Health inspection·September 21, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, and staff interviews, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for one of 34 residents reviewed (Residents 65). Residents Affected - Few Findings include: Review of Resident 65's clinical record on September 18, 2023, revealed diagnoses that included neurocognitive disorder with lewy bodies (a progressive dementia that results from protein deposits in nerve cells of brain. It affects movement, thinking skills, mood, memory, and behavior), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident 65's care plan revealed a focus area: [Resident 65] is at risk for falls due to lewy body dementia .may attempt to get up by self .actual falls, last revised June 24, 2021, with an intervention for, call bell in reach, initiated May 24, 2021. Observation in Resident 65's room on September 18, 2023, at 11:23 AM, revealed her call bell was on the floor, underneath the bed. Interview with Employee 4 (Nurse Aide) on September 18, 2023, at 11:25 AM, revealed she would place Resident 65's call bell within reach. Observation in Resident 65's room on September 19, 2023, at 9:26 AM, revealed her call bell was on the floor, underneath the bed. Further observation on September 19, 2023, at 9:46 AM, revealed Employee 5 (Nurse Aide) left Resident 65's room after providing care, Resident 65's call bell remained on the floor underneath the bed. Interview with Employee 6 (Licensed Practical Nurse) on September 19, 2023, at 9:47 AM, revealed she would go back to Resident 65's room and place her call bell within reach. Interview with the Nursing Home Administrator on September 20, 2023, at 1:41 PM, revealed she would expect Resident 65's call bell to be in reach. 28 Pa code 201.29(d) - Resident Rights 28 Pa Code 211.12(d)(1) Nursing Services Page 1 of 27 395613 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of two residents reviewed who remained in the facility for long-term care (Residents 46 and 120). Residents Affected - Few Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on September 18, 2023, revealed that Medicare coverage for Resident 46 began on July 28, 2023, and that her last covered day was August 17, 2023. The form indicated that the facility initiated discontinuation from Medicare Part A coverage, and that the Resident's benefit days were not exhausted. Further review of the form revealed that neither a Notice of Medicare Non-Coverage (notifies that Medicare will no longer pay for certain services and provides information on appeal rights) nor an Advanced Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) was provided to the Resident or her Representative at the time that Medicare Part A was discontinued. A SNF Beneficiary Protection Notification Review form, completed by the facility on September 18, 2023, revealed that Medicare coverage for Resident 120 began on June 2, 2023, and that his last covered day was July 3, 2023. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the Resident's benefit days were not exhausted. Further review of the form revealed that an ABN was not provided to the Resident or his Representative at the time that Medicare Part A was discontinued. During an interview with the Nursing Home Administrator on September 20, 2023, at 1:49 PM, she revealed the expectation that the appropriate notices should have been provided to Residents 46 and 120. 28 Pa. Code 201.18(e)(1) Management 395613 Page 2 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for two of 34 residents reviewed (Residents 46 and 80), and failed to exercise reasonable care for the protection of the resident's property from loss or theft for two of two discharged residents reviewed (Residents 19 and 153). Findings include: Review of facility policy, titled Personal Property with a last review date of August 7, 2023, revealed 10. The residents belongings and clothing are inventoried and documented upon admission and updated as necessary. Review of Resident 19's clinical record revealed that they were admitted to the facility on [DATE], and were discharged from the facility on September 14, 2023. Further review of the closed clinical record revealed that their Inventory of Personal Effects was completely blank. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 21, 2023, at 10:55 AM, the surveyor shared with the NHA and DON that the Inventory of Personal Effects was completely blank with no information, including regarding her belongings disposition. The DON indicated that they would follow-up and see if they could locate the personal belonging information. She confirmed that it should be done upon admission, and that the secretary usually takes care of this form upon admission to the facility. During a follow-up interview with the NHA on September 21, 2023, at 1:20 PM, the NHA indicated that she had no other information to provide. Observations of Resident 46's room on September 18, 2023, at 12:24 PM, and September 19, 2023, at 9:43 AM, revealed a small personal fan clipped and duct taped to their bed rail; which had an accumulation of a gray colored