**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 complete an accurate Minimum Data Set (MDS) assessment for two of 12 sampled residents. (Residents 19 and 29) Findings include: Clinical record revealed that Resident 19 had diagnoses that included cognitive communication deficit and major depressive disorder. Review of the MDS assessment dated [DATE], revealed that Sections C (the Brief Interview for Mental Status) and D (the Mood assessment/interview) were incomplete. Clinical record review revealed that Resident 29 had diagnoses that included dementia and nontraumatic intracranial hemorrhage (bleeding within the brain in the absence of trauma or surgery). On December 21, 2024, the physician ordered that the facility provide hospice services. Review of the MDS assessment dated [DATE], revealed no documentation that resident had hospice services in place during the review period. The MDS assessment inaccurately reflected that the resident was not receiving hospice services. In an interview on May 21, 2025, at 12:50 p.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident 19's and 29's MDS assessments were inaccurate.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 12 sampled residents. (Resident 7) Findings include: Review of the policy entitled, Medication Administration, last reviewed January 31, 2025, revealed staff was to obtain vital signs if necessary, and document in the medical record the physician ordered medication administration information. Clinical record review revealed that Resident 7 had diagnoses that included atrial fibrillation (an irregular heartbeat), chronic kidney disease, and hypertensive retinopathy (damage to the retina caused by chronic high blood pressure). On July 15, 2024, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff was not to administer the medication if the heart rate was less than 60 beats per minute or if the resident's systolic blood pressure (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). Review of Resident 7's April and May 2025 Medication Administration Records revealed that staff administered or held the medication 86 times with no documentation that the heart rate and blood pressure were assessed prior to medication administrating or holding of the medication per physician's order. In an interview on May 21, 2025, at 10:30 a.m., the Director of Nursing confirmed there was no documented evidence that the heart rate or the blood pressure were taken prior to medication administrating or holding of the medication per physician's order and they should have been there for Resident 7. 28 Pa. Code 211.10(d) Resident care policies. 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, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of two sampled residents with limited range of motion. (Resident 26) Findings include: Clinical record review revealed that Resident 26 had diagnoses that included dementia, muscle weakness, and other abnormalities of gait and mobility. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had cognitive impairment and was dependent on staff for personal hygiene and dressing. Review of the physical therapy progress note dated February 11, 2025, indicated that resident had limited range of motion to his right foot. On March 3, 2025, the physician ordered that staff apply a MAFO (molded ankle foot orthosis-a custom made brace that provided support and control) in Velcro closure sneakers to be worn at all times on the right foot when Resident 26 was out of bed. Observations on May 20, 2025, at 10:30 a.m. and 12:11 pm, and on May 21, 2025, at 9:00 a.m., revealed that Resident 26 was in his wheelchair without the MAFO brace on. In an interview on May 21, 2025, at 10:58 a.m., the Therapy Director confirmed that the resident was identified with a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of his right foot, and that the MAFO brace should have been on when the resident was observed.

Based on policy review, observation, and staff interview, it was determined that the facility failed to administer medications in a manner that prevents the spread of infections on one of two nursing units. (West Wing) Findings include: Review of the facility policy entitled, Infection Control Plan: Standard Precautions, last reviewed January 31, 2025, revealed that gloves should be worn whenever exposure to the mucus membranes (soft tissue that lines the body's canals and organs, such as the eye) is planned or anticipated. On May 20, 2025, at 9:11 a.m., Licensed Practical Nurse (LPN) 1 was observed administering medications to Resident 33. The nurse applied Ocusoft lid scrubs to the eyes of the resident with her ungloved hands. In an interview on May 21, 2025, at 9:30 a.m., the Director of Nursing confirmed that the nurse should have been wearing gloves to administer medications around the eyes. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined the facility failed to store food under sanitary conditions in the dietary department. Findings include: Review of the facility policy entitled, Storage of Food and Supplies, dated November 23, 2022, revealed that all food, non food items, and supplies used in food preparation were to be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Observation during the initial kitchen tour on May 2, 2023, at 9:48 a.m., revealed in the cook's cooler that all ten of the wire shelves had rust and peeled and chipped paint on the bottom and top and along the length of the wire shelves. There was an unwrapped eggplant stored directly on the shelves. In an interview conducted on May 4, 2023, at 10:00 a.m., the Administrator confirmed the presence of rust and paint in the cook's cooler. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.6(c) Dietary services.