Every finding on record at Wesbury United Methodist Commu

Based on review of facility policy and clinical records, observations, and staff interviews it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during the care of a wound for one resident (Resident R11), maintaining sanitary respiratory equipment for two residents (Residents R58 and R114) and implement infection prevention measures for one resident of 28 residents (Resident R129). Findings include:A facility policy entitled Wound Care Procedure for Wounds dated 5/01/26, indicated to remove the soiled dressing; remove gloves and discard in the bag; wash your hands, put on clean gloves, and clean the wound; place soiled gauze used for cleaning in the bag; remove your gloves and place in the bag; wash your hands, put on new gloves; and apply clean dressing. A facility policy entitled Enhanced Barrier Precautions dated 5/01/26, indicated that personal protection equipment (PPE [gloves, gowns, etc.]) for enhanced barrier precautions (EBP) is only necessary when performing high-contact care activities and include transferring, providing hygiene, and assisting with toileting. Resident R11's clinical record revealed an admission date of 4/15/26, with diagnoses that included hyperosmolality (occurs when the blood contains an unusually high concentration of dissolved particles) and hypernatremia (high sodium in the blood, often stems from losing too much water or gaining too much sodium, leading to an imbalance in your body), urine retention, and difficulty swallowing. Observation of wound care on 7/22/26, at 9:38 a.m. revealed that LPN Employee E6 removed the soiled wound dressing from Resident R144's lower back, changed his/her gloves and failed to perform hand hygiene. Further observation of wound care on 7/22/26, at 9:47 a.m. revealed that LPN Employee E6 removed the soiled wound dressing from Resident R144's right ear, failed to perform hand hygiene and change his/her gloves, dated the tape of the new dressing, cleansed the right ear wound, and applied the new dressing. During an interview on 7/22/26, at 10:00 a.m. LPN Employee E6 confirmed that he/she should have performed hand hygiene and changed gloves when discarding the soiled dressings. Resident R58'a clinical record revealed an admission date of 5/19/26, with diagnoses that included stroke, ataxia (difficulty walking), COPD, dependence on supplemental oxygen (oxygen provided by nasal cannula from an oxygen tank or concentrator [medical device that provides supplemental oxygen by taking in room air, removing nitrogen, and delivering oxygen-enriched gas to the patient] to ensure a person's oxygen levels are sufficient]), and long-term respiratory failure with hypoxia (low levels of oxygen in your body tissues that can lead to symptoms like confusion, restlessness, difficulty breathing, rapid heart rate and bluish skin). Resident R58's physician orders revealed an order dated 5/19/26, for oxygen at 1-2 liters per minute (LPM) via nasal cannula every shift (QS), and an order dated 5/19/26 for Ipratropium 0.5 mg Albuterol 3mg (milligrams) /3ml (milliliter) nebulization solution via HHN (a medical device that turns liquid medication into mist and is inhaled by a face mask or holding a plastic pipe) as needed every 6 hours. Observation on 7/20/26, at 2:30 p.m. Resident R58's oxygen tubing with a nasal cannula was lying on top of Resident R58's unmade bed, and his/her HHN was observed hanging by the elastic strap over the door of the nebulizer machine and were not in zip lock type bags. There were also two empty zip lock type bags taped to the nightstand and on the oxygen concentrator casing, and the concentrator was turned on. Further observation at 3:11 p.m. Resident R58's oxygen tubing with a nasal cannula was lying on top of Resident R58's made bed, and his/her HHN was observed hanging by the elastic strap over the door of the nebulizer machine and were not in zip lock type bags. There were also two empty zip lock type bags taped to the nightstand and on the oxygen concentrator casing, and the concentrator was turned on. During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 confirmed that Resident R58's oxygen tubing and HHN should be placed in plastic bags when not in use. Resident R114's clinical record revealed and admission date of 5/26/23, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), dependence on supplemental oxygen, and long-term respiratory failure with hypoxia. Resident R114's physician's orders revealed an order dated 1/03/24, for oxygen at three LPM via nasal cannula QS [every shift]. Observation on 7/20/26, at 3:10 p.m. revealed that Resident R114 was self-propelling in his/her wheelchair through the unit common area, proceeded through the unit activity room and his/her oxygen tubing connected to the portable oxygen tank attached to the wheelchair was dragging on the floor, and the portable oxygen tank was turned on. At that time Nurse Aide (NA) Employee E4 picked up the nasal cannula portion of the oxygen tubing and placed it against the resident's face to reapply it to his/her nose. At the time of the observation, NA Employee E4 confirmed that the nasal cannula should be cleansed before reapplying and draped the oxygen tubing over the handle of Resident R114's wheelchair and walked away. During an observation and interview on 7/20/26, at 3:16 p.m. LPN Employee E3 confirmed the position of the oxygen tubing on Resident R114's wheelchair handle and that the oxygen tubing should be replaced. Resident R122's clinical record revealed an admission date of 3/16/22, with diagnoses that included psychosis (loss of contact