml of morphine on October 29, 2025, at 8:40 AM with the amount remaining documented as 14.75 ml. Staff documented 14.75 as destroyed and signed by two staff members on October 29, 2025. The document did not specify how the medication was destroyed. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 18, 2025, at 2:00 PM. A follow-up interview with the Director of Nursing on December 19, 2025, at 12:32 PM revealed that there was a total of 1.5 ml that was not documented and unaccounted for on Resident 71's Controlled Drug Accountability Sheet and confirmed that staff should have signed where indicated when documenting on the form. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to enhanced barrier precautions for one of 16 residents reviewed (Resident 6).Findings include: The facility policy entitled, Enhanced Barrier Precautions, last reviewed May 7, 2025, revealed that enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP refers to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms during high contact resident care activities. EBP apply when a resident has a wound or indwelling medical device. Indwelling medical devices include central lines. EBPs employ targeted gown and glove use (PPE, personal protective equipment) in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE (personal protective equipment) required. PPE and alcohol-based hand-rub are readily accessible to staff. Residents, families, and visitors are notified of and educated about the implementation of EBPs. Interview with Resident 6 on December 16, 2025, at 10:45 AM revealed that she leaves the facility three times a week for hemodialysis treatment (due to the inability of the kidneys to filter blood, blood is circulated from the resident, through a machine, for the purpose of removing excess fluids and waste products). Observation of Resident 6 during the interview revealed intravenous access tubing from a dressing on her right upper chest. Resident 6 stated that she needed to have the fistula (a connection surgically created between an artery and a vein that is used for hemodialysis treatment) in her left arm revised due to a failure to function and the dialysis center was temporarily using the site to her right upper chest for her treatments. Resident 6 stated that any staff who touch her right upper chest site wear a mask and gloves; however, do not wear a gown. Observation of Resident 6's doorway and room during the interview revealed no indication of the implementation of EBP. Clinical record review of a plan of care developed by the facility to address Resident 6's .tunneled right central venous catheter (a special type of intravenous line when a long, thin, flexible tube is tunneled under the skin and placed into a large vein in your chest) to complete dialysis (initiated December 8, 2025), revealed interventions that included that the contracted dialysis provider maintained the dressings and care of the catheter. There was no intervention to implement EBP. Observation of Resident 6's doorway and room on December 17, 2025, at 12:17 PM and December 18, 2025, at 1:35 PM revealed no indication of the implementation of EBP. Interview with Employee 2 (licensed practical nurse) on December 18, 2025, at 1:35 PM confirmed that the facility did not implement measures for EBP (e.g., signage, accessible PPE, PPE disposal containers) for Resident 6 who had a central line access site in her right upper chest. The surveyor reviewed the above concerns related to EBP for Resident 6 during an interview with the Nursing Home Administrator and the Director of Nursing on December 18, 2025, at 2:00 PM. 483.80(a)(1)(2)(4)(e)(f) Infection ControlPreviously cited deficiency 11/15/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, closed clinical record, and staff interview, it was determined that the facility failed to notify a medical provider of a change in a resident's condition for one out of four residents reviewed (Resident CR1). Findings include: A review of the facility policy titled, Change in a Resident's Condition or Status, revealed a policy statement that noted the facility should promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The policy further noted the nurse will notify the resident's attending physician or physician on call when there is a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, and/or specific instructions to notify the physician of changes in the resident's condition. A review of the facility policy titled, Oxygen Therapy, revealed that a physician must order the oxygen therapy. There were no instructions in the policy related to the titration (assess oxygenation and adjust the rate based on resident response to the treatment) of oxygen therapy. A review of the facility policy for bi-level positive airway pressure (BiPAP, is a non-invasive ventilation machine that can generate two adjustable pressure levels - Inspiratory Positive Airway Pressure (IPAP) - high amount of pressure, applied when the patient inhales and a low Expiratory Positive Airway Pressure (EPAP) during exhalation). The policy noted that Bi-level also known as Bi-PAP must be ordered by a physician. There were no instructions in the policy related to troubleshooting the device or what actions to take if there are problems encountered (such as a mask leak). Closed record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. The resident had a diagnosis list that included: chronic respiratory failure with hypoxia (low oxygen levels in the body), chronic respiratory failure with hypercapnia (abnormal levels of carbon dioxide in the body), chronic obstructive pulmonary disease (COPD, a lung disease caused by obstructed airflow and breathing difficulties), sleep related hypoventilation (breathing that is not sufficient during sleep that may include breathing too shallow or too slow), chronic pulmonary edema (abnormal fluid accumulation in the lungs), and heart failure (the heart has difficulty pumping blood). Physician orders for Resident CR1 included an order dated [DATE], that instructed staff to monitor each shift for shortness of breath while lying flat and this was documented on the Medication Administration / Treatment Administration Records (MAR/TAR) by staff by indicating Y for yes or N for no. Additional physician orders for Resident CR1 dated [DATE], included BiPAP via mask every evening and night shift related to sleep related hypoventilation and an order dated [DATE], for oxygen at four liters per minute via nasal cannula (a type of medical tubing to deliver supplemental oxygen to the nose) continuously. Review of Resident CR1's care plan revealed the resident had an altered cardiovascular status related to their medical history. An intervention included to obtain vital signs as ordered and notify the physician of any abnormal readings. Further review of Resident CR1's care plan revealed the resident had an altered respiratory status related to their medical history. An intervention included: monitor for signs/symptoms of respiratory distress and report to the physician as needed (which included a decreased pulse oximetry). MAR/TAR documentation dated [DATE], for the night shift, revealed that staff documented y for yes to indicate Resident CR1 was having shortness of breath while lying flat. Nursing documentation dated [DATE], at 12:45 AM revealed that Resident CR1 was calling out and his SpO2 (oxygen saturation, the amount of oxygen carried by the blood and measured with a non-invasive medical device that is usually placed on a finger; normal readings are typically between 92 percent and 100 percent) was .only in the high 70s with BiPAP in place. The documentation noted the mask was leaking a lot of air from sides, and the staff were unable to get the mask to stop leaking. The nurse attempted to apply oxygen via nasal cannula at five liters per minute and the resident was mouth breathing and the SpO2 remained unchanged. Staff then applied oxygen at six liters per minute via mask and the SpO2 improved to 99 percent and the resident was satisfied with wearing the oxygen via mask. Interview with the Director of Nursing on [DATE], at 12:35 PM revealed that the mask noted in the above documentation referred to a simple mask (a mask that fits over the mouth and nose to deliver supplemental oxygen). MAR/TAR documentation dated [DATE], at 1:06 AM revealed a Medication Administration Note that indicated the resident was 95 percent on six liters oxygen via mask. MAR/TAR documentation dated [DATE], at 1:39 AM revealed a Medication Administration Note that indicated the BiPAP was held due to the resident's oxygen saturation dropping when the BiPAP was on. The documentation noted the resident was currently on six liters of supplemental oxygen via mask. Further review of the clinical documentation revealed no comprehensive respiratory assessments related to the resident's clinical presentation (such as breathing quality, depth of respirations, work of breathing, lung sounds, skin color, or level of consciousness for signs/symptoms of hypoxia/hypercapnia). Closed clinical documentation for Resident CR1 dated [DATE], at 3:15 AM revealed that staff were called to the resident's room at 1:51 AM due to the resident being without spontaneous respirations and had no palpable carotid pulse (a pulsation of blood flow that can be palpated in the neck). CPR (cardiopulmonary resuscitation) was initiated by staff. Closed clinical record review for Resident CR1 revealed no documentation that the physician was promptly consulted or notified upon staff assessment of the decreased oxygen saturation, the resident was placed on a higher supplemental oxygen flow rate than ordered by the physician, or the resident had shortness of breath as indicated on the MAR/TAR documentation. The facility failed to immediately consult with Resident CR1's physician regarding a significant change in the resident's physical condition (that is a deterioration in health or clinical complications), and a need to alter treatment significantly (that is, a need to commence a new form of treatment). The above information was reviewed with the Director of Nursing and Employee 1, Assistant Director of Nursing, on [DATE], at 1:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on November 12, 2024, at 9:15 AM revealed the following: In the freezer there was a bag of French fries, sausage, meatballs, and tater tots opened, not secured, and no open/use by date. There was an open bag of corn with a use by date of November 10, 2024, past the expiration. In the walk-in refrigerator there was a gallon size container of ranch dressing with a use by date of October 19, 2024, past the expiration. There was a gallon of reduced fat and a gallon of whole milk opened with no use by date. In the dry storage room, there were open bags of rice, pasta, and potato flakes with no open/use by dates. Interview with Employee 3 (registered dietician) on November 15, 2024, at 11:31 AM revealed that staff are to date the food when received, then date again with a use by date once the food product is opened. The exterior of the convection oven contained significant grease and debris buildup on the top of the oven and underneath. The controls were covered in black grease. The floor under the sink contained a significant amount of dust and debris. There was broken glass on the floor. Next to the sink there were plastic racks containing clean dishes, the area contained a significant amount of dirt and food debris where the clean dishes were. The cart that contained the stacks of clean resident meal trays was observed with debris and food crumbs on each shelf. The above findings were reviewed with the Nursing Home Administrator and Employee 1 (assistant director of nursing) on November 13, 2024, at 2:17 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for three of three residents reviewed for supplemental oxygen concerns (Residents 4, 5, and 15). Findings include: Clinical record review for Resident 4 revealed an active physician's order dated November 29, 2023, for staff to apply supplemental oxygen at two liters per minute (lpm) continuously every shift for shortness of breath. Observation of Resident 4 on November 12, 2024, at 11:01 AM, and November 13, 2024, at 10:03 AM, revealed Resident 4 was in bed with oxygen on and running at three lpm. Resident 4 was not short of breath during the conversation with her. Interview with Resident 4 on November 12, 2024, at 11:01 AM revealed that she recently had an upper respiratory infection and staff increased her oxygen due to her illness. Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 10:54 AM confirmed the findings for Resident 4. Clinical record review for Resident 5 revealed an active physician's order dated February 14, 2014, for staff to apply oxygen at three lpm every shift for shortness of breath and to check oxygen saturation (a measurement of how much oxygen is in your blood relative to the maximum amount of oxygen your blood could carry) every shift to keep saturation above 90 percent. Further review of Resident 5's clinical record revealed a diagnosis of chronic obstructive pulmonary disease (COPD, common lung disease making it difficult to breathe), with a plan of care initiated March 11, 2024, indicating Resident 5 has altered respiratory status related to his COPD and nursing staff are to administer his oxygen as ordered by his physician. Clinical record revealed nursing documentation dated September 21, 2024, at 9:37 AM that Resident 5's oxygen saturation was 92 percent and had oxygen running at six lpm. Nursing documentation dated September 21, 2024, at 10:25 AM revealed Resident 5 was sitting in their wheelchair with oxygen running at five lpm. Nursing documentation dated September 22, 2024, at 8:19 AM revealed Resident 5's oxygen saturation was 92 percent and had oxygen running at six lpm. Nursing documentation dated September 22, 2024, at 9:03 AM revealed Resident 5's oxygen saturation was 95 percent and had oxygen running at five lpm. Nursing documentation dated September 22, 2024, at 8:48 PM noted Resident 5's oxygen saturation was in the low 90s and had oxygen running at five lpm. Nursing documentation dated September 22, 2024, at 12:00 PM noted Resident 5's oxygen saturation was currently 94 percent on five lpm with no difficulty breathing at this time. Nursing documentation date September 25, 2024, at 12:28 PM revealed Resident 5 continued on five lpm. Review of Resident 5's oxygen saturation summary for the last two months revealed no documentation of Resident 5's oxygen saturation below 90 percent. Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 11:12 AM confirmed these findings for Resident 5. Clinical record review for Resident 15 revealed a physician's order dated August 10, 2021, for staff to administer supplemental oxygen at three lpm continuously. Observation of Resident 15 on November 12, 2024, at 11:59 AM revealed she was in bed without supplemental oxygen. Resident 15 stated that she wears it all the time, that she, .should have it on. An oxygen room concentrator (medical device that concentrates the oxygen in room air to administer an oxygen-enriched air supply back to the user) at Resident 15's bedside was running; however, the tubing for the nasal cannula (thin tube that runs from the device to the face with two open prongs placed inside the nostrils to administer supplemental oxygen) was on the floor. Resident 15 activated her call bell to obtain staff assistance with her oxygen administration. Observation of Resident 15 on November 12, 2024, at 12:00 PM revealed that Employee 14 (nurse aide) entered the room, obtained the nasal cannula tubing off the floor, and assisted Resident 15 to apply the supplemental oxygen tubing under her nose. Interview with Employee 14 on November 12, 2024, at 2:08 PM confirmed that she did not replace the nasal cannula tubing for Resident 15 but assisted her to use the tubing that was on the floor and potentially contaminated from the unsanitary surface of the floor. Observation of Resident 15 on November 14, 2024, at 12:46 PM revealed she was in her wheelchair in the common dining/activity area, without supplemental oxygen. Interview with Resident 15 on the date and time of the observation revealed that she did not have supplemental oxygen on because the facility did not have portable oxygen tanks for her use when she is in the wheelchair. Resident 15 confirmed that she sometimes gets short of breath without her supplemental oxygen. Interview with Employee 6 (licensed practical nurse) on November 14, 2024, at 12:58 PM confirmed that Resident 15's physician orders instructed staff to ensure Resident 15 utilized supplemental oxygen at all times. Employee 6 confirmed that Resident 15 did not have the necessary equipment to mount a supplemental oxygen tank to her wheelchair; therefore, unless Resident 15 remained in her room, she did not have a supplemental oxygen supply. The surveyor reviewed the above concerns regarding Resident 15's supplemental oxygen use during an interview with Employee 1 on November 14, 2024, at 1:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, resident and staff interview, and review of personnel records, it was determined that the facility failed to ensure specific competencies necessary to care for resident needs for one of one resident reviewed for intravenous access concerns (Resident 163; Employees 5, 7, 8, 9, 10, and 11). Findings include: The facility policy entitled, Infusion Therapy Responsibilities and Scope of Practice, last reviewed without changes on January 3, 2024, revealed that clinicians administering infusion therapies will practice within the scope of practice for their licensure and applicable state laws, and within their clinical level of competency as established by the facility training and competency evaluation programs. Nursing responsibilities in infusion therapy include performing functions and procedures that are consistent with current standards of care, facility policies and procedures, and that are within the scope of the state nurse practice act. Facility/administration responsibilities in infusion therapy include providing education or verifying qualifications of the staff that will be providing infusion therapy. This may include IV fundamental classes, precepting, and/or clinical competency evaluations. According to, Pennsylvania Code, Title 49, Chapter 21, Functions of the LPN, an LPN (licensed practical nurse) may perform only the IV (intravenous) therapy functions for which the LPN possesses the knowledge, skill, and ability to perform in a safe manner. Clinical record review for Resident 163 revealed that the facility admitted her on November 2, 2024. A physician's order dated November 2, 2024, instructed staff to change the primary intermittent tubing for an intravenous (IV) peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) every 24 hours. Physician orders dated November 3, 2024, instructed staff to perform the following: Monitor an IV PICC for signs and symptoms of infection or infiltration (complication of IV therapy when IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein; this can happen when the IV catheter dislodges, punctures the vein, or is not secured properly) Administer Unasyn (intravenous antibiotic) three grams four times a day until November 23, 2024 Flush the IV PICC when being used intermittently with 10 ml (milliliters) of NS (normal saline); infuse medication and then flush with 10 ml NS four times a day for IV antibiotic Interview with Resident 163 on November 12, 2024, at 12:25 PM confirmed that she was admitted to the facility for intravenous antibiotic therapy. Resident 163 pointed to the antecubital area (anterior elbow area) of her left arm and stated that was the intravenous access site staff used four times a day to administer the medication. Observation of Resident 163 on November 12, 2024, at 12:41 PM revealed Employee 5 (licensed practical nurse, LPN) entered the room to disconnect the intravenous tubing. Employee 5 donned gloves, disconnected the IV tubing from Resident 163's left arm, used a prepackaged syringe of 0.9 percent normal saline to flush the IV tubing, and directed Resident 163 to pull her sleeve over the IV access site. Interview with Employee 5 and Employee 6 (LPN) on November 12, 2024, at 12:50 PM revealed that Employee 5 disconnected the IV medication from Resident 163 because Employee 5 had specialized IV certification and Employee 6 (who was the assigned LPN on Resident 163's nursing unit) did not. Review of Resident 163's MAR (medication administration record, an electronic system used by the facility to document the administration of medications) dated November 2024 revealed that Employee 6 initialed that she administered Resident 163's Unasyn IV medication on November 12, 2024, at 12:00 PM and flushed Resident 163's PICC with saline at 12:00 PM. Further review of Resident 163's MAR dated November 2024, revealed that at least six LPNs initialed the completion of PICC line care and/or IV Unasyn administration from November 3, 2024, through November 13, 2024: Employees 5, 7, 8, 9, 10, and 11 (LPNs). The surveyor requested any intravenous or PICC line competencies or specialized trainings (per Pa. Code 21.145b., IV therapy curriculum requirements, an IV therapy course provided as part of the LPN education curriculum (relating to specific curriculum requirements for LPN programs); or as a stand-alone course offered by a provider) completed with Employees 5, 7, 8, 9, 10, and 11, during an interview with the Nursing Home Administrator and Employee 1 (assistant director of nursing) on November 13, 2024, at 2:00 PM, and November 14, 2024, at 2:00 PM. Interview with Employee 1 and the Nursing Home Administrator on November 14, 2024, at 2:00 PM revealed that the facility had no evidence of any competencies or specialized trainings completed with Employees 5, 7, 8, 9, 10, or 11, pertaining to intravenous medication administration via a PICC line. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development 28 Pa Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for three of five residents reviewed (Residents 4, 32, and 15). Findings include: Clinical record review for Resident 4 revealed a consultant pharmacy recommendation dated March 10, 2024, requesting Resident 4's physician consider a trial dose reduction of Resident 4's Buspirone (an antianxiety medication) and Venlafaxine (an antidepressant medication). Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 10:34 AM confirmed that the facility had no evidence that Resident 4's attending physician addressed the March 10, 2024, consultant pharmacist recommendation requesting a review of the possibility of a trial dose reduction, taper, or discontinuation of Resident 4's Buspirone and Venlafaxine. Further review of Resident 4's clinical record on November 14, 2024, revealed there was no evidence the consultant pharmacist reviewed Resident 4's medication regime in June 2024. Interview with Employee 1 on November 15, 2024, at 10:34 AM confirmed these findings for Resident 4 Clinical record review for Resident 32 revealed a consultant pharmacy recommendation dated September 23, 2024, requesting nursing complete an AIMS evaluation (Abnormal Involuntary Movement Scale, a rating scale to measure involuntary movements) due to Resident 32's use of Risperidone (an antipsychotic medication). There was no documentation in Resident 32's clinical record at the time of the pharmacy recommendation nursing staff completed an AIMS evaluation. Interview with Employee 1 on November 15, 2024, at 11:22 AM, confirmed these findings for Resident 32. Clinical record review for Resident 15 revealed a consultant pharmacy recommendation dated May 19, 2024, that requested the physician evaluate the potential for a gradual dose reduction of her psychoactive medications Clonazepam (antianxiety medication), Duloxetine (antidepressant medication), and Olanzapine (antipsychotic medication). Resident 15's clinical record did not contain evidence that Resident 15's attending physician acted upon this recommendation. Interview with Employee 1 on November 15, 2024, at 11:25 AM confirmed that Resident 15 's primary care physician did not respond to the consultant pharmacist's recommendation dated May 19, 2024. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered devices or a care planned intervention for two of 17 residents reviewed (Residents 21 and 25); a deep brain stimulator for one of 17 residents reviewed (Resident 25); and a central venous catheter for one of 17 residents reviewed (Resident 163). Findings include: Clinical record review for Resident 21 revealed a physician's order dated February 24, 2023, that instructed staff to apply a left ankle splint at 6:30 AM and remove the splint at 1:30 PM daily. Staff are to perform passive range of motion exercises before applying the splint. A plan of care developed by the facility to address Resident 21's limited physical mobility related to bilateral hand, elbow, and ankle contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) indicated that Resident 21 had contractures of her bilateral ankles, hands, and elbows. Interventions listed in the plan of care included the implementation of a restorative nursing program to perform passive range of motion exercises prior to a splint/orthotic placement. Observation of Resident 21 on November 13, 2024, at 11:13 AM with Employee 4 (nurse aide) confirmed that staff did not apply Resident 21's left ankle splint as ordered. The black splint was stored on top of furniture in Resident 21's room while she was in bed. The surveyor reviewed the above findings for Resident 21 during an interview with Employee 1 (assistant director of nursing) and the Nursing Home Administrator on November 13, 2024, at 2:00 PM. The facility policy entitled, Infusion Therapy Responsibilities and Scope of Practice, last reviewed without changes on January 3, 2024, revealed that responsibilities in infusion therapy include maintaining an infusion care plan for each resident receiving infusion services. Additional documentation for midline catheters and PICCs includes to document at established intervals: The external length of the catheter and the original length of the catheter inserted Arm circumference before insertion of the PICC, after insertion at regular intervals, and when clinically indicated (to check for edema and rule out deep vein thrombosis), measure the arm 10 centimeters above the antecubital fossa, and characterize any edema as pitting or non-pitting. The facility policy did not address the implementation of limb restrictions or emergency procedures for the duration of PICC infusion therapy. Clinical record review for Resident 163 revealed that the facility admitted her on November 2, 2024. A physician's order dated November 2, 2024, instructed staff to change the primary intermittent tubing for an intravenous (IV) peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) every 24 hours. Physician orders dated November 3, 2024, instructed staff to perform the following: Monitor an IV PICC for signs and symptoms of infection or infiltration (complication of IV therapy when IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein; this can happen when the IV catheter dislodges, punctures the vein, or is not secured properly) Administer Unasyn (intravenous antibiotic) three grams four times a day until November 23, 2024 Flush the IV PICC when being used intermittently with 10 ml (milliliters) of NS (normal saline); infuse medication and then flush with 10 ml NS four times a day for IV antibiotic Review of plans of care developed by the facility to address Resident 163's care needs revealed that the plan of care to address Resident 163's PICC line was not initiated until November 5, 2024 (three days after her admission to the facility with the device). The plan of care did not include verbiage to address restricting the use of her left arm, restrictions to bathing, or additional measures to protect the site during bathing, or emergency procedures in the event of tubing complications or bleeding. Interview with Resident 163 on November 12, 2024, at 12:25 PM confirmed that she was admitted to the facility for intravenous antibiotic therapy. Resident 163 pointed to the antecubital area (anterior elbow area) of her left arm and stated that was the intravenous access site staff used four times a day to administer the medication. Observation of Resident 163's room at the time of the interview revealed no indication that there were measures in place to prevent the inadvertent use of Resident 163's left arm (e.g., for blood pressure assessments or venipuncture for lab testing); or that there were emergency procedures in place (e.g., clamps or dressings) in the event of a complication from the intravenous site (e.g., a break in tubing patency or bleeding). Observation of Resident 163 on November 12, 2024, at 12:41 PM revealed Employee 5 (licensed practical nurse) entered the room to disconnect the intravenous tubing. Interview with Employee 5 and Employee 6 (licensed practical nurse) on November 12, 2024, at 12:50 PM confirmed that Resident 163's room was not equipped with signage or supplies to implement limb restrictions or emergency procedures required for Resident 163's left arm PICC. Employee 6 then telephoned additional facility staff to obtain supplies to implement an emergency kit in Resident 163's room. The surveyor reviewed the above concerns