lint appearing substance. Observations were shared with NHA and DON on September 20, 2023, at approximately 2:20 PM. Email communication received from NHA on September 20, 2023, at 7:19 PM, indicated the small fan was removed so it can be cleaned. During a follow-up interview with the NHA and DON on September 21, 2023, at 9:47 AM, the NHA indicated that they were not sure who put the fan there or how long it had been there. She indicated that it should be kept clean and that they were in the process of getting it cleaned. Observation of Resident 80's room on September 18, 2023, at 12:30 PM, revealed that there were two packages of incontinence briefs stored in public view on a bedside stand. Observation was shared with NHA and DON on September 20, 2023, at 2:22 PM. The DON confirmed that these items should not be sitting out in public view. Email communication received from NHA on September 20, 2023, at 7:19 PM, indicated the incontinence 395613 Page 3 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0584 briefs were put away in the dresser. Level of Harm - Minimal harm or potential for actual harm Review of Resident 153's clinical record revealed that she passed away on September 1, 2023. Further review revealed no documented inventory of personal effects, or accounting for Resident 153's personal effects following discharge. Residents Affected - Few In an email received from the NHA on September 21, 2023, at 1:11 PM, she revealed that she did not have any additional information regarding the whereabouts of Resident 153's personal belongings following discharge. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(e)(1) Management 395613 Page 4 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to implement their established procedures for investigation and protection of residents related in response to potential abuse for one of 34 residents reviewed (Resident 65). Residents Affected - Few Findings include: Review of facility policy, titled Accidents and Incidents - Investigating and Reporting, last revised July 2017, revealed, All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator .the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .the nurse supervisor/charge nurse and/or the department director or supervisor shall complete a report of incident/accident form and submit the original to the director of nursing within 24 hours of the incident or accident incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of Resident 65's clinical record on September 18, 2023, revealed diagnoses that included neurocognitive disorder with lewy bodies (a progressive dementia that results from protein deposits in nerve cells of brain. It affects movement, thinking skills, mood, memory, and behavior), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident 65's clinical record revealed a nursing progress note on June 18, 2023, at 6:32 PM, that stated, Bruise on right arm. During email correspondence with the Nursing Home Administrator (NHA) on September 19, 2023, at 12:37 PM, the surveyor inquired about an investigation related to Resident 65's bruise discovered on June 18, 2023. Interview with the NHA on September 20, 2023, at 1:40 PM, revealed she could not find a report of a incident/accident form related to Resident 65's bruise that was discovered on June 18, 2023. She further revealed she does not have any information to provide that an investigation was conducted, and she would expect a thorough investigation to be completed per the facility policy. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 395613 Page 5 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **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 provide transfer notices and/or transfer notices that contained the required information for four of seven residents reviewed for hospitalizations (Residents 49, 58, 74, and 146). Findings include: Review of Resident 49's clinical record on September 18, 2023, at approximately 1:00 PM, revealed diagnoses including bradycardia (slower that normal heart rate) and peripheral vascular disease (disease process that causes decreased blood circulation to the extremities). Review of Resident 49's clinical record revealed that on February 15, 2023, and July 9, 2023, Resident 49 was transferred from the facility to an acute hospital emergency room due to emergency medical needs. Review of the transfer notice provided as a result of the transfers on February 15, 2023, and July 9, 2023, revealed the notice did not include the name, address (both mailing and electronic mail), and telephone number of the State Long-Term Care Ombudsman nor the name, address, and telephone number of the State agency to which appeals could be submitted. Finally, the transfer notice did not include information on how to obtain a form to request an appeal and/or how to attain assistance with completing and submitting an appeal hearing request. Review of Resident 58's clinical record revealed diagnoses that included congestive heart failure (CHF weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function). Further review revealed that