with reality that affects the mind and causes delusions, hallucinations, and other symptoms), difficulty swallowing, Alzheimer's Disease, and Barrett's Esophagus (condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red). Resident R122's physician's orders revealed an order dated 5/21/26, for oxygen at two LPM via nasal cannula as needed. Observation on 7/21/26, at 8:30 a.m. revealed Resident R122's oxygen tubing lying on the floor next to his/her oxygen concentrator, and an empty zip lock type bag was taped to the top of the oxygen concentrator casing. During an interview on 7/21/26, at 9:09 a.m. LPN Employee E2 confirmed that the oxygen tubing was lying on the floor and should have been stored in the zip lock type bag. Resident R129's clinical record revealed an admission date of 7/22/24, with diagnoses that included non-Hodgkin lymphoma (type of cancer that affects the lymphatic system), stroke with left-sided hemiplegia (condition that causes paralysis on one side of the body due to brain or spinal cord damage), and COPD. Resident R129's' physician's order' revealed an order dated 12/08/25, for EBP every shift. Resident R129's care plan entitled infection included an intervention dated 7/06/26, for staff to wear PPE as appropriate. Observation on 7/21/26, at 9:06 a.m. revealed signage on the outside doorframe to his/her room indicated to implement EBP to provide high-contact resident care, and an equipment storage hanging on the back of Resident R129's door included gowns, masks, gloves, etc. Observation on 7/21/26, at 9:07 a.m. of medication administration with LPN Employee E2, Resident R129 was being assisted to his/her chair by NA Employee E1 after assisting him/her in the bathroom, and NA Employee E1 was not wearing EBP. During an interview at that time NA Employee E1 confirmed he/she did not wear a gown to take resident to the bathroom did know that he/she needed to, and that there is usually stuff hanging on the door. NA Employee E1 then confirmed the presence of PPE hanging on the back of Resident R129's room door. Observation confirmed at that time by LPN Employee E2 that NA Employee E1 did not implement EBP by not wearing appropriate PPE during high-contact care for Resident R129 and that staff are required to wear gloves and a gown when assisting Resident R129 in the bathroom. 28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to help prevent the spread of infection regarding respiratory care equipment for six of 28 residents (Residents R2, R12, R81, R92, R133, and R138).Findings include: Review of facility policy entitled Oxygen Therapy and Equipment dated 5/1/26, indicated All nasal canula tubing (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery), mask, extension tubing, and zip lock style bags will be changed every week by night shift. Review of facility policy entitled Hand Held Nebulizer (HHN) Therapy dated 5/1/26, indicated Those residents with orders for HHN treatments will be issued the proper equipment that will be kept in the resident's room and dated when open. After each treatment, the equipment will be rinsed with tap water, allowed to air dry, and then stored in a zip-lock style bag. HHN apparatus, including T-pipes and mask, will be changed bi-weekly and prn. Resident R2's clinical record revealed an admission date of 6/28/23, with diagnoses that included gastrostomy (a tube that enters that digestive system to provide nutrition), congestive heart failure (CHF - when the heart muscle is weak and not able to pump blood throughout the heart and body efficiently), chronic obstructive pulmonary disease (COPD - when your lungs do not have adequate air flow), muscle weakness, and dysphagia (difficulty swallowing). Resident R2's physician orders revealed an order for oxygen at two liters per minute (LPM) via nasal cannula every shift dated 10/06/25. Resident R2's clinical record lacked evidence of a physician order to change the oxygen tubing and that the oxygen tubing was changed. Observations on 7/20/26, at 2:00 p.m. and 7/21/26, at 9:30 a.m. revealed Resident R2 receiving oxygen at two LPM via nasal cannula with a date of 7/26, written on Resident R2's nasal cannula tubing. Review of Resident R12's clinical record revealed an admission date of 3/16/21, with diagnoses that included, COPD, and acute respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R12's physician orders revealed an order for oxygen at two LPM via nasal cannula at bedtime daily dated 4/28/26. Review of Resident R12's clinical record lacked evidence that the nasal cannula was changed. Observations on 7/20/26, at 1:10 p.m., 2:30 p.m. and again on 7/21/26., at 10:00 a.m. revealed a date of 6/17/26, written on Resident R12's nasal cannula tubing. Review of Resident R81's clinical record revealed an admission date of 4/16/26, with diagnoses that included COPD, chronic respiratory failure, and asthma (a long-term lung disease that causes the airways to narrow and make it difficult to breathe). Review of Resident R81's physician orders revealed an order for Albuterol Sulfate 2.5 mg / 3ml solution for nebulization via HHN three times a day dated 4/16/26. Review of Resident R81's clinical record lacked evidence that the HHN was changed. Observations on 7/20/26, at 12:10 p.m., 2:20 p.m. and again on 7/21/26, at 9:58 a.m. revealed a HHN lying on Residents R81's bedside stand dated 6/26 and was not in a zip lock type bag. Review of Resident R92's clinical record revealed an admission date of 1/31/23, with diagnoses that include pneumonia (an illness that causes respiratory distress, congestion and cough), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R92's