Based on clinical record review, staff interview, and resident interview, it was determined that the facility failed to implement physician's orders for one of 14 sampled residents. (Resident 36) Findings include: Clinical record review revealed that Resident 36 had diagnoses that included a broken right ankle and diabetes. A physician's order dated April 30, 2025, directed staff to apply an anti-embolic stocking (a special sock to prevent blood clots) to the left leg daily and remove every night due to swelling. Observation on June 16, 2025, at 12:30 p.m. revealed that Resident 36 did not have the anti-embolic stocking applied to her left leg, and multiple observations on June 17, 2025 between 10:00 a.m. and 12:50 p.m., revealed that the stocking was not applied to Resident 36's left leg. Review of the Treatment Administration Record (TAR) for June 2025 revealed nurses' initials indicated that the anti-embolic stocking was applied in the morning and removed at bedtime on June 16, 2025 and June 17, 2025. In an interview on June 16, 2025 at 12:30 p.m., the resident stated that she has never had a stocking applied to her left leg. In an interview on June 18, 2025 at 11:45 a.m., the Director of Nursing (DON) confirmed that the order for the anti-embolic stocking to the left leg was an error and that the nurses should not have indicated that it was applied. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of a change in condition for one of 14 sampled residents. (Resident 34) Findings include: Review of facility policy entitled, Change in a Resident's Condition or Status, last reviewed January 30, 2023, revealed that the facility would promptly notify the resident's physician of changes in medical condition or status. Notification was to be made within 24 hours of a change occurring in the resident's medical condition or status. Clinical record review revealed that Resident 34 had diagnoses that included dislocation of left hip, anxiety, and depression. Review of a physical therapy evaluation dated October 20, 2022, revealed that the resident had pain and there was a length discrepancy to the left leg. Review of an x-ray report dated October 21, 2022, revealed that the resident had a dislocation to the left hip. Review of an undated staff statement revealed that the x-ray results were available and at the nursing unit for review on the evening of October 21, 2022. Review of a staff statement dated October 23, 2022, revealed that the x-ray results were reviewed with the certified nurse practitioner (CRNP) at 3:00 p.m., on October 23, 2022, and the resident was transferred to the hospital on the same date. There was no evidence that the CRNP was notified of the results of the x-ray report until October 23, 2022, more than 24 hours after the facility received the results. In an interview on June 14, 2023, at 12:51 p.m., the Assistant Director of Nursing confirmed that there was no evidence that the CRNP was notified of the x-ray results until October 23, 2022, and staff should have notified the CRNP within 24 hours. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to ensure that adaptive equipment to promote safety was provided for one of six residents sampled. (Resident R2) Findings include: Clinical record review revealed that Resident R2 had diagnoses that included dementia with behaviors that included care resistance and impulsiveness. An occupational therapy assesment of February 17, 2023, revealed that the resident had difficulty with self feeding and would often spill both food items and beverages. A Kennedy cup (a device with handles, a lid and straw) was ordered to assist with safe meal completion. The Minimum Data Set (MDS) assessment of March 1, 2023, revealed that the resident required staff assistance with meals. The care plan also noted the need for the Kennedy cup for beverages at meal time. A note by a nurse on April 21, 2023 at 12:00 p.m., revealed that the resident was at the dining table in preparation for the noon meal. The meal tray was placed in front of him as well as his beverages. The resident impulsively reached for his cup with coffee. The cup and beverage fell onto his lap. The resident sustained a reddened area requiring a cold compress. Staff had not provided the adaptive cup for the meal resulting in the resident spilling the beverage on himself. 28 Pa. Code 211.12(d)(1)(5) nursing services.