Resident 58 was transferred to the hospital on August 28, 2023, to be evaluated following a change in condition and was subsequently admitted . Review of available documentation failed to reveal that a notice of transfer was provided to Resident 58 or his Representative at the time of the aforementioned transfer to the hospital. During an interview with the Director of Nursing (DON) on September 21, 2023, at 12:08 PM, she revealed that she was not able to locate a notice of transfer for Resident 58's August 28, 2023, hospitalization. Review of Resident 74's clinical record on September 19, 2023, at approximately 9:30 AM, revealed diagnoses including diabetes mellitus type II (decrease ability of the body to utilize insulin for the transfer of glucose from the blood stream into the cells for nourishment) and end stage renal disease (disease of the kidneys that affects the kidneys ability to filter toxins from the blood to the point that dialysis is required to remove toxins from the blood). Review of Resident 74's clinical record revealed that on August 6, 2023, Resident 74 was transferred to an acute care hospital emergency room from the facility for an emergency medical need. Review of the transfer notice provided as a result of the transfer August 6, 2023, revealed the 395613 Page 6 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0623 Level of Harm - Potential for minimal harm notice did not include the name, address (both mailing and electronic mail), and telephone number of the State Long-Term Care Ombudsman nor the name, address, and telephone number of the State agency to which appeals could be submitted. Finally, the transfer notice did not include information on how to obtain a form to request an appeal and/or how to attain assistance with completing and submitting an appeal hearing request. Residents Affected - Some During a staff interview on September 21, 2023, at approximately 1:30 PM, Nursing Home Administrator (NHA) revealed it was the facility's expectation that transfer notices would contain the required information. Review of Resident 146 clinical record revealed diagnoses that included pneumonia, hypertension (high blood pressure), and encephalopathy (disease in which brain functioning is affected by some agent or condition, such as an infection or toxins in the blood). Further review of Resident 146's clinical record revealed that they were transferred and subsequently hospitalized on [DATE] through 24, 2023, and July 7 through 13, 2023, for emergent medical needs. On September 19, 2023, at 12:52 PM, transfer notices for both hospital transfers were requested via email sent to the NHA and DON. On September 20, 2023, at 12:30 PM, an email communication received from the DON indicated that she could not locate transfer notices for either of the Resident's transfers. During an interview with the DON on September 20, 2023, at 2:36 PM, the DON confirmed that she could not provide a notice of transfer for either hospitalization. During a follow-up interview with the NHA and DON on September 21, 2023, at 9:32 AM, the DON again confirmed that she could not locate transfer notices for either hospital transfer, and further indicated that she would expect those to have been completed at time of the hospital transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management 395613 Page 7 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on resident observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 32 residents reviewed (Residents 80 and 96). Residents Affected - Few Findings include: Review of Resident 80's clinical record revealed diagnoses that included history of transient ischemic attack (TIA-temporary period of symptoms similar to those of a stroke which generally only lasts a few minutes and leaves no residual effects), cerebral infarct (a stroke-damage to the brain from interruption of its blood supply), psychotic disorder with delusions (a mental disorder characterized by a disconnection from reality with an unshakable belief in something that is untrue), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 80's physician orders revealed the following orders: Xarelto (an anticoagulantmedication to prevent clot formation) Tablet 20 MG (Rivaroxaban) Give one tablet by mouth in the evening, dated May 18, 2021; and Seroquel (an antipsychotic) oral tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth two times a day, dated September 18, 2023. Review of Resident 80'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 May 8, 2023, revealed in Section N Medications at question N0410.E Anticoagulants that Resident 80 had received an anticoagulant for seven days in the look-back period. Review of Resident 80's Medication Administration Record from May 2-8, 2023 (the seven day look-back period) revealed that they had only received an anticoagulant on six days. Review of Resident 80's Quarterly MDS with the assessment reference date September 3, 2023, revealed in Section N Medications at question N0450.E, that the physician had documented that a gradual dose reduction of their antipsychotic medication was clinically contraindicated on May 8, 2023. Review of Resident 80's clinical record revealed a psychiatric services note dated May 8, 2023, which recommended that a gradual dose reduction of their antipsychotic be attempted, and there was no documentation noted that indicated that a gradual dose reduction was clinically contraindicated in this note. Review of a psychiatric services note dated May 1, 2023, indicated that a gradual dose reduction of their antipsychotic medication was clinically contraindicated. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 20, 2023, at approximately 2:20 PM, both of the aforementioned coding concerns were shared. Email communication received from the NHA on September 20, 2023, at 5:42 PM, indicated that on the Quarterly MDS with the assessment reference date of May 8, 2023, the anticoagulant was incorrect as it should have been six days. 395613 Page 8 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Email communication received from the NHA on September 21, 2023, at 9:18 AM, indicated that the documented gradual dose reduction clinically contraindicated date on the Quarterly MDS with the assessment reference date of September 3, 2023, was their error. During a follow-up interview with the NHA and DON on September 21, 2023, at 9:48 AM, the NHA indicated that she would expect the MDSs to have been coded accurately at time of completion. Review of Resident 96's clinical record on September 18, 2023, at approximately 12:30 PM, revealed diagnoses including diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and chronic kidney disease stage 3 (decreased ability of the kidneys to filter toxins from the blood). During an interview with Resident 96 on September 18, 2023, at approximately 11:40 AM, Resident 96 reported dental concerns with lower teeth. Resident 96 reported that, prior to admission to the facility, Resident 96 had the upper teeth removed and had planned to have the lower teeth removed, but was admitted to the facility prior to having the dental extractions performed. Observations of Resident 96 during the interview revealed the bottom teeth looked to be decayed. Review of Resident 96's Annual MDS with an assessment reference date of August 21, 2023, revealed section L0200 - Dental, subsection D - Obvious or likely cavity or broken natural teeth, was assessed and coded as, No. Review of assessments of Resident 96 conducted by facility staff on March 30, 2023, and August 22, 2023, revealed that staff assessed Resident 96 as having no dental concerns including, Obvious or likely cavity or broken natural teeth. During observations conducted with the DON on September 21, 2023, at approximately 1:20 PM, it was observed that Resident 96 had multiple decayed and possibly broken teeth on the bottom. Directly after the observation of Resident 96's teeth on September 21, 2023, at approximately 1:25 PM, DON revealed that Resident 96's Annual MDS should have been coded to reflect the state of Resident 96's teeth. 28 Pa. Code 211.5(f) Clinical records 395613 Page 9 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive plan of care for one of five residents reviewed for unnecessary medications (Resident 148). Findings include: Review of Resident 148's clinical record on September 19, 2023, at approximately 1:00 PM, revealed diagnoses that included dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). Review of Resident 148's physician orders revealed an order which was started on July 24, 2023, for Risperdal (an antipsychotic medication) 0.5 milligrams (mg - metric unit of measure) by mouth once a day, which was increased to twice a day on September 11, 2023. Review of Resident 148's comprehensive plan of care revealed Resident 148 did not have a care plan developed or implemented that addressed the use of an antipsychotic medication. During a staff interview on September 21, 2023, at approximately 10:00 AM, the Nursing Home administrator and Director of Nursing revealed that it was the facility's expectation that Resident 148 would have the use of an antipsychotic medication included in the comprehensive plan of care. 28 Pa code 211.12(d)(1)(5) Nursing services 395613 Page 10 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of 34 residents reviewed (Residents 78 and 94). Residents Affected - Few Findings Include: Review of Resident 78's clinical record revealed diagnoses that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and has a pacemaker (a device used to control an irregular heart rhythm). Review of Resident 78's admission 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 July 11, 2023, revealed a BIMS (brief interview for mental status) score of 15, meaning Resident 78 is cognitively intact. During an interview with Resident 78 on September 18, 2023, she confirmed that she has a pacemaker, but her pacemaker monitoring device (a remote monitoring device for implanted heart devices that remotely records abnormal heart rhythms to the physician) that she has at home is missing some parts, so she is scheduled to see the cardiologist (heart doctor) for replacement. The Resident stated