physician orders revealed an order for Ipratropium 0.5 mg Albuterol 3mg /3ml nebulization solution via HHN four times a day as needed dated 12/5/25. Review of Resident R92's clinical record lacked evidence that the HHN was changed. Observations on 7/20/26, at 2:29 p.m. and again on 7/21/26, at 9:55 a.m. revealed an HHN in a zip lock type bag taped to Resident R92's bedside stand dated 6/26. Review of Resident R133's clinical record revealed an admission date of 2/18/21, with diagnoses that include asthma, and obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). Review of Resident R133's physician orders revealed an order for oxygen at two LPM at bedtime daily dated 8/5/21. Review of Resident R133's clinical record lacked evidence that the nasal cannula was changed. Observations on 7/20/26, at 2:38 p.m. and again on 7/21/26, at 10:10 a.m. revealed Resident R133's nasal cannula in a zip lock type bag dated 7/26. Resident R138's clinical record revealed an admission date of 2/19/24, with diagnoses that included COPD, urinary tract infection, muscle weakness, and dependence on supplemental oxygen. Resident R138's physician orders revealed an order for oxygen at three LPM Q.S. [every shift] dated 9/20/24. Resident 138's clinical record lacked evidence of a physician order to change the oxygen tubing and that the oxygen tubing was changed. Observations on 7/21/26, at 10:35 a.m. revealed Resident R138 receiving oxygen at three LPM via nasal cannula with a date of 7/26, written on Resident R138's nasal cannula tubing. During an interview on 7/21/26, at 11:00 a.m. the Director of Nursing (DON) confirmed that Resident R12's nasal canula was dated 6/17/26, Resident's R 81 and R92's HHN's were dated 6/26, and Resident R133's nasal cannula was dated 6/26. He/she also confirmed that the nasal cannulas and HHNs should have been changed per facility protocol for all above noted residents. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to Hospice services for three of 28 residents reviewed (Residents R27, R77, and R122).Findings include: The Skilled Nursing Facility Inpatient Care Services Agreement dated 3/21/23, revealed that: Article II section 2.2 Plan of Care indicated the plan of care should be maintained in consultation with Skill Nursing Facility (SNF) representatives during the period the patient is admitted to the SNF, hospice shall communicate to the SNF any changes in the condition of patient which require updating the Plan of Care for each patient, and provide SNF with the updated Plan of Care; section 2.4 Manner of Communication all communication between the Hospice and SNF pertaining to the care and services provided to the patient shall be documented in the patient's clinical record. Article III section 3.2 Coordination of Services indicated that the SNF will obtain the most recent hospice Plan of Care specific to each patient. Resident R27's clinical record revealed an admission date of 6/08/20, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), difficulty swallowing, difficulty walking, and aphasia (language disorder that affects how you speak and understand language. A physician's order dated 5/22/26, indicated he/she was admitted to hospice services effective 11/17/2025. Further review of Resident R27's clinical record revealed that the most recent hospice staff visit notes were dated 6/18/26, and that the hospice plan of care ended on 7/14/26. Interviews on 7/22/26, at 2:13 p.m. with Licensed Practical Nurse (LPN) Employees E3 and E5, confirmed that Resident R27's hospice care plan was not current and that the clinical record lacked recent hospice staff visit notes. Resident R77's clinical record revealed an admission date of 9/17/25, with diagnoses that included adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), Parkinsonism (clinical syndrome characterized by the four motor signs that are found in Parkinson's disease: tremor, bradykinesia (slowed movements), rigidity, and postural instability.), aphasia, and stroke. A physician's order dated 5/22/26, indicated he/she was admitted to hospice services effective 10/03/25. Further review of Resident R77's clinical record revealed that the most recent hospice staff visit notes were dated 7/01/26, and that the hospice plan of care ended on 5/29/26. Resident R122's clinical record revealed an admission date of 3/16/22, with diagnoses that included psychosis (loss of contact with reality that affects the mind and causes delusions, hallucinations, and other symptoms), difficulty swallowing, Alzheimer's Disease, and Barrett's Esophagus (condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red). A physician's order dated 5/22/26, indicated that he/she was admitted to hospice service effective 1/24/24. Further review of Resident R122's clinical record revealed that the most recent hospice staff visit notes were dated 6/20/26. During an interview on 7/21/26, at 1:57 p.m. LPN Employee E2 confirmed that Resident R77's hospice care plan was not current and that the clinical record lacked recent hospice staff visit notes, and that Resident R122's clinical record lacked recent hospice staff visit notes. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.5(f)(iii) Medical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policies, and staff interviews, it was determined that the facility failed to completely investigate an unwitnessed fall for one of 28 residents (Resident R95).Findings include: A policy entitled Resident Incident Reporting dated 5/0/26, indicated that the charge nurse will complete a Resident Incident Report which will include all documentation related to interviews or resident, staff members, and any other witnesses. A facility policy entitled Incident/Accident Management Program indicated after evaluating and treating the resident immediately, the registered nurse will investigate the circumstances of the incident and look for all possible causes; the registered nurse should talk with the nursing assistants, residents, and any other witnesses. Review of Resident R95's clinical record revealed a current admission date of 3/17/26, with diagnoses including heart disease, muscle weakness, vascular dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), and altered mental status, age-related debility (distinct medical condition that goes beyond normal aging, characterized by a general decline in strength, mobility, and resilience). Resident R95's clinical record revealed that he/she experienced an unwitnessed fall on 4/12/26, at 10:15 p.m. and that continued diagnostic testing on 4/15/26, identified a fractured right clavicle (collar bone). Review of the facility investigation related to Resident R95's unwitnessed fall on 4/12/26, lacked evidence of resident, staff and other witness interviews. During an interview on 7/23/26, at 12:40 p.m. the Nursing Home Administrator confirmed there was no additional documentation to support that Resident R95's fall was thoroughly investigated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1))5) Resident care policies

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 28 residents reviewed (Resident R95).Findings include: Review of a facility policy entitled, Care Plans (Plans of Service) dated 5/01/26, indicated that care plans are updated whenever a change is necessitated by a resident's change in condition, physician, or when scheduled by the minimum data set (MDS [a standardized tool used in nursing homes to evaluate residents' health, functional status, and care needs] team for a quarterly, change in condition, or annual review. A facility policy entitled Incident/Accident Management Program dated 5/01/26, indicated that when a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and put into place an intervention to prevent this from happening again. Review of Resident R95's clinical record revealed a current admission date of 3/17/26, with diagnoses that included heart disease, muscle weakness, vascular dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), and altered mental status, age-related debility (distinct medical condition that goes beyond normal aging, characterized by a general decline in strength, mobility, and resilience). Resident R95's clinical record revealed that he/she experienced an unwitnessed fall on 4/12/26, at 10:15 p.m. and that continued diagnostic testing on 4/15/26, identified a fractured right clavicle (collar bone). Review of the facility's fall investigation dated 4/12/26, indicated that Resident R95's care plan was updated, and lacked documentation of what items were updated. A care plan entitled Falls included interventions dated 3/17/26, and a goal date of 6/15/26. The care plan lacked evidence that the care plan was updated in reference to Resident R95's fall with major injury on 4/12/26. During an interview on 7/23/26, at 12:40 p.m. the Nursing Home Administrator confirmed that Resident R95's falls care plan did not reflect updates related to the fall with major injury from 4/12/26, and that the goal date for the falls care plan was 6/15/26. 28 Pa. Code 211.5(f)(ix) Medical records 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 provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer, and failed to ensure that the necessary resident information was communicated to the receiving health care provider for one of 28 residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission date of 9/22/22, with diagnoses that included left femur fracture (fracture of the longest bone in the body connecting hip and knee), muscle weakness, difficulty in walking, and encounter for orthopedic aftercare (care for fracture of bone). Resident R1 was transferred to the hospital on 4/20/26. The clinical record lacked documentation that Resident R1 and/or their representative were provided with a copy of the facility bed-hold policy, and/or that the necessary resident information was communicated to the receiving hospital. During an interview on 7/23/26, at 9:00 a.m. the Director of Nursing (DON) confirmed that Resident R1 and/or their representative were not provided with a copy of the facility bed-hold policy when transferred to the hospital on 4/20/26, but should have been provided to further explain how long his/her bed could be held during a leave of absence and the cost per day. The DON further confirmed that Resident R1's clinical record lacked evidence that necessary resident information was communicated to the receiving health care provider when Resident R1 was transferred to the hospital on 4/20/26. 28 Pa. Code 201.18(e)(1) Management

