**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan for resident and care needs for one of eight residents (Resident R3). Findings include:Review of the facility policy Care Plan and Interdisciplinary Care Conference dated 1/29/25, indicated an individualized, interdisciplinary care plan is initiated within 24 hours for each resident as part of the delivery process. The care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals.Review of the clinical records indicated Resident R3 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/14/25, included diagnoses of history of transient ischemic attack (TIA) and cerebral infarction without residual deficit (a TIA is a temporary blockage of blood flow in the brain and cerebral infarction is a stroke that does cause permanent damage to brain tissue. This diagnosis means that the patient experienced has experienced both and at that time did not have lasting neurological deficits), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), morbid obesity(having too much body fat, which increases the risk of health problems), chronic pain syndrome (persistent pain lasting longer than 3 months, significantly impacting daily life), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (common consequence of a cerebral infarction (stroke) affecting one side of the body), diabetes (blood sugar too high or too low).Review of Resident R3's facility diagnosis list included history of transient ischemic attack and cerebral infarction without residual deficits, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic pain syndrome, diabetes.Review of the clinical record revealed that Resident R3's comprehensive care plan initiated on 6/20/25, failed to include plans of care with goals and interventions for diabetes. Review of the diagnoses list revealed the diagnosis of diabetes was added on 6/20/25 after resident had been transferred to the hospital for evaluation of symptoms (diaphoresis (sweating), thirsty, blurred vision, headache, elevated blood sugar levels) related to new diagnosis of diabetes.During an interview on 7/31/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop and implement a comprehensive care plan for resident and care needs for one of eight residents.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(5) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide ordered fall mats to prevent possible injuries for one of four residents (Resident R60). Findings include: Review of the facility policy Accidents and Incidents dated 1/26/23, indicated the facility will promote a safe environment for all residents. The policy further indicated the licensed nurse responsible for the resident will update residents plan of care as necessary related to the incident / accident. Review of Resident R60's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R60's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 8/10/23, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), osteoporosis (condition when the bones become brittle and fragile), and a seizure disorder. Review of nursing review assessment and progress note, completed 8/5/23, at 4:14 a.m. indicated Resident R60 was at high risk for falls. Review of a facility provided Fall Huddle Tip Sheet dated 8/11/23, indicated Resident R60 had sustained a fall, and an immediate intervention of fall mats was put into place. Review of a physician's order dated 8/11/23, indicated, Mats and bed pillows to both sides of bed for her safety. Review of a facility provided incident report dated 8/14/23, at 11:10 p.m. indicated Resident R60 had sustained a fall with no injury, and further indicated new intervention was to apply floor mats. During an interview on 8/31/23, at 12:33 p.m. the Director of Nursing confirmed that fall mats were not in place at the time of the second fall, as ordered. During an interview on 8/31/23, at 1:45 p.m the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide ordered fall mats to prevent possible injuries for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.