Based on a review of the facility's policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure the correct dose of medication was administered for one of the 14 residents reviewed (Resident 17). Findings include: Review of the facility's policy titled, General Policies for Administration and Documentation of Medications and Treatments last review date January 2017, revealed medications and treatments will be administered by a licensed nurse, in accordance with the Pennsylvania Nursing Code, physician orders and principles of safe medications administration. The Eight Rights will be observed during each medication/treatment administration: Right person; Right drug; Right dose; Right route; Right frequency; Right time; Right reason; and Right documentation. Review of Resident 17's diagnosis includes Epilepsy (neurological disorder marked by a sudden recurrent episode of sensory disturbance, loss of consciousness, or convulsion, associated with abnormal electrical activity in the brain). Review of Resident 17's physician's form dated April 21, 2023, revealed an order for Dilantin (anti-epileptic drug) 30 mg (miligrams) by mouth once a day was given with Dilantin 100 mg to equal 130 mg for Epilepsy. Review of the facility's documentation, Incident Report revealed a medication error incident occurred on September 2, 2023, at 8:00 a.m. Further review of facility documentation including Investigation Review comment section revealed the incident was discovered on September 4, 2023. The resident required physical assistance with breakfast and slept the rest of the day without eating, reported that her/his body was jerking intermittently. The physician was notified, and a STAT (immediate) blood work was ordered. An additional review of the same report revealed that upon reviewing the medication, it was noted that the resident received an extra dose of 30mg of Dilantin on the morning of September 2, 2023. Review of Resident 17's blood work results dated September 5, 2023, revealed a Dilantin level of 23.0 (normal range was 10-20). Review of the physician's progress note dated September 7, 2023, at 9:41 a.m., revealed resident had no reasonable recall, resident received an extra dose of Dilantin over the weekend, had difficulty feeding themself, had tremors, and was less responsive. A/P (Assessment and Plan) revealed a resolved neuro episode, possibly due to an overdose of Dilantin. The above information was discussed with the Director of Nursing on October 5, 2023, at 11:00 a.m. The facility failed to ensure Resident 17 was administered the correct dose of Dilantin. 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 a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of two residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on [DATE]. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the licensed staff E4 on November 16, 2022, confirmed that the discharge summary was incomplete. 28 Pa Code 211.5 (f) Clinical records

Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure residents were free from accidents and hazards for one of eighteen sampled residents (Resident 2). Findings include: Review of facility policy and procedure titled Administration of Oral Medications, revised March 2022, revealed Oral medications will be administered safely and effectively, following Physicians Orders and all regulations. Further review of this policy and procedure revealed Administration - stay with the resident until all medications have been swallowed. The nurse must see the resident swallow the medication before the drug administration can be recorded. Observation of Resident 2's Medication Administration on November 16, 2022, at 9:11 a.m. revealed Licensed Employee E3 prepare Resident 2's medication for administration and leave the medications at resident's chair side without observing Resident 2 take the medications. Interview with Licensed Employee E on November 16, 2022, at 9:12 a.m. revealed Licensed Employee E3 stating we leave her medications in the room as she is a self-administer. We don't spoon feed her. Review of Resident 2's clinical record failed to reveal documented evidence that Resident 2 was assessed to self-administer medication. Interview with the Director of Nursing on November 16, 2022, at 11:00 a.m. revealed that no residents are permitted or assessed for self-administration of medication and further revealed that all staff should remain with all residents until medication administration is complete. The facility failed to ensure residents were free from accidents and hazards. 28 Pa Code 201.14(a) Responsiblity of Licensee 28 Pa Code 201.12(d)(1) Nursing Services 28 Pa Code 201.18(a)(b)(1)(3) Management