**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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for two of 24 sampled residents. (Residents 27, 78) Findings include: Clinical record review revealed that Section N (Medications) of Resident 27's MDS assessment dated [DATE], indicated that the resident was not on an antipsychotic medication during the seven-day review period. Review of the resident's Medication Administration Record from June 2025 revealed that the resident did receive an antipsychotic (lurasidone) during the seven-day review period. Clinical record review revealed that section O (Special treatments, procedures, and programs) of the MDS assessment dated [DATE], indicated that Resident 78 did not receive tracheostomy care during the seven-day review period. Review of Resident 21's Treatment Administration record from July 2025 revealed that the resident did receive tracheostomy care during the seven-day review period. In an interview on August 13, 2024, at 2:26 p.m., Registered Nurse Assessment Coordinator 1 confirmed the MDS assessments had not accurately reflected the residents' status and had to be modified by the facility. CFR 483.20(g) Accuracy of AssessmentsPreviously cited 7/12/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that the facility failed to provide treatment and services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for two of 24 sampled residents. (Residents 27, 78) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included muscle weakness and difficulty in walking. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required limited assistance from staff for activities of daily living. On April 17, 2025, the physical therapist had recommended a Restorative Nursing Program (RNP) for ambulation. A physician's order dated April 17, 2025, directed staff to provide the RNP for 15 minutes twice a day, seven days a week. There was a lack of documentation to support that between July 16, 2025, through August 13, 2025, the resident was offered restorative ambulation twice a day, as ordered, on 30 of 30 days. Clinical record review revealed that Resident 78 had diagnoses that included anoxic brain damage (lack of oxygen to the brain), persistent vegetative state, and right and left-hand contractures. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for all activities of daily living. A physician's order dated June 7, 2024, directed staff to provide a RNP for passive range of motion to the upper extremities, fingers and shoulders,15 minutes twice a day, seven days a week. On May 7, 2025, the occupation therapist recommended a range of motion program be continued for the bilateral should and fingers. There was a lack of documentation to support that between July 15, 2025, and August 12, 2025, the resident was offered the RNP twice a day, as ordered, on 18 of 30 days. In an interview on August 14, 2025, at 10:05 a.m. the Director of Nursing confirmed that there was no documented evidence that the RNPs were offered on the previously mentioned dates, twice a day, as ordered, to Residents 27 and 78 consistently. In an interview on August 14, 2025, at 11:15 a.m., the Director of Rehabilitation stated Resident 27 needed the RNP for mobility and Resident 78 needed the RNP for hand contractures. CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/MobilityPreviously cited 7/12/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (1A, 1B, 2A, 2B)Findings include:Observations on August 12, 2025, from 9:00 a.m. through 12:17 p.m. revealed the following:Debris and a dark/black substance splattered throughout the hall floors of Units 1A, 1B, 2A, and 2B and rooms 101, 109, 110, and 115.The floor in 217 had red and brown spots between the beds.There were brown spots on the ceiling in the hallway at room [ROOM NUMBER].There were red spots on the wall by the door in room [ROOM NUMBER]. The radiator in the resident lounge was broken with sharp, loose parts lying on the floor. The wall by the left entrance door in the main dining room was damaged. The wall behind both beds in room [ROOM NUMBER] was damaged. The ceiling and wall behind the toilet in room [ROOM NUMBER] were damaged. The mirrors were damaged in the bathrooms in rooms 217, 224, 308, 309, and 310.There were flying winged insects noted around the nurse's station of section 1A and in room [ROOM NUMBER]. Observations on August 13, 2025, at 9:15 a.m. through 11:31 a.m., revealed the following:A strip of peeling wood sticking out of the bottom of the closet door for room [ROOM NUMBER] bed two. Debris and a dark/black substance splattered throughout the hall floors of Unit 1A and rooms 101, 109, 110, and 115.Flying winged insects were noted throughout the hallway in section 1A and in room [ROOM NUMBER].The wall was damaged by the resident's bed in room [ROOM NUMBER]. Observations in the shower room across from nurse's station intersecting halls 100-300 on August 13, 2025 at 11:30 a.m., revealed:The shower room had a musty smell.A grey and brown residue on the floor tiles in all three shower stalls. A yellow substance on the shower chair in the first stall. The non-skid strips in the first and third shower stalls were worn. A residue on all three shower curtains. All three shower curtains were missing hooks. A black substance on the non-skid mat in the third shower stall. A brown and red substance on the floor in front of the scale.