Based on review of clinical records, and staff interviews, it was determined that the facility failed to have complete, accurate, and systematically organized documentation regarding ensuring that additional water ordered for tube feeding is administered per orders for one of 28 residents reviewed (Resident R11).Resident R11's clinical record revealed an admission date of 4/15/26, with diagnoses including hyperosmolality (occurs when the blood contains an unusually high concentration of dissolved particles) and hypernatremia (high sodium in the blood, often stems from losing too much water or gaining too much sodium, leading to an imbalance in your body), urine retention, and difficulty swallowing.Resident R11's physician's orders regarding tube feedings and flushes included:4/15/26, fluid intake mL[milliliters] provided by nursing each shift for hydration.4/16/26, irrigate with 30 mL water before and after medications.4/21/26, flush with 100 mL water every shift for nursing instruction with medications.4/21/26, flush with 100 mL water four times per day for nursing instruction.5/02/26, Jevity 1.5 Cal 0.06 gram-1.5kcal/mL oral liquid at 50 mL per hour enteral tube feeding. Spike and hang bottle at 11:00 a.m. Do not take down until bottle is empty daily regardless of time. Review of Resident R11's Medication Administration Record (MAR) revealed nursing staff documented administration of 100 mL water every shift and four times per day; 30 mL water before and after medication administration; and Jevity infused starting at 11:00 a.m. daily. Review of Resident R11's MAR documentation for fluid intake (mL) provided by nursing each shift lacked direction for staff to include or exclude the 100 mL water flushes every shift and four times per day, Jevity feeding infusion, and 30 mL flushes before and after medication administration resulting in inaccurate and inconsistent documentation of fluid intake provided by nursing staff each shift. Review of Fluid Management Report dated 7/12/26, to 7/21/26, provided by the facility on 7/23/26, indicated Resident R11's 24-hour fluid intake totals ranged between 910 mL to 2340 mL. During an interview on 7/23/26, at 10:30 a.m. the Director of Nursing confirmed 24-hour fluid intake parameters are not clearly written on the MAR, and there is a wide gap in the documentation of the water intake, and that the orders need to be clearer to ensure that Resident R11 is receiving the appropriate amount of water flushes. 28 Pa. Code 211.5(f)(viii)(x) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to post contact information for the State Survey Agency as required for three of four separate nursing units in areas accessible to residents and visitors. (Town Square, Village Center and Memory Support nursing units) Findings include: Observations conducted on 7/3/25, from 10:25 a.m. through 10:40 a.m. with the Nursing Home Administrator (NHA), revealed that the State Survey Agency-Pennsylvania Department of Health contact information posting on the Town Square nursing unit was covered by a binder holder and that Village Center and Memory Support nursing units did not have any postings of the State Survey Agency-Pennsylvania Department of Health contact information. During this time, the NHA confirmed that the State Survey Agency-Pennsylvania Department of Health contact information was not posted in any of the main public areas of the facility or accessible to residents and visitors on the above identified nursing units. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility documents and clinical records, observations, and staff interview, it was determined that the facility failed to ensure cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of 29 residents reviewed (Resident R27). Findings include: A facility document entitled Third Shift Task List indicated that on Tuesdays staff are to clean PAP (positive airway pressure) tubing, humidifier chamber, and nasal pillows (two soft pillows to deliver airflow directly into the nostrils) /mask- wash with mild non-antibacterial soap and rinse with warm water; allow to dry; rinse foam filter with water and allow to dry. Resident R27's clinical record revealed an admission date of 4/01/25, with diagnoses that included obstructive sleep apnea (common sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway), and chronic obstructive pulmonary disease (COPD- lung condition caused by damage to the lungs resulting in restricted airflow and breathing problems). Resident R27's clinical record included a physician's order date 4/10/25, resident may wear home BiPAP (Bi-level positive airway pressure machine that can generate two adjustable pressure levels) as currently set up via nasal pillows daily at bedtime. Resident R27's Medication Administration Records revealed he/she had received the BiPAP every night since admission. The clinical record lacked evidence that the BiPAP machine and equipment had been cleaned by staff. Observations on 6/30/25, at 1:20 p.m. 7/01/25, at 10:01 a.m. revealed a BiPAP machine on Resident R27's nightstand. During an interview on 6/30/25, at 1:20 p.m. Resident R27 confirmed that he/she uses the BiPAP every night at bedtime. During an interview on 7/03/25, at 11:00 a.m. the Director of Nursing (DON) confirmed staff fill out the Third Shift Task List and he/she was not sure where they were kept. The DON confirmed the facility was unable to provide evidence of documentation for cleaning and care of the BiPAP equipment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(x) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, and staff interviews, it was determined that the facility failed to ensure that medications subject to abuse were stored in separately locked, permanently affixed compartment in one of three medication refrigerators observed (Village Center). Findings include: Observation on 7/01/25, at 10:21 a.m. revealed a locked refrigerator in the Village Center medication room that contained a locked clear plastic box intended to safely secure controlled medications that contained a 30 mL multi-dose bottle of lorazepam (anti-anxiety medication subject to abuse). The clear plastic box was affixed to the removable shelving and the shelving was not permanently affixed to the refrigerator. At the time of the observation Licensed Practical Nurse