Health inspection·December 2, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, facility policies and procedures and staff and resident interviews, it was determined that the facility failed to ensure that one of three residents (Resident R1) received the correct medications upon admission to the facility.Findings include: Review of the facility policy Physician Orders dated 3/14/25, indicated medical order transcription can be written, may be entered as an electronic order, and the provider may send a signed and dated fax medical order. The nurse who takes the order will be responsible for executing the order. Review of the facility policy Missed Medication/Medication Error dated 3/14/25, indicated the purpose of the policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner. In the event the medication is not available from the emergency kit the nurse will notify the physician immediately and receive guidance on how to proceed. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of care needs) dated 9/6/25, indicated diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own), abdominal aortic aneurysm without rupture (AAA - a bulge of the main artery that carries blood from the heart to the rest of the body that has widened abnormally but has not yet burst), and high blood pressure. Review of Resident R1's hospital discharge transfer orders dated 8/18/25, indicated discharge medications: Xanax (anxiety medication) 0.25mg (milligrams) four times a day for five days. Prescription printed. Diovan (heart medication) 80mg every evening. Review of Resident R1's physician orders dated 8/18/25, upon admission to the facility, indicated Diovan 80mg every evening; however, failed to include the order for Xanax 0.25mg four times a day for five days. The order for Xanax was not transcribed by the nursing staff. Review of Resident R1's Medication Administration Record (MAR) dated August 2025, failed to include an order for Xanax on 8/18/25, as prescribed. Review of Resident R1's MAR on 8/18/25, indicated the Diovan was not given as prescribed in the evening. Review of Resident R1's progress notes indicated 8/18/25, at 9:25 p.m. indicated MAR note, Diovan not given, awaiting delivery from pharmacy Interview with the Director of Nursing on 9/26/25, at 2:00 p.m. confirmed the admission orders failed to include the physician prescribed Xanax order, and that the nursing staff failed to follow procedures for a missing medication and did not notify the physician of Diovan not being administered to Resident R1 as prescribed on 8/18/25. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services. Residents Affected - Few Page 1 of 3 395300 395300 12/02/2025 Perry Health & Rehab Center 9850 Old Perry Highway Wexford, PA 15090

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Resident R2, R3, and R4).Findings include: Review of the facility policy Routine Resident Care indicated unlicensed staff provide routine daily care by a nurse aide (NA) under the supervision of a licensed nurse. Routine daily care by a NA includes but is not limited to assisting or provides for personal care: bathing, dressing, eating and hydration, and toileting. During an interview on 9/26/25, at 10:24 a.m. when asked if they felt the facility maintained enough staff to care for resident needs, NA Employee E1 indicated on the second and third floors, there's not enough help. The residents are not getting the care they deserve. Showers? That all depends on how many staff we have, we need two staff for all the Hoyer lift residents who have to stay in bed until we find a second person. During an interview on 9/26/25, at 10:28 a.m. Licensed Practical Nurse (LPN) Employee E2 indicated We've had only three aides a lot lately. These twelve-hour shifts are really wearing staff out. During an interview on 9/26/25, at 10:40 a.m. NA Employee E3 indicated it's really hard with three aides for 37 residents on a twelve-hour shift. We have to do all three meals, get residents out and into bed, get them dressed, bathed, most are Hoyer lifts and you need two people for that, so the residents are always waiting longer than they should and showers are not always getting done, as hard as we try. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/3/25, indicated the diagnosis of high blood pressure, post-polio syndrome (a progressive nerve and muscle disorder that affects some who have had polio- muscle weakness, pain, fatigue, and breathing or swallowing difficulties), and Vitamin D deficiency. Section C0500 - Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) indicated a score of 15 - cognitively intact. During an interview on 9/26/25, at 11:42 a.m. Resident R2 indicated My showers are on Monday and Thursday during the daytime. I'm not getting showers like I'm supposed to. Last Thursday I was supposed to get a shower, and the aide tried to lift me without the Hoyer. I told the aide they needed to use the Hoyer on me. I told the aide I use the slide board to get in and out of bed and the aide said, Oh no. The aide said, I got you. The aide wanted me to hold on around their neck to transfer me back to bed and my leg fell down. I'm tired of being disrespected by the staff. I understand they are short staffed, and they need two staff for me, but they have to be respectful towards me. They work twelve-hour shifts now and it's not working. The staff are tired, and they get agitated because they can never find a second helper. There is too little help, and the residents are getting the short end of the stick. Review of Resident R2's shower documentation for the last 30 days indicated only three showers were received by Resident R2. The last shower was 9/8/25. During an interview on 9/26/25, at 11:50 a.m. Registered Nurse (RN) Employee E4 indicated, honestly with three aides and 37 residents, the staff really don't have enough time to give all of the showers. During an interview on 9/26/25, at 11:58 a.m. RN Employee E5 indicated the residents have to wait for everything. The staff need two people to get most of the residents up and finding a second person is often hard, making wait times excessively long. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain 395300 Page 2 of 3 395300 12/02/2025 Perry Health & Rehab Center 9850 Old Perry Highway Wexford, PA 15090

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some life), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section C0500 indicated a BIMS score of 15 - cognitively intact. During an interview on 9/26/25, at 12:10 p.m. Resident R3 indicated I haven't had a shower in over a month. It was supposed to be Wednesday and Saturday, now they say it's Tuesday and Friday. Nobody told me about the change, and I haven't had a shower anyway. Review of Resident R3's shower documentation for the last 30 days indicated only one shower was received by Resident R3. The last shower was 9/2/25. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated the diagnoses of end stage renal failure, heart failure, and high blood pressure. Section C0500 indicated a BIMS score of 15 - cognitively intact. During an interview on 9/26/25, at 12:20 p.m. Resident R4 indicated I haven't been getting my showers lately. The staff are too busy, and they are short staffed. Review of Resident R4's shower documentation for the last 30 days indicated only three showers were received by Resident R4. The last shower was 9/9/25. Interview on 9/26/25, at 2:00 p.m. the Director of Nursing indicated she could not locate shower sheets for Residents R2, R3, and R4 and confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Resident R2, R3, and R4). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(6) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(4)(5)(f.1)(i) Nursing services. 395300 Page 3 of 3