Every finding on record at Williamsport Home, The

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound treatments and foley catheters, for four of four employees reviewed for competencies (Employees 2, 3, 4, and 5).Findings include: A review of the facility documentation revealed that the facility had a total of 17 residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and 28 residents with dressing changes (treatment to and changes in the covering of wounds). A request for nursing staff competencies for dressing changes and catheter care revealed the facility was unable to provide competencies for these for Employees 2 and 3 (licensed practical nurses), and Employees 4 and 5 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Employee 1 (registered nurse/staff development) on January 29, 2026, at 10:05 AM. They confirmed the facility could provide no documentation that ensured Employees 2, 3, 4, and 5 had specific competencies and skill sets to care for the resident needs listed above. 28 Pa. Code 201.20 (a) Staff Development

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assist residents with hearing aid devices for three of three residents reviewed for hearing concerns (Residents 29, 65, and 119).Findings include: Clinical record review for Resident 65 revealed an active physician order dated December 31, 2025, for staff to place hearing aids in Resident 65's bilateral ears in the morning and take them out in the evening. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 6, 2026, revealed that staff assessed Resident 65 with adequate hearing with a hearing aid. The MDS CAA (Care Assessment Area) for communication triggered for staff to develop a plan of care to address Resident 65's potential communication deficits. Review of a plan of care initiated by the facility on January 9, 2026, to address Resident 65's risk for impaired communication revealed interventions that included to ensure hearing aid(s) are in place bilaterally. Interview with Resident 65 on January 27, 2026, at 10:03 AM revealed that her hearing aids were not in her ears and the resident stated they were on her dresser furniture. Due to many personal possessions on top of her dresser furniture, the hearing aids were not readily visible. Interview with Resident 65 on January 28, 2026, at 3:27 PM revealed that her hearing aids were not in her ears and the resident stated that they were still on her dresser furniture. Resident 65 stated, they are there and I am here (in her chair across the room from her dresser). When asked if staff assist her with her hearing aids, Resident 65 stated, that would be nice. Observation of her dresser furniture on the date and time of the interview confirmed the presence of two hearing aids in a charger. Review of Resident 65's treatment administration record (TAR, the electronic documentation by licensed nursing staff for the completion of treatments) dated January 2026 revealed that staff initialed for the application of hearing aids for Resident 65 on January 28, 2026, at 8:00 AM. During an interview with Resident 65 on January 29, 2026, at 10:35 AM Resident 65 pointed to the hearing aid charger on her dresser furniture when she was asked if she was wearing her hearing aids. Resident 65 confirmed that her hearing aids were not in her ears but in the charger on her dresser. Review of Resident 65's TAR dated January 2026 revealed that staff initialed for the application of hearing aids for Resident 65 on January 29, 2026, at 8:00 AM. Interview with Employee 6 (licensed practical nurse) on January 29, 2026, at 10:39 AM confirmed that she initialed for the application of Resident 65's hearing aids on this date, however, she did not ensure the placement of the hearing aids in Resident 65's ears. Clinical record review for Resident 29 revealed an active physician's order dated January 13, 2026, for staff to place hearing aids in his bilateral ears in the morning and place them on the charger at bedtime. Review of an admission MDS assessment dated [DATE], revealed that staff assessed Resident 29's hearing as adequate with a hearing aid. Review of a plan of care initiated by the facility on January 14, 2026, to address Resident 29's risk for impaired communication related to hearing aid use, revealed interventions that included to ensure his hearing aids were in place bilaterally. Observation of Resident 29 on January 27, 2026, at 11:02 AM revealed that he did not have hearing aids in his ears and they were in the charger on his dresser furniture. Resident 29 stated, I haven't been wearing them here. Observation of Resident 29 on January 28, 2026, at 3:30 PM revealed that he was not wearing his hearing aids, and they were observed in the charger on his dresser furniture. Observation of Resident 29 on January 29, 2026, at 10:38 AM revealed that he was not wearing his hearing aids, and they were observed in the charger on his dresser furniture. Review of Resident 29's TAR dated January 2026 revealed that nursing staff initialed that Resident 29 had his hearing aids placed in his ears at 8:00 AM on January 27, 28, and 29, 2026. There was no indication that Resident 29 refused the use of his hearing aids. Interview with Employee 6 on January 29, 2026, at 10:39 AM confirmed that she initialed for the application of Resident 29's hearing aids on this date, however, she did not ensure the placement of the hearing aids in Resident 29's ears. Interview with Resident 119's daughter on January 26, 2026, at 12:11 PM revealed that Resident 119 had hearing aids, but he was not wearing them when she visited the previous Friday evening. Clinical record review for Resident 119 revealed an admission MDS dated [DATE], that assessed that he had moderate difficulty hearing but did not capture that he utilized hearing aids. The MDS CAA for communication triggered for staff to develop a plan of care to address Resident 65's potential communication deficits.Review of a plan of care initiated by the facility on January 23, 2026, to address Resident 119's potential communication deficits revealed no interventions to ensure the use of his hearing aids. An active physician's order dated January 14, 2026, indicated that Resident 119 had an audiology appointment scheduled for February 26, 2026, for a hearing aid check. Review of Resident 119's physician orders and TAR revealed no directions to ensure the use of his hearing aids. Observation of Resident 119 on January 27, 2026, at 9:30 AM revealed that he was not wearing his hearing aids. Resident 119 stated that his hearing aids were in a charger on his dresser. Observation of Resident 119 on January 28, 2026, at 3:33 PM revealed that he was not wearing his hearing aids. Resident 119 confirmed that his hearing aids were in the charger on his dresser. Observation of Resident 119's room on January 29, 2026, at 10:44 AM revealed that Resident 119 was out of his room for his skilled therapy treatment, but his hearing aids were in the charger on his dresser furniture. Interview with Employee 6 on January 29, 2026, at 10:39 AM revealed that Resident 119 had hearing aids and that he typically, doesn't give problems with his (hearing aids). Employee 6 denied ensuring that he had hearing aids in place before leaving his room for his skilled therapy treatment. The surveyor reviewed the above concerns regarding hearing aid use for Residents 29, 65, and 119, during an interview with the Nursing Home Administrator on January 29, 2026, at 12:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medication for one of five residents reviewed for medication review (Resident 9).Findings include: Clinical record review for Resident 9 revealed her medication regime included the use of Quetiapine (antipsychotic medication, a drug that mainly treat psychosis-related conditions and symptoms) 12.5 milligrams in the morning and 25 milligrams at bedtime since April 10, 2025, for expressions or indication of distress related to dementia. Review of behavior monitoring recorded on Resident 9's documentation records for the months of April, May, June, and July 2025, revealed no behaviors documented for the resident. There was no evidence of any further information to