that she doesn't have a remote device at the facility, and there was no remote monitoring device observed in the Resident's room. A review of Resident 78's physician orders included an order written on September 6, 2023, to check the functioning of the pacemaker monitor every shift. A review of the TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed staff signing off that the pacemaker monitor was functioning when the Resident doesn't have a pacemaker monitor. During an interview with the Director of Nursing (DON) on September 20, 2023, at 1:30 PM, the DON stated that the order was entered in error when the facility did an overall evaluation of Residents with pacemakers and entered standing physician orders for care on September 6, 2023. The DON agreed that standing orders did not apply to Resident 78, and the facility should have observed for the actual pacemaker monitor and should not be signing off on the functioning of a device that is not present. Review of Resident 94's clinical record revealed diagnoses that included paroxysmal atrial fibrillation (irregular heart rhythm that can cause symptoms such as fatigue, lightheadedness, and stroke) and presence of a cardiac pacemaker. Review of Resident 94's September 2023 TAR revealed an order to check pacemaker monitor functioning each shift, effective September 7, 2023. Further review of the TAR revealed that nursing staff signed off that these checks were done each shift between September 7 and 19, 2023. Observation of Resident 94's room on September 19, 2023, at 8:47 AM, failed to reveal the presence of a pacemaker monitor. 395613 Page 11 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on September 21, 2023, at 9:48 AM., she confirmed that Resident 94 did not have a pacemaker monitor at the facility, but one was ordered and would be delivered to the facility in approximately one week. During a follow-up interview with the DON on September 21, 2023, at 12:09 PM, she revealed that Resident 94's pacemaker monitor only transmits when pacemaker checks are scheduled with cardiology. She also revealed the expectation that nursing staff would not have been documenting that they were checking that the pacemaker monitor functioning when the monitor was not present. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395613 Page 12 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of four residents reviewed (Resident 77). Residents Affected - Few Findings include: Review of Resident 77's clinical record revealed diagnoses that included depression, muscle weakness, and need for assistance with personal care. Observations of Resident 77 on September 18, 2023, at 11:08 AM; September 19, 2023, at 9:40 AM; and September 20, 2023, at 8:43 AM, revealed that they had thick noticeable facial hair on their chin. Review of Resident 77's care plan revealed that they required extensive assistance of two people with bathing, and that their bath/shower days were on Tuesdays and Fridays. Review of Resident 77's task documentation for bathing revealed documentation which indicated they had received a bed bath on September 19, 2023, at 6:49 PM. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 20, 2023, at 2:25 PM, observations of Resident 77 were shared with the NHA and DON. The DON indicated that she would look into the concern. During a follow-up interview with the DON on September 21, 2023, at 09:31 AM, the DON indicated that the facial hair was taken care of last evening. She further indicated that she would expect staff to offer/complete this task with Resident 77's bath/shower. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395613 Page 13 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, facility policy review, and staff and resident interviews, it was determined that the facility failed to ensure that residents had proper assistive devices to maintain adequate visual ability for one of 34 residents reviewed (Resident 91). Residents Affected - Few Findings include: A review of the facility policy, titled Care of the Visually Impaired Resident, last reviewed August 7, 2023, stated, Residents who have lost or damaged their devices will be assisted in obtaining services to replace the devices. Review of quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 91, dated July 19, 2023, revealed the Resident is cognitively intact with a BIMS (brief interview of mental status) of 14, indicating that the Resident requires minimal assistance with daily care needs and requires corrective lenses. Further, Resident 91's fall risk score, dated September 5, 2023, was 91 (a score of 51 and over is considered high risk for falls). During an interview with Resident 91 on September 18, 2023, when asked if he wears eyeglasses, he replied Yes, but they are bent, and I can't wear them. The Resident pointed to his eyeglasses on the bedside stand, picked them up and showed the bent earpiece, and the right lens fell out as he was showing them. There was also a reddish-brown stain on the lens. Resident 91 said that he fell on September 9, 2023, and hit his head and his glasses were broken. A review of