Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 36 sampled residents. (Residents 36 and 82) Findings include: Clinical record review revealed that Resident 36 had diagnoses that included depression, dementia, anxiety, and hallucinations. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated August 2, 2024, noted that the resident's psychotropic medication was to be addressed in the care plan. An MDS summary dated January 20, 2025, noted that the resident's psychiatric disorders continued. There was no evidence that interventions to address Resident's 36's psychotropic medication were included in the current care plan. Clinical record review revealed that Resident 82 had dementia, depression, and partial blindness. The MDS CAA summary dated December 4, 2024, noted that the resident's psychotropic medication and vision were to be addressed in the care plan. There was no evidence that interventions to address Resident 82's psychotropic medications and vision were included in the current care plan. In an interview on March 21, 2024, at 1:35 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plans or implemented in accordance with the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to restore bladder continence to the extent possible for one of two sampled residents who had urine incontinence. (Resident 92) Findings include: Review of facility policy entitled, Policy Continence Management Program, last reviewed February 16, 2024, revealed that upon admission the nurse was to interview the resident and review any underlying conditions that may affect the resident's ability to participate in a continence management program. Staff was to identify candidates for a bladder incontinence program who required limited to extensive assistance in toilet use and could benefit from a prompted or scheduled toileting plan. A continence evaluation was to be conducted to determine if a 72 hour bowel and bladder tracking was indicated for the resident. If the tracking was indicated, the licensed nurse was to instruct the nursing assistants to fill out the 72 hour bowel and bladder tracking form. Clinical record review revealed that Resident 92 was admitted to the facility on [DATE], and had diagnoses that included anxiety, a history of sepsis, osteoarthritis, and urinary incontinence. The Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented, was frequently incontinent of bladder, and required substantial assistance with toileting. The assessment indicated a discharge goal of partial to moderate assistance with toileting and the assessment also indicated that the resident was not on a toileting program. A review of the care plan initiated February 5, 2024, revealed that the resident was incontinent of bladder. At the time of admission, there was no documented evidence that the facility reviewed underlying conditions that may have affected the ability for the resident to participate in a continence management program. In addition, there was no documented evidence that a continence evaluation was completed for 72 hours to track bowel and bladder continence for the resident as per the facility policy until February 19, 2024, 17 days after the resident had been admitted to the facility. On February 21, 2024, a nurse documented that Resident 92 was incontinent of bladder, required assist of one person for transfers and for assistance with toileting. The note further indicated that the resident was alert and oriented and able to make her needs known. A nurse noted on March 4 and 7, 2024, that the resident was incontinent of bladder. Review of bladder documentation from March 10, 2024, through April 9, 2024, revealed that she had been incontinent of urine at least 50 times. In an interview on April 12, 2024, at 11:08 a.m., the Director of Nursing stated that the facility failed to initiate the continence evaluation and 72 hour bowel and bladder tracking form upon admission as per the facility policy. In addition, the Director of Nursing confirmed that once the tracking form was initiated, there was incomplete documentation during the 72 hours of whether the resident had been continent or incontinent of bladder on certain shifts. 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 develop and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder for one of 33 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, and major depressive disorder. Review of a psychiatric consultation dated January 29, 2024, revealed that Resident 8 stated there was a history of trauma related to emotional abuse. There was no assessment or care plan in Resident 8's clinical record that identified the PTSD diagnosis, symptoms or triggers related to this diagnosis, or resident-specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on April 12, 2024, at 10:40 a.m., the Director of Nursing confirmed that there was no assessment completed or care plan developed to address Resident 8's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide assistance with shaving for one of 33 sampled residents. (Resident 109) Findings include: Clinical record review revealed that Resident 109 had diagnoses that included encephalopathy (a disease of the brain). According to the Minimum Data Set assessment, dated April 9, 2023, the resident could make his needs known and needed assistance from staff for hygiene, including shaving. On May 2, 2023, at 12:33 p.m., the resident was observed in bed with a heavy beard. In an interview at that time, the resident stated that he preferred to be clean shaven and had not been assisted with shaving. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate for one of 33 sampled residents. (Resident 149) Findings include: Clinical record review revealed that Resident 149 was admitted to the facility with diagnoses that included hypotension. On January 13, 2023, the physician ordered for staff to administer Midodrine (a drug used to treat low blood pressure) three times daily and to hold the medication if Resident 149's systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Review of the Medication Administration Record for March through May 4, 2023, revealed that on 12 occasions Resident 149's Midodrine was documented as administered when his systolic blood pressure was greater than 130 mmHg. In an interview on May 5, 2023, at 11:00 a.m., the Director of of Nursing confirmed that staff incorrectly documented that Resident 149's medication had been administered when it was actually held. 28 PA. Code 211.5(f) Clinical records.