indicate the resident was in any emotional distress or having any behavioral concerns in the resident's clinical record. Clinical record review of a pharmacist consultation report for Resident 9 dated July 22, 2025, revealed a recommendation of a GDR (gradual dose reduction) for Resident 9's dose of Quetiapine. A physician response to the recommendation dated July 23, 2025, revealed the physician declined to attempt a GDR of the medication noting family refused, as the rationale as to why the GDR would not be attempted. There was no evidence to indicate a clinical contraindication was identified or documented as a rationale to not attempt the GDR. There was no evidence Resident 9's antipsychotic medications were evaluated at least quarterly with documentation regarding continued clinical appropriateness nor was there any evidence to indicate Resident 9's had a GDR attempted or a clinical contraindication documented to not attempt a GDR based upon the consultant pharmacist's recommendation provided July 22, 2025. The above information was relayed to the Nursing Home Administrator on January 29, 2026, at 11:26 AM. An interview with the Director of Nursing on January 29, 2026, at 1:18 PM confirmed that no further documentation could be found related to this concern. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation, clinical record review and staff and resident interview it is determined that the facility failed to implement treatment and services to prevent a pressure ulcer for one of five residents reviewed for pressure ulcer concerns (Resident 3).Findings include: Observation of Resident 3 in her room on January 26, 2026, at 1:06 PM revealed that she had a left elbow protector on. Concurrent interview of Resident 3 revealed that she has a sore on her arm. She indicated that she has been dealing with if for a long time although it was healed once but opened up again. She indicated the sore was on her elbow and that she was unsure how it happened. Clinical record review for Resident 3 revealed a progress note dated May 31, 2025, at 12:02 PM that indicated Resident 3 was noted to have a skin tear to her left elbow that measured 1.0-centimeter (cm) x 1.0 cm. The area was cleansed and Opti Foam (a foam dressing with a silicone face and border) was applied. Further clinical record review revealed a physician's order dated May 31, 2025, at 11:46 AM for Resident 3's left elbow to be cleansed with normal saline solution, pat dry and apply Opti Foam dressing and to change every three days and as needed for dislodgement or drainage. On June 9, 2025, the order was changed to cleanse left elbow with normal saline, pat dry, apply Opti Foam dressing every five days. The treatment to Resident 3's left elbow was documented as completed. There were no further progress notes or assessments addressing the area on Resident 3's left elbow until a skin and wound progress note was completed by Employee 7, registered nurse/wound nurse, on July 14, 2025, at 2:24 PM. The skin/wound note indicated that Employee 7 was asked to see Resident 3 related to the area on her left elbow not improving. The note indicated that staff reported an odor and drainage on the old dressing. The area now measured 2.5 x 2.5 cm x 0.3 cm. The wound nurse cleansed the area with normal saline, applied medical grade honey (a sterilized honey used in wound healing), and Max orb Silver (a highly absorbent dressing) and covered with Opti foam. The treatment was ordered to be changed daily. The note also indicated that the staff reported that Resident 3 has been noted to be leaning to the left side while in her wheelchair. A skin and wound note dated July 17, 2025, at 11:05 PM revealed that Resident 3 was seen on wound rounds by the nurse practitioner for a facility acquired stage four pressure ulcer (a severe, full-thickness wound extending through skin to expose muscle, bone, or tendons) to the left elbow. The note also indicated that the resident's arms are contracted, which applied pressure to her left elbow when sitting in her wheelchair. The elbow was debrided (removal of damaged tissue) due to unstable eschar (layer of dead tissue that forms over wounds). When the eschar was removed and the wound bed was cleaned out the bone was directly palpable. The note also indicated that the wound measured 2.5 cm x 2.4 cm x 0.8 cm and had a moderate amount of purulent drainage. The note indicated that Resident 3 should use elbow protectors to minimize pressure, friction, and shear to the bony area. Further clinical record review revealed that Resident 3 was never ordered an elbow protector until October 1, 2025. Interview with the Director of Nursing and employee 7 on January 29, 2026, at 9:00 AM confirmed the above noted findings that Resident 3's area on her left elbow was debrided and noted to be a stage four, and that there was no documentation indicating an elbow protector was ordered and put in place for Resident 3 until October 1, 2025. They also confirmed that there was no documentation on the condition of Resident 3's skin tear from May 31, 2025, until July 14, 2025, when Employee 7 was consulted because the wound was noted to be bigger in size with an odor. The facility failed to implement pressure relieving interventions to prevent a pressure area on Resident 3's left elbow. The nursing home administrator was made aware of the above noted concerns related to Resident 3's pressure ulcer on January 29, 2026, at 11:30 AM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(iv)(ix) Medical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for one of three residents reviewed for ROM concerns (Resident 3). Findings include: Clinical record review revealed the facility admitted Resident 3 on March 11, 2025. Resident 3's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 17, 2025, revealed that the resident had no impairments of her upper extremities. Review of her MDS for the dates of May 8, 2025, August 5, 2025, and September 26, 2025, revealed that Resident 3 had no impairment of her upper extremities. Review of her annual MDS dated [DATE], noted staff assessed Resident 3 as having impairment to ROM of one side of her upper extremities. Further clinical record review for Resident 3 revealed that a passive range of motion program (PROM, movement of a body part by another to maintain a resident's ability) was initiated to her bilateral upper extremities on July 24, 2025, and a splint was ordered to her left hand on October 1, 2025. Review of Resident 3's PROM program documentation for the months of November and December 2025, and January 1-26, 2026, revealed the followings dates that her PROM program was not documented as being done: November 21, 24, and 30, 2025, dayshift. December 1, 3, 5, and 6, 2025, evening shift and December 5, 9, 14, and 29, 2025, dayshift. January 6, 15, and 25, 2025, evening shift and January 2, 10, 11, 15, 16, 24, 25, and 26, 2026, dayshift. The above noted information was reviewed with the Director of Nursing on January 29, 2026, at 1:00 PM. The Nursing Home Administrator was made aware at 1:15 PM. The facility failed to ensure that Resident 3 received her ordered PROM program in order to prevent decline or maintain her range of motion. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for two of six sampled residents (Residents 24 and 33). Findings include The facility policy entitled Abuse Prohibition, last reviewed without changes on December 30, 2025, revealed bruises or injuries of unknown origin found on a resident by staff, or reported by the residents themselves will be investigated promptly in an effort to determine how the bruise or injury occurred and rule out potential abuse. Direction of the investigation into bruises or injuries of unknown origin will be determined by the Director of Nursing and Nursing Home Administrator after review and discussion of information presented. All investigative efforts will be documented providing chronology of the investigation, and a list of people working who could reasonably have knowledge of the incident. All statements of direct witnesses, the accused, and if able the resident should be legibly handwritten if possible. The facility shall collect, retain, and safeguard all material pertinent to the investigation of the alleged abuse incident. Clinical record review revealed the facility admitted Resident 33 on February 20, 2018. Nursing documentation dated December 18, 2025, at 2:13 PM revealed nurse aides observed a large bruise on Resident 33's left elbow and forearm during morning care, measuring 12.5 centimeters (cm) by 5 cm, and purple in color. Further review of Resident 33's clinical record revealed a care plan noting Resident 33 is at risk for impaired skin integrity. The facility added an intervention for derma sleeves to Resident 33's bilateral upper extremities at all times except with care on July 7, 2023. Review of the facility investigation into Resident 33's bruise revealed actions taken to prevent future occurrences were to apply Resident 33's derma sleeves as ordered and therapy to assess wheelchair positioning. There was no witness statements obtained related to Resident 33's bruise until January 29, 2026, after the surveyors questioning. The facility was also unable to provide documentation that therapy assessed Resident 33 for wheelchair positioning, or that they investigated if Resident 33's derma sleeves were in place as ordered. Clinical record review revealed the facility admitted Resident 24 on December 13, 2023. Nursing documentation dated December 17, 2025, at 5:38 AM revealed a nurse aide reported that while assisting Resident 24 in the bathroom, a discoloration of her abdomen was noticed. The nurse noted a large discoloration measuring 17 cm by 7.5 cm at the widest point, with small, scattered areas across Resident 24's abdomen. The nurse documented the area was light green and yellow, with light purple areas, showing signs of healing. Resident 24 was unable to explain how bruises happened due to her advanced dementia. Review of the facility investigation into Resident 24's bruises revealed there were no witness statements obtained until January 29, 2026, after the surveyors questioning. Interview with the Director of Nursing on January 29, 2026, at 9:45 AM confirmed these findings for Residents 33 and 24. The facility failed to thoroughly investigate Resident 33 and 24's bruises to rule out abuse or prevent further injuries. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate physician response to a pharmacy recommendation for one of five residents reviewed (Resident 19). Findings include: Clinical record review for Resident 19 revealed a consulting pharmacist report dated June 28, 2025, requesting a gradual dose reduction or a documented rationale for declining for Resident 19's Escitalopram (a medication used to treat depression) 5 mg daily. Resident 19's physician declined the recommendation on July 3, 2025, indicating that the resident's targeted symptoms returned or worsened after the most recent gradual dose reduction and that the continued use is in accordance with the current standard of practice and a gradual dose reduction attempt at this time would likely impair Resident 19's function or cause instability. Interview with the Director of Nursing on January 29, 2026, at 12:42 PM revealed that the facility was unable to provide documentation that a previous dose reduction was attempted and unsuccessful. The facility failed to ensure an appropriate physician response to Resident 19's pharmacy review as noted above. 483.45(c)(4) Pharmacy reviewPreviously cited 2/28/25 28 Pa. Code 211.9 (d)(k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure the administration of pneumococcal immunizations for two of five residents reviewed for immunization concerns (Residents 87 and 119).Findings include: The facility policy entitled, Vaccination of Residents, last reviewed December 30, 2025, revealed that all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. All new residents shall be assessed for current vaccination status upon admission. The facility policy entitled, Pneumococcal Vaccine Policy, last reviewed December 30, 2025, revealed that all residents will be offered the pneumococcal vaccine per Centers for Disease Control and Prevention (CDC) guidelines to aid in preventing infections and pneumonia. Pneumococcal vaccines include Pneumococcal Polysaccharide (Pneumovax 23, PPSV23), Pneumococcal Conjugate (Prevnar 13, PCV13), and Pneumococcal 21 (PCV21). On admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccine unless it is medically contraindicated, the resident and/or responsible party refuses the vaccine, or prior documentation of the vaccination status is provided. Administration of the vaccine will be completed in accordance with the current CDC guidelines. Current CDC guidelines available at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html include that based on shared clinical decision-making, adults 65 years or older have the option to get the PCV20 or PCV21 immunization. They can get the PCV20 or PCV21 if they have received both the PCV13 at any age and the PPSV23 at or after the age of [AGE] years old. The CDC job aide available at https://www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-pneumococcal-508.pdf meant to assist vaccine providers in discussions with older adults considering a PCV20 or PCV21 vaccination, notes that adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 and meet the following criteria: previously received one dose of PCV13 at any age, and previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age). The determination to administer a PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider. Increased risk of exposure to PCV20 or PCV21 serotypes may occur among people who are living in nursing homes or other long-term care facilities. Protection against disease from both PCV13 and PPSV23 is expected to decrease over time. Clinical record review for Resident 87 revealed that the facility admitted her on January 5, 2026. Review of Resident 87's immunization audit report revealed that she received the PPSV23 on June 4, 2013, when she was [AGE] years old. Resident 87 received the PCV13 vaccine on July 17, 2020, more than five years before her admission to the facility. Review of a Vaccination Questionnaire revealed that Resident 87's responsible party gave, permission to administer pneumococcal vaccinations per the CDC guidelines, on January 5, 2026. Resident 87 could receive either the PCV20 or PCV21 per current CDC guidelines as more than five years had elapsed since her last pneumococcal immunization. Interview with Employee 7 (registered nurse/infection preventionist) on January 29, 2026, at 11:46 AM revealed that she believed that Resident 87 received all appropriate pneumococcal vaccinations since she received the PCV13 and PPSV23 and did not identify that she should be given the option to get the PCV20 or PCV21 immunization per CDC current guidelines. Employee 7 confirmed that there is no evidence that Resident 87 was offered either the PCV20 or PCV21, or that she and her physician discussed the appropriateness of the PCV20 or PCV21 vaccines based on her previous pneumococcal immunizations and her current risks in the long-term care facility. Clinical record review for Resident 119 revealed that the facility admitted him on January 14, 2026. Review of Resident 119's immunization audit report revealed that he received the PPSV23 on October 28, 2010, when he was [AGE] years old. Resident 119 received the PCV13 vaccine on December 28, 2018, more than five years before his admission to the facility. Review of Resident 119's Vaccination Questionnaire revealed that staff obtained verbal declination of additional pneumococcal immunizations from Resident 119's daughter on January 14, 2026; due to the reason that Resident 119, .received pneumonia vaccines per CDC guidelines. Interview with Employee 7 on January 29, 2026, at 11:46 AM revealed that she believed that Resident 119 also received all appropriate pneumococcal vaccinations since he received the PCV13 and PPSV23 and did not identify that he should be given the option to get the PCV20 or PCV21 immunization per CDC current guidelines. Employee 7 confirmed that there is no evidence that Resident 119's daughter was educated that a PCV20 or PCV21 immunization may