**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 19 residents reviewed (Resident 3) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses to include atrial fibrillation (an irregular and often very rapid heart rhythm). Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 15, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating she was cognitively intact. A review of Resident 3's social service notes, revealed a note dated August 28, 2024, indicating the resident would like to be discharged home when able. The next social service notes regarding discharge from the facility were not until November 18, 2024, indicating the resident was to be discharged home on December 13, 2024. During the survery ending January 31, 2025 there was no further documentation regarding discharge to home and no documentation regarding the reason the resident did not discharge home on December 13, 2024. A review of the resident's comprehensive care plan, reviewed during the survey ending January 31, 2025, revealed no documented evidence that an individualized discharge plan was revised, as needed to reflect the resident's current desire for discharge or long-term placement at the facility. During an interview with the Nursing Home Administrator on January 30, 2025, at 12:00 PM confirmed there was no documented evidence of a current discharge goal and plan for this resident. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29 (a) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and staff interview, it was determined the facility failed to assure the presence of documented evidence of clinical necessity for administration of an antibiotic drug for two residents out of five sampled residents for unnecessary medication prescribing practices (Residents 34 and 71). Findings included: A review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia and congestive heart failure (CHF - is a condition where the heart is unable to pump blood effectively). A review of a facility documentation entitled Infection Control - Infection Tracker with McGeer's Criteria 2024 assessment (an algorithm that uses criteria to make an empiric diagnosis of UTI in nursing home residents. For resident's that do not have an indwelling urinary catheter and with at least three of the following signs and symptoms must be present prior to a practitioner prescribing antibiotic therapy include a fever (temperature of at least 38°C [100.4°F]), new or increased frequency, urgency, or burning on urination, new flank or suprapubic pain or tenderness, change in character of urine, and worsening of mental or functional status) dated December 6, 2024, at 3:59 PM, and recorded on December 11, 2024, at 3:59 PM, revealed that the form was initiated due to a suspected UTI. Further review of the completed infection tracker McGeer's Criteria form revealed that Resident 34 did not have a fever, rigors (feeling cold or having chills), or new on-set hypotension (low blood pressure), without alternate site of infection, no acute dysuria (burning sensation when urinating), no leukocytosis (is the presence of more white blood cells than normal, which can indicate infection, inflammation, injury or immune system disorders), and no gross hematuria (presence of red blood cells in the urine), increased incontinence (involuntary loss of large or small amounts of urine), increased urgency (need to urinate), or increased frequency). A review of Resident 34's clinical record revealed a nurses' progress note dated December 4, 2024, at 2:17 PM, revealed the facility's contracted CRNP (certified registered nurse practitioner) was in the facility to assess the resident and ordered a urine analysis (UA an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection)with a culture and sensitivity ( C & S a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection). Further review of nurses' progress notes dated December 6, 2024, at 2:07 PM, revealed urine culture results showed a result of greater than 100, 000 colonies/ml (significant number of bacteria in the urine that may cause an infection) A review of physician's orders dated December 6, 2024, at 4:56 PM, revealed orders for Cefdinir (antibiotics) 300 mg twice per day for seven days related to UTI (urinary tract infection). The resident lacked essential clinical indicators such as fever, dysuria, leukocytosis, or gross hematuria. The only criterion met was a urine culture with >100,000 CFU/mL of a single organism, which alone was insufficient to justify antibiotic therapy. As a result, the resident received fourteen doses of an unnecessary antibiotic. During an interview with the facility's Infection Preventionist (IP) on January 30, 2025, at 11:20 AM, confirmed that Resident 34 did not meet the requirements for antibiotic treatment. A review of Resident 71's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included type II diabetes (a condition results from insufficient production of insulin, causing high blood sugar), dysphagia (difficulty swallowing), and cerebral infarction with weakness (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it and the lack of sufficient blood supply to brain cells deprives them of oxygen and critical nutrients, potentially leading to the death of brain cells). A review of nurses' progress notes in Resident 71's clinical record dated November 15, 2024, at 9:35 PM, revealed the resident was catheterized (is a medical procedure