Based on observation, facility policy review, and staff interview, it was determined that the facility failed to properly store medications on two of three hallways on the nursing unit. (100 hallway and 300 hallway) Review of the facility policy entitled, Security of Medication Cart, last reviewed February 24, 2025, revealed that medication carts must be securely locked at all times when out of the nurse's view. Observation on May 13, 2025, from 10:30 a.m. through 10:33 a.m., revealed the medication cart was unlocked and unattended on the 100 hallway. Observation on May 15, 2025, from 9:35 a.m. through 9:40 a.m., revealed the medication cart was unlocked and unattended on the 300 hallway. In an interview on May 15, 2025, at 9:40 a.m., Licensed Practical Nurse 1 confirmed that the medication carts should have been locked. In an interview on May 15, 2025, at 10:30 a.m., the Director of Nursing confirmed that the medication carts should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in one of one medication storage rooms. (Medication and Treatment Room) Findings include: Review of the facility policy entitled, Controlled Substances, last reviewed on February 25, 2024, revealed that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 are to be separately locked in permanently affixed compartments. Observation on June 13, 2024, at 11:20 a.m., revealed the Medication and Treatment Room had controlled substances that were stored in a locked box inside a refrigerator. The locked box was not permanently affixed to the refrigerator and contained 35 doses of lorazepam suppositories. In an interview on June 13, 2024, at 12:23 p.m., the Director of Nursing confirmed that the medication box should have been permanently affixed in the locked refrigerator. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant weight loss for one of two sampled residents with weight changes. (Residents 35) Findings include: Review of the facility policy entitled, Weight Policy, dated August 17, 2022, revealed that any unplanned significant weight changes were to be reported to the physician and the resident's representative. Clinical record review revealed that Resident 35 had diagnoses that included dysphagia following cerebral infarction and chronic kidney disease, stage 4. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and received tube feedings for his nutritional requirements. On April 26, 2023, the resident weighed 151 pounds (lbs). On May 25, 2023, Resident 35 weighed 138 lbs, an 8.61 percent weight loss in one month. There was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. In an interview on July 7, 2023, at 12:18 p.m., the Director of Nursing stated there was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to properly contain refuse in a sanitary manner. Findings include: Observation on July 5, 2023, at 11:10 a.m., revealed that there was trash and debris, including clear plastic bags and paper on the ground around the trash compactor. The recycling dumpster contained cardboard and the lid was open. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, review of policy and staff interview, it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. (Main Kitchen) Findings include: Review of the facility policy entitled, Food Storage, dated August 17, 2022, revealed that products in storage were to be labeled with the date on delivery and once the product was opened the package was to be labeled with an opened and discard date. Observation during tour of the main kitchen dry storage room and refrigerator/freezers on July 5, 2023, at 11:10 a.m., revealed an open unwrapped 25 pound bag of whole grain brown rice received September 1, 2022, one open case of frozen egg rolls shipped September 15, 2022, one open case breaded chicken tenderloin received September 29, 2022, one jar of capers with no expiration date. The following items were past the expiration date: five boxes of grits, best by October 24, 2022, two bottles of white truffle oil with expiration dates of September 28, 2018, and September 27, 2019, one open low fat cottage cheese use by June 15, 2023, one low fat cottage cheese with best by date of June 23, 2023, two plastic containers of dressing, use by May 11, 2023, butter and chive mix use by July 1, 2023, half gallon whole milk, expired June 15, 2023, three wrapped beef packages, use by May 17, 2023. In the freezer there was a layer of frost on the outside of the food packages and boxes. Review of the policy entitled, Cleaning Instructions: Ovens, dated August 17, 2022, revealed that ovens were to be cleaned as needed and according to the cleaning schedule at least once every two weeks. Spills and food particles were to be removed after each use. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed both ovens had a grease buildup on the inside walls, the inside of the doors, and on the oven racks. There were three stained oven racks stored on the floor behind a cookware rack and next to the ovens. Review of the policy entitled, Cleaning Instructions: Deep Fat Fryer, dated August 17, 2022, revealed that the deep fat fryer oil was to be changed at least every 10 times the fryer was used. When the oil color changed to a dark brown, the oil should be changed. Food particles were to be removed from the oil after each use. Further, the baskets were to be cleaned by running them through the dish machine and wiping them dry prior to storage. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed the deep fat fryer oil was dark brown and contained debris. Two fryer baskets were coated with grease and were stored on a stainless steel shelf that had grease and debris on it. Observations on July 5, 2023, at 11:10 a.m., and July 6, 2023, at 11:05 a.m., revealed the table top under the grill was wet with brown liquid spillage and debris. In an interview on July 5, 2023, at 11:10 a.m., the Food Service Director stated that food was to be dated prior to storage and disposed of when items expired. The Food Service Director stated there was no documentation to support that cleaning was scheduled or being completed per facility policy. 28 Pa.Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.