be appropriate based on current CDC guidelines, Resident 119's previous pneumococcal immunization history, and his current risks in the long-term care facility. The surveyor reviewed the above concerns regarding Resident 87 and 119's pneumococcal immunizations during an interview with the Nursing Home Administrator and the Director of Nursing on January 28, 2026, at 2:30 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures and staff interview it was determined that the facility failed to maintain documentation related to staff COVID-19 vaccination that included at a minimum that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, that staff were offered the COVID-19 vaccine, or information on obtaining COVID-19 vaccine, for one of one employee reviewed for COVID-19 vaccination (Employee 8).Findings include: The facility policy entitled, COVID-19-Covid Plan, last reviewed without changes on December 30, 2025, revealed that the facility would vaccinate residents and health care professionals (HCP) against SARS-CoV-2 (COVID-19) as part of their plan's core principles. The facility would encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. HCP should be offered resources and be counseled about the importance of receiving the COVID-19 vaccine. Interview with Employee 8 (environmental services director) on January 29, 2026, at 10:50 AM revealed that she believed that she was up to date with all her recommended COVID-19 immunizations. Employee 8 stated that it was important to her to have all available immunizations as she had medical conditions that put her at risk for infections. Employee 8 presented a COVID-19 immunization card to the surveyor that indicated that her last COVID-19 immunization was in 2022. Employee 8 stated that she received additional vaccines from Employee 7 at the facility, but her card had not been updated. Interview with Employee 7 (registered nurse/infection preventionist) on January 29, 2026, at 11:20 AM revealed that data submitted to NHSN (Centers for Disease Control and Prevention's National Healthcare Safety Network) confirmed that Employee 8 had no additional COVID-19 immunizations after October 17, 2022. Employee 7 denied administering a COVID-19 immunization to Employee 8 and that she likely administered an influenza immunization to Employee 8. Employee 7 confirmed that the facility had no evidence that Employee 8 was offered resources or was counseled about the importance of receiving ongoing COVID-19 vaccines, the risks and benefits of the vaccines, or was offered a COVID-19 immunization after October 17, 2022. Employee 7 confirmed that the facility had no process to obtain ongoing COVID-19 immunization data for staff after initial information is obtained during the hiring process to ensure accurate COVID-19 vaccine status of staff and related information is submitted to the NHSN as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to provide the highest practicable care for implanted cardiac pacemakers for two of 24 residents reviewed (Residents 115 and 7). Findings include: Clinical record review for Resident 115 revealed an active physician order dated January 15, 2026, that the resident had quarterly appointments to check her cardiac device (pacemaker, surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). The appointment scheduled for February 13, 2026, at 9:00 AM was for a, remote interrogation (remote interrogation refers to the process of wirelessly collecting data from an implanted pacemaker and transmitting it to healthcare providers. This technology enables continuous monitoring of the device's performance and the patient's heart rhythm without requiring the patient to visit the clinic physically. Pacemakers equipped with remote monitoring capabilities can communicate data via Bluetooth, cellular networks, or Wi-Fi. This data includes information about the device's function, battery status, and any detected arrhythmias.) A plan of care initiated by the facility on January 15, 2026, to address Resident 115's potential for decreased cardiac output related to a pacemaker revealed no intervention related to a [NAME] pacemaker monitoring machine. Observation of Resident 115's room on January 27, 2026, at 8:51 AM revealed no medical equipment to perform a remote cardiac pacemaker assessment. Interview with Resident 115 on January 27, 2026, at 10:24 AM confirmed that she had an internal cardiac pacemaker. Resident 115 stated that she had a [NAME] machine at her home, but was told to not bring it to the facility. Resident 115 stated that she has the [NAME] machine, next to her bed at her home and that she believes that the machine does continuous monitoring of her pacemaker. Resident 115 stated that should her pacemaker malfunction, the staff at her doctor's office would call her. Resident 115 stated that, this is her second one (pacemaker), the battery got weakened after 10 years in the other one. The surveyor requested the plan of care to address Resident 115's remote pacemaker monitoring while in the facility during an interview with the Nursing Home Administrator and the Director of Nursing on January 27, 2026, at 2:00 PM. Social services documentation dated January 27, 2026, at 5:11 PM (following the surveyor's questioning) revealed that social services staff spoke with Resident 115's responsible party regarding the [NAME] pacemaker machine. Resident 115's responsible party indicated that she would bring the device to the facility the next day.Interview with the Director of Nursing on January 28, 2026, at 11:38 AM confirmed that the facility failed to arrange for the use of Resident 115's pacemaker monitoring device before the surveyor's questioning. Interview with the Nursing Home Administrator on January 29, 2026, at 9:50 AM confirmed that Resident 115's plan of care, revised January 28, 2026, now included the use of a, [NAME] transmitter in her room, however, the plan of care was missing pertinent information (e.g., necessary distance from resident to function, method of communication such as Bluetooth or Wi-Fi connectivity, schedule of monitoring such as at hour of sleep, and applicable cardiac provider's contact information). Clinical record review revealed the facility admitted Resident 7 on February 4, 2022, with diagnoses including presence of cardiac pacemaker. A current physician order-initiated on October 3, 2022, ordered Resident 7 to receive an EKG (an electrocardiogram, a noninvasive test that records the electrical activity of the heart, to diagnosis various heart conditions) every three months for his pacemaker. Further review of Resident 7's clinical record revealed a care plan-initiated February 23, 2022, noting Resident 7 has a potential for decreased cardiac output related to his pacemaker, with an intervention for an EKG every three months. Review of documentation provided by the facility of Resident 7's EKGs revealed there was no documentation of Resident 7 receiving an EKG from April 8, 2025, to October 5, 2025 (6 months). The facility failed to provide the highest practical care to Resident 7 related to his pacemaker. Interview with the Director of Nursing on January 29, 2026, at 10:04 AM confirmed these findings. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on 3 of six nursing units (300 400, and 500 Nursing Units, Residents 14, 3, 81, and 84) and at the facility's main entrance. Findings include: Observation of the 300 Hall Nursing Unit on the following dates and times revealed the following: On February 25, 2025, at 1:31 PM there was a strong odor of urine in Resident 14's room. On February 26, 2025, at 11:27 AM and February 27, 2025, at 1:00 PM and there was an odor of urine in Resident 14's room. Observation of the main entrance to the facility on [DATE], at 1:02 PM and February 27, 2025, at 8:33 AM and 12:48 PM, revealed the following: One medical face mask was discarded on the ground and two others discarded in the landscape adjacent to the main entrance of the facility. A used tissue discarded in the planter next to the main entrance. An overflowing garbage can. Multiple cigarette butts discarded on the ground and landscape at the base of the steps leading to the parking lot in front of the main entrance. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 27, 2025, at 2:45 PM. Observation of the 400 Hall Nursing Unit on the following dates and times revealed the following: On February 26, 2025, at 10:45 AM observation of Resident 81's room revealed that the paint was peeling on the wall next to the bed, the wall next to the closet was all marred, and the frame around the closet was all marred. Observation of the 500 Hall Nursing Unit on the following dates and times revealed the following: Observation of Resident 3's room on February 26, 2025, at 9:22 AM revealed that the frame around her closet was all marred. Observation of Resident 84's room on February 26, 2025, at 10:59 AM revealed that there were rolled towels on her windowsill tight up against the windows. Concurrent interview with Resident 84 revealed that the towels were there to keep the cold air out. The Nursing Home Administrator and the Director of Nursing were made aware of the above noted concerns for Residents 3, 81, and 84, during a meeting on February 27, 2025, at 3:00 PM. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of one resident reviewed (Resident 84). Findings include: Interview with Resident 84 on February 26, 2025, at 11:24 AM she indicated that she has pain and that it is not controlled with the medication that they give her. She said her pain is in her legs and that it is worse when they move her. She indicated that she usually would ask staff for her pain medication and if it is time they will give it to her. A physician's progress note dated December 17, 2024, at 6:08 PM revealed that Resident 84 was seen by orthopedics related to her left leg contracture and they reported that her extremity is bone on bone and that she is not a surgical candidate. They recommended palliative care and pain management. The physician discontinued her Tramadol (a medication used to treat moderate to severe pain) and increased her dose of Oxycodone (a medication used to treat moderate to severe pain). A palliative care progress noted dated December 24, 2024, at 10:29 AM revealed that Resident 84 presented with pain in the left lower extremity and her right ankle. The note also indicated that Resident 84 reports pain and nursing reports that she complains of severe pain in the left lower extremity and right ankle pain. Nursing reported that Resident 84 currently takes her ordered as needed Oxycodone medication and it is effective. The note also indicated that on assessment Resident 84 states she has mild pain without movement and severe pain with movement and care. Clinical record review for Resident 84 revealed current physician orders for Tylenol (a medication used to control mild pain) 325 milligrams (mg) give two tablets every four hours as needed for a pain level of one to three, Oxycodone HCI oral tablets 5 mg give one tablet every four hours as needed for a pain level of four to six, and Oxycodone HCI oral tablets 5 mg give two tablets by mouth every four hours as needed for a pain level of seven to 10. Review of Resident 84's medication administration record (MAR) for December 2024, to February 26, 2025, revealed that she received Tylenol 325 mg two tablets for a pain level of 1-3 on December 5, 18, 28, 29, 2024, and January 4, 10, 12-14, 21, and 26, 2025. Review of Resident 84's MAR for December 2024, to February 26, 2025, revealed that she received Oxycodone 5 mg tablets one tablet every four hours as needed for a 4-6 pain level at least once daily December 19, 21-22, and 24-31, 2024, January 1-12, 14-20, and 23-31, 2025, and February 1-26, 2025. Review of Resident 84's MAR for December 2024, to February 26, 2025, revealed that she received Oxycodone 5 mg tablets two tablet every four hours as needed for 7-10 pain level at least once daily December 20, 23-26, and 28-31, 2024, January 2, 3, 5, 8-12, 15, 17, 21-23, 25-27, 29-31, 2025, and February 4-6, 8, 10, 13-16, 21, 23, and 26, 2025. Interview with the Director of Nursing on February 28, 2025, at 10:01 AM confirmed the above noted findings related to Resident 84's pain. The facility failed to ensure that Resident 84's received pain management that was consistent with professional standards of practice. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 11 residents reviewed for accident hazards (Residents 3, 9, 12, 38, 71, and 262), and review the risk and benefits of side rail utilization with the resident or resident representative, and receive consent for the use of side rails for 5 of 11 residents reviewed for accident hazards (Residents 3, 9, 12, 59, 71). Findings include: Observation of Resident 12's room on February 26, 2025, at 11:23 AM revealed that there were bilateral grab bars observed on the bed. Clinical record review for Resident 12 revealed that the facility completed an enabler bar assessment, review of potential risks, and consent on November 29, 2023. The facility completed an enabler bar entrapment evaluation on December 27, 2023, which indicated that they passed for potential entrapment for zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail, and four (between the top of the compressed mattress and the bottom of the rail at the end of the rail). There was no documentation that indicated the facility assessed zone six (between the end of the rail and the side edge of the head or foot board) for potential entrapment. On May 1, 2024, Resident 12 moved to another room and a different bed. There was no documentation that indicated the facility assessed Resident 12's new bed and grab bars for the potential risk of entrapment. Observation of Resident 9's room on February 25, 2025, at 1:50 PM and February 26, 2025, at 11:24 AM revealed that there were bilateral grab bars observed on the bed. Clinical record review for Resident 9 revealed that the facility completed an enabler bar evaluation on May 2, 2024, when she moved to a new room and a different bed that indicated they passed for potential entrapment in zones one through four. There was no documentation that indicated the facility assessed zone six (between the end of the rail and the side edge of the head or foot board) for potential entrapment. Observation of Resident 71's room on February 25, 2025, at 8:57 AM, 12:58 PM and 1:46 PM revealed that there were bilateral grab bars observed on the bed. Clinical record review for Resident 71 revealed that that was a current physician's order dated August 16, 2024, for the resident to utilize grab bars as enablers to promote independent bed mobility. Since August 16, 2024, Resident 71 had moved to a different room and a different bed three times. There was no documentation that Resident 71's bilateral side rails were assessed with each room move to ensure the grab rails were appropriate, that the resident's ability to utilize them was evaluated, or the risk of entrapment was evaluated. There was no documentation that the facility received consent from Resident 71 or their responsible party to utilize enabler bars or that the facility provided education to Resident 71 and their responsible party regarding the potential risks of utilizing enabler bars. The above information was reviewed during an interview with the Nursing Home Director and the Director of Nursing on February 27, 2025, at 2:45 PM. Observation of Resident 3 on February 25, 2025, at 1:30 PM revealed she was in a chair beside her bed. Observation revealed that her bed had bilateral grab bars on it. Concurrent interview with Resident 3 revealed that when she is in bed, she utilizes the grab bars to turn and to get in and out of bed. Clinical record review revealed that Resident 3 had a physician's order dated October 8, 2024, for bilateral grab bars to use as an enabler to promote independent bed mobility. Further clinical record review revealed a grab bar evaluation completed on October 3, 2024, that indicated the grab bars were indicated and serve as an enabler to promote independence for Resident 3. The evaluation form revealed that there was no risk for entrapment in zones one, two, three, and four as per measurements obtained by staff. The evaluation form did not include an assessment or review of zone six, which could potentially pose