used to drain the bladder) to obtain urine specimen (refers to a sample of urine collection from a patient for diagnostic tests).A CBC (complete blood count that checks different arts of the blood such as the white blood cells to identify infection). A physician's order for Rocephin (antibiotic) IM (intramuscular injection that delivers medication deep into muscle tissue, allowing rapid absorption). A review of the resident's laboratory results dated [DATE], at 8:27 AM, revealed the urinalysis results were unremarkable, urine culture showed no growth, and WBC (white blood cells measures the number of white blood cells in your blood, which are part of your immune system) elevated at 13.05 (reference range for normal parameters 4.0 - 10.80). Additionally, nursing progress notes dated November 16, 2024, through November 18, 2024, documented that the Resident 71's vital signs (temperature, pulse, blood pressure, and respirations) were documented within normal parameters. Rocephin was administered for two days without meeting McGeer's Criteria or having laboratory evidence of an infection During an interview with the facility's Director of Nursing (DON) on January 30, 2025, at 1:15 PM, reported that prior to initiating an antibiotic and as a part of the facility's antibiotic stewardship program licensed nursing staff did not complete the required Infection Tracker form with McGeer's Criteria - 2024 to clinically justify the use of an antibiotic. Additionally, the DON reported that staff did not complete the form as per the antibiotic stewardship program and confirmed that Resident 71's prescribing physician was aware that his signs and symptoms did not meet McGeer's protocol for prescribing an antibiotic. The DON confirmed the facility failed to assure that Resident 71's medication regimen was free from unnecessary medications, Rocephin, and failed to meet antibiotic prescribing practices. 28 Pa. Code 211.2 (3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3) Nursing Services

Based on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source (Resident 23) out of 19 sampled residents. Findings include: Review of Resident 23's clinical record revealed admission to the facility on September 7, 2018, and the resident's payor source was Medicaid. A review of nurses' progress notes in the resident's clinical record dated July 31, 2024, at 1:39 PM, revealed that the facility's contracted CRNP (certified registered nurse practitioner) in to see resident due to complaints of left sided facial pain. NON (new orders noted) for Clindamycin (is a medication used to treat a wide variety of bacterial infections) 300 mg PO (orally) every six hours for 7 days for parotitis (is a serious gum infection that damages the soft tissue around teeth). Further review of Resident 23's clinical record failed to reveal that the facility offered dental services from November 16, 2022, until October 20, 2024. During an interview with the Director of Nursing (DON)on November 30, 2025, at 9:20 AM, confirmed that the facility failed to assure that Resident 23 was annually offered routine dental services. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide effective pain management, administer pain medication as prescribed by the physician, and attempt non-pharmacological interventions prior to administering narcotic pain medication prescribed on an as-needed (PRN) basis for one (1) of three (3) residents sampled for pain (Resident 18). Findings include: A review of the facility's policy titled Pain Management, with a policy review date of December 2024, indicated that an evaluation of pain presence and severity should occur using the appropriate pain scale (numeric pain rating scale, face rating scale, or verbal descriptor scale). The policy further stated that non-pharmacological interventions will be attempted prior to the administration of PRN (as needed) pain medications. If non-pharmacological interventions are ineffective, then when multiple PRN medications are available with corresponding intensity ratings, the resident will receive the medication prescribed for the corresponding pain rating. Documentation of medication administration and effectiveness is required in the electronic medication record (eMAR). A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include fibromyalgia (is a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances), rheumatoid arthritis ( a chronic inflammatory disorder affecting small joints in the hands and feet characterized by painful swelling in the affected areas) and complete rotator cuff tear of the right shoulder (a complete tear of the connecting muscle to bone of the shoulder, characterized by pain of the affected shoulder). A review of Resident 18's physician orders revealed the following PRN pain medication orders: Percocet 5/325mg (narcotic pain medication) one tablet by mouth every four hours as needed (PRN) for severe pain initially ordered on December 31, 2024, and discontinued January 2, 2025. Percocet 5mg (narcotic pain medication) one tablet by mouth every eight hours as needed (PRN) for severe pain initially ordered January 19, 2025, and discontinued January 20, 2025. A review of the resident's December 2024 and January 2025 Medication Administration Record (MAR) revealed the following: The PRN Percocet 5/325mg was administered two times in December: December 31, 2024, at 4:18 PM - medication administered for a pain