Every finding on record at Pavilion at BRMC, The

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for four of 14 residents reviewed (Residents R1, R2, R6, and R30). Findings include: Facility policy entitled Physician Visit Scheduled dated 11/28/25, revealed All attending physicians will visit the residents of the Pavilion at BRMC once monthly and document a progress note relative to the MD visit. Resident R1 was admitted [DATE], with diagnoses that included Dementia (loss of cognitive functioning affecting a person's memory and behaviors), Wernicke Encephalopathy (Neurological Disorder caused by severe deficiency of thiamine leading to brain dysfunction. Commonly seen in people with chronic alcohol abuse, malnutrition and conditions that impair nutrient absorption), and High Blood Pressure. Resident R1's clinical record revealed physician progress notes dated and signed by the physician for 10/23/24, 7/16/25, 8/20/25, 9/18/25, 10/15/26/25, 11/26/25, 12/22/25, and 2/11/26. Clinical record lacked evidence of any physician progress notes being completed between 10/23/24, and 7/16/25, a period of nine months. Resident R2 was admitted [DATE], with diagnoses that included Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), Obstructive and Reflux Uropathy (occurs when the urine flow is blocked due to an obstruction and the urine flows backwards from the bladder into the kidneys), and Functional Quadriplegia (the complete inability to move all both arms and both legs due to severe disability or frailty from other medication condition, without injury to the brain or spinal cord). Resident R2's clinical record revealed the last physician progress note dated and signed by the physician was on 9/28/25. Clinical record lacked evidence of any physician progress notes being completed between 9/28/25, and 4/23/26, a period of seven months. Resident R6 was admitted [DATE], with diagnoses that included Conversion Disorder (also known as functional neurological disorder, is a condition in which psychological or emotional stress manifests as real, involuntary physical symptoms that cannot be explained by neurological or medication conditions), Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and High Blood Pressure. Resident R6's clinical record revealed the last physician progress note dated and signed by the physician on 9/18/25. Clinical record lacked evidence of any physician progress notes being completed between 9/18/25, and 4/23/26, a period of seven months. Resident R30 was admitted [DATE], with diagnoses that included Dementia, Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and High Blood Pressure. Resident R30's clinical record lacked evidence of any physician progress notes being completed between 6/17/25, and 4/23/26, a period of ten months. During an interview on 4/23/26, at 9:02 a.m. the Nursing Home Administrator confirmed that Resident R1, R2, R6, and R30's clinical records lacked evidence of the required physician progress notes at the time of review. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary operations and standards for food safety in one of two resident unit freezers reviewed (Third Floor).Findings include: Observations on 4/21/26, at 11:26 a.m. of the Third Floor freezer revealed two ice packs that are used for treatments on residents stored next to frozen microwave meals. During an interview on 4/21/26, at 11:26 a.m. Certified Nursing Assistant Employee E1 confirmed that the ice packs used as treatments for residents were in the freezer with food. He/she confirmed that ice packs used as treatments should not be stored in the same unit with food. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records and Minimum Data set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of three of 14 residents reviewed (Residents R1, R6, and R10). Findings include: MDS instructions for section P0200 Alarms subsection E Wander / Elopement Alarm indicated to identify all alarms that were used at any time (day or night) during the seven-day look-back period and to code the frequency of use as not used, used less than daily, or used daily. The MDS instructions further indicated that a wander / elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exits sensors worn by/attached to the resident that activates an alarm and/or alert staff when the resident nears or exits a specific area of the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Resident R1 was admitted [DATE], with diagnoses that included Dementia (loss of cognitive functioning affecting a person's memory and behaviors), Wernicke Encephalopathy (Neurological Disorder caused by severe deficiency of thiamine leading to brain dysfunction. Commonly seen in people with chronic alcohol abuse, malnutrition and conditions that impair nutrient absorption), and High Blood Pressure. Resident R1's clinical record revealed a physician's order dated 8/23/24, for a wanderguard bracelet (an alarming security bracelet) to be worn at all times. Review of Treatment Administration Records (TAR) for February 2025, August 2025, and March 2026, revealed staff signage indicating the placement of a wanderguard bracelet was checked every shift for the entire month. Resident R1's quarterly MDS's with Assessment Reference Dates (ARD) of 2/24/25, 8/12/25, and 3/12/26, revealed that section P0200E was coded as Not Used. Resident R6 was admitted [DATE], with diagnoses that included Conversion Disorder (also known as functional neurological disorder, is a condition in which psychological or emotional stress manifests as real, involuntary physical symptoms that cannot be explained by neurological or medication conditions), Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and High Blood Pressure. Resident R6's clinical record revealed a physician's order dated 9/3/24, for a wanderguard bracelet to be worn at all times. Review of TAR for February 2025, August 2025, and February 2026, revealed staff signage indicating the placement of a wanderguard bracelet was checked every shift for the entire month of February 2025, January 2026, and February 2026, and from August 1, 2025, through August 8, 2025, and August 13, 2025, through August 31, 2025. Resident R6's quarterly MDS with ARD 2/25/25, significant change MDS with ARD 8/18/25, and quarterly MDS with ARD 2/5/26, revealed that section P0200E was coded as Not Used. Resident R10 was admitted [DATE], with diagnoses that included Dementia, Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R10's clinical record revealed a physician's order dated 8/11/25, for a wanderguard bracelet to be worn at all times. Review of TAR for September 2025, and March 2026, revealed staff signage indicating the placement of a wanderguard was checked every shift for the entire month of September 2025, and March 2026. Resident R10's quarterly MDS's with ARD's 9/24/25, and 3/12/26, revealed that section P0200E was coded as Not Used. During an interview on 4/22/26, at 12:57 p.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that MDS's indicated above for Residents R1, R6, and R10 were coded incorrectly regarding the usage of a wander / elopement alarm and should have been coded as Used Daily. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records

