Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included cervical disc disorder with myelopathy (spinal cord compressed in the neck), chronic pain, constipation, and muscle weakness. In an interview on June 5, 2025, at 10:50 a.m., Resident 1 stated that he did not receive his simethicone medication (medication to relieve bloating, pressure, and fullness; commonly referred to as gas) for the past four days and that he had severe gas pain. A physician's order dated January 24, 2025, directed staff to administer simethicone twice a day. Nursing documentation dated June 3, 2025, at 10:07 a.m., revealed the pharmacy did not have simethicone available. Further documentation on that date revealed that the physician was made aware that the medication was not available at 5:57 p.m. At that time, the physician ordered the simethicone to be administered twice a day as needed. Review of Resident 1's Medication Administration Record revealed that staff did not administer the simethicone on June 1 through June 4, 2025. In an interview on June 5, 2025, at 1:45 p.m., the Director of Nursing confirmed the medication was not available and administered as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 15 sampled residents. (Resident 52) Findings include: Clinical record review revealed that Resident 52 had diagnoses that included bacteremia (bacteria in the blood), congestive heart failure, and respiratory failure. A physician's order dated June 30, 2024, directed staff to weigh the resident daily and to notify the doctor for a weight gain of two or more pounds (lbs.) in one day. On July 20, 2024, the resident weighed 88.2 lbs. On July 21, 2024, the resident weighed 90.2 lbs., which reflected a weight gain of two lbs. in one day. There was no evidence that staff notified the doctor of the weight change per the order. A review of physician's orders dated July 1 through 9, 2024, and the Medication Administration Record for July 2024, revealed the following: Staff were to change administration tubing with the first dose of ampicillin (an antibiotic) daily. There was no evidence that the tubing was changed as ordered on two occasions. Staff were to administer ceftriaxone sodium (an antibiotic) two grams (g) intravenously (IV) every 12 hours daily. There was no evidence that the medication was administered as ordered on one occasion. Staff were to administer florastor oral capsule 250 milligrams (mg) two times per day. There was no evidence that the medication was administered as ordered on one occasion. Staff were to administer heparin sodium (a blood thinner) five milliliters (ml) via IV. There was no evidence that it was administered on ten occasions. Staff were to administer normal saline 10 ml via IV. There was no evidence to support that it was administered on 19 occasions. Staff were to replace a green antimicrobial cap to each port. There was no evidence that the cap was replaced on 10 occasions. Staff were to administer ampicillin sodium (an antibiotic) 2000 mg via IV three times per day. There was no evidence that the medication was administered as ordered on seven occasions. In an interview on July 25, 2024, at 10:00 a.m. the DON confirmed that there was no evidence staff notified the physician of the weight change or that staff administered the medications or treatments as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 40) Findings included: Review of the facility policy entitled, Catheter Care, last reviewed July 9, 2024, revealed that when a resident had a urinary catheter, an intervention was to prevent the urine in the tubing and drainage bag from flowing back into the bladder. Staff was to ensure that the urinary drainage bag be located below the level of the bladder, but not on the floor, and covered at all times. Clinical record review revealed that Resident 40 had diagnoses that included chronic obstructive pulmonary disease and congestive heart failure. The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance from staff for activities of daily living and had an indwelling urinary catheter. The current care plan revealed that Resident 40 had an indwelling catheter and was at increased risk for infection. On July 23, 2024, from 11:22 a.m. to 12:13 p.m., and again from 1:50 p.m. to 2:10 p.m., Resident 40 was observed in bed with the catheter drainage bag hanging off the bed, uncovered, and directly touching the floor. On July 24, 2024, from 8:25 a.m. to 8:50 a.m., Resident 40 was observed in bed with the catheter drainage bag hanging off the bed, uncovered, and directly touching the floor. In an interview on July 25, 2024, at 11:22 a.m., the Nursing Home Administrator confirmed that the catheter bag should not be uncovered and on the floor. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for one of 13 sampled residents. (Resident 21) Findings include: Clinical record review revealed that Resident 21 had diagnoses that included a right humerus fracture, right ankle contusion, muscle wasting and atrophy (shrinking of muscles). On July 12, 2023, a physician ordered that staff administer a pain medication (oxycodone) every six hours as needed for pain. Review of the medication administration record (MAR) revealed that the resident received the as needed narcotic pain medication 30 times in July 2023, and 14 times in August 2023. There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to or in conjunction with the administration of the as needed narcotic pain medication. In an interview on August 17, 2023, at 8:30 a.m., the Director of Nursing confirmed that there was no documented evidence staff offered non-pharmacological interventions prior to administration of the as needed pain medication. 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 staff interview, it was determined that the facility failed to offer non-pharmacological interventions prior to the administration of as needed anti-anxiety medications for two of 13 sampled residents. (Residents 8, 199) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included Alzheimer's disease and difficulty in walking. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment. On July 26, 2023, and August 12, 2023, the physician ordered an anti-anxiety medication, alprazolam, be given every eight hours as needed for 14 days. Review of the medication administration record (MAR) for July 2023, revealed that staff had administered the as needed alprazolam five times. Review of the MAR for August 2023, revealed that staff had administered the as needed alprazolam 10 times. There was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. Clinical record review revealed that Resident 199 had diagnoses that included chronic ulcer of the right lower leg, anxiety, and hearing loss. The MDS assessment dated [DATE], indicated that the resident had memory impairment and exhibited verbal and other behavioral symptoms one to three days in the assessment period. On August 4, 2023, the physician ordered an anti-anxiety medication, lorazepam, to be given every 12 hours as needed for 14 days. Review of the MAR for August 2023, revealed that staff had administered the as needed lorazepam 10 times. There was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. In an interview on August 17, 2023, at 8:35 a.m., the Administrator confirmed that there was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. 28 Pa. code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to notify residents' responsible parties of a significant weight change and a pressure ulcer for two of 18 sampled residents. (Residents 52, 71) Findings include: Review of the facility policy entitled, Weight Policy, dated July 15, 2022, revealed that a resident's responsible party or family would be notified of a significant weight loss. Clinical record review revealed that Resident 52 had diagnoses that included Alzheimer's dementia, chronic obstructive pulmonary disease, and left femur fracture. Review of the Minimum Data Set (MDS) assessment, dated August 19, 2022, revealed the resident had cognitive impairment and had a weight loss of five percent or more in the last month. Review of Resident 8's care plan revealed that the resident was at risk for nutrional problems. On August 10, 2022, the resident weighed 139.4 pounds (lbs). On August 17, 2022, Resident 52 weighed 119.4 lbs, a 14.35 percent weight loss. There was no evidence that Resident 52's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 71 had diagnoses that included dementia, adult failure to thrive, and atrioventricular block (heart block). Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairment and three stage two pressure ulcers. Review of nursing documentation revealed that on August 29, 2022, the resident developed an open area to the left buttock, classified as a stage two pressure ulcer. On September 6, 2022, a nurse documented that Resident 71 developed open areas on his right buttocks and lower middle spine, both classified as stage two pressure ulcers. There was no documentation to support that Resident 71's responsible party was notified of the development of the three pressure ulcers. In an interview on September 22, 2022 at 10:21 a.m., the Administrator confirmed there was no documentation to support that Resident 52's responsible party was notified of the significant weight loss or that Resident 71's responsible party was notified of the development of pressure ulcers. 28 Pa Code 211.12(d)(1)(5) Nursing services.