Based on review of facility policy, manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of two medication rooms reviewed (200-Hall medication storage room). Findings include: Review of a facility policy entitled Labeling of Medication Containers dated 12/05/24, revealed Labels for stock medications include all necessary information, such as: d. The expiration date when applicable. Manufacturer's recommendations for Aplisol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degeneration which may affect potency. Observations of drug storage on 12/17/24, at approximately 3:46 p.m. in the 200-Hall medication storage room refrigerator revealed one open vial of Aplisol without an opened date, therefore the staff were unable to determine the discard date. During an interview at that time, Licensed Practical Nurse Employee E1 confirmed that the open Aplisol vial lacked an opened date and staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and Resident Council minutes, and resident and staff interviews, it was determined that the facility failed to ensure that residents were updated in a timely manner regarding Resident Council concerns, and the facility failed to correct Resident Council concerns for a period of three months (November 2023 through January 2024). Findings include: Review of facility policy entitled, Resident Council, dated 1/2/24, revealed Resident Council is a social forum where residents are encouraged to discuss and make decisions about the environment in which they live. Residents are free to make grievances and recommendations to benefit all residents living in the nursing home. Procedure of Resident Council meeting indicated, Activity Director or designated staff will conduct the meeting (as per Resident vote). It is the department's director's responsibility to fully investigate and answer concerns. If any department fails to address/investigate concerns, necessary actions will be taken. Review of the Resident Council minutes and Grievances over the past three months, for November 2023 through January 2024, revealed a pattern/trend with issues regarding lengthy waiting times to go to the bathroom. During a Resident Council meeting on 1/29/24, at 10:00 a.m. interviews with Resident R22, Resident R44, and Resident R58, who all attend Resident Council meetings regularly, indicated that concerns of wait times for toileting have been voiced in several past monthly meetings with no resident update or resolution. An interview with the Activity Director on 1/30/24, at approximately 10:00 a.m. confirmed that he/she attends Resident Council meetings and reviews past monthly concerns in new business and old business with residents; and the concerns of lengthy wait times have been voiced by residents during the meetings in November 2023, December 2023, and January 2024 with no resolution. An interview with the Director of Nursing on 1/30/24, at 12:25 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding lengthy waiting times to go to the bathroom from the November 2023, December 2023, and January 2024 Resident Council meetings. No evidence was provided to ensure the residents' concerns verbalized and further stated in the Resident Council minutes for the past three months reviewed was noted of timely corrective actions, in addition to no evidence of the residents being updated in a timely manner of those actions. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, resident and staff interviews, it was determined the facility failed to ensure the provision of a substantial evening snack when up to 14 hours and 45 minutes elapsed from the supper meal to breakfast the next day. Findings include: A review of facility's policy entitled Meal times and frequency with a policy review date of 1/2/2024, revealed meals and evening snack will be served at the following times: Breakfast 7:30 a.m., Lunch 11:00 a.m., Dinner 4:45 p.m., Evening snack 7:00 p.m. In nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day. All residents will be offered a bedtime snack. If a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the next day. Interviews conducted with residents during Resident Council meeting on 1/29/2024, revealed that three of three residents in the meeting indicated that a nourishing evening snack is not consistently served. During an interview on 1/29/2024, at 1:00 p.m. the Dietary Manager and Registered Dietitian confirmed that there was no evidence that dietary staff or nursing staff provided residents with a nourishing evening snack. The Dietary Manager and Registered Dietitian also confirmed that there was more than 14 hours from the evening meal until breakfast the next day. 28 Pa. Code 211.6(a)(b) Dietary services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI-manual that guides facilities with completing resident Minimum Data Set [MDS-periodic assessment of resident care needs] assessments), clinical records, facility documentation, and staff interviews, it was determined that the facility failed to complete the MDS to accurately reflect the resident's status at the time of the assessment for two of 18 residents reviewed (Residents R57 and R67). Findings include: Review of the October 2019 RAI Manual revealed the instructions for completion of M1040 included: review the medical record, including skin care flow sheets or other skin tracking forms; speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review; examine the resident and determine whether any ulcers, wounds, or skin problems are present; check all that apply in the last seven days; and if there is no evidence of such problems in the last seven days, check none of the above. Review of the October 2019 RAI Manual revealed that restraints (a device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) used in the seven-day assessment look-back period were to be documented in Section P (Restraints and Alarms) of the MDS, coding 0 for not used, 1 for used less than daily, and 2 for used daily. Review of Resident R57's clinical record revealed an admission date of 2/19/21, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), pressure ulcer of the lower back, high blood pressure, and kidney disease. A Quarterly MDS dated [DATE], under Section M1040A, indicated that Resident R57 was treated for a foot infection in the look back period. Resident R57's clinical record lacked any evidence of he/she being treated for a foot infection. Review of Resident R67's clinical record revealed an admission date of 5/06/22, with diagnoses that included dementia, stroke, high blood pressure, and weakness. A Quarterly MDS dated [DATE], under Section P0100F, revealed that Resident R67 utilized a limb restraint less than daily. Resident R67's clinical record lacked any evidence of a limb restraint being ordered or used. Observations between 2/06/23, and 2/07/23, revealed Resident R67 self propelling in their wheelchair throughout the facility with no limb restraints observed During an interview on 2/07/23, at 2:00 p.m. the Director of Nursing confirmed that Resident R67 did not have a limb restraint and the MDS Section P0100F as listed above was coded incorrectly. During an interview on 2/08/23, at 11:27 a.m. Registered Nurse MDS Coordinator confirmed that Resident R57 was not treated for a foot infection and the Quarterly MDS dated [DATE], Section M1040A was coded incorrectly. 28 Pa. Code 211.5(f) Clinical records