scale of 3 (mild pain). December 31, 2024, at 9:04 PM - medication administered for a pain scale of 5 (moderate pain). The PRN Percocet 5/325mg was administered three times in January: January 1, 2025, at 9:04 AM - medication administered for a pain scale of 6 (moderate pain). January 1, 2025, at 5:42 PM - medication administered for a pain scale of 6 (moderate pain). January 6, 2025, at 9:36 AM - medication administered for a pain scale of 6 (moderate pain). The PRN Percocet 5mg was administered once in January: January 19, 2025, at 8:58 PM - medication administered for a pain scale of 3 (mild pain). A further review of the resident's January 2025 MAR revealed that the PRN Percocet was administered a total of four times in January. In all instances, no non-pharmacological interventions were attempted prior to administration. Additionally, three of the four doses were administered for pain levels of mild to moderate pain, despite the medication being prescribed only for severe pain. An interview with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at approximately 2:00 PM, confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and documented as ineffective prior to the administration of PRN pain medication. Additionally, they confirmed that the staff administered narcotic pain medication ordered for severe pain to Resident 18 when the resident's documented pain levels were only mild to moderate. The facility administered narcotic pain medication inappropriately for pain levels lower than the prescribed severity and failed to use alternative pain management strategies before resorting to medication. 28 Pa. Code 211.5(f)(vii) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, staff interview, facility policy, and the facility's infection assessment tool, it was determined the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use in accordance with the established infection prevention and control guidelines for two residents out of 19 sampled (Residents 34 and 71). Findings included: A review of a facility policy entitled Antibiotic Stewardship last reviewed December 2024, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The policy stated the facility will monitor and track new antibiotics start rates and antibiotic days of therapy monthly. It also required that antibiotic use protocols address prescribing practices, including documentation of the indication, dose, and duration of the antibiotic, review of laboratory reports to determine necessity, and completion of an infection assessment before prescribing. Additionally, the policy outlined monitoring procedures such as antibiotic use reports, antibiotic resistance reports, and the use of McGeer's criteria for determining the need for antibiotic therapy. A review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia and congestive heart failure (CHF - is a condition where the heart is unable to pump blood effectively). A review of the facility's infection tracker form, entitled Infection Control - Infection Tracker with McGeer's Criteria, dated December 6, 2024, and recorded on December 11, 2024, indicated that the form was initiated due to a suspected urinary tract infection (UTI). However, the completed assessment revealed that Resident 34 did not meet the McGeer's criteria to support the initiation of antibiotic therapy. Specifically, the resident did not have a fever, rigors, acute dysuria, leukocytosis, gross hematuria, or other signs and symptoms necessary to meet at least three criteria for a UTI diagnosis. Despite only meeting one criterion, a physician's order dated December 6, 2024, at 4:56 PM, prescribed Cefdinir 300 mg orally twice per day for seven days. A review of Resident 34's Medication Administration Record (MAR) for December 2024 revealed that the resident received 14 doses of Cefdinir without meeting the documented criteria for initiation of antibiotic therapy. The facility's failure to adhere to antibiotic stewardship protocols resulted in the unnecessary administration of antibiotics. A review of Resident 71's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included type II diabetes (a condition results from insufficient production of insulin, causing high blood sugar), dysphagia (difficulty swallowing), and cerebral infarction with weakness (is a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it and the lack of sufficient blood supply to brain cells deprives them of oxygen and critical nutrients, potentially leading to the death of brain cells). A nursing progress note dated November 15, 2024, at 9:35 PM, indicated that Resident 71 was catheterized ((is a medical procedure used to drain the bladder) to obtain a urine specimen. Orders were noted for STAT laboratory testing, including a complete blood count (CBC) and a basic metabolic panel (BMP), as well as an order to initiate Rocephin 1 gram intramuscularly daily for two days due to an elevated white blood cell (WBC) count. A review of the resident's laboratory results dated [DATE], at 8:27 AM, revealed that urinalysis results were unremarkable, the urine culture showed no growth, and WBC was elevated at 13.05 (reference range: 4.0 - 10.80). However, nursing progress notes from November 16, 2024, through November 18, 2024, documented that the resident's vital signs, including temperature, pulse, blood pressure, and respirations, remained within normal parameters. Despite the lack of clinical signs or symptoms of infection, the resident received two doses of Rocephin, indicating the facility's failure to ensure antibiotic therapy was supported by documented clinical necessity. During an interview with the facility's Infection Preventionist (IP) on January 30, 2025, at 11:20 AM, confirmed that the facility failed to implement antibiotic stewardship protocols for residents 34 and 71. This failure contributed to the initiation and continuation of antibiotic therapy without documented evidence of clinical necessity, inconsistent use of infection surveillance tools, and noncompliance with infection prevention and control guidelines. The facility failed to adhere to its established antibiotic stewardship program by allowing the initiation and continuation of antibiotic therapy without documented clinical indications. guidelines. Cross Refer F757 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, and staff interview, it was determined that the facility failed to act upon identified declines in bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 36). Findings include: A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and muscle weakness. A review of Resident 36's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2023, revealed that the resident was occasionally incontinent of bladder and always continent of bowel. A review of Resident 55's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was now frequently incontinent of bladder and occasionally incontinent of bowel. There was no documented evidence at the time of the survey ending February 2, 2024, that the facility had acted upon the decline in the resident's bowel and bladder continence and developed and implemented an individualized plan to decrease episodes of incontinency and restore normal function to the extent practicable for this resident. Interview with the Nursing Home Administrator on February 2, 2024, at approximately 2:00 PM confirmed that the facility failed to address the resident's increase in incontinency with an individualized plan to improve the resident's function and prevent further decline. 28 Pa. Code 211.12 (d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued use of multiple psychoactive medications, including antipsychotic and duplicate drug therapy for anxiety disorder, prescribed for one resident out of five sampled residents (Resident 73). Findings include: A review of Resident 73's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included anxiety, dementia with behavioral disturbance, Lewy body dementia [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], osteoarthritis [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], and repeated falls. A review of the resident's clinical record physician's orders revealed the following orders: November 9, 2023, Pimavanserin Tartrate Oral Capsule 34 MG [Nuplazid is in the drug class of antipsychotics that is used to treat the symptoms of a certain mental/mood disorder (psychosis) that might occur with Parkinson's disease.] Give 1 capsule by mouth one time a day related to unspecified dementia with behavioral disturbance. November 11, 2023, Sertraline HCL (antidepressant used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to unspecified anxiety disorder. December 12, 2023, Buspirone HCL (anti-anxiety medicine) Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to anxiety disorder. December 13, 2023, Seroquel Oral (antipsychotic used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) Tablet 25 MG Give 1 tablet by mouth at bedtime related to neurocognitive disorder with Lewy bodies. December 16, 2023, Ativan (an antianxiety medication used to treat anxiety) Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to unspecified anxiety disorder and December 30, 2023, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed (PRN) for increased anxiety/agitation related to unspecified anxiety disorder. A review of the facility's consultant pharmacist's consultation report dated January 3, 2024, identified that Resident 73 had experienced multiple falls that occurred on 11/22/2023, 11/23/2023, and 12/20/2023. A comprehensive review of the medical record was conducted and identified that the following medications may contribute to falls: Two (2) antipsychotics: Nuplazid 34 mg daily and Seroquel 25 mg twice per day for Lewy Body dementia. Ativan 0.5 mg once daily and every eight (8) PRN for anxiety (PRN dose not administered prior to any fall). Sertraline 25 mg daily for anxiety, and Buspar 5 mg three times per day for anxiety. The pharmacist requested that the attending physician evaluate these medications as possibly causing or contributing to falls, deducing/discontinuing as appropriate and that if the therapy was to continue it would be recommended that the prescriber document an assessment of risk versus benefits, indicating that the medication is not believed to be contributing to falls in Resident 73; b) the facility interdisciplinary team ensures ongoing effectiveness and potential adverse consequences. A review of the attending physician's progress notes dated January 6, 2024, noted that Resident 73 was receiving Sertraline (Zoloft) and buspirone (Buspar) and Seroquel for the resident's mood. There was no documented evidence that attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder. A review of the physician's response dated January 16, 2024, revealed that a physician extender, a