Health inspection·August 7, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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 one of 25 sampled residents. (Resident 3)Findings include:Clinical record review revealed that Resident 3 had diagnoses that included anxiety, depression, and atrial fibrillation (irregular heartbeat). Review of Resident 3's MDS assessment dated [DATE], indicated that Resident 3 had a tracheostomy (surgical hole in the front of the neck for breathing). Review of Resident 3's clinical record revealed no physician's orders or care plan indicating the resident had a tracheostomy. In an interview on August 7, 2025, at 9:02 a.m., the Administrator confirmed Resident 3's MDS was inaccurate and that Resident did not have a tracheostomy. Residents Affected - Few Page 1 of 2 395878 395878 08/07/2025 Orwigsburg Nursing and Rehabilitation Center 1000 Orwigsburg Manor Dr Orwigsburg, PA 17961

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physicians' orders for four of 25 sampled residents. (Residents 8, 62, 86 and 115)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included chronic kidney failure, congestive heart failure, and diabetes. A physician's order dated March 24, 2025, directed staff to administer a medication (isosorbide mononitrate) daily in the morning for heart disease. 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 115 millimeters of mercury (mm/Hg). Review of Resident 8's medication administration records (MARs) revealed that staff administered the medication six times in May 2025, five times in June 2025, and four times in July when the resident's SBP was less than 115 mmHg.Clinical record review revealed that Resident 62 had a diagnosis of hypertension (high blood pressure). On March 5, 2025, the physician ordered staff to administer a blood pressure medication (losartan potassium) one time a day. Staff were not to administer the medication if the resident's systolic blood pressure was less than 110 mmHg. Review of Resident 62's MAR revealed that staff administered the medication three times in July 2025, when the SBP was less than 110 mmHg. Clinical record review revealed that Resident 86 had a diagnosis of hypertension (high blood pressure). On April 15, 2025, the physician ordered staff to administer a blood pressure medication (metoprolol tartrate) two times a day. Staff were not to administer the medication if the resident's SBP was less than 110 mmHg. Review of Resident 86's MAR revealed that staff administered the medication six times in July 2025, when the SBP was less than 110 mmHg.In an interview on August 7, 2025, at 9:00 a.m., the Administrator confirmed that medications were administered outside of the established parameters for Residents 8, 62, and 86. Clinical record review revealed that Resident 115 had diagnoses that included partial paralysis on the right side following a cerebral infarction (stroke) and chronic respiratory failure with hypoxia (a condition in which the body's tissues do not receive enough oxygen). A physician's order dated June 22, 2022, directed staff on every shift to administer oxygen via a padded nasal cannula at a pressure of two liters per minute (LPM). On August 7, 2025, at 10:34 a.m., Resident 115 was observed sitting in a wheelchair in the second-floor hallway, where staff had placed her with an empty oxygen tank and no nasal cannula. In an interview on August 7, 2025, at 10:45 a.m., the facility Regional Nurse stated that oxygen was not administered to resident 115 per physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Some 395878 Page 2 of 2