regarding care and services for Resident 163's PICC device during an interview with Employee 1 and the Nursing Home Administrator on November 13, 2024, at 2:00 PM. Interview with Employee 1 on November 15, 2024, at 12:01 PM confirmed that the facility policy would require nursing staff measure the length of Resident 163's IV tubing and the circumference of her arm; however, neither instruction was incorporated into her plan of care or physician orders. The interview also confirmed that Resident 163's baseline care plan (initiated on her admitted [DATE]) did not include the presence of her PICC until November 5, 2024 (more than the required 48 hours after admission). Clinical record review for Resident 25 revealed a diagnosis list that contained a history of pressure ulcers. Review of Resident 25's care plan revealed an intervention that included Geri-sleeves (a type of sleeve worn on the arm to prevent skin injury) or long sleeves at all times other than during care to protect the skin integrity on their arms. Review of the current task list for Resident 25 revealed that, Geri-sleeves or long sleeves to be worn at all times, except for personal care. Observation of Resident 25 revealed the following: October 13, 2024, at 9:34 AM: resident observed in bed with a short-sleeved shirt on and no Geri-sleeves. October 14, 2024, at 11:00 AM: resident observed in bed with a short-sleeved shirt on and no Geri-sleeves. October 14, 2024, at 12:20 PM: resident observed out of bed and sitting at the bedside awaiting lunch; had on a short-sleeved shirt with no Geri-sleeves. October 14, 2024, at 2:53 PM: resident observed out of bed and sitting at the bedside with a visitor; had on a short-sleeved shirt with no Geri-sleeves. Observation on November 14, 2024, at 3:14 PM with Employee 1, assistant director of nursing, revealed Resident 25 was sitting at the bedside with a visitor. The resident had on a short-sleeved shirt and no Geri-sleeves. A conversation between Employee 1 and an unidentified staff member at the nurse's station immediately following this observation indicated that Resident 25 may have soiled the Geri-sleeves during lunchtime earlier today and the Geri-sleeves are being washed in laundry. However, observations just prior to lunch on November 14, 2024, at 11:00 AM and 12:20 PM by the surveyor revealed that the resident did not have on Geri-sleeves at that time. A review of the task list documentation on November 14, 2024, at 3:15 PM revealed only one entry documented up to this time that revealed staff documented yes at 1:59 PM that the task of Resident 25's Geri-sleeves or long sleeves were to be worn at all times except for personal care was completed as directed. However, multiple observations by the surveyor on November 14, 2024, did not find the resident was wearing any Geri-sleeves. The facility failed to follow the care planned intervention for Resident 25 regarding Geri-sleeves. The Nursing Home Administrator was informed of the above information for Resident 25 on November 15, 2024, at 12:25 PM. Further review of Resident 25's clinical record revealed a diagnosis list that included the Presence of a Neurostimulator present upon admission on August 26, 2022. There was no care plan noted in Resident 25's clinical record that was associated with the neurostimulator. An attempted interview with Resident 25 on November 13, 2024, at 9:34 AM revealed the resident could not provide any information on the neurostimulator. An interview with Employee 15, registered nurse, and Employee 12, license practical nurse, on November 14, 2024, at 12:30 PM revealed the staff were not aware of a care plan associated with Resident 25's neurostimulator or any specific care interventions or precautions and would have to look further into it. Nursing documentation for Resident 25 dated May 9, 2024, at 5:00 PM revealed that the resident had a video visit with neurology. The settings were increased on the deep brain stimulator and staff are to monitor for possible side effects that included slurred speech, difficulty swallowing, and sedation. The neurology clinic was to be contacted if any issues, concerns, or questions and the telephone number and extension was listed. The facility failed to implement a care plan for Resident 25's implanted neurostimulator that addressed specific care needs or precautions pertinent to the care of the resident. The above information for Resident 25's care plan was reviewed in a meeting with the Nursing Home Administrator and Employee 1 on November 14, 2024, at 2:30 PM. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practical care to promote pressure ulcer healing for one of two sampled residents with pressure ulcers (Resident 25). Findings include: Current physician orders for Resident 25 revealed an order dated November 13, 2024, that instructed staff to apply Medihoney Wound and Burn Dressing External Paste (a type of topical medication used to treat certain skin wounds) to the right ischium (one of the bones of the pelvis) topically every shift for open skin areas on the buttocks and groin and to mix with zinc equal parts and specified half an ounce. Further review of the physician orders for Resident 25 revealed a second order dated October 24, 2024, that instructed staff to apply Zinc Oxide External Paste 40 percent topical to open skin areas every shift for open wound areas to the groin and buttocks and add equal parts to the Medihoney and specified half an ounce. A skin/wound note for Resident 25 dated November 11, 2024, at 2:55 AM revealed the resident had a pressure ulcer to the right ischium with a scant amount of serosanguineous exudate (a type of drainage excreted by the wound). The treatment recommendations included the following: cleanse with normal saline, apply medical grade honey / Desitin (a topical medication containing zinc oxide) to base of the wound, leave open to air, and change every shift and as needed. Observation of wound care for Resident 25 on November 14, 2024, at 11:05 AM revealed Employee 12, licensed practical nurse, prepared Medihoney and Zinc Oxide 20 percent paste by measuring both and then mixing them together - a half ounce of each topical medication. Employee 12 then administered the medications topically to the wound after cleaning with normal saline. The Desitin as recommended by the wound care staff, or the 40 percent concentration of zinc oxide paste as noted in the physician order was not administered as ordered. A follow-up interview with Employee 12 after wound care revealed that the Zinc Oxide paste administered topically to Resident 25 was only 20 percent. An interview with Employee 1, assistant director of nursing, on November 14, 2024, at 2:24 PM revealed that the facility does have the Desitin cream and would obtain additional information. A follow-up interview with Employee 1 on November 15, 2024, at 10:30 AM confirmed the facility does have the Desitin topical treatment as recommended by the wound care staff and the concentration of zinc oxide in the cream is 40 percent. It is unclear why the 40 percent concentration was not administered topically to Resident 25 as recommended by the wound care staff. The Nursing Home Administrator was advised of the above findings on November 15, 2024, at 12:25 PM. 