Wyomissing Health And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement physician's orders for two of five sampled residents. (Residents 1 and 4)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included Parkinson's disease, aphasia (inability to speak), and history of a stroke (a medical condition involving the interruption of blood flow to a part of the brain resulting in brain damage). A review of Resident 1's Minimum Data Set assessment dated [DATE], revealed the resident had an abdominal feeding tube through which he received nutrition and medications. A physician's order dated December 27, 2025, directed staff to administer a medication (amlodipine besylate) daily for hypertension. Review of Resident 1's January 2026 medication administration records (MAR) revealed there was no documented evidence that staff administered this medication at 2:00 p.m., as scheduled, on January 2, 2026. A physician's order dated December 26, 2025, directed staff to administer a medication (carbidopa-levodopa) three times per day for Parkinson's disease. Review of Resident 1's January 2026 MAR revealed there was no documented evidence that staff administered this medication at 12:00 p.m., as scheduled, on January 2, 2026. A physician's order dated December 26, 2025, directed staff to administer a medication for muscle spasms (baclofen) three times per day. Review of Resident 1's January 2026 MAR revealed there was no documented evidence that staff administered this medication at 12:00 p.m., as scheduled, on January 2, 2026. Physicians' orders dated December 26 and 27, 2025, directed staff to perform the following: Staff were to administer 65 milliliters (mL) per hour of a tube feeding formula (Jevity 1.5) daily using an electrical feeding pump through Resident 1's feeding tube from 1:00 p.m. until 7:00 a.m. a total of 19 hours. Staff were to set the feeding tube pump to flush the feeding tube with 60 mL of water before and after each medication administration and feeding. Staff were to flush the feeding tube with 5 mL of water between medications and every shift. Review of Resident 1's January 2026 Treatment Administration Record (TAR) revealed there was no documented evidence that staff flushed the feeding tube on dayshift (7:00 a.m. to 3:00 p.m.) on January 2, 2026, or administered the tube feeding formula as ordered on January 2, 2026. Clinical record review revealed that Resident 4 had diagnoses that included dementia and depression. A physician's order dated October 1, 2025, directed staff to cleanse the resident's right hand's second and third digit finger with a saline solution, to apply an oil emulsion gauze, and wrap with a gauze dressing every day shift for wound care. Review of Resident 4's March 2026 TAR revealed there was no documented evidence that staff administered this treatment on March 12, 2026. Observations on March 16, 2026, at 10:38 a.m., and 2:20 p.m., revealed the resident had band aids on his fingers which were not the correct gauze dressing per the physician's order. In an interview on March 16, 2026, at 3:41 p.m., the Director of Nursing confirmed that there was no evidence that staff implemented the physician's orders as identified and the resident's hand wounds were covered with band aids, not gauze as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and services as ordered by the physician to promote healing and prevent new pressure sores for two of five sampled residents who had pressure sores. (Resident 2, 3) Findings include: Review of the facility's policy entitled Wound Management Protocols- Pressure Ulcers, dated January 2026, revealed that physician/wound consultant would determine the most appropriate treatment to manage a wound, and staff would refer to individual product package and physician order for detailed instructions for use in the care of pressure ulcers.Clinical record review revealed that Resident 2 had diagnoses that included a seizure disorder and metabolic encephalopathy (a brain dysfunction cause by metabolic disturbances leading to confusion, memory loss and altered consciousness). A review of Resident 2's admission skin assessment dated [DATE], revealed that the resident had a pressure sore on his sacrum and lower back. The Minimum Data Set (MDS) assessment, dated December 10, 2025, indicated that the resident required substantial assistance with overall care and that he had one pressure sore and six deep tissue injuries present on admission. A review of the care plan revealed that the resident had an actual skin breakdown. There was an intervention for staff to provide treatments as ordered by the physician. A review of physician's orders dated December 4, 2025, through February 11, 2026, revealed staff were directed to perform the following: Staff were to cleanse the sacral wound with a solution (normal saline), apply a dressing (Santyl), pack the wound with saline moistened gauze to the wound base, and cover with bordered foam dressing ever evening shift (3:00 p.m. to 11:00 p.m.) for wound care. Staff were to cleanse the right hip with a solution (normal saline), pat dry, apply a treatment (skin prep), and to leave open to air every evening shift for wound care. Staff were to cleanse the left hip with a solution (normal saline), apply a medicated dressing (Medihoney), and cover with a bordered gauze every evening shift for wound care. Staff were to cleanse the left lower back with a solution (normal saline), apply a dressing (Santyl), to pack with saline moistened gauze, and to cover with a bordered gauze every evening shift for wound care. Staff were to apply an ointment (Santyl) to wound areas topically every evening shift. Staff were to cleanse the right lower back with a solution (normal saline), apply a