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to administer medications in accordance with physician orders for four of 24 sampled residents. (Residents 2, 6, 19, 34)Findings include: Review of the policy entitled, Medication Administration, last reviewed July 14, 2025, revealed staff were to obtain vital signs if necessary, and document physician indicated medication administration information.Clinical record review revealed that Resident 2 had diagnosis of hypertension (high blood pressure). On April 3, 2025, the physician ordered staff to administer a blood pressure medication (lisinopril) one time a day. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg) or if the resident's heart rate (the number of times a heart beats in one minute) was less than 60 bpm (beats per minute). Review of Resident 2's Medication Administration Records (MAR) for May, June, July, and August 2025, revealed that staff administered the medication three times in May, five times in June, and three times in July when the resident's SBP was below 110 mm/Hg. Review of Resident 2's MARs for May and June 2025, revealed no evidence that staff obtained the resident's heart rate prior to administration of the medication on 23 occasions in May 2025, and 16 occasions in June 2025.Clinical record review revealed that Resident 6 had diagnoses that included atrial fibrillation (irregular heartbeat) and hypertension (high blood pressure). On June 5, 2025, the physician ordered staff to administer a blood pressure medication (midodrine) two times a day for orthostatic blood pressure (a drop in blood pressure when changing positions) and to monitor for supine (laying) and sitting blood pressures. Review of Resident 6's care plan revealed an intervention to monitor blood pressure as ordered. Physician's notes dated June 6 and June 21, 2025, July 9, 21, and 26, 2025, and August 6, 2025, revealed staff were to continue to monitor the resident's blood pressure. There was no documented evidence that staff monitored Resident 6's blood pressure as ordered by the physician.Clinical record review revealed that Resident 19 had diagnoses that included congestive heart failure and type 2 diabetes. A physician's order dated May 3, 2025, directed staff to weigh the resident daily. Review of Resident 19's MAR for May, June, July, and August 2025, revealed no evidence that the resident's weights were obtained per physician's orders on six occasions in May, three occasions in June, four occasions in July, and three occasions in August 2025.Clinical record review revealed that Resident 34 had diagnoses that included hypertension and chronic kidney disease. On July 30, 2022, the physician ordered staff to administer a blood pressure medicine (metoprolol succinate) one time a day. Staff were not to administer the medication if Resident 34's heart rate was less than 60 bpm. Review of Resident 34's MAR for June, July, and August 2025, revealed no evidence that staff obtained the resident's heart rate prior to administration of the medication on 72 occasions.In an interview on August 14, 2025, at 10:10 a.m., the Director of Nursing confirmed that Resident 19's weights were not completed daily per the physician's orders and medications were administered outside of the established parameters for Residents 2, 6, and 34.28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and a review of facility documentation, it was determined that the facility failed to accommodate resident food allergies one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and that he was allergic to bananas. On March 31, 2025, a nurse noted that the resident reported that he had been served yogurt containing bananas at dinner. In an interview on April 5, 2025, at 8:30 a.m., the resident stated that he had recently been served yogurt containing bananas, and that it happened several times before. Review of facility investigation documents confirmed that on March 31, 2025, the resident was served yogurt containing bananas and that he ingested a small amount. The facility investigation further revealed that he had been served food containing bananas on three prior occasions. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b) Management.

