**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, facility documents review, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in three of three nourishment refrigerators; and failed to serve food in a sanitary manner during one of two tray line observations. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with a last revised date of December 6, 2023, revealed, in part, Receiving Guidelines D. All food items will be stored with labels or markings designating: 1. Content; 2. Received Date; 3 Either a) manufacturer information (date/lot) or b) relevant disposal dates; E. Food items without the above information labels or markings upon arrival will have said dates added by staff; and Storage Guidelines A. General 2. Oldest stock will be rotated to the front to allow it to be used first, utilizing the FIFO [First in First Out] method. 3 All opened food items, including opened jars such as mayonnaise, will be: b) Dated with the initial opening date; D. Disposal of Food Items 2. Foods marked with a Best By, Use By, or Freshest Until Date will be kept and utilized after said date as per recommendations by the manufacturer or government resources. Observations of the kitchen on September 30, 2024, at approximately 10:38 AM, during a tour with Employee 2 (Dietary Manager) revealed the following: 1) in the dry storage room, there was a box of brownie mix with a best by date of July 12, 2024, with no other dates noted; a bag of sweet cornbread muffin mix with a best by date of December 28, 2023, with no other dates noted; five 104 ounce cans of diced beets with no dates noted; 16 104-ounce cans of diced carrots with no dates noted; four 2.25 pound cartons of dry hash browns with no dates noted; seven bags of butterscotch pudding mix with no dates noted; six boxes of chocolate cake mix with a best by date of May 10, 2022, and no other dates noted; two boxes of chocolate cake mix with a best by date of [DATE], and no other dates noted; and the scoop for the sugar bin was noted to be laying down in the sugar; 2) in the spice room, there was a bottle of opened vinegar with a best by date of May 23, 2024; nine plastic containers of chili powder with a best by date February 18, 2024; four plastic containers of oregano with a best by date of May 9, 2024, a plastic container paprika with a best by date of February 18, 2024; 3) in the walk-in freezer, there was a half full plastic bag of frozen diced green peppers that was secured with a twist tie, but there were no dates noted; 4) in the walk-in refrigerator there was a case of unsalted butter with a best by date of December 4, 2023, with no other dates noted; 5) in the walk-in beverage cooler there two cases of canned sliced pears, eight cans of sliced apples, and five cans of pear halves with no dates noted on the packaging; 6) in the vegetable walk-in freezer there was a bag of succotash laying on top of box with no dates noted and there was a case of sweet potatoes that had a large amount ice cover the top and side of the case; 7) in the walk-in freezer there two apple pies and approximately 15 chocolate cakes with no dates noted; 8) in the Cook's walk-in refrigerator there were approximately 10 cartons of thawed frozen liquid eggs with no dates noted; 9) in the Cook's Refrigerator 2 there was a half full plastic bag of diced celery that was secured with a twist tie, but there were no noted dates on the packaging. During an immediate staff interview with Employee 2, he indicated that they do not date items upon receipt into the kitchen. He also indicated that once a package was opened, that they should be dated with an open date. He also confirmed that all items observed that contained no dates were not dated in any manner. During a tray line food service observation on the sixth floor on October 2, 2024, at 11:47 AM, Employee 3 was observed leaving the tray line and opening the refrigerator with their right gloved hand. Employee 3 retrieved a package of sliced cheese from the refrigerator and returned to the tray line. Employee 3 was then observed to reach into an opened loaf of bread with their right gloved hand and retrieve two slices of bread with the same gloves. Employee 3 then removed the cheese from the package and placed it onto the bread, and placed the sandwich on the plate to be served to a resident. During an immediate staff interview with Employee 3 on October 2, 2024, at 11:49 AM, Employee 3 confirmed that the Employee should have changed gloves and washed hands, but the Employee focused on making the sandwich. Employee 3 then immediately left the tray line, removed their gloves, washed their hands, applied clean gloves, and returned to the tray line. During a staff interview on October 2, 2024, at 1:28 PM, with Employee 1 (Acting NHA/Chief Performance Improvement Executive), Director of Nursing (DON), and Employee 4 (Chief Operating Officer), Employee 4 indicated that facility staff had already had a meeting to discuss the food and beverage dating concern that was identified. Employee 4 shared that large bulk food items are placed in storage and dated when received there, and confirmed that once items are separated from the original packaging and delivered to the kitchen, the dates do not carry over with the items. Employee 1 confirmed that with the lack of dating at time or receipt/purchase, the facility could not utilize governmental guidelines at Foodsafety.gov as they are dependent on purchase dates to determine expiration dates. Employee 1 confirmed that Employee 3 should have removed their gloves, washed their hands, and applied new gloves after touching the refrigerator door handle. During a final staff interview with Employee 1, Employee 4, and the DON on October 3, 2024, at 10:24 AM, Employee 4 shared that the Employee 2 (Dietary Manager) and the storeroom managers had met and have devised a system to date items when received in the storeroom and a way to date items when they transition to the kitchen. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(3) Management

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for one of 19 records reviewed (Residents 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 27's care plan revealed a care plan focus for an activities of daily living (ADL) self-care performance deficit related to impaired vision, cognitive impairment, and non-ambulatory (unable to walk), with a revision date of August 27, 2023. Interventions included, but were not limited to, uses a Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with bilateral wings, bilateral footrests, and a foam cushion with a pommel. She requires staff to push her in her chair for all mobility. Observation of Resident 27 on December 4, 2023, at 11:22 AM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. Observation of Resident 27 on December 5, 2023, at 10:38 AM, revealed they were seated in their Broda chair, with their legs crossed and dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with the Director of Nursing (DON) and the Chief Performance Improvement Executive on December 6, 2023, at 11:10 AM, the aforementioned observations were shared for further follow-up. Observation of Resident 27 on December 6, 2023, at 12:38 PM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with Employee 2 on December 6, 2023, at 12:42 PM, Employee 2 was asked about Resident 27's footrests. Employee 2 immediately searched Resident 27's room and located the footrests in the top of Resident 27's closet. Employee 2 indicated that they were not sure if the footrests needed to be in place, because, at one point, they were a fall risk concern for Resident 27 because they were attempting to stand up on them. Employee 2 further indicated that Resident 27 had a recent hospitalization and that their condition had declined. She confirmed that Resident 27's legs were dangling and then placed the footrests on Resident 27's Broda chair. During a follow-up interview with the DON and the Chief Performance Improvement Executive on December 6, 2023, at 1:45 PM, the DON confirmed that there had been some concerns in the past with Resident 27's footrests, but that she would look into the concern. During a follow-up interview with the Chief Performance Improvement Executive on December 7, 2023, at 9:43 AM, he indicated that he and the physical therapist had looked at Resident 27's seating and positioning. He confirmed that the footrests should have been present on Resident 27's Broda chair as indicated in their care plan. 28 Pa. Code 211.11(d) Resident Care Plans

Based on review of facility policy, observation, record review, and staff interview, it was determined that the facility failed ensure the resident received care consistent with professional standards to prevent pressure ulcers for one of 21 residents reviewed (Resident 91). Findings Include: Review of facility policy, titled Dressing: Dry-Clean Technique, reviewed March 2023, revealed, 5. Remove the soiled dressing and discard into appropriate receptacle. 6. Remove soiled gloves. Perform hand hygiene and don clean gloves. 7. Clean the wound with the ordered cleaning solution. Review of Resident 91's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and pressure ulcer of the sacral region, stage 3 (ulcer on the skin with full thickness tissue loss). Observation of a dressing change to the dorsum of the right foot (top of foot) of Resident 91 on December 7, 2023, at 10:04 AM, revealed Employee 1 removed the dressing from Resident 91's foot and then cleansed the wound without first performing hand hygiene and donning clean gloves. Interview with the Nursing Home Administrator on December 7, 2023, at 12:48 PM, revealed that she would expect the facility policy to be followed during dressing changes. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the main kitchen and in one of two nourishment refrigerators. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with last review date of October 5, 2021, revealed the following: 9135.13 Receiving guidelines C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out and in subsection, titled The following rules for dry storage will apply in the Dietary Department and in the Storeroom, indicated, in part, at 9135.15 All items will be dated upon receiving. Review of facility policy, titled 9138 Foods with Best By or Use By Dates, with last review date of October 5, 2023, revealed the following: 9138.3 All food items will be stored with labels or markings designated content, received date and either manufacturer information (date/lot) or relevant disposal dates; 9138.5 Foods marked with a best by, use by, freshest until date will be kept an utilized for the time period after this date as recommended by the manufacturer or government resources; Additional information can be obtained from Foodkeeper App FoodSafety.gov. Tour of the main kitchen on December 4, 2023, at 9:47 AM, with Employee 3 (Dietary Manager) revealed the following: 1) in the produce walk-in cooler: a case diced green peppers with a noted Use By Date of November 29, 2023, and a case of oranges with no dates indicated; 2) in the dry storage room: one container of Quaker Oats, unopened, with a Best Before date of May 27, 2023; a container of Quaker Oats, marked with an opened date of March 2023, with a Best Before date of May 27, 2023; and a case containing three 98 ounce cans of evaporated milk with no date marked on the case other than a shipping label dated September 14, 2022; and 3) in the cooks refrigerator: two individual serving size containers of butterscotch pudding with a Best By Date of November 13, 2023. During an immediate interview with Employee 3, Employee 3 indicated that all items should be dated when they are received into the facility. Employee 3 also indicated