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcer Previously cited deficiency 2/23/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure controlled substance medication accountability and security on one of two nursing units (second floor, Residents 12 and 35, Employee 6). Findings include: The facility policy entitled, Controlled Substances, last reviewed without changes on January 3, 2024, revealed that the facility would comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. An individual resident controlled substance record must be made for each resident who will be receiving a controlled substance (one prescription per page). The information on the record must include number on hand, time of administration, and signature of nurse administering the medication. The charge nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing will maintain a set of backup keys for all medication storage areas including keys to controlled substance containers. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. The policy did not include that the licensed staff who are assigned to medication administration on the nursing unit will possess keys to controlled substance containers in the nursing unit's medication cart. The policy also did not stipulate that the licensed nurse who administers a controlled substance to a resident during a shift will ensure the controlled substance count at the time of administration (versus waiting until the end of the shift to ensure that there are no discrepancies). The facility policy entitled, Medication Administration - General Guidelines, last reviewed without changes on January 3, 2024, revealed that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. Observation of a medication administration pass on the second-floor nursing unit on November 12, 2024, at 1:03 PM revealed Employee 6 (licensed practical nurse) prepared medications for administration to Resident 12. Employee 6 accessed a separately locked controlled substance container within the medication cart to obtain one Phenobarbital (anticonvulsant used to control seizures) 32.4 milligram (mg) tablet for Resident 12. Employee 6 did not refer to the controlled substance record for Resident 12's Phenobarbital medication (contained in a book on the nurses' station desk) to ensure the remaining tablet count of the medication in the medication cart agreed with the record. Interview with Employee 6 on November 12, 2024, at 1:05 PM confirmed that she was finished preparing medications for Resident 12 and was going to his room down the hall to administer the medications to him. Employee 6 stated that she signs for the administration of medications, including controlled substances, upon return to the medication cart. Employee 6 left the nurses' station, and medication cart, at that time. Employee 6 did not lock the medication cart, which was left unattended and not within her sight. Upon return to the nurses' station on November 12, 2024, at 1:07 PM Employee 6 identified that she left the medication cart unlocked. Employee 6, then locked the medication cart and obtained the controlled substance record for Resident 12's Phenobarbital medication. Employee 6 recorded that there were 32 tablets left; however, Employee 6 did not obtain the medication from the medication cart to compare the number of tablets left. Interview with Employee 6 on November 12, 2024, at 1:08 PM confirmed that she documented the number of tablets without obtaining the medication from the medication cart to ensure the accurate count of remaining medication tablets. Employee 6 then obtained the Phenobarbital medication to reconcile the number of tablets left in the medication cart with the number of tablets recorded on the controlled substance record. Interview with Employee 6 on November 12, 2024, at 1:30 PM revealed that she was going to prepare medications to administer to Resident 35 for her 2:00 PM medication administration. Employee 6 began by accessing the controlled substance storage in the medication cart to obtain Resident 35's Tramadol (narcotic controlled substance pain medication). Employee 6 reviewed the controlled substance record for Resident 35's Tramadol and noted that the record indicated that there should be 86 tablets of medication. The two containers of Tramadol 50 mg in the medication cart for Resident 35 revealed that she had 85 tablets of the medication remaining. Employee 6 then stated that she, .must have already done her, because the narcotic count indicated that there was one less tablet available. Employee 6 then confirmed that she did not document the administration of Resident 35's 2:00 PM medications at the time of administration; or reconciled the number of tablets left of Resident 35's Tramadol at the time of administration. Employee 6 then documented on Resident 35's controlled substance record that she administered one tablet on November 12, 2024, at 1:00 PM. Resident 35 approached the nurses' station on November 12, 2024, at 1:35 PM. Employee 6 questioned Resident 35 if she wanted her scheduled breathing treatment (scheduled for 2:00 PM) to which Resident 35 agreed. Employee 6 then prepared Resident 35's Ipratropium Bromide inhalation medication and administered the treatment to Resident 35 at her bedside. Review of a Medication Administration Competency Checklist dated January 10, 2024, for Employee 6, revealed that the actions reviewed did not include the appropriate administration of a controlled substance. Interview with Employee 1 (assistant director of nursing) on November 15, 2024, at 11:21 AM indicated that it is the facility's expectation that the nurse who administers a controlled substance signs for the medication at the time of administration, documents the date and time of the administration on the controlled substance record, and ensures that the number of medications is correct. The interview indicated that the facility policy provided was not correct in that the Director of Nursing and the charge nurse have a set of keys to controlled substance containers. The interview indicated that the licensed practical nurse has a set of keys to the medication cart that they are assigned for the shift and the Director of Nursing has a master set of keys. The interview confirmed that the facility policy did not direct staff to reconcile the number of tablets left of a controlled substance at the time of administration. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 1/19/24 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for 1 of 17 residents reviewed (Resident 45). Findings include: Clinical record review for Resident 45 revealed a physician's order dated October 11, 2024, that instructed staff to weigh the resident weekly. Dietary documentation dated October 11, 2024, at 4:27 PM revealed that Resident 45 had lost weight. An intervention from dietary included adding weekly weights to monitor the resident. The weights documented in Resident 45's electronic health record included the following: 10/7/24: 126.0 pounds (lbs) 11/7/24: 124.5 lbs 11/11/24: 125 lbs There was no evidence in Resident 45's clinical record that indicated the weekly weights ordered by the physician and recommended by the dietary staff were completed. The above information was reviewed in a meeting with the Nursing Home Administrator and Employee 1, assistant director of nursing, on November 14, 2024, at 2:24 PM. Employee 1 reported she will attempt to obtain additional information. Facility documentation provided by the facility and titled, Weight Entry, revealed Resident 45's weekly weights were documented (written in by hand) on the sheet along with multiple additional residents. A follow-up interview about Resident 45's weights with Employee 1 on November 15, 2024, at 12:32 PM revealed that dietary staff usually transcribe the newly obtained weights into the electronic health record; however, Resident 45's obtained weights were not transcribed and not part of her clinical record. The facility failed to ensure a complete and accurate clinical record for Resident 45. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for two of 17 residents reviewed (Residents 25 and 163). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled, Enhanced Barrier Precautions, last reviewed without changes on January 3, 2024, revealed that EBP are utilized by the facility to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Further review of the policy revealed that EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply (gloves and gown are applied prior to performing the high contact resident care activity, personal protective equipment (PPE) is changed before caring for another resident, and face protection may be used if there is a risk of splash or spray). The facility further noted examples of high-contact resident care activities that require the use of gown and gloves for EBPs included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (such as central line, urinary catheter, feeding tube, tracheostomy /ventilator, etc.), and wound care (any skin opening requiring a dressing). A review of the current physician orders for Resident 25 revealed a physician's order dated November 13, 2024, that instructed staff to apply Medihoney Wound and Burn Dressing External Paste (a type of topical medication used to treat certain wounds) to the right ischium (one of the bones of the pelvis) topically every shift for open skin areas on the buttocks and groin and to mix with zinc in equal parts that specified half an ounce. Further review of the physician orders for Resident 25 revealed a second order dated October 24, 2024, that instructed staff to apply Zinc Oxide External Paste 40% topical to open skin areas every shift for open wound areas to the groin and buttocks and add equal parts to the Medihoney and specified half an ounce. A skin/wound note for Resident 25 dated November 11, 2024, at 2:55 AM revealed the resident had a pressure ulcer to the right ischium with a scant amount of serosanguineous exudate (a type of drainage excreted by the wound). There was no evidence in the clinical record to indicate that Resident 25 was on any type of enhanced barrier precautions or any type of isolation for the wound. Observation outside of Resident 25's room on November 14, 2024, at 11:00 AM revealed a sign on the wall adjacent to the resident's door that indicated Enhanced Barrier Precautions and a gown, and gloves must be worn for high-contact resident activities. There was a number 1 written with a black colored marker and circled in the upper left hand corner of the sign. There was a plastic storage container located in the room that contained personal protective equipment such as gowns and gloves to use for care. Observation of wound care for Resident 25 on November 14, 2024, at 11:05 AM revealed Employee 12, licensed practical nurse (LPN), entered the resident's room with no gown. Employee 12 proceeded to clean the wound and apply the physician ordered treatments. Employee 12 did not utilize a gown and only wore gloves during the high-contact resident activity. Employee 13, LPN, was also present at the time of Resident 25's wound care. Employee 13 assisted with bed mobility and positioning during the wound treatment. Employee 13 did not utilize a gown. An interview with Employee 12 outside of Resident 25's room regarding the EBP sign and personal protective equipment revealed that the employee believed the EBPs were for Resident 25's roommate. An interview with Employee 1, Assistant Director of Nursing, on November 14, 2024, at 11:49 AM regarding Resident 25's wound care confirmed that the resident was on EBP, and staff should have utilized EBPs during the wound care. Employee 1 also revealed the circled 1 on the EBP sign outside the resident's door indicated which resident in the room was on EBPs, which would have been Resident 25. Employee 1 further noted that the EBPs for Resident 25 should be located, at a minimum, in the resident's care plan to alert staff the resident is on EBPs. Employees 12 and 13 failed to wear the appropriate personal protective equipment during wound care for Resident 25. This surveyor informed the Nursing Home Administrator of the above information during an interview on November 15, 2024, at 12:25 PM. Clinical record review for Resident 163 revealed that the facility admitted her on November 2, 2024. A physician's order dated November 2, 2024, instructed staff to change the primary intermittent tubing for an intravenous (IV) peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) every 24 hours. Physician orders dated November 3, 2024, instructed staff to perform the following: Monitor an IV PICC for signs and symptoms of infection or infiltration (complication of IV therapy when IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein; this can happen when the IV catheter dislodges, punctures the vein, or is not secured properly) Administer Unasyn (intravenous antibiotic) three grams four times a day until November 23, 2024 Flush the IV PICC when being used intermittently with 10 ml (milliliters) of NS (normal saline); infuse medication and then flush with 10 ml NS four times a day for IV antibiotic Interview with Resident 163 on November 12, 2024, at 12:25 PM confirmed that she was admitted to the facility for intravenous antibiotic therapy. Resident 163 pointed to the antecubital area (anterior elbow area) of her left arm and stated that was the intravenous access site staff used four times a day to administer the medication. Observation of Resident 163's room at the time of the interview revealed no indication that there were measures in place for enhanced barrier precautions. Observation of Resident 163 on November 12, 2024, at 12:41 PM revealed Employee 5 (LPN) entered the room to disconnect the intravenous tubing. Employee 5 donned gloves, disconnected the IV tubing from Resident 163's left arm, used a prepackaged syringe of 0.9 percent normal saline to flush the IV tubing, and directed Resident 163 to pull her sleeve over the IV access site. Employee 5 donned gloves to perform the care; however, Employee 5 did not don a gown. Interview with Employee 5 and Employee 6 (LPN) on November 12, 2024, at 12:50 PM confirmed that Resident 163's room was not equipped with signage or supplies to implement the enhanced barrier precautions required due to Resident 163's left arm PICC. Employee 6, then, telephoned additional facility staff to obtain supplies to implement enhanced barrier precautions. The surveyor reviewed the above concerns regarding Resident 163's enhanced barrier precautions during an interview with Employee 1 and the Nursing Home Administrator on November 13, 2024, at 2:00 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control Previously cited deficiency 1/19/24 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to assist dependent residents with activities of daily living for two of four residents reviewed for activities of daily living concerns (Residents 21 and 53). Findings include: Clinical record review for Resident 21 revealed an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], that revealed Resident 21 as totally dependent on the physical assistance of two staff for transferring (moving between surfaces including from bed to wheelchair). Active physician orders for Resident 21 indicated that Resident 21 required a passive mechanical lift to transfer. Observation of Resident 21 on November 12, 2024, at 11:28 AM revealed she was in bed. Observation of Resident 21 on November 13, 2024, at 11:10 AM revealed she was in bed. Interview with Employee 4 (nurse aide) on November 13, 2024, at 11:13 AM revealed that Resident 21 was still in bed because there were no slings for the lift that she required for her transfers out of bed. Employee 4 stated that there was no other reason why Resident 21 remained in bed. The surveyor reviewed the above findings regarding Resident 21 during an interview with Employee 1 (assistant director of nursing) and the Nursing Home Administrator on November 13, 2024, at 2:00 PM. Observation and interview with Resident 53 on November 12, 2024, at 12:54 PM revealed that her hair was disheveled. She stated that she recently returned from dialysis. When questioning Resident 53 she was unable to state when she last received a shower/bath. Clinical record review for Resident 53 revealed her annual MDS dated [DATE], noted staff assessed her as requiring partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for bathing. Further review of Resident 53's clinical record revealed task documentation (electronic system of nurse aide documentation of activities of daily living care) noting her last shower was November 1, 2024. There was one documented refusal, and two bed baths. There were no further attempts to assist Resident 53 with a shower/bath. These findings were reviewed during a meeting with the Nursing Home Administrator and Employee 1 on November 13, 2024, at 2:39 PM, and they confirmed there was no further documentation. Further interview with Employee 1 on November 15, 2024, at 9:20 AM revealed that if a resident refuses a shower/bath, another staff member is to offer at a later time, and if the resident refuses the second time, nursing staff should document that in the clinical record. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions and provide adequate supervision to prevent a fall for one of three residents reviewed for falls that resulted in harm (Resident 5). This deficiency is cited as past non-compliance. Findings include: Clinical record review revealed the facility admitted Resident 5 on March 26, 2015. Review of Resident 5's plan of care initiated on March 26, 2015, indicated that Resident 5 is at risk for falls related to her diagnosis of Alzheimer's dementia, history of falls, syncope, and noncompliance with assistance with transfers. Nursing documentation dated October 5, 2023, at 2:45 PM revealed the Director of Nursing was called to the front porch by staff asking for nursing assistance. Documentation revealed that upon reaching the porch the Director of Nursing was notified that Resident 5 had wheeled herself off the porch and down the steps. Resident 5 was noted to be lying on the ground on her left side with blood from the left side of her head. Nursing documentation noted Resident 5 complained of head and right arm pain. Documentation further revealed that 911 was called and EMS staff reported that Resident 5 would be transferred to the emergency room under a trauma alert. Further review of Resident 5's clinical record revealed she was admitted and remained in the hospital from October 5 to 9, 2023. Review of the hospital discharge summary from October 9, 2023, revealed Resident 5 was admitted with a large forehead laceration with exposed bone, as well as a large hematoma of the left upper extremity extending from the elbow to the hand, along with swelling and a hematoma to the right knee. The summary indicated that sutures were used to close the head laceration and she was diagnosed with a fracture of her left ring finger. Nursing documentation dated October 11, 2023, at 11:48 AM revealed the physician's assistant was made aware of Resident 5's increased right leg pain and the facility requested an x-ray, as only her knee was x-rayed at the hospital. Nursing documentation dated October 12, 2023, at 10:05 AM revealed the physician's assistant and physician reviewed Resident 5's x-ray and noted she needed to be evaluated at the emergency room for a nondisplaced fracture of her distal right femur. Review of the facility's investigation into Resident 5's fall revealed that it occurred while Resident 5 was with other residents outside on a porch activity. Resident 5 was noted to be in her wheelchair approximately 25 feet away from the end of the porch. The investigation indicated Resident 5 self-propelled herself off the end of the porch. The activity aide was assisting another resident when she heard Resident 5's alarm sounding. Resident 5's wheelchair was noted to be at the top of the porch steps tipped over and the activity aide notified nursing staff that Resident 5 had fallen down the steps. The investigation revealed there were 20 residents on the porch with the activity aide. The facility investigation did not determine if Resident 5's wheelchair brakes were engaged at the time of the incident. The activity aide was unable to state if the brakes were engaged or not. Review of the Director of Maintenance's witness statement revealed an inspection was completed on Resident 5's wheelchair and determined all the hardware on the wheelchair worked properly, stating Resident 5's wheelchair would not move forward or backward if the brakes were applied. Further review of Resident 5's clinical record revealed her most recent MDS (Minimum Data Set, an assessment at specific intervals to determine care needs) dated October 16, 2023, revealed staff assessed Resident 5 as dependent to wheel 50 feet. An interview with the Director of Nursing on January 19, 2024, at 2:40 PM revealed that Resident 5 is physically capable of self-propelling, but due to her cognition, and visual deficits, staff coded her as dependent. The facility failed to implement interventions and provide adequate supervision to prevent a fall for Resident 5. These findings were reviewed in an interview with the Director of Nursing on January 19, 2023, at 2:52 PM. The quality assurance team met and developed a safety plan regarding porch activities on October 9, 2023. The plan included the facility will keep a staff/volunteer ratio of one staff to 10 residents while outside, and if at any time more staff is needed to immediately notify staff members in the facility. A retractable gate was placed on the porch on October 9, 2023, and will be closed when residents are attending a porch activity. Education was initiated on October 6, 2023, educating staff regarding brakes being applied to residents' wheelchairs when seated in an area. The Nursing Home Administrator or designee planned to audit porch activities for three months and as needed thereafter to ensure that the safety plan does not need to be updated or revised related to safety concerns. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services