Employees E1 and E2 confirmed that the shelf containing the secured locked box was removable from the refrigerator and therefore not pemanently affixed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical record, observations, and staff interview, it was determined that the facility failed to implement infection control practices regarding Enhanced Barrier Precautions (EBPs-additional infection control precautions put in place for individuals who have an increased risk of multi-drug resistant organisms (MDROs) or who are colonized/infected with MDROs) for a gastric feeding tube (a medical device used to provide nutrition and/or medications when a person cannot swallow or take anything by mouth) for one of 26 residents reviewed (Resident R123). Findings include: Review of the facility policy entitled Enhanced Barrier Precautions implemented 3/2024, indicated that all staff providing direct resident care will adhere to EBPs, in addition to standard precautions, when performing high-contact resident care activities for residents with wounds, indwelling medical devices, and/or suspected or confirmed infection or colonization of certain MDROs. EBP's are designed to reduce transmission of resistant organisms and expands the use of gown and gloves during high-contact resident care activities that are opportunities for transfer of MDROs to staff hands and clothing when Contact Precautions do not otherwise apply to residents with wounds or indwelling medical devices (urinary catheters, vascular access devices, tracheostomies, feeding tubes and wound drains), regardless of MDRO status. Resident R123's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (difficulty swallowing), gastrostomy complications (complication with gastric feeding tube), and muscle weakness. Observations made prior to a gastric feeding tube medication administration for Resident R123 on 8/14/24, at approximately 11:15 a.m. revealed that there were not any EBPs in place. During an interview at that time the Infection Preventionist confirmed that EBPs were not in place and employees should be wearing gloves and gowns when working with gastric feeding tubes. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 26 residents reviewed (Residents R27, R88, and R100). Findings include: A facility policy entitled, Care Plans, plans of service dated 7/2024, indicated Care plans are updated whenever a change is necessitated by a resident's change in condition, physician orders, or when scheduled by the MDS (Minimum Data Set- standardized assessment tool that measures health status in nursing home residents) team for a quarterly, change in condition, or annual review. Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Resident R27's clinical record revealed the last care plan meeting note was dated 5/9/24. Resident R27's care plan revealed a goal date of 8/7/24, indicating that the care plan had not been reviewed and revised to reflect the current care and services. Resident R88's clinical record revealed an admitted [DATE], with diagnoses that included diabetes and hypertension (high blood pressure). Resident R88's clinical record revealed a late entry for the last care plan meeting note dated 8/15/24. Resident R88's care plan revealed a goal date of 7/25/24, indicating that the care plan had not been reviewed and revised to reflect the current care and services. Resident R100's clinical record revealed an admitted [DATE], with diagnoses that included dysphagia (trouble swallowing), difficulty in walking, and muscle weakness. Resident R100's clinical record revealed the last care plan note was a late entry dated 5/10/24, for a 5/03/24 care plan meeting. Resident R100's care plan revealed a goal date of 8/1/24, indicating that the care plan had not been reviewed and revised to reflect the current care and services. During an interview on 8/16/24, at 10:30 a.m. the Director of Nursing confirmed that the care plans for Residents R27, R88, and R100 were not reviewed and revised timely to reflect current resident care and services. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of two residents reviewed for respiratory services (Resident R123). Findings include: Review of facility policy with a policy review date of 6/2024, entitled Oxygen Therapy and Equipment indicated Purpose: to administer oxygen when insufficient O2 (Oxygen) being carried by the blood to the tissues. All residents using Oxygen will be monitored for safe and effective use of Oxygen therapy. Oxygen may be administered as a nursing measure without physician order. Physician to be notified and order received. Resident R123's clinical record revealed an admitted [DATE], with diagnoses that included gastrostomy (surgical procedure that creates an artificial opening into the stomach for nutritional support) complication, contracture (permanent or temporary tightening of muscles, tendons, skin, and nearby tissues that cause joints to shorten and become stiff preventing normal movement) of the left and right hand, and history of a cerebral infarction (area of brain tissue that dies as a result of lack of blood and oxygen). Observation on 8/16/2024, at 12:00 p.m. and on 8/14/2024, at 9:42 a.m. revealed Resident R123 wearing an oxygen nasal cannula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 2 liters per min (lpm - a unit of oxygen flow [NAME] that is delivered to the resident). Resident R123's clinical record revealed an order from 7/20/2023, that reads, assess for O2 use every shift. The clinical record lacked evidence of a physician's order for how much oxygen to deliver. During an interview on 8/16/2024, at 12:30 p.m. the Director of Nursing confirmed that Resident R123 was being administered oxygen therapy and their clinical record lacked a physician's order for the specific oxygen therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to have the required 14-day stop date or provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of 26 residents reviewed (Resident R29). Findings include: A facility policy entitled Psychopharmacological Medication Dosage Reductions dated 7/2024, revealed that Psychotropic medications excluding antipsychotics ordered prn may only be prescribed for a 14-day duration. If the physician or prescribing practitioner wishes to extend the order beyond 14 days, they should document the rationale for the extended time period in the medical record and indicate a specific duration. Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, dementia (impaired ability to remember, think, and make decisions), and muscle weakness. A physician's order dated 8/02/24, identified to administer Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every 4 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. During an interview on 8/15/24, at 12:28 p.m. the Director of Nursing confirmed that Resident R29's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure an expired medication was discarded in a timely manner in one of two medication rooms reviewed (College Way medication room). Findings include: Review of a facility policy entitled Medications, Multidose Vials dated [DATE], indicated Medications may be used until the manufacturer's expiration date or the length of time allowed by state law. When a vial/dispenser has exceeded either expiration date the medication is to be disposed of per facility policy and reordered. Manufacturer's recommendations for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observations of drug storage on [DATE], at approximately 2:34 p.m. in College Way medication room's refrigerator revealed an opened vial of Tubersol with an open date of [DATE]. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the Tubersol vial's open date was past 30 days and the expired medication should have been discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of 27 residents reviewed (Resident R4). Findings include: Review of facility policy entitled Confidentiality and Non-Disclosure Policy dated 8/16/23, indicated a secured computer application will not be left unattended while signed on. During observation of medication administration for Resident R4 on 10/24/23, at 4:10 p.m. Licensed Practical Nurse (LPN) Employee E1 prepared medications for a resident from Village Center Hall medication cart parked in the middle of hall in front of the resident room with the computer open sitting on top of medication cart. LPN Employee E1 then proceeded into resident room to administer medications to a resident in the room, after administering medication the nurse walked over to the roommate behind a privacy curtain. LPN Employee E1 did not cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E1 was unable to view the computer on top of the medication cart parked in the middle of the hallway outside the resident room. During an interview on 10/24/23, at the time of the observation, LPN Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover resident/medication information that was on the computer on top of the medication cart. Employee E1 also confirmed that resident information is to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) bag for one of 27 residents reviewed (Resident R78). Findings include: Review of a facility policy entitled, Catheter, Urinary Bag, Care of dated 8/16/23, indicated, Maintain the dignity of the catheterized resident by concealing the urinary bag from public view in a privacy bag . Review of Resident R78's clinical record revealed an admitted [DATE], with diagnoses that included Urinary Tract Infection; Resistance to Multiple Antibiotics, (occurs when bacteria change in a way that makes antibiotics less effective against them); Benign Prostatic Hyperplasia, (the flow of urine is blocked due to the enlargement of prostate gland); and Obstructive and Reflux Uropathy, (urine cannot flow through the urinary tract due to an obstruction and backs up into the kidneys). Observations on 10/24/23, at 10:18 a.m., and 10/25/23, at 10:18 a.m. revealed Resident R78 laying in his/her bed and with his/her urinary drainage bag visible from the hallway without a privacy bag. During an interview on 10/25/23, at 10:22 a.m. Registered Nurse Employee E3, confirmed that the catheter drainage bag should be covered to ensure resident privacy and dignity. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to follow physician's orders for treatments for one of 27 residents reviewed (Resident R21). Findings include: Review of a facility policy entitled, Oxygen Therapy and Equipment dated 8/16/23, indicated that Humidified O2 [oxygen] bottles will be changed on a weekly basis by night shift or sooner if needed by any shift when the distilled water is used. Review of Resident R21's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath); chronic kidney disease (condition where the kidneys gradually lose their ability to properly filter waste and excess fluids from the blood); and circulatory system disorder, (condition that affects the structural and/or functional abilities of the heart and or the blood vessels, causing fatigue and/or shortness of breath). Review of Resident R21's clinical record revealed a physician's order to Humidify O2 - change weekly and date when in use - Once Weekly for O2 Use. Review of Resident R21's October 2023 treatment