that they were not sure how long items could be used after their Best Before or Best By dates. Observation of the nourishment refrigerator in the treatment room on unit 6B on December 5, 2023, at 10:40 AM, revealed three Mighty Shakes (a nutritional supplement) that were not dated with a thaw date. Each individual carton indicated that the shake was to be used within fourteen days of thawing. Email communication received from the Chief Performance Improvement Executive on December 5, 2023, at 3:11 PM, included information from Foodkeeper App at FoodSafety.gov for evaporated milk which indicated for freshness and quality, this item should be consumed within 12 months if in the pantry from the date of purchase. During an interview with the Chief Performance Improvement Executive on December 6, 2023, at 1:47 PM, he confirmed that the mighty shakes should have been dated with a thaw date. He further indicated that they need to look at their process to determine guidelines to follow in regards to Best By/ Best Before dates. He also added that they would have to do a lot of research to determine when the case of evaporated milk arrived at the facility, but confirmed that the shipped date on the case was September 14, 2022. During a follow-up interview with the Director of Nursing and the Chief Performance Improvement Executive on December 7, 2023, at 10:34 AM, the Chief Performance Improvement Executive confirmed that the other items in question were not dated upon arrival to the kitchen which could have helped identify the true date the items needed discarded. He again indicated that the facility would be looking at their process in regards to the Best By/ Best Before dates and the appropriate timeframe for discarding. 28 Pa code 211.6(b)(d) - Dietary Services

Based on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required committee members attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022- February 2023). Findings include: Review of facility's Quality Assurance and Performance Improvement Program, last reviewed March 21, 2023, indicated the QAPI Committee is composed of at least the following individuals: QAPI Director (Chairperson) QAPI Specialist Chief Executive Officer QAPI Coordinator Medical Director RN Assessment Coordinator Chief Operating Officer Chief Social & Rehab Executive Infection Control Preventionist Director of Nursing A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of December 2023 through November 2023, revealed that the Infection Control Preventionist was not in attendance for the December 2022, January 2023, or February 2023 QAPI meeting. During an interview on December 7, 2023, at 11:06, the QAPI Chief performance Executive Director informed the surveyor there is not a designated mandatory quarterly meeting date because they hold monthly meetings. During an interview on December 7, 2023, at 12:45 PM, the QAPI Chief performance Executive Director confirmed that the individuals noted on the sign-in sheets were the only ones in attendance at the corresponding meetings, and confirmed that the facility failed to ensure that all required individuals were in attendance for the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022-February 2023). 28 Pa. Code 201.18(e)(1)(2)(3) Management

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for three of 20 residents reviewed (Residents 37, 58, and 77). Findings include: A review of the clinical record for Resident 37 on December 12, 2022, revealed diagnoses that include Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Unspecified Psychosis (condition that affects the mind and makes it hard to tell what is real and what is not. It can cause delusions, hallucinations, and disorganized speech or behavior). Further review of the clinical record revealed Resident 37 receives the medication Risperdal (antipsychotic) for Psychosis that requires, at minimum, an annual review to determine the need for a gradual dose reduction. A review of Resident 37's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated November 21, 2022, revealed Section N. Medication Review, Subsection N0450, E. requests the date the physician documented the GDR (gradual dose reduction) as clinically contraindicated. The date entered is 1/23/2020. The most recent documentation by the physician that a GDR was contraindicated was October 5, 2022. During an interview with the Employee 2 (Registered Nurse Assessment Coordinator) and Medical Director on December 14, 2022, at 10:30 AM, both agreed Subsection N0450, E., of the MDS, should have been dated October 5, 2022. Review of Resident 58's clinical record revealed diagnoses that included Alzheimer's Disease and hypertension (high blood pressure). Review of Resident 58's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of June 28, 2022, revealed in section J Health Conditions that Resident 58 experienced one fall with injury (except major) and one fall with no injury since the last assessment, with assessment reference date of April 5, 2022, was completed. Further review of Resident 58's clinical record and facility provided incident reports revealed that Resident 58 had experienced a fall with no injuries on April 30, 2022; a fall with minor injury on May 15, 2022; and a fall with no injuries on May 20, 2022. Director of Nursing and Employee 2 were made aware of the MDS coding concern on December 14, 2022, at 10:10 AM. Employee 2 indicated she would look into it. During an interview with Employee 2 on December 14, 2022, at 10:23 AM, Employee 2 confirmed that the June 28, 2022, MDS was coded inaccurately. Review of Resident 77's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 77's October 25, 2022, comprehensive MDS revealed that the assessment was coded to indicate that the date the physician most recently documented that a gradual dose reduction of Resident 77's antipsychotic medication was clinically contraindicated was February 11, 2022. Review of Physician Medication Review form, dated October 11, 2022, revealed that no changes in Resident 77's antipsychotic medications were recommended at that time. During an interview with the Medical Director on December 14, 2022, at 10:55 AM, he confirmed that it would have been more accurate to note the October 11, 2022, date as the date the physician last documented that a gradual dose reduction was contraindicated on the October 25, 2022 MDS. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on policy reviews, observations, and interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety in the dietary department. Findings include: Review of facility policy titled Refrigeration and Storage Procedures with a reviewed date of October 5, 2021, revealed the following: 9135.3 *Add Expiration Date if there is not one on the product already*; 9135.13 C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out.; and 9135.15 Storage will be neat and arranged for easy identification of items. Similar food items will be grouped together in a system, labels facing the aisle space. All items will be dated upon receiving. Oldest stock will be rotated to the front to allow this stock to be used first, i.e. first in, first out. Review of policy titled Instructions Turbo Wash Pot & Pan Sink & 3 Bay Sink with a reviewed dated of October 20, 2022, indicated the following: Fill wash sink with warm water to fill line. Indented marking ; Fill rinse sink with warm water. ; Fill sanitizing sink ¾ full with the automated dispenser provided. ; Test sanitation water with a PH strip for accuracy. ; and If sanitation PH levels do not meet the requirements contact Eco Lab immediately. Initial kitchen tour was conducted on December 12, 2022, at approximately 9:55 AM, with Employee 3. The following observations were noted: in one of the walk-in freezers there was a sealed bag of diced onions that had a best by date of December 7, 2022; in one of the walk-in refrigerators there was a sealed bag of diced green peppers slightly pale in color in a metal bin that had no dates noted on the sealed packaging; and in dry storage there was a bag of mixed spices/ seasonings for lentil bread per Employee 3 that was not labeled or dated. It was also noted that there were two bottles of test strips for the 3-compartment sink that had an expiration date of January 2022. Employee 3 indicated that the only dishes that are washed in the main kitchen are the items used for cooking and meal preparation, and that all these items are ran through the dishwasher. During an interview with Nursing Home Administrator (NHA) and Employee 2 (Chief Performance Improvement Executive) on December 13, 2022, at approximately 02:05 PM, Employee 2 indicated that he would expect items to be labeled and dated as per facility policy and that the test strips would not be expired. Email communication received from NHA on December 14, 2022, at 11:52 AM, indicated the following: 1) The items in question were disposed of at the time of the tour. The subsequent delivery of frozen items were individually labeled (such as when multiple units in a single box). 2) Test strips are being obtained locally to replace what had expired. 3) Staff education has commenced and will continue/be ongoing. 28 Pa code 211.6(b)(d) - Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of two residents reviewed for pressure ulcers (Residents 20 and 55). Findings include: Review of Resident 20's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and muscle weakness. Review of Resident 20's active care plan revealed that he currently had a pressure ulcer on his sacral area. Review of Resident 20's current physician orders failed to reveal any treatment orders for an active, open wound on his sacrum. Review of nursing progress note dated December 7, 2021, indicated that the wound on Resident 20's sacral area was resolved. During an interview with the Director of Nursing (DON) on December 14, 2022, at approximately 11:40 AM, she confirmed that Resident 20 did not have a current pressure ulcer on his sacral area, and that his care plan had been updated. Review of Resident 55's clinical record on December 14, 2022, at approximately 10:00 AM, revealed diagnoses including diabetes mellitus (disease that results in decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 55's clinical record revealed that on November 14, 2022, facility staff assessed Resident 55 to have a pressure ulcer of the sacrum and on November 16, 2022, facility staff assessed Resident 55 as having developed a pressure ulcer of the right heel. Review of Resident 55's comprehensive plan of care revealed that Resident 55 had a care plan with a focus of .history of an unstageable pressure ulcer to the right and left heels; left ankle skin issues [related to] immobility, which was initiated on December 29, 2017 and last revised May 21, 2021. Review of the care plan goal revealed it stated, [Resident 55] will have intact skin, free of redness, blisters or discoloration by/through review date, which was initiated on October 1, 2018, and last revised on October 6, 2021. Review of the interventions for the care plan revealed the most recent revision to interventions was dated October 1, 2018. Review of Resident 55's comprehensive plan of care revealed that facility staff did not update the aforementioned care plan, goal, or interventions, to include the actual pressure wounds developed by Resident 55 on November 14, 2022, and November 16, 2022. During a staff interview on December 14, 2022, at approximately 12:00 PM, DON confirmed that Resident 55's care plan had not been updated to include the pressure ulcers that had developed. During the staff interview, DON revealed staff should have updated Resident 55's care plan. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services