Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of 27 sampled residents. (Residents 2, 13)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included end stage kidney disease and diabetes mellitus (DM). On July 11, 2025, the physician ordered staff to administer insulin (Lispro) three times a day for DM. Staff were not to administer the medication if Resident 2's blood sugar was less than 100 milligrams per deciliter (mg/dL). Review of Resident 2's Medication Administration Record (MAR) revealed that staff administered the medication two times in July 2025 and three times in August 2025, when the resident's blood sugar was less than 100 mg/dL.Clinical record review revealed that Resident 13 had diagnosis of diabetes mellitus and hypertension (high blood pressure). On July 16, 2025, the physician ordered staff to administer insulin (Lispro) subcutaneously (fatty tissue layer beneath the skin) with meals. Staff were not to administer the medication if Resident 13's blood sugar was less than 120 mg/dL. Review of the MAR for July and August 2025, revealed that Resident 13 received the medication on six occasions, when the resident's blood sugar was less than 120 mg/dL. Physician's orders dated August 8, 2025, directed staff to administer a blood pressure medication (hydrochlorothiazide) once daily. Staff were to hold the medication if the resident's systolic blood pressure (SBP, the measure of the pressure when the heart beats) was below 110 millimeters mercury (mm/Hg). Review of Resident 13's MAR revealed that staff administered the medication two times in August 2025 when the resident's SBP was less than 110 mm/Hg. Physician's orders dated August 11, 2025, directed staff to administer a blood pressure medication (metoprolol) twice daily. Staff were to hold the metoprolol if the resident's SBP was <110 and heart rate was below 65 beats per minute (bpm). On August 20, 2025, the physician ordered staff to administer a blood pressure medicine (amlodipine besylate) once daily. Staff were not to administer the medication if Resident 13's SBP was less than 115 mm/Hg. Review of the MARs for August 2025 revealed no evidence that staff obtained the resident's heart rate or blood pressure prior to administration of the metoprolol on 23 occasions, additionally staff administered the medication two times in August 2025 when the resident's SBP was less than 110 mm/Hg. Review of the MARs for August 2025 revealed no evidence that staff obtained Resident 13's blood pressure prior to administration of the amlodipine on eight occasions. In an interview on August 28, 2025, at 9:54 a.m., the Director of Nursing confirmed that the medications were administered outside of the established parameters for Residents 2 and 13 and that there was no evidence that staff obtained or recorded Resident 13's blood pressure or heart rate prior to the administration of the medications as ordered.28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations during an environmental tour, it was determined that the facility failed to maintain a clean and sanitary environment for residents and staff on one of three nursing units. (Second Floor)Findings include:During an environmental tour of the second floor nursing unit on August 4, 2025, from 10:01 a.m. until 10:31 a.m., the following was observed: room [ROOM NUMBER], a heavy and pervasive odor of urine was present in the residents' shared bathroom. room [ROOM NUMBER], an odor of stool and urine in a toilet bowel that had not been flushed for a period of time was observed; the toilet seat was soiled.room [ROOM NUMBER], there was a strong odor of stool and urine in the shared bathroom and soiled clothing and bathing items were stored on the floor.room [ROOM NUMBER], there was a strong urine odor in the shared bathroom.room [ROOM NUMBER], there was a strong urine odor at the entrance to the resident room and near the resident beds.room [ROOM NUMBER], there was a urine odor throughout the resident roomThe floor of the hallway on the second floor nursing unit and the common area was dusty, stained, and in need of cleaning.28 Pa. Code 201.18(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to assess, develop, and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for two of 27 sampled residents. (Residents 99, 109) Findings include: Clinical record review revealed that Resident 99 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, major depressive disorder, and schizoaffective disorder. There was no assessment or care plan in Resident 99's clinical record that identified the PTSD diagnosis, symptoms and/or triggers related to this diagnosis or resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. Clinical record review revealed that Resident 109 had diagnoses that included PTSD, anxiety, depression, and schizoaffective disorder. There was no assessment or care plan in Resident 109's clinical record that identified the PTSD diagnosis, symptoms and/or triggers related to this diagnosis or resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on August 31, 2023, at 11:20 a.m., the Social Services Director confirmed that there was no assessment completed or care plan developed to address Resident 99's or 109's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of weekly menus, clinical record review, observation, and interview, it was determined that the facility failed to accommodate each resident's food preferences for one of 27 sampled residents. (Residents 18) Findings include: Review of the breakfast menu for Tuesday, August 29, 2023, revealed that scrambled eggs, biscuit, banana, orange juice and cream of wheat were offered for breakfast. Clinical record review revealed that Resident 18 had a diagnosis of depression. Review of the Minimum Data Set (MDS) assessment, dated May 27, 2023, revealed the resident had moderate cognitive impairment and was able to clearly communicate. The care plan stated the resident had a risk for nutrition problems and staff was to honor the resident's food preferences. On August 29, 2023, at 9:33 a.m., the resident was heard yelling, This breakfast is horrible. The resident was observed eating scrambled eggs and a biscuit. Review of the resident's meal ticket that was on the breakfast tray revealed the resident disliked eggs and there were special instructions for no eggs at breakfast. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a) Resident rights.