dressing (Medihoney), and to cover with a bordered gauze every evening shift for wound care. Staff were to cleanse the lower spine with a solution (normal saline), apply a dressing (Santyl), to pack with saline moistened gauze wrap, and to cover with a bordered gauze every evening shift for wound care. Staff were to cleanse the right plantar foot with a solution (normal saline), to cover with a medicated (betadine) moistened gauze, and cover with a padded dressing, and to wrap with gauze every evening shift for wound care. Review of the Treatment Administration Record (TAR) for December 2025, and January 2026 through March 2026, revealed there was no evidence that any of the wound treatments were completed as ordered to the resident's sacrum, right hip, left hip, left lower back, right lower back, and lower spine on December 12 and 28, 2025. There was no evidence that any of the wound treatments were completed as ordered on January 21, 25, and 31, 2026, and March 10, 2026. Clinical record review revealed that Resident 3 had diagnoses that included a sacral pressure ulcer and multiple sclerosis. A review of a wound care note dated March 16, 2026, revealed that the resident had a pressure sore on the sacrum. The MDS assessment dated [DATE], indicated that the resident had was cognitively intact and was dependent on staff for all care. A review of the care plan revealed that the resident had an actual wound on her sacrum and required assistance with all activities of daily living. There was an intervention for staff to provide treatments as ordered by the physician and for staff to reposition Resident 3 in bed. Review of a physicians' orders dated March 7, 2026, directed staff to apply black foam, a negative pressure wound therapy dressing cover, and attach to a wound therapy (a vacuum pump) running at 125 millimeters of mercury continuously to the resident's sacral wound. Staff were directed to change the dressing every Monday, Wednesday, and Friday, and as needed, and to check the placement and function of the negative pressure wound therapy setting every shift. Review of the TAR for March 2026, revealed that there was no documented evidence the treatment was functioning when staff checked it on the evening shift (3:00 p.m. to 11:00 p.m.) and night shift (11:00 p.m. to 7:00 a.m.) on March 15, 2026, or on the day shift (7:00 a.m. to 3:00 p.m.) on March 16, 2026. Observations on March 16, 2026, at 10:40 a.m., revealed the resident was flat on her back and the head of her bed was flat. A wound therapy pump was observed sitting on a bedside table. The pump was turned off and not connected to the resident. In an interview with Resident 3 during the observation period, she stated that the wound therapy system pump was not functioning, it had not been working since the afternoon on the previous day, and that staff does not reposition her. In an interview with Licensed Practical Nurse (LPN) 1 on March 16, 2025, at 11:05 a.m., LPN 1 stated the wound pump started beeping on the afternoon of March 15, 2026, when LPN 1 was assigned to care for Resident 3. LPN 1 could not find any problems with the machine. LPN 1 stated that she attempted to change the canister and tubing, but the facility did not have the correct supplies for this machine, so the machine was turned off and disconnected from Resident 3 at that time. Observation on March 16, 2026, at 2:20 p.m., revealed that Resident 3 was still lying flat on her back in bed. In an interview with Resident 3 at that time, she revealed that staff had not repositioned her since 10:40 a.m., and the resident wanted to be repositioned. In an interview on March 16, 2026, at 3:35 p.m., the Director of Nursing stated that there was no documented evidence that the treatments had been completed to the wounds for Resident 2, or that Resident 3 had been repositioned, and the wound therapy for Resident 3 had not been in place as it should have been per the physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician ordered medication was available from the pharmacy for two of seven sampled residents. (Residents 1, 7)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neoplasm (tumor) related pain and pancreatic cancer. A review of the care plan revealed interventions for staff to administer medications as ordered by the physician. On February 7, 2026, a physician ordered for staff to administer oxycodone (a pain medication) every three hours as needed for severe pain. On February 9, 2026, a nurse noted that the resident complained of pain and that she was unable to administer the oxycodone medication because it was unavailable. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included polyneuropathy (damage to nerves caused by diabetes) and diabetes. On February 5, 2026, a physician ordered for staff to administer insulin glargine (medication to treat diabetes and maintain blood sugar levels) at bedtime, metoprolol tartrate (blood pressure medication) two times a day, metformin (medication to manage blood sugar levels) two times a day, and gabapentin (medication to treat nerve pain) two times a day. On February 5, 2026, a nurse documented that the mediations were unavailable from pharmacy and therefore not administered. In an interview on February 17, 2026, at 12:30 p.m., the Director of Nursing confirmed that the medications had not been administered as ordered by the physician because they had not been available from the pharmacy, and that staff should have utilized the emergency supply.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(1)(3) Management.28 Pa. Code 211.12(d)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to file timely reports of allegations of abuse to officials, including the State Survey Agency, for two of six sampled residents. (Residents 3 and 5)Findings include:Review of the facility policy titled, Abuse Policy - Prevention and Management, last reviewed August 2025, revealed that the facility prohibited abuse, mistreatment, neglect, and exploitation, for all residents. Procedures to prohibit abuse included the reporting of incidents, investigations, and the facility's response to the results of their investigations immediately upon receiving information concerning a report of suspected neglect or abuse. The designee was to report allegations involving abuse or neglect to the appropriate state and local authorities. Incidents resulting in no serious bodily injury were to be reported no later than 24 hours after identifying a suspicion of abuse. Clinical record review revealed that Resident 3 had diagnoses that included intellectual disability, liver transplant failure, heart failure, and type II diabetes. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had no memory impairment. Review of facility documentation dated December 29, 2025, revealed that the resident was heard yelling from his room that Resident 4 had struck him. Resident 3 was observed being shoved onto his bed before the residents were separated. There was a lack of evidence to support that the facility reported the incident of alleged abuse to the required state and local agencies until January 19, 2026, 21 days after the incident. Clinical record review revealed that Resident 5 had diagnoses that included dementia with agitation and type II diabetes. The MDS assessment dated [DATE], indicated that the resident had significant memory impairment. Review of facility documentation dated January 14, 2026, revealed that Resident 5 was observed in an altercation in which his roommate, Resident 6, shoved him onto his bed. Resident 5 had injuries to his lip and eye. There was a lack of evidence to support that the facility reported the incident of alleged abuse to the required state and local agencies until January 19, 2026, five days after the incident. In an interview on January 19, 2026, at 1:20 p.m., the Administrator confirmed that the facility failed to report the incidents of alleged abuse to the required state and local agencies in a timely manner. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards by failing to ensure that a Registered Nurse (RN) conducted assessments for two of five sampled residents. (Residents 1 and 2) Findings include:Review of Title 49, Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, indicated that under Responsibilities of the RN, 21.11, General Functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.The 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place.Clinical record review revealed that Resident 1 was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus, other lack of coordination, chronic obstructive pulmonary disease, generalized anxiety disorder, suicidal ideation, and history of venous thrombosis and embolism. An Admission/readmission Assessment which included an initial skin assessment, was completed on December 5, 2025, by an LPN (Employee E1), and there was no evidence that an RN had reviewed or co-signed the assessment.Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included unspecified cirrhosis of the liver, hepatic encephalopathy, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, and acute kidney failure. An Admission/readmission Assessment which included an initial skin assessment, was completed on December 5, 2025, by an LPN (Employee E1), and there was no evidence that an RN had reviewed or co-signed the assessment.During an interview on January 2, 2026, at 3:54 p.m., the Director of Nursing confirmed that the initial admission/readmission assessments for the above residents were conducted by an LPN, without the oversight or assistance of an RN.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for three of 19 sampled residents. (Residents 12, 51, and 100)Findings include: Clinical record review revealed that Resident 12 was admitted on [DATE], and had diagnoses that included peripheral vascular disease. On August 15, 2025, a physician ordered that staff obtain a blood test (a Complete Blood Count) on August 18, 2025. A review of Resident 12's clinical record revealed there was no documented evidence to support that the blood test was obtained as ordered. In an interview on August 28, 2025, at 9:29 a.m., the Director of Nursing confirmed that the ordered blood work was not done, and that nursing staff did not communicate the order to the laboratory. Clinical record review revealed that Resident 51 was admitted on [DATE], and had diagnoses that included chronic kidney disease, failure to thrive, and congestive heart failure. On August 2, 2025, a physician ordered that staff weigh the resident every day. A review of Resident 51's weights revealed that there was no documented evidence to support that staff weighed the resident on August 3, 4, 5, 6, 9, 10, 13, 16, 17, 18, 22, and 23, 2025. Clinical record review revealed that Resident 100 was admitted on [DATE], and had diagnoses that included liver cell cancer and edema. On June 28, 2025, a physician ordered that staff weigh the resident every day. A review of Resident 100's weights revealed that there was no documented evidence to support that staff weighed the resident on July 4 and 6, 2025, and August 4, 10, 12, 16, and 20, 2025. In an interview on August 28, 2025, at 9:10 a.m., the Director of Nursing confirmed that there was no documentation to support that staff weighed Residents 51 and 100 as ordered by the physician. CFR 483.25 Quality of CarePreviously cited 10/24/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to document an inventory of personal belonging on admission for one of 19 sample residents. (Resident 58)Findings include: Review of the facility policy entitled, Inventory/Personal Belongings, dated January 2025, revealed that a documented inventory of all residents' personal belongings was to be completed upon admission by the nursing department and that the inventory was to be kept in the clinical record. Clinical record review revealed that Resident 58 was admitted to the facility on [DATE]. There was no evidence in the clinical record that the facility documented an inventory of the resident's personal belongings. In an interview on August 28, 2025, at 9:30 a.m., the Director of Nursing confirmed that there was no documented inventory of the resident's personal belongings in the clinical record. 28 Pa Code 201.18(b)(2) Management. 28 Pa Code 201.24 (c) admission policy.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves, and Ombudsman information, in writing upon transfer and failed to provide copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for five out of five residents who were transferred out of the facility. (Residents 7, 11, 12, 13, and 51) Findings include:Clinical record review revealed that Resident 7 was transferred to the hospital on August 11, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 11 was transferred to the hospital on May 13, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 12 was transferred to the hospital on May 27, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 13 was transferred to the hospital on May 23, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 51 was transferred to the hospital on July 5, 2025, after a change in condition. There was no documented evidence to support that the resident and/or the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital and that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman.In an interview on August 28, 2025, at 12:10 p.m., the Director of Nursing confirmed that the notifications of transfer were not sent for these residents and resident representatives and that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman.28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to verify professional license/registration status prior to the start of employment for two of five newly hired employees. (Employee 1 and Employee 2) Findings include:A review of the facility policy entitled, Abuse Policy- Prevention and Management, dated August 2024, revealed that the facility would conduct screening for all potential hires. This would include an inquiry to the state nurse aide registry, and they would record the results of the screening. Employee 1 (E1) had been working in the facility as a nurse aide since May 26, 2025, and an inquiry to the state nurse aide registry was not completed until August 27, 2025.Employee 2 (E2) had been working in the facility as a nurse aide since June 30, 2025, and an inquiry to the state nurse aide registry was not completed until August 27, 2025.In an interview on August 28, 2025, at 9:25 a.m., the Director of Nursing confirmed there was no documented evidence that the state nurse aide registry verification results for E1 and E2 were done prior to the start of employment per facility policy.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include: During a tour of the facility conducted on August 9, 2025, at 9:15 a.m., the staffing information that was posted in the lobby was dated for August 8, 2025. In an interview on August 9, 2025, at 3:00 p.m., the Director of Nursing confirmed that incorrect staffing data was posted. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 20 sampled residents. (Resident 101)
Findings include:
Clinical record review revealed that Resident 101 had diagnoses that included hypertension, heart disease, and dementia. Physician's orders dated July 25, 2024, directed staff to administer amlodipine and metoprolol (medications for high blood pressure) once daily; staff were to hold the medications if the resident's systolic blood pressure (SBP, the measure of the pressure when the heart beats) was below 100 millimeters mercury (mmHg). Staff were to also hold the metoprolol if the resident's heart rate was below 60 beats per minute. Review of the medication administration records for August and September 2024 revealed no evidence that staff obtained the resident's blood pressure before they administered amlodipine 12 times in August and one time in September. There was no evidence that staff obtained the resident's blood pressure or heart rate before they administered metoprolol eleven times in August and one time in September.
In an interview on October 24, 2024, at 11:28 a.m., the Director of Nursing confirmed that there was no evidence that staff obtained and recorded the resident's blood pressure and heart rate prior to administration of the medications, per the physician's order.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, review of facility documentation, and staff interview, it was determined that the facility failed to provide nail care to promote foot health for one of 20 sampled residents. (Resident 12)
Findings include:
Clinical record review revealed that Resident 12 had diagnoses that included protein calorie malnutrition and cognitive communication deficit. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment. A physician's order dated September 13, 2024, directed staff to consult podiatry services as needed. On October 23, 2024, at 11:22 a.m., the resident was observed in bed; her toenails were long and jagged. Review of a facility resident list dated July 15, 2024, revealed that the resident was identified as in need of podiatry services at that time. There was no evidence that the resident was seen by a podiatrist or provided with foot care.
In an interview on October 24, 2024, at 9:34 a.m., the Director of Nursing confirmed that the resident was identified to need podiatry services in July 2024 and had not been seen by a podiatrist.
CFR 483.25(b)(5) Foot care
Previously cited 10/21/2023
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide nail care to maintain good foot health for one of six sampled residents. (Resident 2)
Findings include:
Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included diabetes mellitus and hypertension. The Minimum Data Set assessment dated [DATE], indicated that the resident had no cognitive impairments and required partial to moderate staff assistance for care. On July 21, 2023, the physician ordered for a podiatry consult as needed. Review of the wound consultant's note on August 9, 2023, revealed that a podiatry consult was recommended to trim Resident 2's toe nail. On August 16, 2023, the wound consultant noted that the resident's toe nails were long and mycotic and that she requested a Band-Aid to an abrasion on her toe until she was seen by podiatry. On October 3, 2023, a nurse noted that the resident was added to the podiatry list at the resident's request. In an interview on October 21, 2023, at 1:00 p.m. Resident 2 stated that she had not seen a podiatrist since admission and had requested to see one. Observation on October 21, 2023, at 1:50 p.m. with LPN 1 revealed that the resident's toenails were long and in need of nail care.
In an interview on October 21, 2023, the Director of Nursing stated that Resident 2 had not been seen by a podiatrist since admission to the facility.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 20 sampled residents. (Resident 12)
Findings include:
Clinical record review revealed that Resident 12 had diagnoses that included dementia, depression, and anxiety. On August 7, 2023, a physician ordered that staff administer a medication patch (rivastigmine) 4.6 milligrams (mg) once a day for dementia. Observation on September 27, 2023, at 8:58 a.m., revealed licensed practical nurse (LPN) 1 and LPN 2 identified and retrieved a 9.5 mg rivastigmine patch from the medication cart. LPN 1 proceeded to administer the patch, which was the incorrect dose, to Resident 12.
In an interview on September 27, 2023, at 10:29 a.m., LPN 2 confirmed that the incorrect rivastigmine patch was administered to Resident 12.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to assess and provide nutritional interventions in a timely manner for one of five sampled residents at risk for weight loss. (Resident 44)
Findings include:
Review of the facility's policy entitled, Weight Assessment and Interventions, dated June 29, 2023, revealed that staff was to weigh residents monthly. Staff was to verify any weight changes of five pounds or more by re-weighing the resident within 24 hours. If the weight change was confirmed, staff was to notify the dietitian who was to respond within 72 hours. Staff was also to notify the attending physician and resident representative of unplanned significant weight changes.
Clinical record review revealed that Resident 44 had diagnoses that included stroke, malnutrition, and dysphagia. Review of the care plan revealed that the resident was at risk for nutrition problems and that staff was to weigh the resident per policy. On June 3, 2023, the resident weighed 144.8 pounds (lbs.). On July 4, 2023, the resident weighed 135.6 lbs., a 6.06 percent weight loss. There was no documented evidence that staff verified the resident's weight loss per facility policy or notified the dietitian, physician, and resident's representative of the weight loss. On August 15, 2023, the resident weighed 134.1 lbs., an additional loss of 1.5 lbs. There was no evidence that the facility addressed the resident's weight loss identified on July 4, 2023, until August 18, 2023, or implemented nutrition interventions until August 23, 2023.
In an interview on September 28, 2023, at 10:03 a.m., the Director of Nursing confirmed there was no documented evidence that the re-weights were obtained to verify the weight loss and that the dietitian, physician and resident's representative were notified of the significant weight loss per facility policy.
CFR 483.25 (g)(1) Maintains acceptable parameters of nutritional status
Previously cited 10/6/2021, 9/30/2022
28 Pa. Code 211.10(a) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on one of two nursing units. (Second floor)
Findings include:
Observation of the pantry on the second floor nursing unit on September 27, 2023, at 11:06 a.m., revealed a microwave with a piece of tape covering the lower part of the control panel and the top part of the button that opened the door. Inside the microwave, there were areas of a dark brown substance and exposed rust.
Observation of the east shower room on the second floor nursing unit on September 27, 2023, at 11:40 a.m., revealed the toilet assist bars above the toilet were loose on both sides.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.