certified registered nurse practitioner, and the resident's attending physician) addressed the pharmacist's recommendations and decreased the resident's dose of the antipsychotic drug Seroquel dose to 25 mg at bedtime and increased the resident's antidepressant Zoloft to 50 mg oral daily. Through survey ending February 2, 2024, there was no documented evidence provided that the resident's attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder and that the physcian had thoroughly evaluated the combination of these medications and their potential side effects that may be negatively affecting the resident. Interview with the Director of Nursing (DON) on February 2, 2024, at 10:24 AM, confirmed that Resident 73's attending physician failed to document an evaluation of potential adverse consequences, including an assessment of the resident's condition and documented the clinical necessity of each psychoactive drug, including antipsychotics and duplicate drug therapy for anxiety disorder, in maintaining or improving the resident's function and abilities. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.2 (d)(3) Medical Director. 28 Pa. Code 211.5(f) Medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for one resident (Resident 1) out of seven reviewed. Findings included: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses of alcohol use and repeated falls. A review of Resident 1's Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 25, 2023, revealed that the resident's cognition was moderately impaired. A review of an admission Elopement assessment dated [DATE], revealed that the resident was assessed to be at high risk for eloping from the facility. A progress note dated June 6, 2023, at 1:29 PM revealed that the facility's director of maintenance saw the resident coming out of the building from the exit near the staff time clock. The resident stated he wanted to go outside and followed the staff in front of him from the time clock. An incident report dated June 6, 2023, at 1:16 PM revealed the Employee 1, the Maintenance Director, witnessed Resident 1 exiting the building. Nursing staff brought the resident back into the facility and assessed for injuries at that time. Further it was indicated the resident exited the facility through a door Employee 2 Housekeeping had just exited out of due to the door not closing all the way shut. Employee 1 followed the resident while Employee 2 went to get nursing staff to help him back into the building. Employee 1's witness statement dated June 6, 2023, indicated that Employee 1 watched the resident walk out of the time clock exit door and started walking down the sidewalk towards the rear of dietary. Employee 1 stated she followed the resident around the building where he had stopped, talking to dietary workers. A written witness statement from Employee 2 dated June 6, 2023, revealed that Employee 2 stated that after she left the building from the time clock door and got into her car, she noticed Resident 1 was outside the facility and went to get staff inside the facility to help bring him back inside. A written witness statement from Employee 3 LPN (license practical nurse) dated June 6, 2023, indicated that dietary staff approached her to inform her that Resident 1 was outside the building. Employee 3 went outside and brought the resident back into the facility. The facility staff failed to ensure the doors at the staff time clock were secured when staff exited the facility and failed to ensure awareness that a resident with a known risk for elopement was behind them exiting the facility when they were leaving. An interview with the Director of Nursing on September 8, 2023, at approximately 1:00 PM confirmed the facility failed to provide adequate safety measures and supervision of a resident with known high elopement risk placing the resident at risk for accidents and injury. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The resident was brought back into the facility. A head to toe assessment was completed with no injuries noted. The resident will be offered to go to the courtyard daily. He was placed on 15 minute checks for 72 hours. A head count was completed to ensure all residents were in the facility. All doors were checked for functioning and locking. All windows were checked to ensure proper functioning. 2. To identify like residents that have the potential to be affected the DON or designee will complete new elopement assessments on all residents. If a resident is at risk for elopement care plans will be updated along with the elopement risk book. To identify like residents that have the potential to be affected the maintenance director or designee will complete door checks for functioning and window checks to ensure no other residents could elope. 3. To prevent this from reoccurring the DON or designee will educate current staff on the elopement policy and to ensure doors are firmly closed when exiting locked doors. When new staff members are hired, they will be educated on the elopement policy. Elopement drills will be held every shift to ensure staff members are aware of what to do in case of an elopement. 4. To monitor and maintain ongoing compliance the nursing home administrator or designee will hold and elopement drill monthly for three months. To monitor and maintain ongoing compliance the nursing home administrator or designee will interview five staff weekly for four weeks then monthly for two months to ensure comprehension of elopement policy and education. To monitor and maintain ongoing compliance the maintenance director or designee will complete an audit weekly for four weeks and then monthly for two months to ensure all doors and windows are locked and functioning appropriately. 5. These results of the audits will be forwarded to the facilities QAPI committee for further review and recommendations. The facility's plan of correction was completed on June 7, 2023 28 Pa Code: 201.18 (e)(1) Management 28 Pa. Code: 211.12 (d)(3)(5) Nursing Services

