Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucometer meter (BGM - a device to collect and measure the level of glucose [sugar] in the blood) for two of ten residents observed during the administration of medications (Residents R40 and R28). Findings include: Review of facility policy entitled Blood Glucose Monitoring dated 3/21/24, indicated Blood glucose meters will be cleaned and disinfected in between use Observation of medication administration on 11/04/24, between 4:10 p.m. and 4:30 p.m. revealed Licensed Practical Nurse (LPN) Employee E1 removed a BGM from the medication cart, entered Resident R40's room, obtained a blood glucose level, returned to the medication cart, and placed the meter in the medication cart. LPN Employee E1 proceeded to Resident R28's room, removed a BGM from the medication cart, entered Resident R28's room, obtained a blood glucose level, returned to the medication cart, and placed the meter in the medication cart. During an interview on 11/04/24, at 4:29 p.m. surveyor asked LPN Employee E1 if he/she would ever need to clean the BGM, and responded that the BGM was to be cleaned between each resident. LPN Employee E1 then proceeded to identify the approved cleansing wipes located in the medication cart. LPN Employee E1 further confirmed that he/she did not clean / disinfect the BGM as required between each resident during the observed medication administration process. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c)(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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard an open expired bottle of liquid protein (a supplement to help with wound healing) in one of two medication carts (West Two). Findings include: Review of facility policy entitled Medical Nutritional Supplements dated 3/2023, indicated that unused supplements that were being used by the nurse at the medication cart may be labeled with the date opened, store in refrigerator and discarded after 48 hours. Observation on [DATE], at 3:40 p.m. of the [NAME] Two medication cart revealed an opened bottle of liquid protein with an expiration date of 11/2023 and an opened date of [DATE]. During an interview with Licensed Practical Nurse (LPN) Employee E1 on [DATE], at 3:40 p.m. revealed that two residents receive liquid protein daily. During an interview with LPN Employee E1 on [DATE], at 3:47 p.m. he/she confirmed that the opened bottle of liquid protein expired on 11/2023, and should have been discarded. He/she also confirmed that the bottle of liquid protein was opened on [DATE], which was after the manufacturer's expiration date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to develop an elopement specific comprehensive care plan for a resident identified as an elopement risk upon admission for one of 17 residents reviewed (Resident R25). Findings include: Review of a facility policy entitled, Care Plan & Interdisciplinary Care Conferences reviewed 3/23/22, indicated that the care plan will be individualized for each resident based upon available resident-specific information including assessments, and that the care plan will be reviewed and updated when there are newly identified risk factors. Review of Resident R25's clinical record revealed and admission date of 8/26/22, with diagnoses that included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) history of falling, and Delta MS (altered mental status or delirium- mental state in which you are confused, disoriented, and not able to think or remember clearly). A Nursing Evaluation dated 8/26/22, which included a Wander Risk Assessment that indicated Resident R25 was cognitively impaired with poor decision-making skills and independently ambulatory (walking ability), and that the facility should consider initiating a care/service plan for wandering risk. An admission Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) Section C0100- Cognitive Patterns dated 8/30/22, indicated that Resident R25's Brief Interview for Mental Status (BIMS- structured evaluation aimed at evaluating aspects of cognition in elderly patients) was a score of 13 out of 15 (intact cognitive response). The clinical record lacked evidence of a resident specific care plan regarding wandering/elopement risk. Further review of Resident R25's clinical revealed a Progress Note dated 8/29/22, which indicated that at 7:07 a.m. he/she was found outside, down the steps and walking in the parking lot, the main door was still locked, staff not sure how he/she got out. During an interview on 1/05/23, at 9:17 a.m. the Director of Nursing confirmed that Resident R25 was known to ambulate without his/her walker prior to this incident, and that according to the score on the Wander Risk Assessment, a care plan addressing wandering/elopement should have been implemented. During an interview on 1/06/23, at 9:46 a.m. the Social Worker confirmed that although Resident R25's BIMS was a 13 at the time of the assessment, that can change from day to day and often does. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from a safe area) and failed to investigate an elopement for a resident (Resident R25). Findings include: Review of a facility policy entitled, Elopement reviewed 3/23/22, indicated that an elopement occurs when a resident leaves the facility without the knowledge of the facility and that nursing personnel must report and investigate all reports of missing residents. Review of Resident R25's clinical record revealed an admission date of 8/26/22, with diagnoses that included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) history of falling, and Delta MS (altered mental status or delirium- mental state in which you are confused, disoriented, and not able to think or remember clearly). A Nursing Evaluation dated 8/26/22, which included a Wander Risk Assessment that indicated Resident R25 was cognitively impaired with poor decision-making skills and independently ambulatory (walking ability), and that the facility should consider initiating a care/service plan for wandering risk. Further review of Resident R25's clinical revealed a Progress Note dated 8/29/22, which indicated that at 7:07 a.m. he/she was found outside, down the steps and walking in the parking lot, the main door was still locked, staff was not sure how he/she got out. During an interview on 1/05/23, at 9:17 a.m. the Director of Nursing confirmed that Resident R25 was known to ambulate without his/her walker prior to this incident, and that according to the score on the Wander Risk Assessment, a care plan addressing wandering/elopement should have been implemented. The Director of Nursing also confirmed that it is believed that Resident R25 walked out the main door when a housekeeper entered the vestibule to clean, and the employee's badge disabled the lock. During an interview on 1/06/23, at 9:40 a.m. Housekeeping Employee E3 confirmed that at the time of the incident he/she did not hear the door open or see Resident R25 leave through the vestibule, it was early morning and there was no one in the lobby, and he/she didn't know Resident R25 was outside until floor staff rushed out the door, and when he/she followed them outside Resident R25 was already down the steps and in the lower parking lot walking behind cars, and he/she was not aware how staff was made aware that Resident R25 left the building. During an interview on 1/06/23, at 9:52 a.m. Registered Nurse (RN) Employee E2 confirmed that on 8/29/22, at approximately 7:07 a.m. he/she was made aware by a unit staff member (no longer employed) that per the monitor at the nurse's station there was a person walking around outside. RN Employee E2 confirmed that Resident R25 was observed on the monitor walking around the lower parking lot behind the parked cars, and staff rushed out the main entrance to find Resident R25 was already down in the lower lot walking around looking for his/her car. Observation of the facility camera monitoring system revealed that the camera's are positioned to monitor activity outside of the facility entrance, and visitor and staff parking lots. Due to a lack of witness statements/interviews with staff from the previous and present shifts at the time of the incident, and the facility's failure to determine the exit point of Resident R25's departure from the building, and the approximate length of time he/she was outside of the building, the facility failed to thoroughly investigate the elopement of Resident R25 on 8/26/22 and to ensure adequate supervision to prevent future elopements. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.11 (d) Resident Care Plan 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (Ground floor). Findings include: Observation on 1/03/23, at 1:30 p.m. on the Ground floor medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol PPD which has been entered and in use for 30 days should be discarded. At the time of the observation, Registered Nurse Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing confirmed on 1/05/23, at 11:00 a.m. that the PPD vial should be identified with an open date to indicate after 30 days of use, the vial would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documents and staff interview, it was determined that the facility failed to comply with all the requirements when asking a resident or his or her representative to enter into an agreement for binding arbitration. Findings include: Review of the facility's admission Agreement packet contained the document Arbitration and Limitation of Liability Agreement. Section C entitled Withdrawal Period indicated Each party shall have three (3) business days from the execution of this agreement to cancel the agreement by notifying the other party in writing, by certified mail return receipt requested, of its desire to cancel. During an interview on 1/6/23, at 10:28 a.m. Nursing Home Administrator confirmed the arbitration agreement, which is part of the facility's admission packet and signed by thirty-one residents or his or her representative who currently reside in the facility does not allow the resident or his or her representative the right to rescind the agreement within thirty (30) calendar days of signing it. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights

Based on review of facility documents and staff interviews, it was determined that the facility failed to comply with all requirements when asking a resident or his or her representative to enter into an agreement for binding arbitration. Findings include: Review of the facility's admission Agreement packet contained the document Arbitration and Limitation of Liability Agreement. Section A entitled Arbitration Provisions indicated The arbitration proceedings shall take place in Allegheny County, Pennsylvania and The arbitrator shall designate a time and place within Allegheny County, Pennsylvania for the final arbitration hearing . During an interview on 1/6/23, at 10:28 a.m. Nursing Home Administrator confirmed the arbitration agreement, which is part of the facility's admission packet and signed by thirty-one residents or his or her representative who currently reside in the facility does not allow for a selection of a venue that is convenient to both parties. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights