Every finding on record at Windber Woods Senior Living & Rehabilitation CTR

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include:A facility policy for food storage dated December 18, 2025, revealed that food would be stored closed to open air and that no employee food or drinks would be stored in pantry refrigerators. Observations of the walk in cooler on February 24 ,2026 at 9:09 a.m. revealed a half of a box of dinner rolls and a full box of dough balls open to air. Observations in the prep refrigerator in the kitchen revealed an employee fountain drink that was half full. Observations of the refrigerator in the medication room on Spruce on February 27, 2026, at 8:45 a.m. revealed a cup of [NAME] coffee, a sandwich, two containers of yogurt and an Oikos yogurt drink belonging to an employee. Interview with the Dietary Director on February 24, 2026, at 9:12 a.m. indicated that food should be stored closed to air and employee food should never be stored in the prep refrigerator. Interview with the Assistant Director of Nursing on February 27, 2026, at 9:08 a.m. confirmed that no food should be stored in the medication refrigerator in the medication room and that there is a separate refrigerator. 28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 207.4 Ice Containers and Storage.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 33 residents reviewed (Residents 10, 13, 14, 92).Findings include:The facility's policy regarding psychotropic medication use, dated December 18, 2025, indicated that non-pharmacological approaches (intervention intended to improve the health or well-being of individuals that do not involve the use of drugs or medicine) are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.A significant change Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 10 dated January 26, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included dementia and depression.Physician's orders for Resident 10 dated January 21, 2026, included an order for the resident to receive 50 milligrams (mg) of Trazadone (an antidepressant medication) every eight hours as needed for anxiety and agitation.Review of the Medication Administration Record (MAR) for Resident 10 dated February 2026 revealed that 50 mg of Trazodone was administered to the resident on February 1 at 8:29 a.m.; on February 2 at 7:22 a.m.; on February 4 at 9:53 a.m.; on February 6 at 9:58 a.m.; on February 7 at 8:35 a.m.; on February 7 at 10:09 p.m.; on February 9 at 8:40 a.m.; on February 10 at 8:29 a.m.; on February 11 at 7:28 a.m.; on February 12 at 7:18 a.m.; on February 13 at 7:40 a.m.; on February 14 at 7:33 a.m.; on February 15 at 7:06 a.m.; on February 16 at 7:53 a.m.; on February 17 at 7:46 a.m.; on February 18 at 7:22 a.m.; on February 19 at 7:55 a.m.; on February 20 at 9:17 a.m.; on February 24 at 9:38 a.m.; on February 25 at 8:01 a.m.; and on February 26 at 8:38 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Tramadol on these dates and times.Interview with the Nursing Home Administrator on February 27, 2026, at 12:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Tramadol to Resident 10 on the above-mentioned dates and times and there should have been. She also confirmed that there was no duration included in the physician's order on January 21, 2026, and no documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Tramadol for Resident 10 beyond 14 days.An admission MDS assessment for Resident 13 dated December 16, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included dementia and depressionPhysician's orders for Resident 13 dated January 28, 2026, included an order for the resident to receive 0.25 milligrams (mg) of Xanax (an antianxiety medication) every twelve hours as needed for anxiety and agitation for fourteen days.Review of the Medication Administration Record (MAR) for Resident 13 dated January and February 2026 revealed that 0.25 mg of Xanax was administered to the resident on January 28 at 7:49 a.m.; on January 29 at 6:45 p.m.; on January 30 at 7:15 p.m.; on February 1 at 8:29 a.m.; on February 1 at 9:13 p.m.; on February 3 at 8:35 a.m.; on February 4 at 8:29 a.m.; on February 4 at 8:32 p.m.; on February 5 at 9:05 a.m.; on February 7 at 7:00 p.m.; on February 9 at 8:24 a.m.; and on February 10 at 8:14 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Xanax on these dates and times.Interview with the Nursing Home Administrator on February 27, 2026, at 12:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Xanax to Resident 13 on the above-mentioned dates and times and there should have been.A quarterly MD assessment for Resident 14 dated January 26, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs.Physician's orders for Resident 14 dated June 7, 2026, included an order for the resident to receive 0.5 mg of Ativan (an antianxiety medication) every eight hours as needed for anxiety and behaviors.Review of the MAR for Resident 14 dated June 2025 revealed that 0.5mg of Ativan was administered to the resident on June 9 at 4:24 p.m., June 10 at 3:30 p.m., June 11 at 6:21 p.m., and June 12 art 7:32 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times.Interview with the Nursing Home Administrator on February 24, 2026, at 2:45 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Ativan to Resident 14 on the above-mentioned dates and times and there should have been.A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the resident was cognitively impaired, had no behavioral symptoms, received psychotropic medications including antianxiety medications, and had diagnosis that included anxiety and depression. Physician's orders for Resident 92, dated November 21, 2025, December 8, 2025, January 2, 2026, January 19, 2026, and February 11, 2026, included orders for the resident to receive 1 mg of Ativan (an antianxiety medication) every six hours as needed for anxiety and agitation for fourteen days. Review of the MAR for Resident 92, dated December 2025, through February 2026, revealed that 1 mg of Ativan was administered to the resident on December 1 at 3:22 p.m.; December 3 at 9:53 a.m. and 5:46 p.m.; December 4 at 9:00 a.m. and 4:50 p.m.; December 5 at 2:03 a.m.; December 8 at 7:03 p.m.; December 11 at 12:34 p.m. and 10:43 p.m.; December 14 at 5:43 p.m.; December 15 at 5:41 p.m.; December 20 at 5:53 p.m.; January 2 at 7:21 p.m.; January 3 at 5:48 p.m.; January 5 at 3:33 p.m.; January 9 at 2:10 a.m. and 5:54 p.m.; January 11 at 6:08 p.m.; January 14 at 4:58 p.m.; January 19 at 7:27 p.m.; January 24 at 9:56 a.m.; January 26 at 4:51 p.m.; January 28 at 3:24 p.m.; January 29 at 3:28 a.m.; and February 12 at 10:07 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times. Interview with the Nursing Home Administrator on February 26, 2026, at 4:33 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering as needed Ativan to Resident 92 on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation of a bruise to rule out neglect and/or abuse for one of 33 residents reviewed (Resident 61). Findings include: The facility's policy for abuse prohibition, dated December 18, 2025, indicated that the facility will have procedures in place to identify suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse. This information may be obtained through or risk management reporting policy currently in place. The facility's policy for risk management reporting, dated December 18, 2025, indicated that all injuries/incidents are required to be reported through risk management in the electronic medical record. This includes abrasions, bruises, skin tears, falls, elopement, and acts of aggression toward other residents. The risk management report is the actual investigation into the cause of the injury or incident and to rule out abuse. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed). A nurse's note for Resident 61 dated February 13, 2026, revealed that the resident was given a shower, and the nurse aide noticed a bruise on his right knee. There was no documented evidence that an investigation was initiated to identify the cause of the bruise or to rule out abuse. Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that she was unable to find an incident report or investigation for Resident 61's bruise that occurred on February 13, 2026. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 27, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 27, 2026, identified repeated deficiencies related to failure to correct deficient practices related to care plan revision, quality of care, services to prevent/heal pressure ulcers, safe environment that is free of accident hazards, laboratory services, complete and accurate accounting of controlled medications and infection control. The facility's plan of correction for a deficiency regarding a failure to revise residents' care plans, cited during the survey ending March 27, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan revisions. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding services to prevent/heal pressure ulcers. The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. The facility's plans of correction for deficiencies regarding laboratory services, cited during the survey ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F773, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding laboratory services. The facility's plan of correction for a deficiency regarding complete and accurate accounting of controlled medications, cited during the survey ending March 27, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding complete and accurate accounting of controlled medications. The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending March 27, 2025, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding infection control. Refer to F657, F684, F686, F689, F773, F755, F880 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 33 residents reviewed (Resident 3). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 17, 2026, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had medical diagnosis that included stroke, hemiplegia and dementia. Care plan for Resident 3 dated August 5, 2025, indicated that the resident has the potential for pressure ulcer development and required extensive-total assist with bed mobility. An intervention dated January 23, 2026, indicated that the resident was to have B Prevalon boots ( medical devices designed to prevent heel pressure injuries in non-ambulatory, bedridden patients) on all times when in bed, and her skin integrity checked with application and removal.Physician's orders for Resident 3, dated January 22, 2026, included an order for the resident to have B Prevalon boots on all times when in bed. Check skin integrity with application and removal.Observations of Resident 3 on February 24, 2026, at 11:00 a.m. and on February 26, 2026, at 10:15 a.m. revealed the resident lying in bed without the presence of B Prevalon boots. Interview with Nurse Aide 2 on February 26, 2026, at 10:15 a.m. revealed that Resident 3 did not have B Prevalon boots in place, and that she did not have any B prevalon boots available in her room to put in place as ordered. Interview with the Nursing Home Administrator on February 26, 2026, at 12:49 p.m. revealed that B prevalon boots were not added to Resident 3's task list to alert nurse aides to apply them, they should have been available in her room, and there was no documented evidence that they were being applied as ordered. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of guidance from the Centers for Disease Control (CDC - the national health protection agency) and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile (C-diff-a bacteria that can cause severe diarrhea and inflammation of the colon) infection for one of 33 residents reviewed (Resident 11). Findings include: The Facility's policy regarding isolation and transmission-based precautions dated December 18, 2025, indicated that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Residents with diarrhea and suspected clostridium difficile will be placed on contact precautions while awaiting laboratory results.A quarterly Minimum Data Set (MDS) assessment (required assessment of a resident's abilities and care needs) for Resident 11, dated February 10, 2026, revealed that the resident was cognitively impaired, was always incontinent of bowel, required assistance for staff with daily care needs, and had diagnosis that included high blood pressure and a stroke. A nurses note dated February 23, 2026, at 2:43 p.m. stated that Resident 11 had tested positive for clostridium difficile.A laboratory test dated February 23, 2026, revealed that Resident 11 was positive for clostridium difficile.Observations on February 25, 2026, at 9:54 a.m. revealed that Resident 11 was lying in his bed and did not have contact isolation signs on his door.Interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:54 a.m. confirmed that Resident 11 did not have contact isolation on door and he should have.Interview with the Nursing Home Administrator on February 25, 2026, at 10:48 a.m. confirmed that Resident 11 did not have contact isolation signs on door and that he should have had them. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for two of 33 residents reviewed (Resident 61 and 95). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed). A nurse's note for Resident 61 dated February 13, 2026, revealed that the resident was given a shower, and the nurse aide noticed a bruise on his right knee. There was no documented evidence that registered nurse assessment of the bruise was completed. Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented evidence that a registered nurse assessment was completed for the bruise that was identified on Resident 61's right knee on February 13, 2026. A quarterly MDS assessment for Resident 95 dated January 17, 2026, indicated that the resident had severe cognitive impairment, was dependent on staff for most daily care needs, and had diagnosis that included dementia.Physician's orders for Resident 95 dated January 25, 2026, included for the resident to have he left shin wound cleansed with wound cleanser, dry with gauze, apply a small amount of bacitracin, cover with nonadherent dressing, and secure with kerlix and tape every day. A nurse's note for Resident 95 dated January 25, 2026, indicated that the resident had an old bruise/blood collection that opened on her left shin area. As of February 26, 2026, there was no documented evidence of any further assessments of the resident's change in skin condition to her left shin that was identified on January 25, 2026. An interview with the Director of Nursing on February 27, 2026, at 3:13 p.m. revealed Resident 95 had a previous blood blister that opened on her left shin, and that there was no documented evidence of any assessments of the change in skin condition since it was identified on January 25, 2026, and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

.Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for five of 33 residents reviewed (Residents 1, 5, 68, 92, 97). Findings include: A facility policy for Comprehensive Care Planning, dated December 18, 2025, indicated that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received oxygen therapy and had diagnoses that included respiratory failure, congestive heart failure and pneumonia. A care plan for the resident, dated November 16, 2025, indicated that the resident had pneumonia. There was no documented evidence in the resident's clinical record that indicated the resident had an active diagnosis of pneumonia. Interview with the Assistant Director of Nursing on February 26, 2026, at 10:48 a.m. confirmed that Resident 1 did not have an active diagnosis of pneumonia and was not currently being treated for it, and that the care plan should have been resolved.An admission MDS assessment for Resident 5, dated January 30, 2026, indicated that the resident had cognitive impairment, required assistance with daily care needs, and had diagnoses that included cognitive communication deficit. A care plan dated January 24, 2026, revealed that Resident 5 had an indwelling catheter.A nurse's note for Resident 5, dated February 7, 2026, at 11:59 a.m. indicated that the resident was incontinent of a large amount of urine this morning since her indwelling urinary catheter (a tube inserted in the bladder) was discontinued.An interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an indwelling catheter.Interview with the Administrator on February 25, 2026, at 10:25 a.m. confirmed that Resident 5 did not have an indwelling catheter and her care plan should have been revised to reflect that. A quarterly MDS assessment for Resident 68, dated February 13, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of cancer. A nursing note for Resident 68, dated September 10, 2025, at 12:35 a.m. revealed that the resident returned from the hospital on September 9, 2025, and had a dry dressing to her port site from her mediport (a small medical device surgically implanted under the skin, usually in the chest, providing long-term, easy access to a vein for chemotherapy, medication, fluids, or blood draws) being de-accessed (removing the specialized needle from the port device under your skin). A care plan for the resident, dated April 21, 2025, indicated that she had a mediport to her right chest and was receiving Heparin flushes and saline flushes intravenously to her accessed mediport every evening shift, and that staff may access her mediport for blood draws one time a day every seven days and as needed. There was no documented evidence that the resident had orders to flush her mediport. Interview with the Assistant Director of Nursing on February 26, 2026, at 11:28 a.m., revealed that Resident 68 does not currently have orders to flush her mediport due to it being de-accessed and that they do not do anything with her port at this time. She also revealed that currently, they do not draw labs from the mediport and confirmed that the care plan should have been revised to reflect that they were not flushing the mediport. Interview with the Nursing Home Administrator on February 27, 2026, at 10:15 a.m. revealed that Resident 68 has her blood draws at the cancer center and if they use her mediport, they do the flushes there. She indicated that if she did not get the flushes at the cancer center, they would flush them every 30 days to keep the port open, but since the cancer center flushes it so frequently, they no longer do the flushes at the facility. She confirmed that the care plan should have been revised to reflect that they no longer do the flushes to her mediport. A quarterly MDS assessment for Resident 92, dated November 19, 2025, indicated that the resident was cognitively impaired, had no behavioral symptoms, received psychotropic medications including antianxiety medications, and had diagnoses that included anxiety and depression. A care plan for the resident, dated February 1, 2026, indicated that the resident was receiving Ativan (an antianxiety medication); however, there was no documented evidence in the resident's clinical record that she was ordered Ativan. Interview with the Director of Nursing on February 26, 2026, at 3:46 p.m. confirmed that Resident 92's care plan should have been revised to reflect that the Ativan was discontinued. A quarterly MDS assessment for Resident 97, dated January 9, 2026, revealed that the resident was cognitively intact and was moderately dependent on staff for daily care needs. The current care plan for Resident 97 indicated that she had actual skin impairment from necrotizing fasciitis (a bacteria that destroys skin and soft tissue) and surgical wounds on her back. There was no documented evidence in the resident's clinical record that indicated the resident had an active diagnosis of necrotizing fasciitis or surgical back wounds. Interview with the Nursing Home Administrator on February 26, 2026, at 12:47 p.m. confirmed that Resident 97 was not currently receiving treatment for necrotizing fasciitis and surgical wounds and the care plan should have been resolved.28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders and clarify physician's orders for four of 33 residents reviewed (Resident 2, 5, 8, 68). Findings include: An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated December 10, 2025, revealed that the resident was cognitively impaired, requires assistance from staff for daily care needs, and had medical diagnosis that included dementia.A Pharmacist recommendation review dated January 16, 2026, revealed that the pharmacist recommendation was to change Resident 2's multivitamin to a multivitamin-M and discontinue vitamin B12, vitamin D, magnesium oxide and folic acid. On January 30, 2026, the physician agreed to the pharmacist recommendation.A review of Resident 2's January 2026 and February 2026 Medication Administration record revealed that the multivitamin was not changed to multivitamin M and that Vitamin B12, Vitamin D, Magnesium oxide, and folic acid were administered to the resident.Interview with the Director of Nursing on February 26, 2025, at 12:55 p.m. confirmed that there was no documented evidence that Resident 2's multivitamin was changed to multivitamin M and that Vitamin B12, Vitamin D, Magnesium oxide, and folic acid were discontinued per pharmacy recommendations.An admission MDS assessment for Resident 5, dated January 30, 2026, indicated that the resident had cognitive impairment, required assistance with daily care needs, and had diagnosis that included cognitive communication deficit.A nurse's note dated February 7, 2026, at 11:59 a.m. revealed Resident 5 had a large amount incontinent urine this morning since her indwelling catheter (a tube inserted in the bladder) was discontinued.An interview with Licensed Practical Nurse 1 on February 25, 2026, at 9:52 a.m. confirmed that Resident 5 did not have an indwelling catheter.Physician's orders for Resident 5 dated January 23, 2026, included an order to change foley catheter as needed for leakage or blockage. An interview with the Nursing Home Administrator on February 25, 2026, at 10:25 a.m. confirmed that Resident 5 does not have an indwelling catheter and that the physician's order to change foley catheter for blockage and leakage as needed should have been discontinued. A quarterly MDS assessment for Resident 8, dated December 23, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of hypertension (high blood pressure).Physician's orders for Resident 8, dated May 4, 2025, indicated that the resident was to receive 25mg carvedilol (a medication to treat high blood pressure) and to hold the medication if her pulse was less than 60 beats per minute (bpm) or her systolic blood pressure (the top number of the blood pressure) was less than 100.Review of resident 8's Medical Administration Records (MAR) for January and February 2026 revealed that she received 25mg Carvedilol on January 10 with a pulse of 58 bpm, January 19 with a pulse of 58bpm, January 23 with a pulse of 56, January 30 with a pulse of 50, and February 8 with a pulse of 58. Interview with the Director of Nursing on February 25, 2026, at 3:10 p.m. confirmed that Resident 8's carvedilol should have been administered on the above times and dates and should have been held according to the parameters on the physician's orders.A quarterly MDS assessment for Resident 68, dated February 13, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, received an anticoagulant medication (medication that thins the blood) and had a diagnosis of cancer. A nursing note for Resident 68, dated February 2, 2026, at 7:48 a.m. revealed that the resident was seen by the physician and orders were obtained to hold her Eliquis (an anticoagulant medication) three days prior to her upcoming breast biopsy. A physician's order for Resident 68, dated February 3, 2026, indicated that staff was to hold her Eliquis three days prior to her breast biopsy. A nursing note for Resident 68, dated February 3, 2026, at 3:33 p.m. revealed that the resident's biopsy was scheduled for February 18, 2026, at 10:00 a.m. Review of resident 68's clinical records revealed that she was hospitalized on [DATE], and returned to the facility on February 11, 2026. There was no documented evidence that the facility clarified the order to hold the Eliquis three days prior to her biopsy when she returned from the hospital. A nursing note for Resident 68, dated February 17, 2026, at 10:21 a.m. revealed that the facility received a phone call from the Breast Care Center regarding holding the resident's Eliquis three days prior to her appointment and the Eliquis was given. Her biopsy was rescheduled for March 4, 2026. Interview with the Nursing Home Administrator on February 25, 2026, at 1:37 p.m. confirmed that Resident 68's Eliquis should have been clarified when she returned from the hospital to hold it prior to her biopsy and it was not, resulting in her biopsy having to be rescheduled. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 33 residents reviewed (Resident 14)Findings include: The facility's policy regarding falls, dated December 18, 2025, indicated that residents identified as fall risks will have interventions in place to prevent further falls. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14 dated February 27, 2026, indicated that the resident was cognitively impaired, and required assistance for daily care. Resident 8's current care plan, indicated that the resident was at risk for falls. Fall interventions included keeping her personal belongings within reach, and that she would have a reacher tool (used to grab objects that are beyond your reach). Observations of Resident 14 on February 24, 2026, at 10:45 a.m. revealed that the resident was in her wheelchair and did not have her reacher available in her room. Observations on February 26, 2025, at 1:15p.m. revealed that the resident was in her wheelchair in her bedroom reaching for items on her stand and did not have her reacher available to her. Interview with Nurse Aide 3 on February 26, 2026, at 1:16 p.m. confirmed that Resident 14's reacher was not in her room and was missing. Interview with the Nursing Home Administrator and Director of Therapy on February 26, 2026 at 2:52 p.m. confirmed that Resident 14's reacher tool should have been available to her. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for one of 33 residents reviewed (Resident 1). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received oxygen therapy and had diagnoses that included respiratory failure, congestive heart failure and pneumonia. Physician's orders for Resident 1, dated November 13, 2025, included orders for the resident to receive oxygen at a flow rate of 1-5 liters per minute (LPM) via nasal cannula (a small tube that delivers oxygen through the nasal passages) to keep her pulse oximetry (measures blood oxygen levels) greater than 90 percent. May titrate as needed for pulse oximetry less than 90 percent and/or shortness of breath. Observations of Resident 1on February 24, 2026, at 10:42 a.m., February 25, 2026, at 12:44 p.m. and February 26, 2026, at 8:45 a.m. revealed that the resident was lying in bed with oxygen being supplied via nasal cannula at a flow rate of 3 LPM. There was no documented evidence in the resident's clinical record that the facility was documenting her use of oxygen and that they were checking her pulse oximeter to ensure she was getting the appropriate liter flow. Interview with the Assistant Director of Nursing on February 26, 2026, at 10:48 a.m. confirmed that there was no documented evidence in Resident 1's clinical record that the facility was documenting her use of oxygen and that they were checking her pulse oximeter to ensure she was getting the appropriate liter flow. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to follow facility policy for the care and monitoring of residents receiving dialysis for one of 33 residents reviewed (Resident 61). Findings include:Review of the facility's dialysis policy, dated December 18, 2025, revealed that when a resident is requiring dialysis an order will be written for the dialysis, place of treatment, port check every shift and as needed, medications to be held prior to dialysis, and any specific orders from dialysis including dietary restrictions, fluid restrictions and intake and output and laboratory studies. The Licensed Practical Nurse/Registered Nurse will monitor the dialysis port or catheter every shift and as needed. The nurse will report any bleeding, redness, inflammation, drainage or catheter dysfunction. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 17, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had a diagnosis of ends stage renal disease and was receiving dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys have failed). Care plan for Resident 61 dated February 11, 2026, indicated that the resident had end stage renal failure and required hemodialysis, and staff were to monitor his fistula (a surgically created connection between an artery and a vein designed to provide long-term access for hemodialysis) and watch for signs or symptoms of infection and monitor the bruit and thrill (the audible whooshing and palpable buzzing sensations felt over a functioning hemodialysis fistula or graft, confirming adequate blood flow) as per orders. Review of Resident 61's clinical records that included medication and treatment administration records dated February 2026, revealed no documented evidence that the resident had orders for dialysis that included when and where it was scheduled, and there was no documented evidence that staff were monitoring the resident's dialysis fistula site.Interview with the Nursing Home Administrator on February 26, 2026, at 12:00 p.m. confirmed that there was no documented evidence that the resident's clinical record included orders for dialysis treatments, or that the resident's fistula was being monitored per the resident's care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 12). Findings include: The facility's policy regarding medication administration, dated December 18, 2025, indicated that documentation of narcotic administration will be done in accordance with applicable law including documenting necessary medication administration treatment information on appropriate forms, and removal of fentanyl patches (a narcotic medication) will require two signatures to ensure proper disposal of the patch. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 12, dated January 8, 2026, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included Parkinson's (a progressive neurological disease that affects movement). Physician's orders for Resident 12 dated October 27, 2025, included an order for the resident to receive one 25 microgram (mcg) per hour fentanyl transdermal (through the skin) patch, applied every 72 hours for pain management and to remove per schedule. Review of the controlled drug record (tracks each dose of a controlled medication) and Medication Administration Record (MAR) for Resident 12 for December, 2025 and January, 2026, revealed that there were not two signatures for the removal and disposal of the 25 mcg/hour fentanyl patch for December 26, 2025 and January 5, 8, 11, and 14, 2026. Interview with the Director of Nursing on February 26, 2026, at 12:53 p.m. confirmed that there was not two signatures for the removal and disposal of the fentanyl patches for Resident 12 on the above dates. Current physician's orders for Resident 12 included an order for the resident to receive one 37.5mcg/hour fentanyl transdermal patch applied every 72 hours and to remove the patch per schedule. Review of the controlled drug record for Resident 12 revealed that a 37.5mcg/hr fentanyl transdermal patch was signed out on February 23, 2026, however a review of Resident 12's MAR for February, 2026 revealed no documented evidence the patch was administered on the above date. Interview with the Nursing Home Administrator on February 27, 2026 at 8:35 a.m. confirmed that there was no documented evidence that the fentanyl patch that was signed out on February 23, 2026, was administered to Resident 12. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.Findings include: Observations during medication administration on February 26, 2026, and February 27, 2026, revealed that three medication administration errors were made during 38 opportunities for error, resulting in a medication administration error rate of 7.89 percent. Manufacturer's directions for Trelegy Ellipta (medication that reduces inflammation in the airways)100-62.5-25 micrograms/activation (mcg/act), dated January 2019, indicated to advise patients to rinse his/her mouth with water without swallowing after inhalation to reduce the risk of candida albicans, an infection of the mouth and pharynx (throat). Physician's orders for Resident 68, dated February 11, 2026, included an order for the resident to receive one puff (inhalation) of 100-62.5-25 mcg/act of Trelegy Ellipta daily in the morning for chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). Observations during medication administration on February 26, 2026, at 8:18 a.m. revealed that Licensed Practical Nurse 4 administered one puff of Resident 68's Trelegy Ellipta then proceeded to give her a drink of iced tea. Interview with Licensed Practical Nurse 4 at 8:40 a.m. revealed that she was not sure if she needed to have Resident 68 rinse her mouth out with water without swallowing after administering Trelegy Ellipta. Interview with the Nursing Home Administrator on February 26, 2026, at 4:33 p.m. confirmed that Licensed Practical Nurse 4 should have had Resident 68 rinse her mouth out with water and spit after administering her Trelegy Ellipta. Manufacturer's directions for use of Xtandi (used to treat prostate cancer), dated January 2025, revealed that tablets should be taken whole and should not be cut, crushed or chewed. Instructions on the bottle indicated that the medication should be swallowed whole and should not be cut, crushed, or chewed. Manufacturer's directions for use of Ferrous Sulfate (an iron supplement), dated March 2020, revealed that tablets should be taken whole and should not be chewed or crushed. Physician's orders for Resident 31, dated January 5, 2026, included an order for the resident to receive 160 milligram (mg) of Xtandi daily for prostate cancer. Physician's orders for Resident 31, dated January 5, 2026, included an order for the resident to receive 325 mg of Ferrous Sulfate daily. Observations during the medication administration on February 27, 2026, at 8:14 a.m. revealed that Licensed Practical Nurse 5 crushed Resident 31's Ferrous sulfate tablet and crushed one 40 mg tablet of Xtandi, and then administered the crushed medications to the resident. Observations during the medication administration on February 27, 2026, at 8:14 a.m. revealed that Licensed Practical Nurse 5 prepared and administered one 40 mg table of Xtandi to Resident 31. The physician's order indicated that the resident was to receive 160 mg of Xtandi daily. The medication was supplied in a bottle containing 40 mg tablets. Interview with Licensed Practical Nurse 5 on February 27, 2026, at 8:45 a.m. confirmed that Resident 31's Ferrous Sulfate and Xtandi should not have been crushed, and confirmed that she should have administered Resident 31 a total of four 40 mg tablets of Xtandi to equal the ordered dose of 160 mg and she did not. Interview with the Nursing Home Administrator and Director of Nursing on February 27, 2026, at 10:35 a.m. confirmed that Resident 31's Ferrous Sulfate and Xtandi should not have been crushed, and that Resident 31 received the incorrect dose of Xtandi. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 4).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 12, 2026, revealed that the resident was cognitively intact and had diagnoses that included a urinary tract infection. Physician's orders for Resident 4, dated June 24, 2025 included an order for staff to obtain a urine specimen to rule out a urinary tract infection. A progress note for Resident 4, dated June 24, 2025, revealed that the writer performed a straight catheterization (the manual insertion of a plastic tube into the bladder to drain urine) on the resident at this time to obtain a urinalysis and culture and sensitivity (UA C&S - urine tests to check for the presence of bacteria and determine which antibiotics the bacteria is sensitive to).There was no documented evidence that staff obtained a physician's order to obtain Resident 4's urine specimen via catheterization. Interview with the Nursing Home Administrator on February 25, 2026, at 2:05 p.m. confirmed that there was no evidence that a physician's order was obtained for Resident 4 to be catheterized to obtain the urine specimen on June 24, 2025 and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to the administration of the medication for two of 33 residents reviewed (Residents 1 and 14). Findings include: A facility policy related to psychotropic medications, dated December 18, 2025, indicated that resident and/or representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2025, revealed that the resident was cognitively intact, received psychotropic medications, including antidepressant medications, and had a diagnosis of depression. A nursing note for Resident 1, dated November 20, 2025, at 3:21 p.m. revealed that the resident was seen by the physician and orders were obtained to increase her Sertraline (an antidepressant medication) dose to 100 milligrams (mg) daily. Physician's orders for Resident 1, dated November 21, 2025, included an order for the resident to receive 100 mg of Sertraline daily for depression. There was no documented evidence in Resident 1's clinical record to indicate that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Sertraline. Interview with the Nursing Home Administrator on February 25, 2026, at 4:15 p.m., confirmed that there was no documented evidence in Resident 1's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Sertraline. She indicated that she was not aware that an informed consent needed to be completed when initiating or increasing psychotropic medications. A Quarterly MDS assessment Resident 14, dated May 27, 2026, revealed that the resident was cognitively impaired, received psychotropic medications, including antidepressant medications. Physician's orders for Resident 14, dated June 7, 2025, included an order for the resident to receive 0.5mg of Ativan (an antianxiety medication) every 8 hours as needed for anxiety and behaviors. There was no documented evidence in Resident 14's clinical record to indicate that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Ativan. Interview with the Nursing Home Administrator on February 24, 2026, at 2:26 p.m., confirmed that there was no documented evidence in Resident 14's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Ativan. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on review of manufacturer's directions for use, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to follow the manufacture's direction for use, resulting in a significant medication error for one of 44 residents reviewed (Resident 85), which resulted in Resident 85 requiring medical intervention to correct a critically low blood sugar. Findings include: The manufacturer's direction for use for Insulin Lispro (a rapid acting insulin), dated July 2023, indicated to administer the dose of Insulin Lispro within 15 minutes before a meal or immediately after a meal. The facility's policy regarding medication administration, dated December 20, 2024, indicated that medications are to be administered in a safe and legal manner. Medications given need to follow the 5 Rights: right resident, right time, right drug, right frequency, and right route. Pour the medication reading each order on the computer screen and comparing the directions on each medication box. That manufacturer's guidelines will be followed for all rapid, short, intermediate, and long-acting insulin. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 85, dated February 3, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included diabetes. A care plan for the resident, dated February 24, 2025, revealed that the resident has diabetes with hyperglycemic (high blood sugar) and hypoglycemic (low blood sugar) readings. Physician's orders for Resident 85, dated February 6, 2025, included an order for the resident to receive 22 units of Insulin Lispro in the evening for diabetes. Information provided by the facility revealed that the first meal cart was delivered to Resident 85's unit at 5:15 p.m. and the second meal cart was delivered to the unit at 5:20 p.m. A nursing note for Resident 85, dated February 17, 2025, at 5:00 p.m. completed by Registered Nurse 1 revealed that the resident's accu-check at 5:00 p.m. was 35 milligrams per deciliter (mg/dL) (a normal range is generally considered to be 70 to 100 mg/dL). The resident is lethargic (feeling tired, lacking energy, and sluggish) and diaphoretic (profuse sweating, or being covered in sweat). The resident will open eyes and respond minimally verbally. The resident was administered Glucagon (used along with emergency medical treatment to treat very low blood sugar) and per the physician, recheck the resident's accu-check in 15 minutes. The rechecked accu-check was 49 mg/dL. The resident was given another administration of Glucagon. The accu-check was checked again in 15 minutes and was 59 mg/dL. At this time the resident was awake and alert and becoming more to her baseline. The resident was being fed by staff at this time. A Medication Administration Audit Report for Resident 85, dated February 17, 2025, revealed that Licensed Practical Nurse 2 administered the 22 units of Insulin Lispro to the resident at 4:05 p.m. (more than one hour prior to the meal delivery). The physician was advised that prior to the hypoglycemic episode, the resident received 22 units of her Insulin Lispro, and that the resident had not eaten within 15 minutes to 30 minutes of receiving her insulin. Registered Nurse 1 stated that a rule of thumb is to not administer the resident their insulin until the trays hit the hall, especially if they are unfamiliar with the resident to avoid this in the future. Interview with the Nursing Home Administrator on March 26, 2025, at 1:55 p.m. confirmed that per the manufacturer's instructions, Licensed Practical Nurse 2 should have waited until 15 minutes before the meal or until immediately after the meal to give the 22 units of Insulin Lispro to Resident 85. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care and maintenance of intravenous catheters and failed to ensure that intravenous catheters were flushed according to facility policy for three of 44 residents reviewed (Residents 1, 45, 255). Findings include: The facility's policy regarding intravenous fluid/medication administration, dated December 20, 2024, indicated that if administering only, flush before and after each infusion or per protocol for the access device. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated February 26, 2025, revealed that the resident was cognitively intact, was understood, could understand others, and was receiving intravenous (IV-into the vein) medications. Physician's orders for Resident 1, dated February 20, 2025, included an order for the resident to receive a 10 milliliter (ml) flush with normal saline every shift for 12 days for IV patency. Physician's orders for Resident 1, dated February 28, 2025, included an order for the resident to receive one gram (gm) of Vancomycin (an antibiotic) IV in the morning. Resident 1's Medication Administration Record (MARs) for February and March 2025 revealed that staff administered the IV Vancomycin on February 28, 2025, through March 4, 2025. Physician's orders for Resident 1, dated March 4, 2025, included an order for the resident to receive 750 milligrams (mg) of Vancomycin intravenously in the morning. Resident 1's MAR for March 2025 revealed that staff administered the Vancomycin on March 5 and 6, 2025; March 8, 9, and 10, 2025; and March 14, 15, and 16, 2025. Physician's orders for Resident 1, dated March 19, 2025, included an order for the resident to receive one gram Vancomycin intravenously every other day. Resident 1's MAR for March 2025 revealed that staff administered the Vancomycin on March 19 and 21, 2025. Physician's orders for Resident 1, dated March 22, 2025, included an order for the resident to receive 1250 mg of Vancomycin intravenously every other day. Resident 1's MAR for March 2025 revealed that staff administered the Vancomycin on March 22, 26, and 27, 2025. Physician's orders for Resident 1, dated March 27, 2025, included an order for the resident to receive 1500 mg Vancomycin every other day. Resident 1's MAR for March 2025 revealed that the staff administered the Vancomycin on March 27, 2025. There was no documented evidence that staff flushed the Resident 1's peripherally inserted central catheter (PICC - a long, thin, flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart, used for long-term IV access, medication administration, and blood draws) with normal sterile saline solution before and after the administration of the Vancomycin on the above dates. Interview with the Nursing Home Administrator on March 27, 2025, at 12:50 p.m. confirmed that there was no documented evidence that Resident 1's PICC was flushed with the 10 ml of normal saline before and after the administration of the Vancomycin. Physician's orders for Resident 45, dated February 20, 2025, included an order for the resident to receive a 10 ml normal saline flush every shift for IV patency. Resident 45's MARs for March 2025 revealed that there was no document evidence that staff administered the 10 ml normal saline flush during the dayshift on March 3, 4, 7, 11, 12, and 13, 2025; during the evening shift on March 7, 2025; and during the night shift on March 13 and 19, 2025. Physician's orders for Resident 45, dated February 22, 2025, included an order for the resident to receive two gm of Ceftriaxone (an antibiotic) intravenously in the afternoon. Resident 45's MARs for February and March 2025 revealed that staff administered the IV Ceftriaxone on February 22 through 28, 2025, and on March 1, 2, 8 through 10, and 14 through 26, 2025. However, there was no documented evidence that staff flushed the resident's PICC with normal sterile saline solution before and after the administration of the Ceftriaxone. Interview with the Nursing Home Administrator on March 27, 2025, at 8:50 a.m. confirmed that there was no documented evidence that Resident 45's PICC was flushed with the 10 ml of normal saline during the dayshift on March 3, 4, 7, 11, 12,and 13, 2025; during the evening shift on March 7, 2025; and during the night shift on March 13 and 19, 2025, and that there was no documented evidence that the resident's PICC was flushed with normal sterile saline solution before and after the administration of the Ceftriaxone. An admission noted, dated March 23, 2025, at 9:50 a.m., indicated that Resident 255 was admitted to the facility with a right knee infection and was to continue IV Rocephin (antibiotic medication), and he had a single lumen PICC line in place. Physician's orders for Resident 255, dated March 23, 2025, included an order for the resident to receive a 10 ml normal saline flush every shift for IV patency. Physician's orders for Resident 255, dated March 24, 2025, included an order for the resident to receive two gm of Ceftriaxone intravenously in the afternoon for a septic right knee joint. Resident 255's MAR March 2025 revealed that staff administered the IV Ceftriaxone on March 24 through 26, 2025. However, there was no documented evidence that staff flushed the resident's PICC with normal sterile saline solution before and after the administration of the Ceftriaxone. Interview with the Nursing Home Administrator on March 27, 2025, at 12:08 p.m. confirmed that that there was no documented evidence that the Resident 255's PICC was flushed with normal sterile saline solution before and after the administration of the Ceftriaxone 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for four of 44 residents reviewed (Residents 19, 41, 60, 102), and failed to ensure that bowel protocols were followed as ordered by the physician for two of 44 residents reviewed (Residents 52, 82). Findings include: The facility's policy regarding medication administration, dated December 20, 2024, indicated that medications are to be administered in a safe and legal manner. Medications given need to follow the 5 Rights, right resident, right time, right drug, right frequency, and right route. Recently a sixth right was implemented. The right documentation. Pour the medication reading each order on the computer screen and comparing the directions on each medication box. After the resident takes the medication, electronically record your signature. Any narcotic medication given must be signed off in the narcotic book at the time the medication is given. Physician's orders for Resident 19, dated February 11, 2025, included an order for the resident to receive one 25 milligram (mg) tablet of Metoprolol (used alone or in combination with other medications to treat high blood pressure) two times a day. Staff was to hold the medication if the resident's systolic blood pressure (the top number) was less than 100 millimeters of mercury (mmHg) or for a heart rate less than 60 beats per minute (BPM). A care plan for Resident 19, dated May 16, 2024, revealed that the resident had an altered cardiovascular status related to hypertension (high blood pressure) and staff was to administer the resident's medications as per the physician's order. Staff was also to monitor the resident's vital signs as per the physician's orders, and as needed. Review of the Medication Administration Records (MARs) for Resident 19, dated February and March 2025, revealed that staff administered a 25 mg dose of Metoprolol at 8:00 a.m. on March 12 and 19, 2025, and at 8:00 p.m. on February 12, 15, 16, 20, 24, and 25, 2025, and March 6, 16, and 19, 2025; however, there was no documented evidence that staff obtained the resident's blood pressure and heart rate as ordered prior to the medication administration on the dates and times listed. Interview with the Nursing Home Administrator on March 25, 2025, at 11:57 a.m. confirmed that there was no documented evidence that staff obtained Resident 19's blood pressure and heart rate prior to the 25 mg tablet of Metoprolol being administered to determine if the medication should have been held on the above dates. Physician's orders for Resident 41, dated September 22, 2024, included an order for the resident to receive one 240 mg tablet of Verapamil (used to treat high blood pressure) at bedtime for hypertension. Staff was to hold the medication if the resident's systolic blood pressure was less than 100 mmHg. A care plan for Resident 41, dated October 9, 2024, revealed that the resident had hypertension, and staff was to administer the resident's anti-hypertensive medications as per the physician's order. Staff was also to obtain the resident's blood pressure as per the physician's orders, as well as needed. Review of the MARs for Resident 41, dated February and March 2025, revealed that staff administered the 240 mg tablet of Verapamil at 9:00 p.m. on February 12, 15, 16, and 20, 2025, and on March 6, 16, 19, and 20, 2025; however, there was no documented evidence that staff obtained the resident's blood pressure prior to the medication being administered to determine if the medication should have been held. Interview with the Nursing Home Administrator on March 26, 2025, at 9:15 a.m. confirmed that there was no documented evidence that staff obtained Resident 41's blood pressure prior to the medication being administered to determine if the medication should have been held on the above dates. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated February 7, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diabetes (body does not use insulin effectively or does not produce enough insulin). A care plan for Resident 60, dated September 23, 2023, revealed that the resident had diabetes and staff were to obtain labs and accu checks (a blood glucose monitor that tests the level of sugar in the bloodstream) as physician ordered. Physician's orders for Resident 60, dated December 9, 2024, included an order for the resident to receive accu checks before breakfast and in the evening two times a day; call the physician if the reading is less than 70 milligrams per deciliter (mg/dL) or above 450 mg/dL. Review of the MAR for Resident 60, dated March 2025, revealed that staff did not obtain an accu check on March 13 and 19, 2025, per physician's orders. Interview with the Director of Nursing on March 26, 2025, at 2:38 p.m. and a statement signed by Licensed Practical Nurse 3 confirmed that there was no documented evidence that accu checks were obtained per physician's orders for the dates listed above. The facility's policy regarding medication administration, dated December 20, 2024, indicated that the bowel protocol was implemented with a physician's order upon admission to the facility or when the resident experienced constipation unless otherwise indicated. The facility's bowel protocol policy, dated December 20, 2024, included orders for the resident to receive 30 cubic centimeters (cc) of Prune whip (remedy for constipation) as needed for constipation if no bowel movement by the second day and one Glycerin suppository (a laxative inserted rectally) as needed if no bowel movement by the third day, and one soaps suds enema (a liquid inserted rectally to stimulate a bowel movement) as needed for constipation if no bowel movement by the fourth day. Physician's orders for Resident 52, dated May 9, 2022, included orders for the resident to receive 30 cubic centimeters (cc) of Prune whip (remedy for constipation) as needed for constipation if no bowel movement by the second day and one Glycerin suppository (a laxative inserted rectally) as needed if no bowel movement by the third day. Physician's orders, dated October 14, 2024, included orders for one soaps suds enema (a liquid inserted rectally to stimulate a bowel movement) as needed for constipation if no bowel movement by the fourth day. Resident 52's bowel records for February 2025 revealed that the resident did not have a bowel movement from February 1-8, 2025. The MAR's revealed that staff did not administer any laxative on February 4 and 5, 2025. Resident 52's bowel records for March 2025 revealed that the resident did not have a bowel movement from March 1-6, 2025. The MAR's revealed that staff did not administer a soaps suds enema on March 4, 2025, and did not administer any laxative on March 5, 2025. Resident 52's bowel records for March 2025 revealed that the resident did not have a bowel movement from March 12-23, 2025. The MAR's revealed that staff did not administer a soaps suds enema on March 4, 2025, and did not administer any laxative on March 13, 15, and 16, 2025. Interview with the Director of Nursing on March 27, 2025, confirmed that Resident 52's physician's orders for bowel medications were not followed. A quarterly MDS assessment for Resident 102, dated March 5, 2025, revealed that the resident was cognitively intact, was understood and understood others, and was receiving opioid (a controlled substance) medication for pain. Physician's orders for Resident 102, dated February 10, 2025, included an order for the resident to receive one 5-325 milligram (mg) tablet of Oxycodone-Acetaminophen (a controlled substance to treat pain) every six hours as needed for pain. The resident's MAR for February 2025 indicated that a dose of Oxycodone-Acetaminophen was administered to the resident on February 5, 2025, at 8:32 a.m. and 3:59 p.m.; February 6, 2025 at 10:15 a.m.; and February 14, 2025, at 6:00 p.m. and 8:00 p.m. However, according to Resident 102's controlled medication record for February 2025 there was no documented evidence that the doses of Oxycodone-Acetaminophen were signed out at these times, indicating that 5-325 mg Oxycodone-Acetaminophen was not administered as documented on the MAR. Interview with the Director of Nursing on March 27, 2025, at 11:21 a.m. confirmed that there was no documented evidence of the removal of 5-325 mg Oxycodone-Acetaminophen for Resident 102 on the controlled medication record; therefore, the 5-325 mg Oxycodone-Acetaminophen could not have been administered to the resident at the above times. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address care needs for one of 44 residents reviewed (Resident 60). Findings include: A facility policy for care plans, dated December 20, 2024, indicated that resident care plans will have multiple focuses, goals, and interventions according to their needs, level of care, and capabilities. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated February 7, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and diagnoses that included high blood pressure and diabetes. Observations of Resident 60 on March 26, 2025, at 8:35 a.m. revealed that he had two containers of smokeless tobacco and an empty milk carton that he was using as a spittoon. There was no documented evidence that a care plan was developed to address the resident's use of smokeless tobacco. An interview with the Nursing Home Administrator on March 26, 2025, at 9:30 a.m. confirmed that there was no documented evidence that a care plan was developed for Resident 60 to address his use of smokeless tobacco/chew. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect caused by staff failing to properly transport a resident in a wheelchair with leg rests, which led to a resident fall that required sutures for a laceration for one of two residents reviewed (Resident 2). This deficiency was cited as past noncompliance. Findings include: The facility's abuse policy, dated December 14, 2023, indicated that staff will be educated on identifying and preventing resident abuse, neglect, mistreatment, and misappropriation of resident property; staff members will be required at orientation and forward on a yearly basis to attend in-servicing related to abuse, neglect, mistreatment, and misappropriation of resident property. Nurse Aide 1 was educated on the facility's abuse policy on May 9, 2024. The facility's policy on wheelchair safety, dated December 14, 2023, indicated that the residents will be encouraged to self-propel if physically able. If the resident needs to be transported long distances, leg rests will be applied for safety. A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated September 20, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included anxiety and lumbar disc degeneration (breakdown of discs in spine). A nursing note for Resident 2, dated August 28, 2024, at 12:00 p.m., indicated that the resident had a fall out of her wheelchair and fell forward, hitting her head off the floor in the solarium. The resident had a 2-centimeter (cm) laceration on the left side of her head and her right eye was beginning to bruise. The physician was notified and ordered the resident to be transported to the local emergency room . A nursing note for Resident 2, dated August 28, 2024, at 3:35 p.m., revealed that the resident had no fractures but had received four sutures to the laceration on the left side of her head. An incident report for Resident 2, dated August 29, , at 1:43 pm., revealed that the resident had fallen asleep in her wheelchair and was being assisted to her room in her wheelchair without leg rests by Nurse Aide 1. The resident fell forward and hit her head on the floor in the solarium. A witness statement by Nurse Aide 2, dated August 28, 2024, revealed that she witnessed Nurse Aide 1 pushing Resident 2 in her wheelchair, while the resident was sleeping, with no leg rests on the wheelchair, and the resident fell forward hitting her head on the solarium floor. Interview with the Nursing Home Administrator on October 23, 2024, at 12:12 p.m. confirmed that Nurse Aide 1 should have had leg rests on Resident 2's wheelchair while she was transporting her. A review of the facility's plan of correction included the following: Reeducation on transporting residents in wheelchairs with leg rests completed for all nursing staff, including agency and hospice staff, activities, therapy and dietary staff. Audits of residents that require leg rests when being transported. Audits completed weekly on all staff transporting residents in wheelchairs. Interviews with nursing staff on October 23, 2024, revealed that they had been educated on transporting residents safely with legs rests. A review of the facility's corrective actions revealed that they were in compliance with F600 on October 16, 2024. Interview with the Nursing Home Administrator on October 23, 2024, at 12:22 p.m. revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of two residents reviewed (Resident 2), resulting in a fall that required four sutures. This deficiency was cited as past non-compliance. Findings include: The facility's policy on wheelchair safety, dated December 14, 2023, indicated that the residents will be encouraged to self-propel if physically able. If the resident needs to be transported long distances, leg rests will be applied for safety. A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated September 20, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included anxiety and lumbar disc degeneration (breakdown of discs in spine). A nursing note for Resident 2, dated August 28, 2024, at 12:00 p.m., indicated that the resident had a fall out of her wheelchair and fell forward, hitting her head off the floor in the solarium. The resident had a 2-centimeter (cm) laceration on the left side of her head and her right eye was beginning to bruise. The physician was notified and ordered the resident to be transported to the local emergency room . A nursing note for Resident 2, dated August 28, 2024 at 3:35 p.m., revealed that the resident had no fractures but had received four sutures to the laceration on the left side of her head. An incident report for Resident 2, dated August 29, 2024 at 1:43 pm., revealed that the resident had fallen asleep in her wheelchair and that Nurse Aide 1 was transporting her to her room without leg rests on the wheelchair. The resident fell forward and hit her head on the floor in the solarium. A witness statement by Nurse Aide 2, dated August 28, 2024, revealed that she witnessed Nurse Aide 1 pushing Resident 2 (who was asleep) in her wheelchair without egress, and the resident fell forward out of the wheelchair, hitting her head on the solarium floor. Interview with the Nursing Home Administrator on October 23, 2024, at 12:12 p.m. confirmed that Nurse Aide 1 should have had put the leg rests on Resident 2's wheelchair while she was transporting her. A review of the facility's plan of correction included the following: Reeducation on transporting residents in wheelchairs with leg rests completed for all nursing staff, including agency and hospice staff, activities, therapy, and dietary staff. Audits of residents that require leg rests when being transported. Audits completed weekly on all staff transporting residents in wheelchairs. Interviews with nursing staff on October 23, 2024, revealed that they had been educated on transporting residents safely with legs rests. A review of the facility's corrective actions revealed that they were in compliance with F689 on October 16, 2024. Interview with the Nursing Home Administrator on October 23, 2024, at 12:22 p.m. revealed that staff education was completed, and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, as well as observations and resident interviews, it was determined that the facility failed to provide ongoing pain evaluation and management for two of 26 residents reviewed (Residents R5, R7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R5, dated May 19, 2015, revealed that the resident was confused, required extensive assistance with activities of daily living, had no recent falls, and had no signs or symptoms of pain. The physician's orders [REDACTED]. A nursing note, dated July 14, 2015 at 12:40 p.m., revealed that Resident R5 was sitting on her buttocks against the wall in the corner of her room with her legs bent. She had no complaints of pain at the time, had an abrasion to her right knee, a cut in front of her right ear, and was able to move all of her extremities without difficulty. She was assisted by three staff members, placed into bed, and 650 mg of Tylenol was administered at 3:34 p.m. for complaints of pain in both legs, which was effective. A nursing note, dated July 15, 2015 at 2:51 a.m., revealed that Resident R5 was in bed and was assisted to a standing position by two staff members. She complained of severe right hip pain once standing, was unable to bear weight and was assisted back into bed. There was no documented evidence that the resident's change in condition and complaints of pain were assessed by a Registered Nurse, that the physician was notified, or that the resident was treated for [REDACTED]. A nursing note, dated July 15, 2015 at 7:32 a.m., revealed that Resident R5 complained of pain in the right thigh and was unable to move her leg. There was no documented evidence that the resident's continued complaints of pain and inability to move her leg were assessed by a Registered Nurse, or that she was treated for [REDACTED]. A nursing note, dated July 15, 2015 at 10:00 a.m., revealed that Resident R5 was medicated with 650 mg of Tylenol for complaints of right thigh pain. At 11:00 a.m., it was noted that the Tylenol was only effective for partial relief of the pain in the right thigh area, and there was no evidence that the physician was notified that the Tylenol was ineffective until 2:20 p.m., 3 hours and 20 minutes later, when orders were received for 5/325 mg of [MEDICATION NAME] (a narcotic pain medication) four times a day as needed for moderate pain, and also for a physical therapy evaluation. There was no documented evidence that the resident was medicated with [MEDICATION NAME] at that time. A nursing note, dated July 16, 2015 at 12:00 a.m., revealed that Resident R5 was assisted onto the bed pan by two staff members and complained of severe pain in the right hip and leg during turning. She had facial grimacing and was yelling out and swearing at the staff related to being in pain. She was medicated with [MEDICATION NAME] at that time; however, there was no documented evidence that the resident's pain was assessed by a Registered Nurse, including the possible cause, severity, or location. A nursing note, dated July 17, 2015 at 4:47 a.m., revealed that Resident R5 required assistance to turn in bed and complained of severe pain in the right hip and leg during assistance with care. There was no documented evidence that the resident's continued complaints of pain during care were assessed by a Registered Nurse at that time, or that the physician was notified until 12:20 p.m., 8 hours and 20 minutes later, at which time orders were received to transfer the resident to the hospital for x-rays of the right hip, femur, and pelvis due to pain following a fall and the inability to ambulate. A nursing note, dated July 17, 2015, revealed that the orthopedic physician did not see a clear fracture on the x-rays and indicated that if further evaluation was warranted, a CT (a computerized scan) should be ordered to evaluate for a fracture. A physician's orders [REDACTED]. Interview with the Director of Nursing on January 11, 2016 at 4:20 p.m., confirmed that Resident R5 was not assessed by a Registered Nurse in a timely manner, that the physician was not notified timely, and that the resident did not receive timely or effective treatment for [REDACTED]. A quarterly MDS assessment for Resident R7, dated October 16, 2015, revealed that the resident was alert and oriented, able to make her own decisions, and had occasional pain that would interrupt her daily activities. physician's orders [REDACTED]. Per the Medication Administration Record, [REDACTED]. Observations of Resident R7 on January 10, 2016 at 11:46 a.m., revealed that she reported to Licensed Practical Nurse 10 that it hurt to touch her feet. The nurse offered the resident a pain pill, then put a small pillow under the resident's heels, at which time the resident grimaced and winced, then asked that the pillow be removed. Interview with the resident at that time revealed that she would have preferred that staff just give her pain medication rather than having to ask for it, as she sometimes forgot to ask for it. The surveyor informed Licensed Practical Nurse 10 about the resident's stated preference regarding her pain medication. However, there was no documented evidence that the effectiveness of Resident R7's pain control regimen was evaluated on January 10, 2016. Observations on January 11, 2016 at 8:50 a.m., revealed that Resident R7 exclaimed, My feet hurt terribly! I had a pain pill about 15 minutes ago. Maybe it needs time to take effect. Resident R7 asked the surveyor to let nursing staff know that she wanted her pain relief to be sustained. She indicated that she thought she would remember to ask the nurse for better pain control but forgets things so quickly that she may not remember to. She added, Nobody wants pain! The resident's information was conveyed to the Licensed Practical Nurse 2, per the resident's request. Interview with Licensed Practical Nurse 2 at that time revealed that Resident R7 had a pain pill approximately one hour ago, not 15 minutes, and the medicine should have taken effect by now. Observations on January 11, 2016 at 9:00 a.m., revealed that Licensed Practical Nurse 2 contacted the Registered Nurse supervisor, and Registered Nurses 7 and 8 arrived at the resident's room and spoke with her. However, as of January 11, 2016 at 4:10 p.m., there was no documented evidence that an evaluation or assessment of the resident's pain control regimen was completed. Interview with the Director of Nursing on January 11, 2016 at 4:20 p.m., confirmed that Resident R7's pain control regimen was not evaluated in a timely manner, and the resident did not receive timely or effective treatment for [REDACTED]. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 2/20/15. 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 2/20/15. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 2/20/15.