**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, it was determined that the facility failed to maintain accurate assessments for two of 35 residents reviewed (Residents 97 and 108). Findings include: Review of Resident 97's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated November 12, 2024, revealed under Section J - Health Conditions that the resident had two falls with major injury (bone fractures, joint dislocations, closed head injuries, or subdural hematomas) since admission/readmission or the prior assessment. Review of Resident 97's clinical record since the resident's admission to the facility on August 13, 2024, failed to reveal evidence of any falls with major injury. Interview with the Director of Nursing on December 5, 2024, at approximately 11:00 a.m. confirmed Resident 97 did not have any falls with major injury since being admitted to the facility and that the resident's MDS was coded inaccurately. Review of Resident 108's Quarterly MDS dated [DATE], revealed Resident 108 had a significant weight loss and a significant weight gain. Review of Resident 108's clinical record and weight summaries failed to reveal evidence of significant weight loss. Interview with the Director of Nursing on December 5, 2024 at 10:58 a.m. confirmed Resident 108 did not have a significant weight loss and that Resident 108's Quarterly MDS was coded inaccurately. 28 Pa. Code: 211.5(f) Clinical records 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, it was determined that the facility failed to ensure behavioral health services were offered in a timely manner for one of two residents reviewed for mood and behaviors (Resident 97). Findings include: Review of Resident 97's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, anxiety and other symptoms and signs involving emotional state. Review of Resident 97's progress notes revealed a nurse's note on August 14, 2024, which stated, Resident was resting in recliner, resident was crying earlier stating that she was ready to die, she does not want to harm herself but just ready to die. Further review of Resident 97's progress notes revealed a nurse's note on October 4, 2024, which stated, I went in at 10am. to give meds. and resident was still in bed. She said 'I just want to die, I can't get up in the mornings anymore'. I asked her if she feels depressed, she said yes. [Physician] was here and notified. Review of Resident 97's physician progress notes revealed a physician note on October 4, 2024, which stated: I spoke with nursing who reports that patient sometimes wakes up [stating] she does not want to live anymore, and does not want to get out of bed. Further review of the physician note revealed: I did offer her medication, which is not inclined to take, and I agree with her. She does like to have good conversations and appreciates when someone takes the time to listen to her, and I think this will be the best treatment for her. Review of Resident 97's physician's orders revealed an order dated October 18, 2024, for behavioral health (psychology) evaluation and treatment for increased depression and anxiety. Review of Resident 97's progress notes revealed a Behavioral Note from the psychologist on November 27, 2024 to evaluate the resident for depression and anxiety. The delay in obtaining a psychology evaluation for Resident 97 was discussed with and confirmed with the Director of Nursing on December 5, 2024, at approximately 9:30 a.m. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to administer as needed pain medications for appropriate pain levels and prior to non-pharmaceutical interventions for two of 40 residents reviewed. (Residents 42 and 270) Findings include: Review of facility policy and procedure titled Pain Assessment and Management Record Procedure, undated, revealed evaluation of pain (pain scale) and alternative interventions are used and documented in conjunction with oral medications. Review of Resident 42's physician orders revealed an order dated June 15, 2023, Hydrocodone (narcotic pain reliever) with Acetaminophen (Tylenol) Tablet 5-325 MG (milligrams); Give 1 tablet by mouth every four hours as needed, for pain/ back/ behavior. A list of interventions are also noted 1-22. Review of Resident 42's Medication Administration Record for September, October, and November 2023 revealed the resident received the medication for undocumentated pain level and undocumented non-pharmaceutical interventions (NPI's) a total of one time (October 27). Undocumented NPI's a total of five times (September 29, October 1 and 7, and November 5 and 19, 2023). Review of Resident 270's physician orders revealed an order dated July 3, 2023, Tramadol (opioid pain medication) by moth every six hours as needed for chronic back pain; behavior. A list of interventions are noted 1-22. Review of Resident 270's Medication Administration Record for October, November, December 2023, revealed the resident received the medication with undocumented NPI's a total of 18 times (October 6, 7, 14, 21, 22, 28, November 12, 17, 26, 28, December 1, 2, 3, 9, 16, 17, 23, 30, and 31, 2023). Interview with the Director of Nursing and the Nursing Home Administrator on January 24, 2024, at 10:30 a.m. confirmed prn pain medications were not administered with documented NPI's and the prn pain medications for Resident 42 did not include a pain level per policy. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services