Based on review of facility policies, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 19 residents reviewed was free of neglect during care (Resident R5). Findings include: Review of facility policy entitled Resident abuse, neglect, exploitation, and misappropriation of resident property policy, last reviewed 12/28/2023, revealed Neglect: The indifference or disregard for resident care, comfort or safety, resulting in or may result in physical harm, pain, mental anguish, or emotional distress. neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to the resident resulting in, or may result in physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitiled Fall Protocol, with a policy review date of 12/28/2023, revealed that it is the policy of the Pavilion at BRMC to make every attempt at preventing residents from falling. Review of Resident R5's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, muscle weakness, hearing loss, chronic pain, history of falling, age related physical debility, and macular degeneration (an eye disease that causes vision loss). Review of Resident R5's Activities of Daily Living (ADL) related care plan originally dated 5/4/2020 and last reviewed 7/24/2024, revealed resident has an ADL self-care performance deficit related to confusion, poor vision, and extreme hard of hearing (HOH). Toilet transfer is dependent. Transfers requires extensive assistance of two staff members. Toilet use: is an extensive assist of 1-2 assist for toileting and has stress incontinence. Review of R5's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 7/16/2024, revealed that Section GG0130 Self-care revealed Toileting Hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, identified that Resident R5 required Substantial/maximal assistance; Section GG0170 F: toilet transfer: the ability to get on and off a toilet or commode revealed that Resident R5 required partial/moderate assistance. Section C Cognitive Patterns revealed that section C0500 brief interview for mental status (BIMS) summary score revealed a score of 01, indicating cognitive impairment. Review of Resident R5's progress notes from 9/26/2024, at 3:05 p.m. revealed, This writer called to second floor for resident observed on bathroom floor. Resident assessed and found to have bruising to front and back of head, and both knees, with the left knee being significantly swollen. MD [Medical Doctor] notified and orders obtained to send resident to ER [emergency room ] for evaluation. Son notified and agreeable. Report called to ER, and resident transported to ER via stretcher. Review of Resident R5's CT scan report of the cervical spine without contrast dated 9/26/2024, at 4:24 p.m. revealed an acute nondisplaced (broken bone where pieces of bone didn't move far enough to be out of alignment) type 2 dens fracture (Fracture at the base of the odontoid process [also called the dens] which is a bony projection on the C2 vertebrae in the neck) During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 12/5/2024, at approximately 1:30 p.m., it was confirmed that a Nurse Aide (NA) employee assisted Resident R5 into the restroom to use the toilet. Resident R5 was assisted onto the toilet and was left unattended in the restroom. Employees were at change of shift and report was given to the next shift. The resident was found on the floor in the restroom by the next shift staff members. Review of a witness statement to the DON and NHA on 9/27/2024 by NA Employee E1, revealed the following information: it was at the end of the shift and Resident R5 came out from the activity and asked if she could be taken to the bathroom. On coming NA's and off going NA's were at the nurse's station and were giving one another report prior to the end of the shift. NA Employee E1 took Resident R5 to the bathroom and stood in the doorway of the bathroom. NA Employee E1 then proceeded to the room doorway and told the evening shift staff members that Resident R5 was on the toilet in the bathroom and would need assisted off. Staff acknowledged that Resident R5 was on the toilet in the bathroom and NA Employee E1 stated that she was going to go home. Interviews with staff members by the DON and NHA that worked the evening shift did acknowledge that NA Employee E1 did pass along that Resident R5 was in the bathroom. Review of a witness statement dated 9/26/2024, from NA Employee E2, who found Resident R5 in the bathroom on 9/26/2024, revealed, I came onto the floor got report, and started getting my list of residents up and ready for dinner. When I entered room [ROOM NUMBER], I heard groaning in the bathroom and upon entering saw [Resident R5] on his/her front on the floor with head and shoulders under the wheelchair, not stuck on anything. I called for the nurse without leaving the resident. Found [Resident R5] on the floor at 2:40 p.m. Review of a witness statement dated 9/27/2024, from NA Employee E3, revealed I worked 6-2 Thursday, 9/26/2024. [Resident R5] got up for lunch. She was in the dining room for lunch. Then when bingo began, [Resident R5] told the activities director that she needed to go to the bathroom. [NA Employee E1] said he/she would take [Resident R5] to the bathroom. Second shift came in and was given report and told that [Resident R5] was on the toilet. The day shift NA's left the floor. During interviews on 12/6/2024, at 9:45 a.m. with NA Employee E4, NA Employee E5, NA Employee E6, and NA Employee E3 it was confirmed that the nursing staff was re-educated regarding fall safety and assisting residents when in the restroom. Resident plans of care are reviewed for levels of assistance and care with baths. All employees interviewed revealed that residents are not to be left unmonitored in the restroom for safety purposes. An interview conducted with Licensed Practical Nurse (LPN) Employee E7 on 12/6/2024, at 10:00 a.m. revealed that it is not the practice of the nursing staff to leave residents in the bathroom unattended. Staff should always be aware someone is in the bathroom to watch or monitor resident for safety. Resident plans of care are reviewed for levels of assistance and care with toileting. During an interview with the DON and NHA on 12/5/2024, at approximately 2:30 p.m. it was confirmed that Resident R5 was placed in the restroom unattended by NA Employee E1 and then was left unattended in the bathroom of room [ROOM NUMBER] at change of shift with Resident R5 being found on the floor resulting in a neck fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide proper resident supervision during toileting that resulted in a fall with actual harm of a fracture of the neck (C2 vertebrae) for one of 19 residents reviewed (Resident R5). Findings include: Review of facility policy entitiled Fall Protocol, with a policy review date of 12/28/23, revealed that it is the policy of the Pavilion at BRMC to make every attempt at preventing residents from falling. Review of Resident R5's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, muscle weakness, hearing loss, chronic pain, history of falling, age related physical debility, and