Based on a review of employee files and the facility's abuse prohibition policy and staff interviews, it was determined that the facility failed to implement abuse prohibition procedures for fully screening one potential employee out of five reviewed to ensure that they were eligible for employment in a long-term care nursing facility. Findings include: A review of the facility's policy Pennsylvania Resident Abuse last reviewed by the facility in January 2023, revealed that under the area of employee screening, the facility will generally attempt to obtain references from 2 prior employers for an applicant. A review of the personnel files of newly hired employees, revealed that Employee 1 (Housekeeping) was hired January 12, 2023. On the employee's application for employment, he indicated that he had one previous employer. There was no indication that the facility contacted the previous employer to screen the employee for employment in a long-term care nursing facility. Interview with the Employee 2, Human Resources on March 2, 2023, at approximately 11:00 AM., confirmed that the facility had failed to contact the former employer of one newly hired employee to screen the employees for employment in the facility. 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to identify use by/discard dates for multidose insulin pens on one of two medication carts sampled (Residents 3 and 7). Findings include: A review of the facility's policy and procedure entitled Storage and Expiration Dating of Medications and Biologicals last revised January 2023 revealed if a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that open vial. An observation of the 500 Hall Medication Cart on March 2, 2023, at approximately 9:30 AM revealed Resident 3's Lispro Insulin Pen 100 units/ml (milliliters) was dated January 29, 2023. Further observation revealed Resident 7's Lispro Insulin Pen 100 units/ml was dated January 27, 2023. An interview with Employee 3, LPN (license practical nurse), on March 2, 2023, at the time of the observation confirmed that the insulin pens located in the medication cart were past the use by date and should have been discarded after 28 days of opening. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.9(k)(1)(2) Pharmacy services

Based on a review of facility submitted information, observations and staff interview, it was determined that the facility failed to consistently maintain a safe environment for staff, residents and the public as a result of staff's failure to implement safe practices in the outside courtyard. Findings include: Information dated February 24, 2023, at 3:45 AM, submitted by the facility revealed that in response to a facility alarm the local fire department responded and extinguished a small fire outside the building in the adjacent courtyard. Facility staff had also responded to the alarm with fire extinguishers and as a precautionary measures any residents close to that exterior wall within the facility were relocated. The fire fighters checked and confirmed that the fire had not entered the building and there were no signs of fire or smoke inside the building. Observations on March 3, 2023, at approximately 9:30 AM, of the exterior courtyard outside the 200 hall of the building revealed come charred areas and holes on the ground where a fence post had been located. The facility also boarded up that side of the building where evidence of heat damage had occurred during the incident on February 24, 2023. An interview with the Nursing Home Administrator (NHA) on March 3, 2023, at the time of the observation revealed the NHA stated that the facility concluded that staff were smoking in a non-designated area on the facility grounds and carelessly threw a still lit cigarette into the mulch, which caused the fire outside the facility. The NHA stated since it was a non-designated smoking area there was no receptacle to safely extinguish and discard cigarette butts. The NHA stated that staff are aware, and are only supposed to smoke across from the building, where there is proper containment for the cigarette butts. An interview on March 3, 2023, at approximately 12:30 PM, the Nursing Home Administrator confirmed that staff failed to adhere to this established facility smoking rules and created an unsafe environment for staff, residents and the public. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: The fire alarm was pulled at 2:38 AM on February 24, 2023. The residents were evacuated from the area. The residents were moved from the 200 hall to the end of the hallway before the fire trucks arrived. The fire trucks arrived at 2:45 AM. The fire extinguishers were replaced on sight by the Fire Marshall. The physician and responsible parties of the residents were notified on February 24, 2023. The door was checked at the site of the fire to ensure the locking mechanism was intact and functioning. Staff were stationed by the door to monitor for any hazards. To identify any residents of the potential to be affected the DON (director of Nursing) or designee will complete head to toe assessments on residents in the affected area to include the 100 203 100 nursing halls. Those assessments include lung sounds vital signs and pulse ox. Any issues will be reported to the physician and the resident's responsible party. To identify like residents that have the potential to be affected the social worker or designee will complete psychosocial visits with the residents to ensure residents feel safe in the environment and allow residents to voice concerns related to the evacuation or fire. To identify issues that have the potential to affect residents the maintenance director or designee will check the function of the locking mechanisms and all doors to ensure proper function period to identify the like issues that have the potential to affect residents the housekeeping staff or designee will complete environmental rounds To prevent this from happening again the interdisciplinary team or designee will educate current staff on what to do in case of concerns of fire or actual fire which include fire drill policy fire watch competency fire safety in service fire watch tour in calling the alarm company or fire trucks. To prevent this from happening again the maintenance director designee will complete fire drills on all 3 shifts. On the spot education will be completed as needed for employees with identified issues prevent this from happening again the regional director of clinical services will complete education with the human resource director and the maintenance director to ensure that all fire education is completed upon higher to include a review of fire and row and tour of the fire panel period to prevent this from happening again the nursing home administrator or designee will complete education on designated smoking areas now to safely extinguish smoking materials and a safe smoking kit. To monitor and maintain ongoing compliance the licensed staff will complete head to toe assessments on residents in the 100 200 and 300 halls including pulse ox, lung sounds, and vital signs twice a day for 72 hours. Any issues will be reported to the physician and responsible party. To monitor and maintain ongoing compliance the social worker or designee will complete five random psychosocial visits weekly for four weeks then monthly for two months to ensure residents feel safe in the environment and allow residents to voice any concerns related to the evacuation or the fire. To monitor and maintain ongoing compliance the maintenance director or designee will complete fire drills weekly for four weeks on alternating shifts and then monthly for two months. On the spot education will be completed as needed for employees with identified issues. To monitor and maintain ongoing compliance the housekeeping staff or designee will complete environmental rounds five days a week for four weeks and then monthly for two months on the facility campus to ensure that cigarette butts are not in the mulch or an any area that can be combustible period. To monitor and maintain ongoing compliance the human resources director or designee will complete Five random audits of employee files including all new employees hired in the last week every week for four weeks and then monthly for two months to ensure fire education was completed period to monitor and maintain ongoing compliance the nursing home administrator or designee will audit the designated smoking area five days a week for four weeks and then monthly for two months to ensure proper signage is posted, observe the smoking extinguish receptacles, and observe the fire extinguishers. To monitor and maintain ongoing compliance the interdisciplinary team or designee will complete walking rounds every shift of the campus to ensure that employees are smoking in the designated smoking areas. All results of the audits will be forwarded to the facility's QAPI committee for further review and recommendation. The facility's date completion date for these corrections was February 25, 2023. 28 Pa. Code 209.3 (b) Smoking 28 Pa. Code 207.2(a) Administrators responsibility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to ensure the pharmacist conducted drug regimen reviews at least monthly for one resident out of 18 sampled (Resident 74), Findings include: Review of Resident 74's clinical record revealed that she was initially admitted to the facility on [DATE], with diagnoses to have included Alzheimer's disease [is a generally progressive disorder that is a type of brain disorder that causes problems with memory, thinking and behavior], anxiety and depression. Review of Resident 74's clinical record revealed no documented evidence that the licensed pharmacist conducted drug regimen reviews for irregularities with the resident's medication regimen during the months of July 2022, August 2022, September 2022, October 2022, November 2022, December 2022, January 2023, and February 2023. Interview with the Director of Nursing (DON) on March 3, 2023, at 11:00 AM, verified that there was no documented evidence that the pharmacist had conducted drug regimen reviews of Resident 74's medication regimen at least monthly. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services.