Every finding on record at Paul's Run

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards for one of three residents reviewed (Residents R7).Findings Include: Review of Resident R7's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Parkinsons's disease (progressive neurological disorder that primary affects movement), hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Review of Resident R7's medication regimen review, dated June 30, 2026, revealed Paroxetine together with apixaban may increase the risk of bleeding. The interaction may be more likely with kidney or liver disease. Please monitor for any unusual bleeding or bruising, or have other signs and symptoms of bleeding such as dizziness; lightheadedness; red or black, tarry stools; coughing up or vomiting fresh or dried blood that looks like coffee grounds. Further review of Resident R7's medication regiment review revealed the physician signed off and agreed with the recommendation. Review of Resident R7's clinical record revealed no documented evidence that the resident was being monitored for bleeding. Interview on July 23, 2026, at 10:00 a.m. with Director of Nursing, Employee E1, confirmed there was no documented evidence that Resident R7 was being monitored for bleeding. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided during transfer for one resident which resulted in a fall incident for one of three residents reviewed for falls (Resident R14).Findings include:Review of facility policy Fall Prevention Protocol, not dated, revealed each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Clinical record review revealed Resident R14 was admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Accident (known as stroke, disruption of blood flow to brain, which can lead to brain damage), hemiplegia and hemiparesis affecting right dominant side (affect movement/sensation on one side of body). Review of Resident R14's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated August 11, 2025, revealed transfers required two or more persons physical assists. Review of Resident R14's nursing progress note, dated August 18, 2025, revealed Resident R14 was in the middle of transference from wheelchair to bed when she/he lost her/his balance and fell on the floor. Resident observed to have a new bruise on right forearm after the fall occurred. Resident is assist of 2 staff but was being assisted by 1 nurse aide during time of fall. Review of facility incident report, dated August 19, 2025, revealed on August 18, 2025 at 7:22 p.m. Resident R14 lost her/his balance during transferring from wheelchair to bed and fell down on the floor. Interview on August 29, 2025 at 10:45 a.m. with Director of Nursing, Employee E3, confirmed Resident R14 required a two person assist at time of transfer. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.10 (d) Resident Care Policies.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report a resident's fall incident and bruise to the local State agency as required for one of four residents reviewed for falls (Resident R14).Findings include:Review of facility policy Investigating Incident Reports and Adverse Events, not dated, revealed all adverse events occurring to residents will be investigated for root cause and to rule out abuse and neglect. An adverse event includes falls, both witnessed and unwitnessed.Clinical record review revealed Resident R14 was admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Accident (known as stroke, disruption of blood flow to brain, which can lead to brain damage), hemiplegia and hemiparesis affecting right dominant side (affect movement/sensation on one side of body). Review of Resident R14's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated August 11, 20245 revealed the resident require required two or more persons physical assists for transfers.Review of Resident R14's nursing note, dated August 18, 2025, revealed Resident R14 was in the middle of transfer from wheelchair to bed when she/he lost her/his balance and fell on the floor. Resident observed to have a new bruise on right forearm after the fall occurred. Resident is an assist of 2 staff but was being assisted by 1 nurse aide during time of fall.Review of facility incident report, dated August 19, 2025, revealed on August 18, 2025, at 7:22 p.m. Resident R14 lost her/his balance during transferring from wheelchair to bed and fell down on the floor.Review of facility reported information to the State agency for August 2025 revealed no evidence that the facility reported to the State Agency the fall sustained by the resident while being transferred by one nurse aide and not two nurse aides as required.Interview on August 29, 2025 at 10:50 a.m. with Director of Nursing, Employee E3, confirmed the facility failed to report Resident R14's incident to the State agency. 28 Pa. Code:201.14(a)(c) Responsibility of licensee.28 Pa. Code:201.18(b)(1)(e)(1) Management.