macular degeneration (an eye disease that causes vision loss). Review of Resident R5's Activities of Daily Living (ADL) related care plan originally dated 5/4/2020 and last reviewed 7/24/2024, revealed resident has an ADL self-care performance deficit related to confusion, poor vision, and extreme hard of hearing (HOH). Toilet transfer is dependent. Transfers requires extensive assistance of two staff members. Toilet use: is an extensive assist of 1-2 assist for toileting and has stress incontinence. Review of Resident R5's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 7/16/2024, revealed that Section GG0130 Self-care revealed Toileting Hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, identified that Resident R5 required Substantial/maximal assistance; Section GG0170 F: toilet transfer: the ability to get on and off a toilet or commode revealed that Resident R5 required partial/moderate assistance. Section C Cognitive Patterns revealed that section C0500 brief interview for mental status (BIMS) summary score revealed a score of 01, indicating cognitive impairment. Review of Resident R5's progress notes from 9/26/2024, at 3:05 p.m. revealed, This writer called to second floor for resident observed on bathroom floor. Resident assessed and found to have bruising to front and back of head, and both knees, with the left knee being significantly swollen. MD [Medical Doctor] notified and orders obtained to send resident to ER [emergency room ] for evaluation. Son notified and agreeable. Report called to ER, and resident transported to ER via stretcher. Review of Resident R5's CT scan report of the cervical spine without contrast dated 9/26/2024, at 4:24 p.m. revealed an acute nondisplaced (broken bone where pieces of bone didn't move far enough to be out of alignment) type 2 dens fracture (Fracture at the base of the odontoid process [also called the dens] which is a bony projection on the C2 vertebrae in the neck) During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 12/5/2024, at approximately 1:30 p.m., it was confirmed that a Nurse Aide (NA) employee assisted Resident R5 into the restroom to use the toilet. Resident R5 was assisted onto the toilet and was left unattended in the restroom. Employees were at change of shift and report was given to the next shift. The resident was found on the floor in the restroom by the next shift staff members. Review of a witness statement to the DON and NHA on 9/27/2024 by NA Employee E1, revealed the following information: it was at the end of the shift and Resident R5 came out from the activity and asked if she could be taken to the bathroom. On coming NA's and off going NA's were at the nurse's station and were giving one another report prior to the end of the shift. NA Employee E1 took Resident R5 to the bathroom and stood in the doorway of the bathroom. NA Employee E1 then proceeded to the room doorway and told the evening shift staff members that Resident R5 was on the toilet in the bathroom and would need assisted off. Staff acknowledged that Resident R5 was on the toilet in the bathroom and NA Employee E1 stated that she was going to go home. Interviews with staff members by the DON and NHA that worked the evening shift did acknowledge that NA Employee E1 did pass along that Resident R5 was in the bathroom. Review of a witness statement dated 9/26/2024, from NA Employee E2, who found Resident R5 in the bathroom on 9/26/2024, revealed, I came onto the floor got report, and started getting my list of residents up and ready for dinner. When I entered room [ROOM NUMBER], I heard groaning in the bathroom and upon entering saw [Resident R5] on his/her front on the floor with head and shoulders under the wheelchair, not stuck on anything. I called for the nurse without leaving the resident. Found [Resident R5] on the floor at 2:40 p.m. Review of a witness statement dated 9/27/2024, from NA Employee E3, revealed I worked 6-2 Thursday, 9/26/2024. [Resident R5] got up for lunch. She was in the dining room for lunch. Then when bingo began, [Resident R5] told the activities director that she needed to go to the bathroom. [NA Employee E1] said he/she would take [Resident R5] to the bathroom. Second shift came in and was given report and told that [Resident R5] was on the toilet. The day shift NA's left the floor. During interviews on 12/6/2024, at 9:45 a.m. with NA Employee E4, NA Employee E5, NA Employee E6, and NA Employee E3 it was confirmed that the nursing staff was re-educated regarding fall safety and assisting residents when in the restroom. Resident plans of care are reviewed for levels of assistance and care with baths. All employees interviewed revealed that residents are not to be left unmonitored in the restroom for safety purposes. An interview conducted with Licensed Practical Nurse (LPN) Employee E7 on 12/6/2024, at 10:00 a.m. revealed that it is not the practice of the nursing staff to leave residents in the bathroom unattended. Staff should always be aware someone is in the bathroom to watch or monitor resident for safety. Resident plans of care are reviewed for levels of assistance and care with toileting. During an interview with the DON and NHA on 12/5/2024, at approximately 2:30 p.m. it was confirmed that Resident R5 was placed in the restroom unattended by NA Employee E1 and then was left unattended in the bathroom of room [ROOM NUMBER] at change of shift with Resident R5 being found on the floor resulting in a neck fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on a review of facility policy, facility grievances, and resident and staff interviews, it was determined that the facility failed to provide acknowledgement of a complaint/grievance and actively work toward resolution of that complaint/grievance for two of 19 residents reviewed (Residents R9 and R11). Findings include: Review of the facility policy entitled, Pavilion Complaint/Grievance Policy, dated 12/28/23, revealed that the Pavilion grievance official will oversee the Pavilion grievance process, receive and track grievances through their conclusion, will lead any necessary investigation by the facility, will maintain confidentiality of all information associated with grievances, will be responsible in issuing written grievance decision to the resident/resident representative and will coordinate with state and federal agencies as necessary in light of specific allegations. The grievance official of the Pavilion will also take immediate action to prevent potential violation of any resident right while the alleged violation is being investigated. During an interview on 1/03/24, at 10:00 a.m. Resident R9 indicated he/she discussed concerns with administrative staff about being left on the toilet for long periods of time. Resident R9 further indicated administrative staff implied the concern would be addressed, however, no resolve of the grievance had occurred. During an interview on 1/03/24, at 1:00 p.m. Resident R11 indicated he/she discussed several concerns with administrative staff such as a brace for his/her right knee, a dental appointment, cell phone usage by staff during care, and urine collection device not being emptied. Resident R11 indicated further that no resolve of the grievances had occurred. On 1/04/24 at 8:40 a.m., the Nursing Home Administrator (NHA) provided two complaints/grievances from residents/resident representatives for review and there was no evidence that the concerns were investigated, tracked through to a conclusion, and that a written grievance decision was provided to the resident/resident representative. During an interview on 1/05/24, at 10:15 a.m. the Director of Nursing confirmed that the facility lacked evidence that the complaints/grievances for Residents R9 and R11 as noted above, were investigated, tracked through to a conclusion, and that a written grievance decision was provided to Resident R9 and Resident R11. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1)(3) Management

