Based on review of clinical records, facility documentation, resident council minutes, facility policies, and interviews with residents and staff, it was determined that the facility failed to demonstrate evidence that residents are educated on filing grievances and that grievances forms/ boxes were available and accessible for residents on nursing units for five of 5 floors reviewed (Building 8, Floor 3, 4, 5, 6 and 10).Review of facility policy titled Code of Corporate Compliance revealed that Residents are treated in a manner that preserves dignity, autonomy, self-esteem, civil rights and involvement in their own care. Fair Acres Geriatric Center employees receive training about resident rights to clearly understand their role in supporting them. Observation of Building 8, 3rd floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E3, Licensed Practical Nurse, on July 18, 2025 at 10:45 am revealed that there are no grievance forms available and if resident would like to make a complaint they call the phone number posted on the wall. Interview with Employee E4, Unit Secretary, on July 18, 2025 at 10:48am revealed there were no grievance forms available behind the nursing station. Observation of Building 8, 4th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E5, Unit Manager/ Licensed Practical Nurse, on July 18, 2025 at 10:54am revealed that if residents would like to place a grievance we could give them a blank envelope and they could place it in the facility internal mailbox. Confirmed no grievance forms/ drop box available on unit. Observation of Building 8, 5th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E7, Licensed Practical Nurse, on July 18, 2025 at 11:05am confirmed no grievance forms/ drop box available on unit. Employee stated If resident has a complaint or concern they would report it to the unit manager. Observation of Building 8, 6th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit.Interview with Employee E8, Registered Nurse, confirmed no grievance forms or boxes available and accessible for residents on nursing unit.Observation of Building 8, 10th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit.Interview with Employee E12, Licensed Practical Nurse, confirmed no grievance forms or boxes available and accessible for residents on nursing unit.Observation of Building 8, main lobby, revealed complaint box on receptionist desk. Interview with Employee E13, Utility aide, confirmed no grievance forms available. Residents would just write on a plain piece of paper and put it in the box if they have a complaint. Interview with Employee E1, Director of Nursing confirmed facility has no grievance policy. If residents want to file a grievance then they would either write on a plain piece of paper and drop it in the main lobby complaint box or would call the phone number listed on the Nursing Unit. Review of Resident council minutes dated May 14, 2025 and June 11, 2025 revealed no discussions/ education on the topic of filing a grievance. 28 Pa. Code 201.29(a) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon facility policy review, clinical record review, and interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 134). Findings include: Review of facility records revealed a policy titled [NAME] Rx Policy and Procedures Manual, Subject: Medication Regimen Review, dated June 1, 2023, documenting resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the pharmacy's consulting records and reported to the resident's attending physician, the facility's Medical Director and Director of Nursing as appropriate. The physician will accept and document that the irregularity has been reviewed. The attending physician should document his or her rationale in accordance with federal and state regulations. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue D-Mannose (a dietary supplement used to treat or prevent urinary tract infections), as the resident continues to have urinary tract infections (UTIs). Use should also be avoided in patients with diabetes (disease that affects how the body uses blood sugar) due to effects on blood sugar. Review of R134's clinical record failed to reveal that the above recommendation was addressed by the physician. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Melatonin (a hormone that regulates day and night cycles) for insomnia, as the resident is also ordered Trazadone (an antidepressant) for insomnia. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Glucosamine-Chondroitin (supplement for joint pain) for osteoarthritis, as pain has been uncontrolled with use of this supplement, and it is likely not contributing to pain relief. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue PreserVision AREDS 2 (a multivitamin), as resident is already ordered a daily multivitamin with minerals (Centrum Silver Women 50+). Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to change timing of Omeprazole (a stomach acid reducer), to 30-60- minutes prior to breakfast to optimize effectiveness. Review of R134's clinical record failed to reveal that the above recommendations were addressed by the physician. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 24, 2025, at 1:30 p.m. when the above information was presented, the DON confirmed there was no documented evidence of a response by the physician to the recommendations made by the consulting pharmacist. 483.45 Drug Regimen Review, Report Irregular, Act on 28 Pa. Code 211.5(f) Clinical records