Based on review of clinical records, facility policy, and interviews with staff, it was determined that the facility failed to ensure the resident was assessed after a significant weight loss for one of three residents reviewed for weight loss (Resident R75). Review of facility policy Recording the Weight of Each Resident, dated 2024, revealed if the resident's weight has 5% or greater change from the previous month the nursing staff is responsible to re-weigh the resident within 48 hours. If after the re-weight is completed, the resident shows a 5% weight gain or loss, the dietitian will notify the IDT and complete proper documentation. The nursing staff or designee will alert the appropriate individuals of significant changes. Clinical record review revealed Resident R75 was admitted to the facility on [DATE] with a diagnosis that included congestive heart failure (CHF-affects your heart's ability to pump blood), malnutrition (diet does not provide enough nutrients or the right balance for optimal health) and depression. Review of Resident R75's clinical record revealed physician's order, dated July 25, 2025, for CHF: check weight daily, notify doctor if gain of 2-3#/day or 5#/week or if heart failure symptoms present. Perform standing in the morning. Further review of Resident R75's clinical record revealed the following notable weights documented:- 8/12/25: 178.6 pounds (lbs) standing- 8/13/25: 176.0 lbs standing- 8/15/25: 176.0 lbs wheelchair- 8/20/25: 175.6 lbs wheelchair- 8/21/25: 174.0 lbs wheelchair- 8/22/25: 153.6 lbs standing- 8/23/23: 151.4 lbs standing- 8/24/25: 152.7 lbs standing- 8/25/25: 151.4 lbs wheelchair- 8/26/25: 153.6 lbs standing- 8/28/25: 153.0 lbs standing Review of Resident R75's clinical record revealed no assessment or documentation related to Resident R75's significant weight loss. Interview on with Employee E5, Dietician, confirmed Resident R75 was not assessed related to the resident documented weight loss. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement enhanced barrier precautions for eight of eight residents reviewed (Resident R16, R48, R82, R88, R416, R4, R1 ) Findings Include: Review of facility policy dated November 2023 Enhanced Barrier Precautions revealed it is the policy of the facility to use enhanced barrier precautions with residents who are at risk for acquisition and colonization of multidrug resistant organisms (MDRO's). The use of Enhanced Barrier Precautions is indicated during high contact resident care activities for residents with chronic wounds and/or indwelling devices regardless of MDRO colonization. A review of Resident R16's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder, the relationship between the nervous system and bladder function is disrupted by injury or disease). Further review of Resident R16's clinical record revealed a physician order for a foley catheter (sterile tube that is inserted into the bladder to drain urine). Observation of Resident R16 in room [ROOM NUMBER]D on October 15, 2024, revealed resident resting in bed with eyes closed and a urine collection bag was hanging on the side of the bed. Further observation revealed no signage on the resident's door to indicate that the resident was on enhanced barrier precautions. Review of Resident R48's clinical record revealed a physician order dated March 27, 2024, for a coude catheter (type of urinary catheter to drain urine). Further review of Resident R48's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R82's clinical record revealed a physician order dated April 15, 2024, for a suprapubic catheter (a type of urinary catheter that is inserted into the bladder through an incision in the belly to drain urine). Further review of Resident R82's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R88's clinical record revealed a physician order dated May 10, 2024, for a suprapubic catheter. Further review of Resident R88's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R416's clinical record revealed a physician order dated October 2, 2024, for a foley catheter. Further review of Resident R416's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Observations of Resident R416 in room [ROOM NUMBER]D on October 15, 2024, at 10:26 a.m. revealed no signage on the resident's door and/or in the resident's room to indicate that the resident was on enhanced barrier precautions. Interview on October 16, 2024, at 11:45 a.m. with Registered Nurse, Employee E8, confirmed Resident R82, R88, and R48 had catheters. Further interview with Registered Nurse, Employee E8, revealed no residents were on enhanced barrier precautions. Follow-up observations on October 16, 2024, at 11:45 a.m. revealed no signage on the resident doors and/or in the resident rooms to indicate that Residents R82, R88, and R48 were on enhanced barrier precautions. Interview on October 17, 2024, at 11:11 a.m. with Infection Preventionist, Employee E9, confirmed enhanced barrier precautions were not in place. Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia; depression; essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris; osteoarthritis of the knees; repeated falls; obstructive and reflux uropathy; and difficulty in walking. Further review Resident R4's October 2024 physican orders revealed an order for Coude Catheter 20 French/ 30 ccwater. Catheter care every shift. Cleanse area with soap and water every shift. Observation of Resident R4's room did not reveal enhanced barrier precaution signage and there was no evidence of PPE (personal protective equipment) available outside room [ROOM NUMBER]. Interview on October 16, 2024 at 11:30 a.m. with Employee E5 confirmed that staff does not wear a gown while performing urinary catheter care. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with the diagnoses of heart disease of native coronary artery without angina pectoris. Observation of treatment to Resident's R1 sacral and heel wounds on October 17, 2024 at 10:40 a.m. with Wound nurse, Employee E15, and Licensed nurse, Employee E5, revealed hand sanitizer and and gloving were maintained. There was no transmission based signage or PPE (personal protective equipment) supply noted outside of room [ROOM NUMBER]. Interview on October 17, 2024 at 11:00 a.m. with Employee E15 confirmed there was no transmission based precaution signage or PPE available during wound care for Resident R1. The facility did not implement enhanced barrier precautions related to catheter care and wound care. 28 Pa. Code 211.10( d) Resident care policies 28 Pa. Code 211.112(d)(1) Nursing services

Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's needs for one of two residents reviewed for nutrition (Resident R52). Findings Include: Review of facility policy dated January 16, 2024, Recording The Weight of Each Resident revealed if a resident shows a 5% weight gain or loss, the Dietitian should be notified. Any resident with a significant weight loss should be included on the 24 hour report for that day. Review of Resident R52's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 13, 2024, revealed Resident R52 had moderate cognitive impairment and had diagnoses of weakness and Cerebral Vascular Accident. Observation of Resident R52 on October 15, 2024, at 11:05 a.m. revealed Resident R52 had bilateral hand tremors. Interview with Resident R52 on October 15, 2024, at 11:05 a.m. Resident R52 reported mealtimes can be difficult because the food falls off the utensil. Continued interview with Resident R52 revealed the resident will get frustrated at mealtimes and ends up not eating. Resident R52 reported history of weight loss. Review of Resident R52's clinical record revealed the resident was readmitted to the facility following a hospitalization on [DATE]. Continued review of Resident R52's clinical record revealed the resident was weighed on March 8, 2024, at 168.5 pounds. Review of Resident R52's nutrition assessment dated [DATE], completed by Registered Dietitian, Employee E11, revealed Resident R52 had a fair appetite and was not able to feed self. Resident R52 was noted with meal intakes of 25-50%. Resident R52's nutritional needs were assessed based on intact skin at that time. Recommendations included to provide a 4-ounce supplement (contained 240 calories & 10 grams protein) one time per day to increase PO (by mouth) intake. Continued review of Resident R52's nutrition assessment dated [DATE], revealed the resident's nutrition diagnosis was inadequate PO intake related to diagnoses and advanced age, as evidence by meal consumptions of 25-50%. Review of Resident R52's medication/treatment administration, physician orders, and clinical record revealed no documented evidence the 4-ounce supplement as implemented as recommended by the Registered Dietitian, Employee E11, on March 12, 2024. Review of Resident 52's physician order history revealed a physician order with a start date of March 27, 2024, for a calorie count over 3 days and to send the results to dietary when completed. Review of Resident R52's clinical record revealed no documented evidence the calorie count was completed as ordered. Continued review of Resident R52's clinical record revealed no documented evidence the Registered Dietitian followed-up with the ordered calorie count. Further review of Resident R52's clinical record revealed Resident R52 was noted with discoloration to the left sacrum on March 26, 2024. Resident R52 was subsequently assessed by the Nurse Practitioner, Employee E13, on April 2, 2024, who identified the area on the left sacrum as a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). Review of Resident R52's clinical record revealed Resident R52 was assessed by the Nurse Practitioner, Employee E13, again on April 9, 2024.The Nurse Practitioner, Employee E13, revealed the stage 2 pressure ulcer had worsened and was now categorized as an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the would bed is obscured by slough or eschar). Review of Resident R52's clinical record revealed no documented evidence the Registered Dietitian followed-up to reassess the resident's nutrition needs to align with Resident R52's increased calorie and protein needs to promote wound healing. Resident R52 was weighed again on April 4, 2024, at 158.3 pounds which reflected a 10 pound and 6.44% significant weight loss from March 8, 2024. Review of Resident R52's clinical