Based on observations, review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity by placing a wander guard bracelet (a device with a small box on a plastic bracelet placed on an at risk wandering person to alert the staff if that person attempts to exit the facility without staff supervision) on one of two residents reviewed for wander guard usage (Resident R24). Findings include: Review of a facility policy entitled General Safety Practices at The Pavilion dated 12/28/2023, revealed All residents at risk for elopement will be placed on the second floor and a wander guard bracelet will be initiated. Review of Resident R24's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), heart failure (a condition where the heart cannot supply the body with enough blood), presence of artificial knee joint, and edema (swelling to an area of body due to holding excessive fluid). Review of residents that reside on the second floor locked unit revealed that only eight of 25 residents had wander guards in place. Further review of Resident R24's clinical record revealed, no evidence of an evaluation for elopement risk. Review of MDS Section C - Cognitive Patterns C0500 with assessment dates of 2/24/23, 5/11/23, 8/8/23 and 11/5/23, revealed a BIMS (Brief Interview of Mental Status- cognitive interview to check mental status of a person with a score of zero being severely impaired and 15 being alert and oriented) of 15 on all four dates. Review of MDS Section E Behavior E0900 with assessment dates of 2/24/23, 5/11/23, 8/8/23 and 11/5/23 revealed a Wandering - Presence and Frequency (assessment codes as 0-behavior not exhibited through three indicating that the behavior of this type occurred daily) assessment coded as zero-behavior not exhibited, on all four dates for Resident R24. Observations on 1/2/2024, at 4:06 p.m. revealed a wander guard bracelet on Resident R24's left ankle. Interview with Resident R24 on 1/2/2024, at 4:06 p.m. revealed he/she had the wander guard bracelet placed several years ago due to him/her leaving the facility and going to the store. He/she stated that he/she did not know that they were not allowed to leave the facility, he/she used to sit outside the facility without supervision. When he/she returned to the facility staff placed a wander guard bracelet on Resident R24 and placed Resident R24 on the second floor locked unit. Resident R24 also stated that he/she told the facility he/she would not leave the facility again without staff knowledge. Resident R24 also revealed that he/she had cut the wander guard bracelet off several times and staff would replace it but never asked him/her why he/she kept cutting it off. He/she revealed that he/she is embarrassed by the wander guard bracelet. Resident R24 stated that when he/she goes out to appointments, he/she finds the wander guard bracelet embarrassing and stated, it's my house arrest. During an interview on 1/4/2024, at 3:19 p.m. the DON (Director of Nursing) revealed that facility had no evidence of elopement assessments being completed. He/she also revealed that Resident R24 had cut off his/her wander guard bracelet on several occasions and that facility staff had replaced the wander guard bracelet. Observation on 1/5/2024, at 9:05 a.m. revealed the wander guard bracelet remained on Resident R24's left ankle. During an interview at that time, Resident R24 stated yes I still have the little box, it's embarrassing, my house arrest. Interview with Employee E1 on 1/5/2024, at 8:40 a.m. revealed that he/she has worked at the facility for one year in a full time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working. Interview with Employee E2 on 1/5/2024, at 8:50 a.m. revealed that he/she has worked at the facility for three years in a full-time position on the second floor locked unit. He/she revealed that Resident R24 has had no elopement episodes while he/she was working. Interview also revealed that Resident R24 has verbally communicated to him/her when he/she was going out into the garden which is part of the second floor locked unit. Interview with DON on 1/4/2024, at 3:19 p.m. he/she confirmed that Resident R24 should have been reassessed for the use of the wander guard bracelet. He/she also confirmed that the use of a wander guard is not appropriate for a resident that is alert and oriented with a BIMS of 15. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed correctly to indicate the code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 19 residents reviewed (Resident R39). Findings include: Review of a facility policy Advance Directives-Health Care Proxy, MOLST/POLST, Living Will dated [DATE], revealed All adult individuals in New York State and in Pennsylvania have the right to self-determination in Health Care and the right to express their preferences regarding health care treatment, including decisions to continue or refuse routine or major medical treatment, as well as life-sustaining treatment without which the individual is expected to die. Advance directives such as health care proxies (HCP), living wills and consents to Do Not Resuscitate (DNR) orders allow an adult to express his/her healthcare treatment preferences and wishes, in order to be prepared for those situations in which that individual may be unable to communicate for him/herself. Instructions - It is a BRMC-OGH goal to encourage Health Care Proxy completion among competent patients, and to place those documents in the permanent medical record in ambulatory, acute, and long-term care settings. For patients who are already incapacitated with no proxy, it is a goal to identify surrogate decision makers as early as possible and actively engage them in the care of those patients. Review of Resident 39's clinical record revealed an admitted [DATE], with diagnoses that included weakness, urinary tract infection, failure to thrive, and Parkinson's disease (a disorder of the central nervous system that affects movement, often tremors). Resident R39's clinical record indicated Full Code on the Code Status Form dated [DATE], signed by Resident R39's power of attorney (POA). A physician order dated [DATE], indicated Resident R39 to be a DNR. Review of Resident R39's clinical record on [DATE], at 2:00 p.m. lacked evidence of a POLST. During an interview on [DATE], at 3:20 p.m. the Registered Nurse Assessment Coordinator (RNAC) provided Resident R39's POLST which indicated a Full Code status. The RNAC confirmed the POLST was not maintained, but should be on Resident R39's clinical record for direction of Resident R39's plan of care. During an interview on [DATE], at 3:25 p.m. the RNAC confirmed Resident R39's code status was documented in error as a DNR as a physician order and should be a Full Code as indicated by the POA and POLST. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan regarding the use of side rails for one of 17 residents reviewed (Resident R32). Findings include: Review of a facility policy entitled Resident Care Plan dated 12/28/23, indicated that the facility will develop a comprehensive care plan of care to reflect the needs of the resident, be individualized and resident driven, and utilize nursing assessments, evaluations, etc. Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included dementia, generalized muscle weakness, heart disease, arthritis, and limitations of activities due to disability. Current physician's orders for January 2024, indicated that Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record lacked evidence of a care plan to address his/her side rail use. Review of Resident R32's clinical record documentation the daily use of side rails on both sides of his/her bed for November 2023, December 2023, and January 2024. Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half rails were in the up position. During an interview on 1/03/24, at 10:50 a.m. Registered Nurse Employee E3 confirmed that Resident R32 always has his/her side rails up on both sides of the bed. During an interview on 1/04/24, at 11:00 a.m. the Registered Nurse Assessment Coordinator confirmed there was no evidence that a care plan was developed for Resident R32's use of side rails on both sides of the bed. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy and clinical records, and staff interview, it was determined that the facility failed to administer supplemental oxygen as ordered and promote cleanliness regarding respiratory care equipment according to physician orders for one of 19 residents reviewed (Resident R17). Findings include: Review of a facility policy entitled Care of Oxygen Tubing/Nebulizer Tubing and Filters dated 12/28/23, indicated that oxygen concentrator filters will be cleaned monthly. Review of a facility policy entitled Medication Administration dated, 12/28/23, revealed that medications shall be administered in accordance with the orders of the prescribing Healthcare Practitioner, and oxygen administration must have a physician order, the order must be written on the Medication Administration Record (MAR) and the nurse is to monitor oxygen flow rate every shift. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), heart disease, heart failure, muscle wasting, amputation of left fingers and left foot, high blood pressure, unsteady on feet, and difficulty walking. The most recent physician's order dated 12/25/23, indicated to administer oxygen at two liters per minute (LPM) through a nasal cannula (a device that gives you additional oxygen [supplemental oxygen or oxygen therapy] through your nose), as needed for shortness of breath/wheezing. The December 2023 MAR indicated that Resident R17 was receiving his/her oxygen at two LPM on two-to-three shifts daily. Observations on 1/02/24, at approximately 4:00 p.m. and on 1/03/24, at 8:50 a.m. revealed that Resident R17 was in bed and his/her oxygen concentrator filter was blowing a significant amount gray fluffy substance into the air, and the oxygen flow rate was set at one and a half LPM. During an interview on 1/02/24, at approximately 4:00 p.m. Resident R17 confirmed that he/she was supposed to receive oxygen at two LPM. During an interview on 1/03/24, at 8:55 a.m. the Nursing Home Administrator and Director of Nursing confirmed that upon opening the oxygen concentrator filter casing, the filter was covered with copious amounts of a gray fluffy substance, and had not been cleaned recently, and that the oxygen flow rate was set for one and a half LPM, and that Resident R17 was ordered two LPM. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records and facility policy, and staff interviews it was determined that the facility failed thoroughly review and assess the use of bed rails prior to their use and review the risk versus benefits of using bed rails with the resident's representative and obtain informed consent for the installation and use of bed rails prior to the installation for two of 19 residents reviewed (Residents R32 and R67). Findings include: Review of a facility policy entitled Side Rails and Use of 1/2 Side Rails dated 12/28/23, indicated that half side rails may be utilized to assist a resident with bed mobility and transfers or to assist the resident with bed controls but only after an individual Side Rail assessment is completed on admission, quarterly, annually, and as needed. Resident R32's clinical record revealed an admitted [DATE], with diagnoses that included dementia, generalize muscle weakness, heart disease, arthritis, and limitations of activities due to disability. Review of current physician's orders for January 2024, revealed Resident R32 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for November 2023, December 2023 and January 2024 Further review of Resident R32's clinical record revealed no evidence of that an individual Side Rail assessment was completed upon admission, quarterly, annually, or as needed, and lacked the required informed consent from the resident/representative for the use of side rails prior to installation. Multiple observations on 1/02/24, and 1/03/24, revealed Resident R32 in bed positioned on his/her side and both half side rails were in the up position. Review of Resident R67's clinical record revealed an admitted [DATE], with diagnoses that included Down Syndrome (genetic condition that causes mild to serious physical and developmental problems), long-term kidney disease, malnutrition, and embolism and thrombosis (clots get stuck in an artery and block blood flow, the blockage starves tissues of blood and oxygen). Review of current physician's orders for January 2024, revealed Resident R67 was to have siderails up on both sides of his/her bed to promote independence with bed mobility and transfers. The clinical record revealed a care plan addressing self-care deficit and included an intervention to use half rails during the provision of care and included access to bed controls. Review of Resident R32's clinical record documentation revealed daily use of side rails on both sides of his/her bed for December 2023, and January 2024. Further review of Resident R67's clinical record revealed an incomplete individual Side Rail assessment dated [DATE] (upon admission) and lacked the required quarterly Side Rail assessment and informed consent from the resident/representative for the use of side rails prior to their installation. During an interview on 1/04/24, at 1:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed there was lack of evidence that the required periodic side rail assessments were completed, and that informed consents were not obtained from the resident/representative for the use of side rails prior to installation. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 201.18(b)(1) Management

Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of 19 residents (Resident R32). Findings include: Review of a facility policy entitled Standard Precautions dated 12/28/23, revealed that staff are expected to change their gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms, and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Observation of wound care on 1/03/24, at 3:12 p.m. revealed that Registered Nurse (RN) Employee E3 performed hand hygiene and donned (put on) clean gloves; removed the soiled dressing containing a moderate amount of exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation); picked up the multi-use bottle of wound cleanser; applied wound cleanser solution to two, four inch by four inch cotton gauzes; cleansed the wound of a moderate amount of exudate; opened the sealed package of wound dressing (Promogran- cellulose, collagen and silver dressing); used scissors to cut the Promogran to the size of the wound bed; opened the sealed package of Allevyn (dressing indicated for exudate absorption in wound care); applied the Allevyn to the wound; obtained a wound label and used a pen to write the date on the label. During an interview at that time RN Employee E3 confirmed that he/she didn't know if staff was supposed to change gloves and cleanse hands during dressing changes when going from dirty to clean areas. During an interview on 1/04/24, at 1:50 p.m. the Director of Nursing confirmed that staff are to change gloves and perform hand hygiene after removing soiled dressings, and after wound cleansing if exudate present. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of clinical records and staff interviews, it was determined that the facility failed to discontinue a medication per physician orders for one of 19 residents reviewed (Resident R39). Findings include: Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included morbid obesity, atrial fibrillation (irregular heartbeat), anxiety, and major depressive disorder. Resident R39's clinical record revealed that on 12/09/22, the physician ordered Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 24 hours as needed (prn) for anxiety. On 12/20/22, the pharmacist notified the physician that the prn order of Ativan 0.5 mg every 24 hours required a rationale to be extended beyond 14 days. On 12/30/22, the physician's written order indicated Use on PRN basis for anxiety for 2 weeks. Review of Resident R39's clinical record revealed the ordered Ativan 0.5 mg every 24 hours prn for anxiety was not discontinued after 2 weeks and was still an active order on Resident R39's physician orders for 1/01/23-1/31/23 and 2/01/23-present. During an interview on 2/15/23, at approximately 1:00 p.m. the Director of Nursing confirmed that the Ativan order for Resident R39 should have been discontinued per physician orders and was not. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (affecting the mind) medication for two of six residents reviewed for unnecessary medications (Residents R36 and R39). Findings include: Review of Resident R36's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, chronic obstructive pulmonary disease (a group of disease causes breathing difficulties), and anxiety. A physician order dated 2/6/23, identified to administer Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every six hours as needed (PRN) for agitation. Review of Resident R36's February 2023 Medication Administration Record (MAR) revealed that he/she received PRN Ativan on 2/6/23, and 2/12/23. Review of February 2023 Behavioral Intervention Monthly Flow Record and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan two of two times the Ativan was utilized in February 2023. During an interview on 2/14/23, at 11:00 a.m. Licensed Practical Nurse Employee E2 stated that non-pharmacological interventions should be documented on the Behavioral Intervention Monthly Flow Record and/or in the clinical record progress notes. During an interview on 2/14/23, at 3:20 p.m. the Nursing Home Administrator confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan two of the two times it was administered in February 2023. Review of Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included morbid obesity, atrial fibrillation (irregular heartbeat), anxiety, and major depressive disorder. A physician order initiated 12/30/22, identified to administer Ativan 0.5 mg by mouth every 24 hours PRN for anxiety. Review of Resident R39's January 2023 MAR revealed that he/she received PRN Ativan on 1/5/23, 1/14/23, 1/19/23, 1/20/23, and 1/27/23. Review of the January 2023 Behavioral Intervention Monthly Flow Record and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan the five of five times the Ativan was utilized in January 2023. During an interview on 2/15/23, at 1:00 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan five of the five times it was administered in January 2023 for Resident R39. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observation and staff interviews, it was determined that the facility failed to appropriately label over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on one of two medication carts (2nd floor). Findings include: During medication pass observation on 2/13/23, between 4:14 p.m. and 4:50 p.m. Residents R28 and R3 received Colace (medication for constipation) per physician orders and Resident R37 received [NAME]-Bid (probiotic) per physician orders from an over-the-counter stock bottle. Inspection of the Colace and [NAME]-Bid bottles revealed that they lacked any resident names for use. During an interview at the time of observation, Licensed Practice Nurse (LPN) Employee E1 confirmed that both the Colace and [NAME]-Bid bottles lacked any resident names. Observation of 2nd floor medication cart on 2/14/23, at 11:42 a.m. revealed that the cart contained open stock medication bottles of Calcium Antacid, Multi-Vitamins with Minerals, Antacid Liquid, Tylenol Liquid, and Vitamin D that lacked any resident names for use. During an interview at the time of observation, LPN Employee E2 confirmed the bottles lacked any resident names. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policies and staff interview, it was determined that the facility failed to document the evaluation of the resident's discharge needs, the discharge plan and conversations with family/resident in the clinical record for one of 17 records reviewed (Resident R8). Findings include: Review of the Discharge Planning policy, dated 1/21/22, revealed discharge planning will be initiated no later than seven days from admission to the facility. The resident's discharge plan will be documented in the clinical record and the plan of care. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R8's Return to the Community care plan, dated 12/12/21, revealed that the facility would establish a pre-discharge plan with the resident/family and evaluate progress and revise plan, evaluate the resident's motivation to return to the community, evaluate and record the resident's abilities and strengths with family and interdisciplinary team (IDT) and make arrangements with required community resources to support independence post-discharge. Review of the clinical record lacked documentation of the evaluation of the resident's discharge needs, the discharge plan and any events initiated or contacts made with other entities and family involvement. During an interview on 3/10/22, at 12:13 p.m. the Director of Nursing confirmed that the clinical record lacked documentation regarding the resident's discharge needs, events initiated to assist the resident with future discharge plans to the community or any communication with family and/or the resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(h) Clinical records