record revealed the humidifier bottle was changed on 10/22/23. Observations on 10/25/23, at 11:21 a.m., 10/26/23, at 2:18 p.m., and 10/27/23, at 10:20 a.m. revealed that Resident R21's oxygen humidifier bottle was dated for 10/14/23. During an interview on 10/27/23, at 10:26 a.m. Registered Nurse Employee E3 confirmed that the oxygen humidifier bottle was dated 10/14/23, and was not changed per physician's orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of 27 residents reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's Disease, (brain disorder that destroys memory and thinking skills and, eventually, the ability to carry out simple tasks); sleep related non-obstructive alveolar hypoventilation, (breathing that is too slow and/or shallow during sleep); and dependence on supplemental oxygen. Review of Resident R12's physician's order dated 5/26/23, revealed oxygen ordered at two liters per minute via nasal cannula (tubing into the nostrils to administer oxygen) every shift. Observations on 10/26/23, at 10:10 a.m. and 10/27/23, at 10:23 a.m. revealed that R12's oxygen concentrator had a significant amount of white dust and white cobweb substances obstructing the concentrator's air inlet port. During an interview on 10/27/23, at 10:26 a.m. Registered Nurse Employee E3, confirmed that the oxygen concentrator air inlet area should not be obstructed with white dust and cobweb substances. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of four neighborhoods (Town Square). Findings include: Review of a facility policy entitled Cleaning of Resident Wheelchairs dated 8/16/23, indicated that all wheelchairs are to be cleaned quarterly and daily as needed by housekeeping personnel. Observation on 10/25/23, at 10:22 .a.m. revealed Resident R32's wheelchair was soiled with dried liquid substances that also had a build-up of some debris on the left side of the wheelchair and on the left larger wheel. Observation also revealed that Resident R32's wheelchair's bilateral armrests were cracked, peeling, and torn. During an interview on 10/25/23, at 10:25 a.m. Registered Nurse Employee E3 confirmed that Resident R32 had damaged wheelchair armrests with cracked, peeling and torn protective covering and that the left side of the wheelchair was dirty and in need of cleaning. 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, facility policy and an incident report and staff interviews, it was determined that the facility failed to provide a medical treatment in a manner that protected a resident from injury from a heat producing device resulting in actual harm for one resident (Resident R1). Findings include: Resident R1's admission sheet showed an admission date of [DATE], and [DIAGNOSES REDACTED]. An event report submitted to the State Department of Health, dated 7/24/14, disclosed an event that occurred on 7/22/14, at 2:30 p.m. The report revealed that Registered Nurse (RN), Employee E1, received a physician's orders [REDACTED]. The mixture of milk and molasses was heated in the microwave and administered rectally as an enema to Resident R1. After the enema was given, the facility staff noticed that the resident's bottom area was reddened. On 7/23/14, at 6 a.m., the resident was observed to have developed open and fluid filled blisters on the right and left buttocks. The resident's physician examined these areas and determined that the blisters were caused by the skin having been burned and ordered burn treatments to be initiated. On 7/24/14, after the resident's abdomen became swollen with symptoms of pain and discomfort, the physician sent the resident to the hospital for treatment. The hospital diagnosed Resident R1 as having colitis (an inflammation of the inner lining of the bowel) and proctitis (inflammation of the rectum and anus). Review on 8/6/14, of the facility policy titled, "Enema, Cleansing and Retention," which was applicable at the time of the incident and effective 3/11/14, indicated in the procedure for a milk and molasses enema to make sure the mixture was at room temperature. Review of Resident R1's nurses' notes dated 7/22/14, at 8:05 p.m., indicated that a physician's orders [REDACTED]. The nurses' notes dated 7/23/14, at 6:00 a.m., documented the discovery of multiple blistered areas on the resident's buttocks. The nurses' notes dated 7/23/14, at 11:35 p.m., revealed that the resident was having lower, mid-abdominal pain with moaning and groaning and that the resident's abdomen was swollen. The nurses' notes dated 7/24/14, at 10:30 a.m., indicated that the resident was sent to the hospital for abdominal pain. Review of the hospital records dated 7/24/14, disclosed that Resident R1 had a CT scan which diagnosed the resident as having proctitis. During an interview on 8/6/14, at 11:00 a.m., Employee E1 revealed that the mixture of milk and molasses was heated in a microwave and then administered to Resident R1, and following the administration of the enema, the resident developed areas of blistered skin and abdominal pain. During an interview on 8/6/14, at 1:00 p.m., Resident R1's physician confirmed that the blistered areas and proctitis were, by all indications, caused by the burns of the enema mixture having been heated in a microwave and administered to the resident. The facility failed to provide adequate care and supervision to a resident at risk for injury from a heat producing device resulting in actual harm to the resident. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 2/21/14. 28 Pa. Code 201.18(b)(2)(e)(1) Management. 28 Pa. Code 211.12(d)(2) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/21/14, 6/26/14.