record revealed the Registered Dietitian did not re-assess Resident R52's nutrition status and nutritional needs until April 26, 2024. Interview on October 18, 2024, at 12:36 p.m. with Registered Dietitian, Employee E12, confirmed Resident R52 had a significant weight loss from March 8, 2024, to April 4, 2024, and was not assessed until April 26, 2024. Further interview with the Registered Dietitian, Employee E12, confirmed the supplement was not implemented as recommended from the nutrition assessment on March 12, 2024. The Registered Dietitian, Employee E12, also confirmed there was no follow-up to the calorie count that was ordered by the physician on March 27, 2024. Registered Dietitian, Employee E12, was unable to provide evidence of the results from the calorie count. Continued interview on October 18, 2024, at 12:36 p.m. with Registered Dietitian, Employee E12, confirmed there was no nutrition follow-up to re-assess Resident R52's energy needs when the skin breakdown was identified on April 2, 2024. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included the information necessary to properly care for a resident within 48 hours of admission for two of 24 residents reviewed. (Resident R69) Findings include: Facility policy titled Baseline Care Plan (2024), indicated that This facility will develop an initial person-centered care plan within the first forty-eight (48) hours of admission for every resident. The Baseline Care Plan will provide instructions for care of the resident. Completion and implementation of the Baseline Care Plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among all facility staff members, increase resident safety and safeguard against adverse events that are most likely to occur in the immediate days after admission prior to development of the Comprehensive Care Plan and to ensure the resident and representative are informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan or a copty of the Baseline Care Plan. Review of Resident R69's clinical record revealed Resident R69 was admitted to the facility on [DATE] with a diagnosisof aftercare following joint replacement surgery, major depressive disorder, urinary tract infection, and Type 2 diabetes (condition that affects how the body uses sugar as a fuel). Review of Resident R69's clinical record revealed Resident R69 had a care plan initiated September 23, 2024. The baseline care plan only included one focus area, which was resident will transition to long term care after rehab. Resident R69 did not have a completed baseline care plan until September 26, 2024, which is after Resident R69's 48 hours of admission. Review of Resident R315's clinical record revealed Resident R315 was admitted to the facility on [DATE] with a diagnosis of heart failure (condition where the heart cannot pump as well as it should), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident R315's clinical record revealed Resident R315 had a care plan initiated October 7, 2024. Resident R315's baseline care plan did not include the minimum healthcare information necessary to properly care for Resident R315 until after 48 hours of Resident R315's admission. Interview on September 17, 2024 at 11:40 a.m with Employee E7, Licensed Practical Nurse, confirmed Resident R69 and Resident R315 did not have a their baseline care plans completed within 48 hours of admission. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of five residents reviewed for monthly medication review. (Resident R6 and R34). Findings Include: Review of the policy Medication Regimen Review dated June 28, 2019, revealed that the consultant pharmacist performs a comprehensive medication regimen review at least monthly. Findings and recommendations are reported to the Director of Nursing and Attending Physician. Recommendations are acted upon and documented by the facility staff and/or prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident R6's medical record revealed that resident was admitted on [DATE], with diagnoses including dementia (general term for a decline in cognitive function). A review of the consultant pharmacist report for Resident R6 on July 21, 2024, included a recommendation to increase Memantine (medication to treat Alzheimer's type dementia) gradually to 10 milligrams (mg) twice a day for an optimal response. A review of Resident R6's physician orders for October 2024, revealed that the resident was still receiving 10 mg of Memantine once a day at bedtime as ordered on April 10, 2024. A review of Resident R6's physician progress notes revealed no review of the July 21, 2024, pharmacy recommendation to gradually increase the dose of memantine to 10 mg twice a day, to include what action, if any, would be taken and the rationale for not taking any action. Interview with the Director of Nursing on October 20, 2024, revealed that there was no documentation available to review related to the recommendations made by the consultant pharmacist or whether they were acknowledged by the physician and implemented or not and why. Review of Resident R34's physician order history and medication administration record revealed the resident was ordered Potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood) from July 6, 2024, through August 2, 2024, when the resident was discharged home. Review of facility documentation dated July 16, 2024, revealed that based on a monthly medication review for Resident R34, the consulting pharmacist recommended to administer Potassium chloride with 4 (ounces) of fluid or food to reduce the risk for esophageal erosion. The consulting pharmacist further specified to add directions to the medication administration record to avoid an error. Review of Resident R34's clinical record revealed no documented evidence the consultant pharmacist's recommendation from July 16, 2024, was addressed or implemented. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for one of two records reviewed for hospitalization s (Residents R111). Findings include: Review of progress notes for Resident R111 revealed a note, dated July 20, 2024, at 3:48 p.m., which indicated that the resident had abdominal pain, nausea, and vomiting and was subsequently transferred to a local hospital emergency department for evaluation. Further review revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of Resident R111's facility-initiated emergency transfer to the hospital. Interview on October 18, 2024, at 1:25 p.m. with Social Services, Employee E10, confirmed that the Office of the State Long-Term Care Ombudsman was not notified of Resident R111's facility-initiated emergency transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor). Findings include: A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor. Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway . Every staff, and/or visitor going into COVID room must put on all PPE when going into the resident's room who are diagnosed with COVID. Observation conducted on December 28, 2023, between 10:35 a.m. to 10:40 a.m. on the second floor, revealed Housekeepers, Employee E8 and E9 were going in and out of the COVID rooms without appropriate PPE such as mask N95, and face shield. Also, Employee E9 was observed exiting COVID room without appropriately doffing and putting dirty gown in a clean cart with other clean gowns. When Housekeepers, Employee E8 and E9 were interviewed, they both reported that they were train on PPE to be put on upon entrance and taken prior to exit COVID rooms. On December 28, 2023, at 11:00 a.m. interview with Director of Nursing, Employee E3 and Assistant Director of Nursing, Employee E10, confirmed that all staff and visitor going into COVID rooms must put on all PPE when going into resident's room who are diagnosed with COVID and doffed when exiting by infection control policies and procedures. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 PA. Code 211.12(d)(5) Nursing services

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete one of 30 residents reviewed (Resident R77). Findings Include: Review of Resident R77's dietary progress note dated December 28, 2023, revealed that the resident was trending weight loss for past several months. The dietician was monitoring weekly weights, labs, meal intake and tolerance. Review of Resident R77's November 2023 meal intake documentation revealed that on 19 days only one meal intake was documented. December 2023's meal intake documentation revealed that for 12 days only one meal was documented. Continued review of December 2023's meal intake documentation on December 5, 9 and 15, 2023 only two meals were documented. Interview with the Registered Dietician on January 2, 2023, at 12:00 p.m. stated the resident was not on weekly weight when the dietician completed the documentation on December 28, 2023. Dietician also confirmed that the meal intake documentation was not consistently completed for Resident R77. 28 Pa. Code 211.5(f)(ii) Medical records

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Findings include: The facility incurred a medication error rate of 6.25%. Review of R34's physician order revealed an order dated November 1, 2021, to administer Amlodipine Besylate 5 milligrams, give one tablet orally in the morning, for hypertension; hold for systolic blood pressure (SBP) less than 100. (Systolic Blood Pressure indicates how much pressure the blood is exerting against the artery walls when the heart contracts). (Hypertension is high blood pressure; if an individual has high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood). On December 28, 2023, at 9:38 a.m., observed that Employee E13, a Licensed Nurse, administered Amlodipine Besylate 5 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Amlodipine Besylate 5 Mg tablet. Review of Resident R34's physician order revealed an order dated November 1, 2021, to administer Losartan 100 mg tablet, give one tablet orally, in the morning, related to Essential (Primary) Hypertension, hold for Systolic Blood Pressure (SBP) less than 100. On December 28, 2023, at 09:38 a.m., observed that Licensed nurse, Employee E13, administered Losartan 100 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Losartan 100 mg. At the time of the observation, interviewed with Employee E13, confirmed the findings. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on observation and clinical records review, it was determined that the facility failed to ensure that that physician orders were followed related to urinary catheter size for one of one residents reviewed with a urinary catheter. (Resident R42) Findings include: Review of Resident R42's clinical record revealed that Resident R42 was admitted to the facility on [DATE] with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder and Malignant Neoplasm of Right Female Breast (The term malignant means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin). Review of physician order dated December 1, 2023, for Resident R42, indicated an order for suprapubic catheter size 18 French/10cc balloon. On December 29, 2023, at 10:29 a.m., reviewed the suprapubic catheter of Resident R42, in the presence of Licensed nurse, Employee E13, and observation completed at the time revealed that Resident R42 had suprapubic catheter size 16 French, with the balloon size not clear. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included continuous oxygen administration for one of 33 residents reviewed (R41) Findings include: Review of Resident R41's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses that included Heart Failure (a condition that develops when the heart doesn't pump enough blood for the body's needs. This can happen if the heart can't fill up with enough blood. It can also happen when the heart is too weak to pump properly), Atrial Fibrillation (an irregular and often very rapid heart rhythm; it can lead to blood clots in the heart, increases the risk of stroke, heart failure and other heart-related complications), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, it causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body). Review of physician order for Resident R41, dated November 25, 2023, indicated an order to administer Oxygen continuously at 2 Liters/minute, via nasal canula/mask, every shift. Review of the care plan for Resident R41, revealed that there were no focus, interventions, and outcomes (goals) care- planned for oxygen administration. On December 29, 2023, at 10:27 a.m., interview with the Director of Nursing confirmed the above findings. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of policies, information provided by the facility, and clinical records review, and staff interviews, it was determined that the facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe for one of 27 residents reviewed (Resident 21). Findings include: A nursing note for Resident 21, dated December 7, 2023, revealed that the resident was observed by the nursing assistant with bluish discoloration above left eyebrow ridge. It measured 1.5 centimeter (cm) x 2.5 cm, and the area was slightly elevated. Review of facility investigation dated December 7, 2023, at 4:30 p.m., revealed that the nursing assistant reported bruise to left eyebrow ridge measured 1. 5cm x 2. 5cm. The bruise was dark purple in color. Resident stated he was punched in the face by the person that took me to the get my hair cut. Further review of investigation revealed a statement by Licensed Practical Nurse (LPN), Employee E14, indicated she observe the bruise before lunch time when she was assisting nurse aide, Employee E15, to transfer Resident R21. Employee E14 asked Employee E15 about the bruise, what it was, Employee E15 did not know what it was. The statement did not include any evidence that Licensed Practical Nurse(LPN), Employee E14 reported this allegation to administrator or to the supervisor. Review of a statement by nurse aide, Employee E16, dated December 7, 2023, revealed that she observed a small spot on the corner of his eye when she went into his room to ask him if he wanted a haircut. Review of a statement written by Director of Nursing (DON) dated December 8, 2023, revealed that she noticed a bruise to lateral side of his left eye of Resident R21. She asked Resident R21 what happened, and his response was I was punched, Resident was unable to identify the person but stated It was the little one that took me to get my haircut. Resident also stated, she didn't like something and just punched me. Resident R21 told the DON Please don't tell her I am afraid of her. When asked why resident replied, because she is always rough with me but now I am afraid she's gonna come back and kill me. Review of a corrective action document for nurse aide, Employee E15, dated December 12, 2023, revealed that on December 7, 2023, LPN, Employee E14 noticed a red area on the side of the resident's left eye and questioned Employee E15 who provided care to him. Employee E15 stated nothing unusual happened during her shift. Employee E15 was place on investigatory suspension. Continued review of the document revealed that on December 12, 2023, Employee E15 denied anything occurred on her shift. When questioned about LPN's conversation about the resident's area of concern with his left eye she denied anything occurred and did not report this incident. Review of a corrective action document for nurse aide, Employee E16, dated December 14, 2023, revealed that Employee E16 noticed a red area to the side of Resident R21's left eye. Employee E16 failed to report the finding to any nurse or