**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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for two of 20 sampled residents. (Residents 11, 21) Findings include: Clinical record review revealed that Section N (Medications) of Resident 11's MDS assessment dated [DATE], indicated that the resident was not on an opioid medication during the seven-day review period, however review of the resident's record revealed that the resident did receive an opioid (tramadol) during the seven-day review period. Clinical record review revealed that section P of the MDS assessment dated [DATE], indicated that Resident 21 used a chair or other alarm less than daily during the seven-day review period. Review of Resident 21's clinical record revealed that the resident was not ordered and did not use a chair or other alarm during the seven-day review period, as inaccurately identified on the MDS assessment. In an interview on July 12, 2024, at 9:50 a.m., the Nursing Home Administrator confirmed the MDS assessments had not accurately reflected the residents' status and had to be modified by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for two of 20 sampled residents. (Residents 16, 40) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included bilateral hand contractures and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required assistance from staff for activites of daily living including personal hygiene. On July 11, 2024, at 10:35 a.m., Resident 16 was observed in his wheelchair and his fingernails and beard were long. The resident stated that he preferred his nails and beard to be short and that he had asked for them to be cut. Clinical record review revealed that Resident 40 had diagnoses that included diabetes mellitus and hypertension. Review of the MDS assessment dated [DATE], revealed that the resident required assistance from staff for activities of daily living including personal hygiene. On July 11, 2024, at 10:50 a.m., the resident was observed in his room with long, discolored fingernails with sharp edges. He had a bandage to his right hand and stated that he had scratched himself. The resident further stated that he preferred his nails to be short and that staff had not provided nail care. In an interview on July 11, 2024, at 2:45 p.m., the Director of Nursing stated that nail care was to be completed on resident shower days (twice a week). 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 ensure each resident received timely treatment and services to maintain hearing abilities for one of 20 sampled residents. (Resident 33) Findings include: Clinical record review revealed that Resident 33 had diagnoses that included diabetes mellitus and congestive heart failure. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had some difficulty hearing and used a hearing appliance. In an interview on July 10, 2024, at 1:00 p.m., Resident 33 stated that she has not received her hearing aides and has been waiting almost a year. Review of facility documentation revealed that on August 9, 2023, Resident 33 was seen by audiology and the physician determined that she would benefit from hearing aides. There was no documented evidence that the resident received hearing aides or that facility addressed this recommendation until July 11, 2024. In an interview on July 12, 2024, at 12:40 p.m., the Nursing Home Administrator confirmed that the facility did not address the recommendation until July 11, 2024.

Based on clinical record review and observation, it was determined that the facility failed to provide adaptive equipment to assist with eating meals for one of 20 sampled residents. (Resident 44) Findings include: Clinical record review revealed that Resident 44 had diagnoses that included aspiration pneumonia and dysphagia. On May 13, 2024, the physician ordered for staff to provide assistance to Resident 44 at meals and for all food to be served in bowls. The care plan indicated that the resident was to receive her food in bowls. On July 9, 2024, from 11:45 a.m. through 12:30 p.m., the resident was observed in the dining room for lunch. She was served her meal on a regular plate. The resident was feeding herself and had a large amount of food spilt on her clothing protector. In an interview on July 12, 2024, at 12:20 p.m., the Director of Nursing confirmed that the resident should have received her food in bowls. 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 interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for two of 20 sampled residents. (Residents 11, 21) Findings include: Clinical record review revealed that Resident 11 had diagnoses that included traumatic brain injury, functional quadriplegia (complete inability to move due to severe disability), and bilateral hand contractures. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for all activities of daily living. Review of Resident 11's current care plan revealed that the resident is at high risk for contractures due to immobility and that staff was to provide a restorative nursing program for passive range of motion to bilateral upper extremities at fingers and shoulders to reduce risk for further contracture twice a day. There was a lack of documentation to support that the resident was offered restorative range of motion on 18 of 30 days. Clinical record review revealed that Resident 21 had diagnoses that included chronic pain and osteoarthritis. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and required limited assistance from staff for activities of daily living. In an interview on July 10, 2024, at 10:55 a.m. Resident 21 stated no one was walking him like they were supposed to. Review of Resident 21's current care plan revealed that he had self-care performance deficit due to his physical limitations and that staff was to provide a restorative nursing program to ambulate with a four wheeled walker and gait belt, with assistance of one staff person with a wheelchair to follow 50 to 125 feet twice a day. There was a lack of documentation to support that the resident was offered restorative ambulation on 17 of 30 days. In an interview on July 12, 2024, at 12:25 p.m. the Nursing Home Administrator confirmed that there was no documented evidence that the restorative nursing programs were completed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards on two of four nursing units. (Station 2A, Station 2B) Findings include: Observation on July 9, 2024, from 10:48 a.m. through 10:57 a.m., on Station 2A, medication in applesauce was left unattended on top of the medication cart. The medication was accessible to three cognitively impaired, mobile residents in the area. Observation on July 10, 2024, from 09:03 a.m. through 09:16 a.m., on Station 2B, medication in vanilla pudding was left unattended on top of the medication cart. The medication was accessible to three cognitively impaired, mobile residents in the area. In an interview on July 11, 2024, at 02:45 p.m., the Nursing Home Administrator confirmed that medication should not be unattended on the medication cart. 28 Pa. Code 211.12(d)(1)(5) Nursing services.