Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's current status for one of 13 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus, muscle weakness, need for assistance with personal care, and major depressive disorder. A physician's orders dated April 21, 2024, July 22, 2024, and March 28, 2025, directed staff to apply and monitor an electronic monitoring device to the resident's arm. Review of the MDS assessments dated July 13, 2024, October 13, 2024, and January 13, 2025, section P indicated the resident did not use the electronic monitoring device. The MDS inaccurately reflected the use of an electronic monitoring device. In an interview on June 5, 2025, at 10:12 a.m., the Director of Nursing confirmed that Resident 2's MDS assessments were inaccurate and did not reflect the resident's current status.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 13 sampled residents. (Resident 29, 36) Findings include: Clinical record review revealed that Resident 29 had diagnoses that included congestive heart failure, coronary artery disease, and hypertension. A physician's order dated May 23, 2025, directed staff to weigh the resident daily. A review of the Medication Administration Record (MAR) for May and June 2025, and Treatment Administration Record (TAR) for May and June 2025, revealed that there was no evidence that staff weighed Resident 29 as ordered on May 25 and 26, 2025, and June 1 and 2, 2025. Clinical record review revealed that Resident 36 had diagnoses that included dementia, protein-calorie malnutrition, and chronic kidney disease. A physician's order dated April 29, 2025, directed staff to weigh the resident weekly. A review of the MAR and TAR for May 2025, revealed that there was no evidence that staff weighed Resident 36 as ordered between May 2 and May 27, 2025. In an interview on June 5, 2025, at 9:49 a.m. and 1:03 p.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted to weigh the residents as ordered. 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 resident and staff interview, it was determined that the facility failed to provide services to improve and/or maintain activities of daily living that included ambulation for three of 14 sampled residents. (Residents 2, 7, 40) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included a history of fractured ribs, vascular dementia, and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required supervision/touching assistance with ambulation. Review of the restorative program plan of care that was recommended by physical therapy on January 5, 2024, indicated that the recommendation was for a restorative ambulation program to be implemented by staff. The goal was for the resident to maintain the current level of mobility of walking 200 feet, two times a day with a roller walker and assistance of one person. A review of the current care plan revealed that the resident was on a restorative nursing program for ambulation. The intervention was for the resident to ambulate 200 plus feet with a walker and assist of one two times a day. Review of nursing documentation for the last 30 days revealed that there was a total of six times that the resident was only offered assistance with walking one time a day. In addition, there was a total of five days that there was no documented evidence that the staff had assisted the resident at all with the restorative ambulation program. Clinical record review revealed that Resident 7 had diagnoses that included polyosteoarthritis, age related physical disability and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was alert and used a walker for ambulation. On May 30, 2024, a physician documented that the resident was alert and communicative. Review of a physical therapy Discharge summary dated [DATE], indicated that the resident had met the goal of walking 50 feet with a walker, with supervision and stand by assistance for safety. The summary further indicated that the resident had reached maximum potential and the recommendation was for staff to provide a restorative program for ambulation. Review of the current restorative plan of care that had been initiated by physical therapy revealed that the resident was to ambulate 20 to 50 feet one to two times a day with a roller walker and assist of one with a gait belt. Review of nursing documentation for the last 30 days revealed that there was a total of 14 times that the resident was only offered assistance with walking one time a day. In addition, there was a total of three days that there was no documented evidence that the staff had not assisted the resident at all with the restorative ambulation program. In an interview on July 10, 2024, at 10:16 a.m., the resident stated that she does like to walk, but that she was not offered assistance to walk daily on a consistent basis. Clinical record review revealed that Resident 40 had diagnoses that included Alzheimer's disease, dementia, and high blood pressure. The MDS assessment dated [DATE], indicated that the resident had confusion, but could usually communicate with and understand others. Review of a physical therapy Discharge summary dated [DATE], indicated that the resident had met the goal of walking 75 feet with a walker, with a minimum of one assistance for safety. The summary further indicated that the resident had reached maximum potential and the recommendation was for staff to provide a restorative program for ambulation. Review of the current restorative plan of care that had been initiated by physical therapy revealed that the resident was to ambulate 50 to 100 feet daily with a roller walker and assist of one with a gait belt and a wheelchair to follow. Review of nursing documentation for the last 30 days revealed that there was a total of 15 days that there was no documented evidence that staff had assisted the resident at all with the restorative ambulation program. In an interview on July 11, 2024, at 9:30 a.m., the Director of Nursing stated that there was no documented evidence that the restorative ambulation programs had been consistently offered to the aforementioned residents as recommended by physical therapy. 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 treatment in accordance with physician's orders for one of three sampled residents with pressure ulcers. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included heart failure and muscle weakness. The Minimum Data Set assessment dated [DATE], indicated that the resident required assistance from staff for personal hygiene. Review of the care plan revealed that there was a risk for skin impairment related to the resident's fragile skin, decreased mobility, and incontinence. Review of a nursing note dated May 31, 2024, indicated that the resident had a new pressure related wound on the buttocks. On July 5, 2024, a physician ordered for staff to cleanse and provide a treatment to the wound twice a day on the day and evening shift and as needed for dislodgement of the dressing. Observation on July 10, 2024, at 9:45 a.m., of a wound treatment for Resident 15 with the licensed practical nurse (LPN1) revealed that the dressing to be removed had a date of July 9, 2024, and the initials matched those of the LPN1. In an interview at the time of the observation, LPN1 confirmed that the old dressing was the one placed, dated, and initialed from dayshift on July 9, 2024, and that the previous evening's treatment was not completed as ordered. In an interview on July 11, 2024, at 10:23 a.m., the Director of Nursing confirmed that the wound care had not been completed on the evening shift of July 9, 2024, as per the physician 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 and staff interview, it was determined that the facility failed to maintain clinical records that were accurate for three of 16 sampled residents. (Resident 25, 37, 109) Findings include: Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses that included osteoporosis and fracture of the lumbar vertebra. On June 1, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every four as hours as needed for severe pain. Review of the current care plan indicated that Resident 25 had pain related to her fracture and that staff was to utilized non medication interventions and administer as needed pain medication if non medication interventions were ineffective. Review of the Medication Administration Record (MAR) for June 1 through 21, 2023, revealed that Resident 25 received the as needed narcotic pain medication on 18 occasions. There was no documented evidence that staff offered non medication interventions prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 37 had diagnoses that included osteoarthritis and hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body following a stroke). On May 6, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every eight as hours as needed for severe pain. Review of the MAR for June 1 through 21, 2023, revealed that Resident 37 received the as needed narcotic pain medication on five occasions. There was no documented evidence that staff offered non medication interventions prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 109 was admitted to the facility on [DATE], with diagnoses that included osteoporosis. On June 14, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every four hours as needed for moderate pain. Review of the MAR for June 14 through 21, 2023, revealed that Resident 109 received the as needed narcotic pain medication on six occasions. There was no documented evidence that staff offered non medication interventions on five occasions prior to the administration of the as needed pain medication. In an interview on June 22, 2023, at 11:57 a.m., the Director of Nursing confirmed that staff offered but did not document non medication interventions prior to the administration of narcotic pain medication. 28 PA. Code 211.5(f) Clinical records.