**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, product labeling review, and interviews with staff, it was determined that the facility failed to store food under sanitary conditions in the main facility kitchen. Findings Include: At initial kitchen tour was held on February 12, 2024 at 9:25 a.m. with the Director of Dining, Employee E4 and Chef, Employe E5. Review of facility policy titled, Food Receiving and Storage dated April 2022 states, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation reads, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for sale transport and quality before being accepted. 3. Foods that are prepared offsite will only be accepted from institutions that are subject to federal, state or local inspection. The food and nutrition services manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Residents may consume foods from sources not procured by the facility 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food is designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in- first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Initial tour of the dry storage pantry revealed several items labeled incorrectly, unlabeled, undated, or expired. The items found included the following: One package of pasta wrapped in saran wrap with a date of January 5, 2025. Two packages of pasta in saran wrap undated and unlabeled. A large container of Semolina flour with a date of January 4, 2022. A large container of Peanuts with a date of May 11, 2022. Observation was made of the walk-in freezer with Chef, Employee E5. Observation of the walk-in freezer revealed both unlabeled and expired items. The following were items found: Sixteen container of Fish stock unlabeled and undated. Sixteen containers of [NAME] unlabeled and undated. Four packages of beets unlabeled and undated. Two packages of cranberries unlabeled and undated. A large container of forty individually sealed Meatloaf unlabeled and undated A container of [NAME] de porc with a date of 210910. Pork sauce dated with a date of October 23 with no year date. A quart of Fig jam with a date of October 10 with no year date. A large container of individual beef tenderloins with a date on October 29 with no year date. Halibut with a date of January 7 with no year date. Salmon with a date of January 7 with no year date. A large container of Flat Iron steaks with a date of November 21 with no year date. A large container of Duck stew with a date of November 23 with no year date. Forty-five egg white cartons with a date of May 11, 2021. Review of the walk-in refrigerator with Chef, Employee E5 revealed items undated and unlabeled the items included the following: Two containers of cheese wrapped in saran wrap labeled February 3 with no year date. Two containers of liquid crab cake mix with a date of February 11 with no year date. Cooked Chicken with a date February 10 with no year date. Two prepared pasta with a date of June 11 with no year date. Two packages of Seaweed salad unlabeled and undated. Pancetta wrapped in saran wrap unlabeled and undated. Turkey wrapped in saran wrap unlabeled and undated. A large container of Chicken stock unlabeled and undated. A large container of brine unlabeled and undated. Marinated flank steak unlabeled and undated. A container of chicken legs dated February 9 with no year date. Three container of shrimp chowder with no lids on but placed next to them. Interview with Chef Employee E5 stated that the soup was made February 11, 2024 and he stated it takes to six hours to cool before placing the lids on. He was unsure was time is was made on February 11, 2024. Two packages of mozzarella cheese in saran wrap unlabeled and undated. Two packages of swiss cheese in saran wrap unlabeled and undated. One large container of cooked chicken quarters partially saran wrapped and exposed to air. Chef Employee E5 confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews with staff and review of policies and procedures, it was determined that the facility failed to ensure timely access to personal and clinical records for one of seven residents reviewed. (Resident R168) Findings include: The facility policy titled Nursing Services dated March 12, 2023, indicated that the clinical records person or designee was responsible for ensuring that each resident had access to his/her personal records upon request. The policy indicated that each resident would receive confidential treatment of his/or her personal and medical records. The policy stated that the clinical records would be released within 24 hours, after the written consent by the resident or the resident's legal representative was received. The policy also indicated that a copy of the records (in an electronic form or format when such records are maintained electronically) would be provided to the resident or resident's responsible party, within 24 hours of the facility receiving the notice of the request Clinical record review revealed that Resident R168 was admitted to the facility on [DATE] for short term rehabilitation and discharged on July 22 2022. The clinical record for Resident R168 indicated that the responsible party for this resident was his spouse. Clinical record documentation of the closed record for Resident R168 revealed that the spouse of this former resident had requested on December 7, 2022, a personal copy of resident R168's entire medical record. The request was documented, signed and dated by the responsible party for Resident R168. Interview with the Nursing Home Administrator (NHA), on April 19, 2023 at 10:00 a.m. confirmed the responsible party for Resident R168 as his wife. Further during interview with NHA, it was confirmed that the responsible party for Resident R168 was not given electronic access to the personal medical record for Resident R168, within 24 hours of the facility receiving the notice of the request. The NHA reported during this interview that the resident's responsible party did not receive a personal copy of the record for Resident R168 until January 13, 2023; thirty-six days following the signed and dated request from the responsible party. 