supervisor. It was the responsibility of all staff to report any concerns (inclusive of but limited to falls, injuries, cuts, and/or bruises) to the assigned charge nurse and/or the nursing supervisor. Review of a corrective action document for LPN, Employee E14, dated December 14, 2023, revealed that Employee E14 noticed a red area to the side of Resident R21's left eye. Employee E14 failed to report the finding to any nurse or supervisor. Review of a timeline of the facility camera revealed that LPN, Employee E14 and nurse aide, E15 was in resident's room at 12:08 p.m., (Employee E14 first observed that bruise and questioned Employee E15). At 12:11 p.m., Nurse aide, Employee E16 went into resident's room, she observed the bruise. At 12:17 p.m. resident was taken to the beauty salon. At 2:52 p.m. Nurse aide, Employee E15 left the unit after her shift. At 5:05 nursing assistant, Employee E17, called the nurse to resident's room who called the supervisor at 5:08 p.m., Continued review of facility investigation dated December 7, 2023, revealed that Employee E14, E15, and E16 failed to report Resident R21's alleged injury of unknown origin to the administrator or supervisor as required and failed to initiate an investigation in a timely manner. Interview with the Nursing Home Administrator (NHA) on December 29, 2023, at 11:00 a.m. confirmed that Employee E14, E15, and E16 failed to report Resident R21's bruise to the left eye area in a timely manner. NHA stated Employee E14, E15, and E16 did not report the injury and left for their shift. It was reported by Employee E17, subsequently facility investigation was initiated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and staff interviews, it was determined that the facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control. Findings include: Review of facility infection control practice documentations revealed no evidence that the facility employed an Infection Preventionist who completed specialized training in infection prevention and control. A request for a copy of the approved Infection Preventionist specialized training in infection prevention and control certification was made to the nursing home administrator, Employee E1, and Director of Nursing, Employee E2, on December 27, 2023, at 10:42 a.m. Facility Nursing Home Administration did not provide the documentation that the facility employed an Infection Preventionist who completed Infection Preventionist completed specialized training in infection prevention and control. Interview with the Director of Nursing, Employee E2 on January 2, 2024, at 12:08 p.m. confirmed that the Director of Nursing assumed the duties of the Infection Preventionist (IP). The DON confirmed that no facility staff, who was responsible for infection control program, completed the required IP specialized training and education course and was not certified. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to urinary catheters, oxygen, use of anticoagulant medication and diabetes for three of 29 residents reviewed (Resident R127, R139 and R306). Findings include: Review of Resident R139's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool) assessment, dated March 1, 2022, revealed that the resident was admitted to the facility February 22, 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that Resident R139 received anticoagulant (blood thinning) medication. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed physician orders, dated February 23, 2022, for blood glucose monitoring twice per day and [MEDICATION(S)] (a medication used to treat diabetes and blood glucose levels) once daily in the morning. Review of Resident R139's care plan, dated printed March 16, 2022, revealed that the resident had cardiovascular disease, recent surgery related to right [CONDITION(S)] and that the resident had recent unplanned weight loss. There was no care plan developed for blood sugar blood sugar monitoring, medication for diabetes management. Further review of the resident's care plan revealed no interventions for the use of an anticoagulant medication. Interview on March 16, 2022, at 1:42 p.m. licensed nurse, Employee E3, confirmed that no care plans were developed for Resident R139 related to diabetes management or anticoagulant medications. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident R127 on March 15, 2022, at 11:02 a.m. revealed that the resident was receiving oxygen via nasal canula. Review of care plan for Resident R127 which was developed on February 17, 2022 revealed no evidence that the facility developed a care plan for Resident R127 for the care and management of oxygen use. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident R306 on March 15, 2022, at 1:40 p.m. revealed that the resident had a urinary catheter device connected to a urinary drainage bag. Review of care plan for Resident R306 which was developed on March 7, 2022 revealed no evidence that the facility developed a care plan for Resident R306 for the care and management of urinary catheter. Interview with the Director of Nursing, Employee E2, on March 17, 2022, at 11:45 a.m. confirmed that the facility did not develop a comprehensive person centered care plan for Resident R127 for the care and management of oxygen use and Resident R306 for the use of urinary catheter. 28 Pa. Code 211.11(d) Resident care plan