Based on review of clinical records and facility policies and resident and staff interviews, it was determined that the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Wound Care policy, dated 1/21/22, revealed the nursing staff will follow the wound care protocol or the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R30's clinical record revealed that Resident R30 was sent out to the hospital on 2/24/22. The nursing note, dated 2/24/22, revealed Resident R30 had two Stage 2 (partial-thickness loss of skin) pressure ulcers identified on the buttocks (one on the right and one on the left) with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R30 returned from the hospital on 2/28/22 and the Nursing Home Transfer/Home Health Transfer Sheet dated 2/28/22, revealed Resident R30 had one Stage 2 wound on the right buttock. Review of the clinical record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/09/22, at 10:20 a.m. Registered Nurse Employee E1 stated that there was no order obtained to treat Resident R30's wound upon return from the hospital on 2/28/22. During an interview on 3/09/22, at 2:24 p.m., Resident R30 indicated that his/her right buttocks area was feeling better since the nurse applied a treatment to their wound. During an interview on 3/10/22, at 1:28 p.m. Licensed Practical Nurse Employee E2 confirmed that there was no order obtained between 2/28/22 and 3/09/22 (nine days) from the physician after Resident R30 was readmitted from the hospital with the Stage 2 pressure ulcer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on observation, review of clinical records and facility policies, and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for one of one residents who received [CONDITION(S)] (mechanical cleansing of the blood similar to kidney function) (Resident R65). Findings include: Review of the Medication Administration policy, dated 1/21/22, revealed medications shall be prepared and administered in accordance with the orders of the prescribing Healthcare Practitioner responsible for the resident's care and accepted standard of practice . and unless the prescribing practitioner directs otherwise, medications shall be administered at established times. Resident R65's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records (MARs) from 1/24/22 through 3/10/22 revealed that Resident R65 did not receive the following medications at 11:00 a.m. on the identified dates while at [CONDITION(S)]: Calcium Acetate not received on 1/29/22, 2/01/22, 2/03/22, 2/04/22, 2/05/22, 2/08/22, 2/10/22, 2/12/22, 2/17/22, 2/22/22, 2/24/22, 2/26/22, 3/01/22, 3/05/22, 3/08/22 and 3/10/22 [MEDICATION(S)] not received on 1/29/22 Glucometer check with [MEDICATION(S)] insulin coverage per sliding scale not completed on 1/29/22, 2/01/22, 2/03/22, 2/05/22, 2/08/22, 2/10/22, 2/12/22, 2/15/22, 2/17/22, 2/22/22, 2/24/22, 2/26/22, 3/01/22, 3/05/22, 3/08/22, 3/10/22. During an interview on 3/10/22, at 10:44 a.m. Licensed Practical Nurse Employee E2 confirmed that the medications identified above were circled on the MARs and identified as not given due to Resident R65 at [CONDITION(S)]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of Pennsylvania Department of Health (DOH) Interim Guidance and Centers for Medicare and Medicaid Services (CMS) resources, and interviews with staff and resident representatives, it was determined that the facility failed to ensure residents' rights to receive visitors without a reasonable clinical and safety cause, for all residents reviewed for visitation concerns (Residents R2, R14, R16, R22, R49, R50 and R57). Findings include: The Pennsylvania DOH Interim Guidance for Skilled Nursing Facilities During COVID-19 dated March 29, 2021, noted that skilled nursing facilities are to follow the visitation guidance set forth in the CMS Memorandum QSO-20-39-NH with the subject Nursing Home Visitation - COVID-19 as amended March 10, 2021. The CMS QSO-20-39-NH Memorandum, in the March 10, 2021 revision, stipulated that, Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status) except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. The memorandum also directed that the nursing homes should enable visits to be conducted with an adequate degree of privacy and that facilities shall not restrict visitation without a reasonable clinical or safety cause. During interviews conducted on May 10, 2021, from 2:00 p.m., through 5:05 p.m., Residents R2, R14, R16, R22, R49, R50 and R57 complained that the visitation restrictions imposed by the facility did not allow for adequate visitation opportunities and that there was insufficient time to visit when they were allowed visits. The residents also revealed that visitation was restricted to short periods on certain days and that they and their families were told that there was no visitation allowed on Fridays, Saturdays and Sundays. Residents R2 and R50 reported that they were unable to have visits as their families were able to visit on weekends only due to their schedules, and that weekend visitation was not permitted according to the facility's rules. Resident R49 stated they would like to see their grandchild but were not permitted as they were not yet [AGE] years of age and no family members under the age of 18 were permitted to visit. A posting at the main elevators of the facility stated that visitation was restricted to the following times: Monday 5:30 to 6:30 p.m., Tuesday from 9:30 to 10:45 a.m., Wednesday from 9:30 to 10:45 a.m. and 5:30 to 6:30 p.m., Thursday from 9:30 to 10:45 p.m., and no visitation allowed on Fridays, Saturdays or Sundays. Limiting visitation by appointment only, to less than six hours per week in the lobby entrance area for the facility with a capacity of 95 residents. A letter dated May 10, 2021, sent to the resident's family members, stated that the above restrictions and limitations on visitation remained in place. During interview on May 12, 2021, at 1:45 p.m., the Nursing Home Administrator (NHA) confirmed the visitation restrictions as above: 30 minutes or less, no visitation on Fridays, Saturdays or Sundays and no family members [AGE] years of age or younger permitted to visit their family members. The NHA disclosed that the facility met all the criteria for visitation at present and for a few weeks since March 10, 2021, the date of the guidance directing the facility to allow indoor visitation at all times and for all residents. 28 Pa. Code 201.18 (b)(2) Management 28 Pa. Code 201.29 (j) Resident rights