Resident 91's clinical record confirmed that he fell on September 9, 2023, and, as a result, had a hematoma (bruise that causes blood to collect and pool under the skin) on the right side of his forehead. Ice was applied to his forehead, but there was no documentation regarding the broken eyeglasses. During an interview with the Director of Nursing (DON) on September 19, 2023, she stated that Resident 91 will be scheduled to see the eye doctor. The DON was informed that the eyeglasses cannot be worn until he is seen by the eye doctor. The DON went to Resident 91's room, observed the eyeglasses, cleansed the reddish-brown stain off the lens, and sent them for immediate repair. The DON informed the unit manager to contact her directly if the eyeglasses are broken and unable to be worn. During an interview with the DON on July 19, 2023, at 1: 30 PM, she agreed the eyeglasses should have been fixed sooner so that Resident 91 didn't have to go without his glasses from September 9, 2023, to September 20, 2023. 28 Pa. Code 201.18(1) Management 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395613 Page 14 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident environment is free from accident hazards for one of 32 residents reviewed (Resident 29). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included depression and cognitive communication deficit (difficulty in thinking and how someone uses language). Observation of Resident 29's room on September 18, 2023, at 10:24 AM, revealed two colored tablets in a clear medication cup on their overbed table. During an immediate interview with Resident 29, they indicated that the tablets were TUMS and that they have their own stock. Observation of Resident 29's room on September 19, 2023, at 9:49 AM, revealed four colored tablets in a clear medication cup on their overbed table. Further review of Resident 29's physician orders revealed an order for Tums Tablet Chewable (Calcium Carbonate Antacid) Give one tablet by mouth every eight hours as needed, dated March 11, 2022. There was no order noted indicating that they could self-administer any medications. Review of Resident 29's assessments and evaluations revealed no documentation that they were capable of self-administering any of their medications. Review of Resident 29's care plan indicated a care plan focus for being at risk for communication/cognitive loss related to confusion, short-term and long-term memory impairments, last revised on July 14, 2023. There was no documentation noted on the care plan that they could self-administer any of their medications. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 20, 2023, at 2:30 PM, observations and the aforementioned record review findings were shared. Email communication received from the NHA on September 20, 2023, at 7:19 PM, indicated that the Daughter had brought in the Tums and they were in a drawer (in Resident 29's room). The email further indicated that they had removed them and that the Daughter was educated to not bring in medications. During a follow-up interview with the DON on September 21, 2023, at 9:32 AM, the DON indicated that she was not sure how long the Resident has had the Tums. She indicated that they found them hidden in her room. She further indicated that education was completed with the Resident and her Daughter regarding bringing medications in from outside. When asked if staff should have identified the medication in the medicine cup at the bedside and completed a follow-up, the DON indicated, Yes, they should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395613 Page 15 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide medications, as ordered by the prescriber, to meet the needs of each resident for one of 34 residents reviewed (Resident 16); and failed to maintain an accurate accounting of the final disposition of medications upon discharge for two of two closed records reviewed (Residents 19 and 153). Findings Include: Review of facility policy, titled Medication and Treatment Orders, last revised July 2016, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of Resident 16's clinical record revealed diagnoses that included type 2 diabetes mellitus with hyperglycemia (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and gangrene (a type of tissue death caused by a lack of blood supply). Review of Resident 16's medical record revealed a progress note on September 16, 2023, at 2:25 AM, that stated, Registered Nurse assessment for the Resident due to missed insulin doses. Resident was reported to have an episode of sweating heavily. Skin warm and dry upon assessment. Nurse aide reported needing to change bed sheet due to excessive sweating. Resident alert and oriented to baseline. Stated he feels fine. No signs or symptoms of low or high blood sugar. Denies shortness of breath, pain. Vital signs within normal limits. Resident blood sugar obtained 198. Orders for insulin confirmed and will resume in morning. Doctor aware, no new orders at this time. During email correspondence with the Nursing Home Administrator (NHA) on September 19, 2023, at 