Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 18 sampled residents. (Resident 24) Findings include: Clinical record review revealed that Resident 24 had diagnoses that included congestive heart failure and hypertension. A physician's order dated May 6, 2024, directed staff to weigh the resident daily and to call cardiology with a three pound weight gain in one day or a five pound weight gain in one week. Review of Resident 24's Medication Administration Record (MAR) for February and March 2025, revealed that Resident 24 had more than a three pound weight gain on February 2, 18, 24, and 26, 2025, and March 3 and 16, 2025. There was no documented evidence to support that the cardiologist was notified of the weight gain on the aforementioned dates. Further review of Resident 24's clinical record revealed on January 24, 2025, the physician ordered staff to administer a medication (carvedilol) twice a day for hypertension. Staff were not to administer the medication 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 mercury (mm/Hg) or if the resident's heart rate was less than 60. Review of the MAR for February and March 2025 revealed that staff administered the medication on February 23 and 24, 2025, and March 17, 2025, when Resident 24's SBP was less than the ordered parameters. In an interview on March 20, 2025, at 9:37 a.m., the Director of Nursing confirmed that there was no documented evidence that the cardiologist was notified of the weight gain and the medication was administered outside of the ordered parameters. CFR(s) 483.25 Quality of Care Previously cited 4/4/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of two sampled residents who required adaptive equipment with meals. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included Parkinson's disease, dementia, and dysphagia. Review of the care plan revealed that the resident was at risk for nutrition problems with an intervention for adaptive equipment. The intervention was for staff to provide a partitioned scoop dish on blue Dycem (non-slip material that prevents objects from slipping), and weighted utensils for all meals. On March 18, 2025, from 12:15 p.m. through 12:30 p.m., and on March 19, 2025, from 12:10 p.m. through 12:20 p.m., Resident 6 was observed in the dining room without a partitioned scoop dish, blue Dycem, and weighted utensils. In an interview on March 20, 2025, at 9:27 a.m., the Director of Nursing confirmed that the resident should have received the partitioned scoop dish, blue Dycem, and weighted utensils. 28 Pa. Code 211.12(d)(1)(3)(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 implement physician's orders and follow bowel protocol for one of 18 sampled residents. (Resident 44) Findings include: Review of the facility policy entitled, Bowel Management, last reviewed January 8, 2024, revealed that staff on all shifts were to monitor a resident's bowel movements and take action to prevent complications of constipation and/or fecal impaction. The resident's bowel movements were to be charted daily in the clinical record. Staff were to administer an oral laxative for no bowel movement in nine shifts. If ineffective, staff were to administer a suppository the following shift. If the suppository was ineffective, staff were to administer an enema on the following shift. Clinical record review revealed that Resident 44 had diagnoses that included muscle weakness and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of the care plan revealed the resident had a history of constipation and staff were to administer bowel protocol medications as needed. Review of physician's orders dated February 10, 2024, directed staff to administer magnesium hydroxide suspension (an oral laxative) as needed for no bowel movement in nine nursing shifts, a Dulcolax suppository as needed if an oral laxative was ineffective, and an enema as needed if the Dulcolax suppository was ineffective. An additional physician's order dated February 19, 2024, directed staff to administer a bisacodyl suppository as needed for constipation. Review of documentation and medication administration records for March and April 2024, revealed no evidence that the resident had a bowel movement March 5 through 8 (12 shifts), March 10 through 13 (12 shifts), March 21 through 25 (15 shifts), and March 28 through April 2 (18 shifts). There was no documentation to support that physician's orders and facility policy for bowel management were implemented to address Resident 44's constipation/lack of bowel movements on the identified dates/shifts. In an interview on April 4, 2024, at 11:07 a.m., the Director of Nursing confirmed that staff did not implement the physician's orders or follow bowel protocol per the facility policy. 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 that catheter care and services were consistently provided for one of one sampled residents with an indwelling urinary catheter. (Resident 47) Findings included: Clinical record review revealed that Resident 47 was admitted to the facility on [DATE], with diagnoses that included benign prostatic hyperplasia (enlarged prostate), urinary tract infection, and retention of urine. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment and had an indwelling urinary catheter. Review of Resident 47's current care plan revealed that the resident had an indwelling catheter with an intervention to follow up with the urologist. In an interview on April 2, 2024, at 12:01 p.m., Resident 47 stated staff did not assist him consistently with catheter care. On November 22 and 27, 2023, the nurse practitioner documented that the resident was to have follow-up with the urologist and that staff was to assist the resident with catheter care every shift. On February 14, 2024, the nurse practitioner again documented that the resident was to follow-up with the urologist for further evaluation. Review of the catheter care task documentation from March 5, 2025 through April 3, 2024, revealed three shifts with missing documentation, 18 shifts documented as not applicable, and one shift documented as not completed. There was also a lack of documentation to support that Resident 47 had been seen by the urologist in a timely manner as recommended by the nurse practitioner. In an interview on April 4, 2024, at 11:22 a.m., the Director of Nursing confirmed that there was no documentation to support the urinary catheter care had been consistently completed and that Resident 47 had not seen by a urologist in a timely manner. 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 staff interview, it was determined that the facility failed to adequately monitor and assess significant weight loss for one of two sampled residents at risk for weight loss. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included Alzheimer's disease, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. Review of mini nutrition assessments dated December 28, 2023, and March 27, 2024, indicated that the resident was at risk for malnutrition. On October 5, 2023, the resident weighed 175.3 pounds (lbs.). On November 6, 2023, the resident weighed 164.2 lbs., which reflected a significant weight loss of 6.3%. There was no evidence that a dietitian assessed or addressed the significant weight loss until December 1, 2023. On January 8, 2024, the resident weighed 167.6 lbs. On February 5, 2024, the resident weighed 156.4 lbs., which reflected a significant weight loss of 6.6%. There was no evidence that a dietitian assessed or addressed the significant weight loss until February 19, 2024. In an interview on April 4, 2024, at 10:16 a.m., Dietitian 1 confirmed that the significant weight loss was not assessed or addressed in a timely manner. 28 Pa Code 211.12(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to ensure that the facility environment remained free of accident hazards in the shower room. (Spa 3665) Findings include: During multiple observations of the shower room from May 16, 2023, at 11:50 a.m., to May 17, 2023, at 12:55 p.m., a cabinet was unlocked and contained a package of disposable razors, shaving cream, deodorant, barrier cream, body lotion, anti-itch cream, a hairdryer and toothpaste. There was no locking mechanism on the door to the shower room to prevent a resident from entering the room. In an interview on May 16, 2023, at 1:00 p.m., the Director of Nursing stated that there were eight residents that resided on the nursing unit that were ambulatory and cognitively impaired. 28 Pa. Code 211.12(d)(5) Nursing services.