28 Pa. Code 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not ensure that proper documentation was maintained in the clinical record related to a resident-initiated discharge to the community that included resident's or resident representative's verbal or written notice of the intent to leave the facility for one of three discharged residents reviewed (Resident R51). Findings include: Review of Resident R51's clinical record revealed that resident was admitted to the facility on [DATE], from a local hospital with diagnoses of Delirium due to physiological condition, Atrial Fibrillation, Retention of Urine, Hypertensive Heart Disease, Obstructive Sleep Apnea, Embolism and Presence of Cardiac Pacemaker and was discharge from the facility back to the community (Independent Living) on March 10, 2023. Further review of Resident R51 clinical record revealed that responsible party was his wife. Review of nursing progress note dated March 10, 2023, revealed that Resident R51 was discharge to Independent Living. Further review of clinical record revealed that there was no documentation regarding the event leading to resident R51's discharge. Further, there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. Review of Resident R51's Discharge MDS assessment dated [DATE], Section A 2000 revealed that resident was discharged to the community on March 10, 2023. Further, Section C0500 (BIMS Score) revealed that Resident R51's BIMS score was 4 suggesting that Resident R51 was cognitively impaired. Interview with Social Worker, Employee E4 conducted on April 21, 2023, at 10:26 a.m. revealed that resident was discharge as per wife's request but confirmed that she did not document the verbal notice of discharge from Resident R51's wife. Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E5 conducted on April 21, 2023, at 11:23 a.m. confirmed that there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. 28 Pa. Code 201.29(f) Resident's rights 28 Pa. Code 210. 25 Discharge policy 28 Pa. Code 211.5(f) Clinical record

Based on group interview, observations and interviews with staff, it was determined that the facility failed to display proper contact information, including the appropriate phone number for filing complaints concerning any suspected violation of state or federal nursing facility regulations for two of two nursing units. (Second Floor and Third Floor) Findings include: During a group interview with Resident R3, Resident R6, Resident R41 and Resident R94 on June 3, 2022, at approximately 10:15 a.m. Resident R41 indicated that he did not know how to contact the Pennsylvania Department of Health if he had a complaint. Resident R3 agreed and said he also did not know where to find this information. When asked if they know how to contact the Pennsylvania Department of Health, Residents R6 and R94 shook their heads no. Observations of both nursing floors after the group meeting on June 6, 2022, at approximately 10:45 a.m. revealed that the State Department of Health contact information was not posted as required. Interview with the Nursing Home Administrator, and Employee E9, Quality Assurance Coordinator, on June 6, 2022, at approximately 9:20 a.m. confirmed that the contact information was not posted as required. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) (e)(1) Management 28 Pa. Code 201.29(i) Resident rights

Based on observations and resident and staff interviews, it was determined that the facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on both nursing floors. (Second Floor and Third Floor) Findings include: During a group interview conducted on June 3, 2022, at 10:00 a.m. with four alert and oriented residents (Residents R41, R3, R6 and R94), the residents stated that they were not aware of how to file a grievance with the facility. The residents were also unaware of who was the Grievance Official in the facility. All four residents in attendance stated that they were unaware of any postings in the facility, which was comprised of two nursing floors, regarding how to file a grievance. Observations during a tour of the Second Floor and Third Floor and bulletin boards throughout the facility, conducted at approximately on June 3, 2022 11:00 a.m., after the group interview, revealed no posting about the Grievance Procedure, or who was the Grievance Official, or a box to place a grievance anonymously. There were no postings on the Second or Third floors related to how to file a grievance. During an interview with Employee E5, Nursing Home Administrator(NHA), and Employee E9, QA Coordinator, on June 6, 2022, at approximately 9:20 a.m., the NHA acknowledged that the facility failed to post the grievance process including the Grievance Official contact information in a prominent location on both nursing floors of the facility as required. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c)(d)(e) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for one of three closed records reviewed (Residents R44). Findings include: Review of Resident R44's clinical record revealed that resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and cerebral infarction (stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood). Review of nursing documentation revealed that on April 1, 2022, the resident was transported to the emergency room via 911- Emergency Medical Services, and that the resident's wife and physician were notified. Interview on June 6, 2022, with the Director of Nursing confirmed that the Admissions Director, who normally notifies the Office of the State Long-Term Care Ombudsman for emergency transfers to the hospital, had not sent these notifications for the past six months. The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges. 28 Pa. Code 201.14(a) Responsibility of licensee