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to assure that medications were properly dated when opened and discarded in a timely manner on two of three nursing units (Second and Third floor medication rooms). Findings include: The facility policy entitled Medication Administration, dated 9/27/19, indicated that multi-dose vials expire within 28 days of opening or with the manufacturer's expiration date if sooner and are to be properly disposed of on the unit. Manufacturer's recommendations for the use of multi-dose vials of Purified Protein Derivative (PPD - a combination of proteins, injected under the skin to determine exposure to tuberculosis) indicated that PPD is to be discarded one month after use/opening. Observation of medication storage on the Second floor medication room on 5/12/21, at 10:20 a.m. revealed an open vial of PPD, without an open date on the vial, and was present in the medication refrigerator. During an interview at the time of the observation, Registered Nurse (RN) Employee E1 confirmed the PPD vial was open and undated and needed to be discarded. Observation of medication storage on the Third floor medication room on 5/12/21, at 10:50 a.m. revealed an open vial of PPD, without an open date on the vial, and was present in the medication refrigerator. During an interview at the time of the observation, RN Employee E2 confirmed the PPD vial was open and undated and needed to be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records and facility policies, and staff and physician interviews, it was determined that the facility failed to monitor and identify in a timely manner, complications associated with indwelling urinary catheters (tube inserted into the bladder to facilitate urine drainage) resulting in harm to two of six residents (Residents R1 and R14), failed to correctly demonstrate appropriate catheter care to prevent infection for one of six residents (Resident R1), failed to secure the catheter tubing for one of six residents (Resident R1) and failed to suspend the urinary catheter bag off the floor to prevent potential contamination of the system for two of six residents (Residents R10 and R14). The findings include: The "Foley Catheter (a specific type of indwelling urinary catheter)" policy, dated 7/11/14, revealed that, "Foley catheter care will be done every shift with soap and water by the direct care staff" and that the Foley catheter, "will be secured every shift from pulling (i.e., leg strap)". The "Insertion, Care and Removal of Urinary Catheters" policy dated 7/11/14, revealed that during the provision of catheter care to the uncircumcised male resident, the foreskin is to be retracted and the area around the catheter insertion site at the meatus (opening at the tip of the penis) is to be washed with soap and water and rinsed well. Resident R1's quarterly Minimum Data Set assessment (MDS-periodic review of resident care needs) dated 7/22/14, revealed an admission date of [DATE], which included [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. Resident R1's urinary catheter care plan, last updated 9/17/14, indicated that Resident R1 had a size 18 urinary catheter ordered and that the tubing was to be secured to the upper leg to prevent the catheter from being pulled out. During an interview on 9/23/14, at 12:30 p.m., Resident R1's family member (RF1) stated that in August, he/she discovered Resident R1 had, "pus coming out of the penis" and that he/she wasn't convinced that the catheter care was being done appropriately. The nursing notes dated 8/07/14, reflected that the family member, RF1, called the physician and was concerned about Resident R1's increased confusion. The documentation also revealed that in response to the family concerns, an assessment was done and revealed the presence of, "pus like secretions coming out of the penis" and that the catheter was draining dark yellow urine. With the Director of Nursing (DON) present, observations of the provision of catheter care to Resident R1, conducted on 9/24/14, from 10:00 a.m. through 10:20 a.m., revealed Nurse Aide (NA), Employee E4, cleaning the meatus of the penis without retracting the foreskin. When Employee E4 was asked to pull back the foreskin to observe if there was any drainage present, it was revealed that the meatus of the penis was torn approximately 4.4 centimeters as measured by Licensed Practical Nurse (LPN), Wound Nurse, Employee E5. The area appeared beefy red at the catheter insertion site and along the opened area extending from the meatus and with a scant amount of drainage noted at the insertion site. Resident R1 also lacked a device to secure and/or stabilize the catheter tubing. During the time of the observation of Resident R1's catheter care, the DON confirmed that Employee E4 failed to appropriately retract the foreskin, failed to cleanse the area around the catheter insertion site, confirmed that the meatus was torn and also confirmed that the device to stabilize the catheter tubing was not in place. Review of the clinical record revealed no documentation by nursing or the physician to indicate that the facility had identified Resident R1's torn meatus prior to the observation of catheter care on 9/24/14. During an interview on 9/24/14, at 1:50 p.m., Resident R1's physician indicated that a tear of the meatus should have been identified by the care givers during the delivery of appropriate catheter care. The initial MDS, dated [DATE], revealed that Resident R14 was admitted to the facility on [DATE], with an indwelling urinary catheter for urine retention (an inability to fully empty the bladder during urination). The current quarterly MDS, dated [DATE], revealed Resident R14's continued presence of an indwelling urinary catheter. During an observation of Resident R14's indwelling urinary catheter on 9/24/14, at 12:50 p.m., with the DON, it was observed that Resident R14's meatus had a 3.1 centimeter tear as measured by Employee E5. Review of the clinical record revealed no documentation by nursing or the physician to indicate that the facility had identified Resident R14's torn meatus prior to the observation on 9/24/14. During an interview at the time of the observation, the DON confirmed that Resident R14's meatus was torn and there was no evidence that the tear was documented. During observation of residents with indwelling urinary catheters on 9/24/14, from 12:35 through 1:00 p.m., the following was observed: Observation at 12:45 p.m., Resident R10 was lying in bed with the catheter bag on the floor. During an interview on 9/24/14, at 12:45 p.m., the Infection Control Nurse, Employee E6, confirmed that the catheter bag should not have been in contact with the floor to prevent potential contamination of the system. Observation on 9/24/14, at 12:48 p.m. revealed a facility employee to be transporting Resident R14 down the hall in a wheelchair. The urinary catheter bag, housed inside a cloth bag, was dragging on the floor beneath the wheelchair. 28 Pa Code 211.12(d)(1)(5) Nursing services.