Based on facility policy, observation and staff interviews, it was determined that the facility failed to provide services necessary to prevent complications related to the use an indwelling urinary catheter for two of 28 residents reviewed (Resident R137 and 306) Findings include: Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Observation of Resident R137 on March 15, 2022, at 1:40 p.m. revealed that the resident had a urinary catheter (a flexible tube which is placed into the bladder to drain urine) device connected to a small urinary drainage bag (a leg bag). The resident was observed in supine position (lying horizontally with the face and torso facing up). It was also observed that the urinary drainage bag was attached to residents' anterior aspect of the leg which was above the level of resident's bladder level. Observation of Resident R306 on March 15, 2022, at 1:45 p.m. revealed that the resident had a urinary catheter device connected to a leg bag. The resident was observed in supine position. It was observed that the urinary drainage bag was attached to residents' anterior aspect of the leg which was above the level of resident's bladder level. Interview with nursing assistant, Employee E4, on March 15, 2022, at 1:40 p.m. confirmed that Resident R137 and R306 was using a urinary drainage leg bag while in the bed. Employee stated the night shift staff placed the leg bag when they got the resident up in the morning and she did not change the leg bag to larger drainage bag when the resident went to bed for a nap after lunch. Observation of Resident R137 on March 16, 2022, at 2:22 p.m. with Employee E5, Licensed Practical Nurse, revealed that the resident had a urinary catheter device connected to a leg bag. The resident was observed in supine position. It was observed that the urinary drainage bag was attached to residents' anterior aspect of the leg which was above the level of resident's bladder level. Interview with the Director of Nursing, Employee E2, on March 16, 2022, at 2:45 p.m. confirmed that a larger urinary drainage bag should have been placed while the resident is in the bed for a longer period and the drainage bag should be placed below the level of residents' bladder. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on the review of clinical records and staff interviews, it was determined that the facility failed to complete comprehensive assessments that accurately reflected the resident status for one of 28 residents reviewed (Residents R20). Findings include: Review of clinical record for Resident R20 revealed that the resident started receiving hospice services (end of life care to support resident and family) on August 16, 2019. Review of Resident 20's Minimum Data Set (MDS - periodic assessment of resident needs) dated August 23, 2019 revealed that the facility completed a significant change in status assessment. Review of the Section 'O' (Special Treatments and Programs) of the MDS assessment revealed that hospice services were not been provided. Review of a quarterly MDS for Resident 20's, dated November 20, 2019 revealed that the hospice services were not provided. Interview with the Assistant Director of Nursing, Employee E3, on January 28, 2020 at approximately 1:00 p.m. stated, Resident R20 was on hospice services since August 16, 2019. Interview with Registered Nurse Assessment Coordinator (RNAC), Employee E5, on January 28, 2020 at approximately 1:00 p.m. confirmed that Resident R20's MDS dated [DATE] and November 20, 2019 did not accurately reflected resident's hospice services. The facility failed to complete comprehensive assessments that accurately reflected Resident 20's hospice status. 28 Pa. Code 211.5(f) Clinical records Previously cited 2/19/19.

Based on review of clinical records and staff interviews, it was determined that the facility failed to transmit a Minimum Data Set (MDS-federally-mandated assessments of a resident's abilities and care needs) to the required electronic system of the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System Assessment Submission (QIES) and Processing System, within 14 days of completion as required for one of 28 residents reviewed (Residents R2) Findings include: Review of clinical record for Resident R2 revealed that the resident was admitted to the facility on [DATE]. Review of clinical record revealed that the facility completed a quarterly Minimum Data Set (MDS- assessment of resident care needs) assessment for Resident R2 on November 20, 2019 as required by the CMS. Review of clinical record for Resident R2 revealed that the quarterly MDS assessment dated [DATE] was not transmitted to CMS, Quality Improvement and Evaluation System, within 14 days of completion. Interview with the Registered Nurse Assessment Coordinator, Employee E5, on January 29, 2020, at approximately 11:00 a.m. confirmed that the MDS for Resident R2 dated November 20, 2019 was not submitted to CMS in a timely manner. 28 Pa. Code 211.5(f) Clinical records. Previously cited 2/19/19.