a risk for entrapment between the end of the grab bar device and the side of the headboard. The Director of Nursing was made aware of the above noted concerns related to Resident 3 on February 27, 2025, at 3:08 PM. Review of the census for Resident 59 revealed the resident changed rooms on October 30, 2024. Observation of Resident 59 on February 26, 2025, at 9:36 AM revealed the resident was in bed and had bilateral enabler bars attached to the bed. The Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 15, 2025, revealed that facility staff assessed Resident 59 as having a BIMS (Brief Interview for Mental Status) of 99, which indicated the resident was unable to complete the assessment interview. Current physician orders for Resident 59 dated February 12, 2025, revealed an order for grab bars to assist with independent mobility. A Plan of Care note dated February 13, 2025, at 3:41 PM revealed documentation that indicated Resident 59 recently had grab bars applied to his bed, and staff reported the grab bars had improved bed mobility. Documentation for Resident 59 titled, Grab Bar/Side Rail Evaluation, noted the resident was assessed as not capable. However, staff further assessed that the grab bars were indicated and serve as an enabler to promote independence. Further review of the documentation, Grab Bar/Side Rail Evaluation, for Resident 59 revealed consent was obtained verbally from the responsible party and dated February 27, 2025 (after the grab bars were applied to the bed). An interview with the Director of Nursing on February 27, 2025, at 12:18 PM confirmed that the risk assessment/evaluation and consent was not completed until after the grab bars were placed on Resident 59's current bed. An observation of Resident 262 on February 25, 2025, at 2:01 PM revealed the resident was in bed with bilateral enabler bars on the bed. Clinical record review for Resident 262 revealed a side rail evaluation dated February 7, 2025, assessing the need for the enabler bars to promote independence and consent by the resident for the enabler bars. Review of an entrapment zone measurement sheet for Resident 262 revealed the form was not completed until February 25, 2025, and indicated the risk of entrapment was assessed for zones 1 through zone four, but did not assess for the risk of entrapment in zone 6 as noted above. An observation of Resident 38 on February 26, 2025, at 10:30 AM revealed the resident was in bed with bilateral enabler bars on the bed. Review of an entrapment zone measurement sheet for Resident 38 indicated the risk of entrapment was assessed for zone 1 through zone four, but did not assess for the risk of entrapment in zone 6 as noted above. The concerns regarding Residents 262 and 38 not being assessed for risk in zone six were reviewed with the Nursing Home Administrator and Director of Nursing on February 27, 2025, at 3:10 PM. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure a timely physician response to consultant pharmacist recommendations for three of five residents reviewed (Residents 21, 57, and 64). Findings include: The facility policy Monthly Medication Regimen Review, last reviewed on February 11, 2025, revealed that if an identified irregularity requires urgent action, the pharmacist will immediately report the irregularity to the Director of Nursing or designee and the attending physician by phone. Review of a medication regimen review for Resident 57 dated September 26, 2024, revealed a Consultation Report, which noted the pharmacist made a recommendation of a gradual dose reduction (GDR) for the resident's Duloxetine (a medication used to treat depression, anxiety, and sometimes pain). Further review of this documentation for Resident 57 revealed that the physician had responded to the recommendation by declining it, signing, and dating the document on November 15, 2024. The documentation was also dated and signed by the Director of Nursing on November 20, 2024. Review of a medication regimen review for Resident 64 dated August 29, 2024, revealed a Consultation Report, which noted the pharmacist made a recommendation to reduce the resident's omeprazole (a medication used to treat certain stomach problems) to 20 milligrams (mg) twice a day and administer 30 to 60 minutes before food. Further review of this documentation for Resident 64 revealed that the physician had responded to the recommendation by accepting it, signing, and dating the document on October 25, 2024. The documentation was also dated and signed by the Director of Nursing on October 25, 2024. Review of a medication regimen review for Resident 64 dated October 24, 2024, revealed a Consultation Report, which noted the pharmacist made a recommendation of a GDR for the resident's Olanzapine (an antipsychotic medication). Further review of this documentation for Resident 64 revealed that the physician had responded to the recommendation by accepting it, signing, and dating the document on November 27, 2024. The documentation was also dated and signed by the Director of Nursing on December 2, 2024. The facility failed to address in their policy and procedure, for monthly medication regimen review, an appropriate time frame for physician response to a pharmacist recommendation and ensure a timely physician's response to monthly recommendations made by the pharmacist. The above information for Residents 57 and 64 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 27, 2025, at 2:45 PM. Review of a medication regimen review for Resident 21 dated September 26, 2024, revealed a Consultation Report, which noted the pharmacist made a recommendation to decrease Resident 21's Omeprazole (a medication used to treat gastroesophageal reflux disease- a digestive disorder in which the stomach acid irritates the food pipe lining) dose to 20 milligrams 30-60 minutes before food. Further review of this documentation for Resident 21 revealed that the physician had responded to the recommendation by accepting it, signing, and dating the document on November 5, 2024, one month and 10 days after the recommendation was made. The Director of Nursing was made aware of the above noted concerns related to the untimely response by the physician for Resident 21's consultant pharmacy recommendation in a meeting on February 27, 2025, at 3:10 PM. 483.45(c) Drug Regimen Review Previously cited 2/2/24 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of two residents reviewed for dental concerns (Resident 84). Findings include: Interview and observation of Resident 84 on February 26, 2025, at 11:06 AM while she was in bed revealed that she had her own teeth. Resident 84 indicated that she had not seen a dentist since she had been in the facility. Clinical record review for Resident 84 revealed that her current payment source was the state Medicaid benefit. Further clinical record review for Resident 84 revealed no evidence of her receiving dental services over the past 12 months. Interview of the Director of Nursing on February 28, 2025, at 8:00 AM revealed that there was no evidence that Resident 84 received dental care or that she was offered dental care and refused treatment. The facility failed to provide Resident 84 with routine prophylactic dental cleanings as covered under the State plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 24 residents reviewed (Resident 100). Findings include: Clinical record review for Resident 100 revealed the resident was admitted to the facility on [DATE]. Review of the resident's list of active diagnosis revealed Post Traumatic Stress Syndrome (PTSD) added on January 22, 2025. Review of an admission MDS (Minimum Data Set - an assessment completed at periodic intervals of time to assess resident care needs) dated January 28, 2025, for Resident 100 revealed the resident was listed as having a diagnosis of PTSD. Interview with Resident 100 on February 25, 2025, at 12:02 PM revealed the resident indicated hearing sirens specifically were traumatizing to him due to his history, but stated he did not have an official diagnosis of PTSD from a psychologist or medical professional. In an interview with Employee 2, social services, on February 27, 2025, at 10:30 AM, Employee 2 indicated Resident 100 did have a history of trauma with hearing sirens, which she addressed in his plan of care, but the resident did not have a diagnosis of PTSD. A social service progress note dated February 27, 2025, at 3:00 PM noted social service contacted Resident 100's medical providers and confirmed the resident did not have a diagnosis of PTSD and it would be removed from his list of diagnosis. Resident 100's clinical record inaccurately reflected that the resident had a diagnosis of PTSD. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 27, 2025, at 3:30 PM. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security for one of six nursing units (300 Hall Nursing Unit). Findings include: Observation of the 300 Hall Nursing Unit on February 25, 2025, revealed the following: At 8:48 AM, upon arrival to the 300 Hall Nursing Unit, the surveyor observed the unit's medication cart unlocked while it was near the soiled utility room. No licensed staff were observed in the vicinity. There were several unlicensed staff pushing residents in wheelchairs past the medication cart while it was unlocked. At 8:49 AM, Employee 1, licensed practical nurse, returned to the medication cart from down the hallway and out of view of the medication cart. Employee 1 left the 300 Hall Nursing Unit's medication cart while they were away from the medication cart and did not have direct visualization of the medication cart. Interview on February 25, 2025, at 9:18 AM with Employee 1 acknowledged that their medication cart was left unsecure while they were away from it. The findings were reviewed during an interview on February 26, 2025, at 9:00 AM with the Nursing Home Administrator and the Director of Nursing. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(l)(3)(e)(1) Management 28 Pa. Code 201.29 (c)(3)(4) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to administer medication to a resident based on professional standards of practice resulting in the potential for a significant medication error for one of 5 residents reviewed for administration of medications (Resident 262). Findings include: In an interview with Resident 262 on February 25, 2025, at 2:03 PM the resident indicated there was a mix up with her medications Zofran (a medication used to treat nausea and vomiting) and Ativan (a medication used to treat anxiety) from when she was at the facility the first time, and she should not have had them the second time. Clinical record review for Resident 262 revealed the resident was admitted to the facility on [DATE], and sent to the hospital after a change in condition on January 26, 2025. A progress note for Resident 262 dated January 27, 2025, at 12:39 PM noted facility staff met with a family member of the resident who was in the facility collecting the resident's personal belongings who indicated they had chosen to not hold the resident's bed at the facility and did not know how long the resident would be in the hospital. A review of Resident 262's medication orders prior to her transfer to the hospital on January 26, 2025, revealed the resident was ordered Lorazepam (Ativan) as needed for anxiety on January 24, 2025, and Zofran as needed for nausea on January 24, 2025, and both medications were discontinued from the orders on January 29, 2025, when the resident was not in the facility. Resident 262 was readmitted to the facility on [DATE], with several new diagnosis including Torsades de Pointes (a life-threatening heart rhythm disorder, which is noted to be caused by prolonged QT intervals, the time between the Q wave and the T wave of lower heart function) and medication orders. Resident 262's medication orders upon readmission from the hospital did not include Lorazepam (Ativan) or Zofran. A review of a controlled medication utilization record for Resident 262 for Lorazepam, revealed the sheet indicated the medication was received on January 25, 2025 (after the medication was ordered as noted above on January 24, 2025, during the resident's first admission to the facility). Documentation on the controlled medication record revealed a staff member documented the resident was administered a dose of the medication on February 9, 2025, at 7:53 PM. There was no documentation or evidence to indicate the resident was having anxiety at the time or before the administration of the Lorazepam on February 9, 2025, that the resident's physician was contacted due to the resident having anxiety, or that that resident had a physician's order to administer Lorazepam on February 9, 2025, as it was not ordered upon the resident's readmission to the facility. There was also no evidence on Resident's 262's medication administration record of the drug being administered, only the controlled medication sheet. Further clinical record review for Resident 262 revealed a late entry progress note dated February 12, 2025, at 6:52 PM for February 10, 2025, at 9:48 AM that noted during the morning medication pass the resident complained of not feeling well and was nauseous with ginger ale being given without helping. It was noted the on-call provider was called and a new order for a one-time dose of Zofran was obtained. The note indicated it was given and effective. There was no evidence in Resident 262's clinical record of a physician's order for the Zofran as noted above, or any documentation on the resident's medication administration record that the drug was administered as noted. A review of the Food and Drug Administration's (FDA) label for Zofran, revealed a drug label warning for QT interval prolongation and Torsade de Pointes to avoid in patients with congenital long QT syndrome, cardiac failure or arrhythmias. There was no evidence this warning was reviewed prior to the drug being administered as noted above on February 10, 2025. In an interview with the Director of Nursing (DON) on February 28, 2025, at 1:40 PM the DON indicated the above information was identified by the facility as a resident concern. They confirmed the Lorazepam was administered without a physician's order on February 9, 2025, and the medication card for Resident 262 remained in the facility accessible to staff even after the drug was discontinued on January 29, 2025, when the resident was hospitalized . It was confirmed the Lorazepam dose on February 9, 2025, was not noted as administered on the resident's medication administration record and only on the controlled substance sheet. In the same interview, the DON confirmed there was no evidence of a verbal/written physician's order to administer Zofran to Resident 262 on February 10, 2025, and there was no documentation on the resident's medication administration record to indicate the drug was administered. There was no evidence the staff member or provider if contacted, acknowledged or addressed the FDA warning regarding the resident's diagnosis of Torsades de Pointes and the Zofran before it was administered on February 10, 2025. Resident 262 did not exhibit an adverse reaction to the administration of the above medications. The facility provided evidence of counseling to the nurse who administered the Lorazepam without and order, and who did not document on the medication administration record that the drug was administered. Counseling was provided to the nurse who did not enter a physician's order for the resident to receive Zofran and document on the medication administration record that it was administered. The facility provided evidence of staff education regarding verbal orders to licensed staff although all staff were not yet educated at the time of review. There was no evidence of staff education regarding the disposition of resident medications upon discontinuation of a medication as the medication card containing Lorazepam remained available in the facility for Resident 262 on February 9, 2025, after the drug was discontinued on January 29, 2025. The above findings were reviewed with the Nursing Home Administrator on February 28, 2025, at 2:45 PM. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.9 (a)(1), (d), (j.1)(1)(3)(4)(5) Pharmacy services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to store oxygen and respiratory care equipment consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 28 and 74). Findings include: Observation of Resident 28 on February 25, 2025, at 2:43 PM revealed a nebulizer machine (a small machine that turns liquid medicine into a mist that can be easily inhaled) sitting on the resident's stand beside her bed. A mouthpiece connected to the tubing coming from the machine was observed hanging down in front of the stand uncovered. Resident 28 indicated they received nebulizer treatments two or three times a day. An observation of Resident 28 on February 26, 2025, at 9:25 AM revealed the nebulizer machine again sitting on the resident's stand beside her bed with the mouthpiece hanging down in front of the stand uncovered. Clinical record review for Resident 28 revealed the resident was ordered Ipratropium-Albuterol Solution (a liquid) to inhale by mouth using a nebulizer every four hours as needed for shortness of breath on January 30, 2025. A review of Resident 28's medication administration record for February 2025, revealed the resident had not been administered the solution via the nebulizer since it was last administered on February 22, 2025. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 26, 2025, at 3:35 PM Observation of Resident 74's room on February 25, 2025, at 11:45 AM revealed he was in bed with supplemental oxygen on. His oxygen source was a free-standing oxygen cylinder tank. The tank was not in a stand or secured. The Nursing Home Administrator was made aware of Resident 74's oxygen tank and the safety concerns at 12:05 PM on February 25, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to assess and implement interventions to maintain a resident's continence status for one of four residents reviewed (Resident 9). Findings include: The MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) Resident Assessment Indicators (RAI) 3.0 Manual, Section H indicated that each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. Clinical record review for Resident 9 revealed that since July 3, 2024, Resident 1 had a physician's order to transfer and ambulate with use of a gait belt, a rolling walker, and one staff assistance. The facility completed an annual MDS assessment on January 24, 2025. The facility identified that Resident 9 was moderately impaired, with a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; 8-12 indicates moderately impaired) of 10, was frequently incontinent of bowel and bladder, and not on a toileting plan. Review of Resident 9's task interventions (an action intended to improve the resident's health and comfort) revealed that the facility placed them on a check and change toileting program since April 16, 2024, and a restorative ambulation program since October 17, 2024. Further review of January 8, 2025, through January 14, 2025, (the annual MDS lookback/review period) revealed that Resident 9 was incontinent of bowel 3 times, continent of bowel five times, incontinent of urine 10 times, continent of urine 13 times, and actively participated in the restorative ambulation program during six of the seven day and evening shifts reviewed. Resident 9 ambulated between five and 160 feet during this time period. Review of Resident 9's nursing documentation revealed the following: On January 24, 2025, at 2:52 PM staff documented that Resident 9 remained frequently incontinent of bowel and bladder. Staff report Resident 9 does have continent episodes at times and will assist them to the toilet per her request, however, was usually always incontinent even when the resident voided. The facility will continue a check and change toileting program to ensure the resident was kept clean, dry, and odor free. Resident 9 was on a resident nursing program for ambulation and was able to meet, at times exceed, her ambulation distance goal with no changes at that time. On January 28, 2025, at 10:47 PM staff documented that Resident 9 was alert, verbal, and able to make needs known. They ambulate with a rolling walker, a gait belt, and assist of one staff member and needed one staff to assist with activities of daily living, bed mobility, and toileting. Staff noted that Resident 9 had mixed incontinence of bladder and was continent of bowel. There was no documentation that staff identified Resident 9's potential to increase and/or maintain bowel and/or bladder continence, completed a bowel and bladder tracker, and assessed Resident 9 for either a prompted or scheduled toileting program after the January 2025, annual MDS assessment. The above information was reviewed with the Director of Nursing on February 7, 2025, at 1:23 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records and select facility policies and staff interview, it was determined that the facility failed to provide the necessary care and services to prevent deterioration and infection of a surgical wound for one of 5 residents reviewed (Resident CR1). Findings include: The facility's policy entitled, Skin Care Policy, last reviewed July 6, 2016, revealed that physician's orders [REDACTED]. Clinical record review revealed that the facility admitted Resident CR1 on September 2, 2016, after a right femoral to left femoral artery bypass (the femoral artery is the largest artery in the thigh. It supplies oxygen-rich blood to the leg. The blockage is due to plaque buildup or [MEDICAL CONDITION]. [MEDICAL CONDITION] in the leg arteries causes [MEDICAL CONDITION]. The same process causes [MEDICAL CONDITION] and stroke). Review of the hospital discharge summary dated September 2, 2016, revealed that Resident CR1 had orders for the resident's left groin wound to be cleaned with Sure-Cleanse (a wound cleanser) and [MEDICATION NAME] (a topical antiseptic solution for the treatment and prevention of infection in wounds) and covered with [MEDICATION NAME] (a non-adherent dressing), and a wound VAC (Vacuum Assisted Closure - a negative-pressure wound therapy - a technique using a vacuum dressing to promote healing in acute or chronic wounds) was applied to the right groin wound. Review of the facility's admission assessment of Resident CR1 dated September 2, 2016, revealed that the facility performed a full body assessment of the resident and noted awareness of Resident CR1's wounds to his right and left groin. Review of the Admission physician's orders [REDACTED]. Review of the Resident CR1's Treatment Administration Record dated September 2016, revealed that the facility did not change the dressing on Resident CR1's left groin, or provide any treatment to this surgical wound, from September 2, 2016 to September 12, 2016, when the resident went for a follow up evaluation appointment with the vascular surgeon (a surgical subspecialty involving diseases of the vascular system, or arteries and veins). Review of the vascular surgeon's consultation report dated September 12, 2016, revealed that Resident CR1 had bilateral (both sides) wound infections in the groin. The vascular surgeon noted that the resident's groin was really red, hot, beefy (bright red in color), warm and there was foul smelling drainage emanating from the area. The surgeon immediately admitted Resident CR1 to the hospital and ordered an Infectious Disease (a subspecialty of internal medicine that focuses on diagnosing and managing infections) consult, that resulted in the plan for surgical drainage of the resident's wound that was completed on September 13, 2016. Review of the operative reports revealed that Resident CR1 underwent three surgical procedures for debridement (removal of damaged tissue) of both the right and left infected groin wounds on September 13, September 16, and September 19, 2016. An interview with the Director of Nursing (DON) on October 19, 2016, at 2:50 PM confirmed these findings regarding Resident CR1. The DON stated that the facility was aware of the dressing on Resident CR1's left groin upon admission, but had not requested a physician's orders [REDACTED]. 483.25 Quality of Care Previously cited deficiency 7/13/16 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 7/13/16 28 Pa. Code 211.12(a)(d)(3) Nursing services. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services. Previously cited 7/13/16