12:37 PM, the surveyor inquired about an incident report related to Resident 16's missed insulin doses. Review of select facility incident form dated September 16, 2023, revealed: Therapeutic interchange for Novolog and Basaglar (change of insulin to a different brand) ordered by pharmacy on September 11, 2023. Previous insulin for pending discontinue were discontinued on September 12, 2023, new insulin orders were not confirmed resulting in missed doses and missed blood sugar checks for four and a half days, no complaints of low or high blood sugar symptoms. Review of Resident 16's physician orders revealed an order for Insulin Lispro (1 UnitDial) Subcutaneous Solution Pen-injector 100 unit/ml, with a start date of August 7, 2023, and an end date of September 11, 2023. Review of Resident 16's physician orders revealed an order for Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml, inject 13 unit subcutaneously two times a day for diabetes mellitus, with a start date of August 7, 2023, and an end date of September 11, 2023. Review of Resident 16's physician orders revealed an order for Basaglar KwikPen 100 unit/ml Solution pen injector, inject 13 unit subcutaneously two times a day related to type 2 diabetes mellitus with hyperglycemia, with a start date of September 16, 2023. Further review of Resident 16's Basaglar order revealed it was ordered on September 11, 2023, at 395613 Page 16 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0755 1:10 PM, and not confirmed by a nurse until September 16, 2023, at 1:42 PM. Level of Harm - Minimal harm or potential for actual harm Review of Resident 16's physician orders revealed an order for Novolog FlexPen 100 unit/ml Solution pen injector, inject as per sliding scale, related to type 2 diabetes mellitus with hyperglycemia, with a start date of September 16, 2023. Residents Affected - Few Further review of Resident 16's Novolog order revealed it was ordered on September 11, 2023, at 1:10 PM, and not confirmed by a nurse until September 16, 2023, at 1:48 AM. Review of Resident 16's MAR (Medication Administration Record- documentation for medication/treatment administered or monitored), revealed no documentation to indicate insulin was administered to Resident 16 from September 11, 2023, after 8:00 AM, until September 16, 2023, at 8:00 AM. Interview with the Director of Nursing (DON) on September 21, 2023, at 1:25 PM, revealed the confirmation of the new insulin orders on September 11, 2023, were missed until September 16, 2023, at 1:42 AM, and she would expect a licensed nurse to be confirming orders at least every shift to avoid missing medications. Review of facility policy, titled Discharge Medications, revised March 2022, revealed, Controlled substances may not be released to the resident upon discharge .The nurse shall complete the medication disposition record, including the resident's name . the date of discharge .the name of each medication, the quantity or amount of each medication .the signatures of the person receiving the medications and the nurse releasing the medications. Review of facility policy, titled Controlled Substance Disposal, revised August 2020, revealed, All controlled substances remaining in the facility after a resident has been discharged or an order discontinued are disposed of: in the facility by the Director of Nursing and consultant pharmacist (or other licensed personnel as permitted by state regulations .Disposition is documented on the facility's Drug Destruction log or similar form .The following information is entered on the facility's Drug Destruction log or similar form. a. Date of destruction b. Resident's name c. Name and strength of medication d. Prescription number e. Amount of medication destroyed f. Signature of witnesses Review of facility policy, titled Returning Medications to the Pharmacy, revised August 2020, revealed, Discontinued or unused medications are returned to the provider pharmacy for credit whenever possible .Completed medication disposition forms are kept by the facility for two years, or according to applicable law or regulation. Review of Resident 19's clinical record revealed that they were a Resident at the facility from June 26, 2023, to September 14, 2023, with diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), depression, and left ankle fracture. Review of closed record on September 21, 2023, at 12:42 PM, revealed two Controlled Drug Administration Record Tablet forms that indicated the Resident had a total of 35 (30 on one form and 5 on the other) methadone ( a controlled narcotic used to treat chronic pain) tablets remaining at discharge. The form was signed by the Resident with no date indicated. The section of the form where the disposition of the medications was to be documented with staff signatures was not completed. There was also a form, titled Pharmacy Return for Credit Request, was signed by Resident 19 and a 395613 Page 17 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0755 Level of Harm - Minimal harm or potential for actual harm staff member on September 14, 2023. The staff member signed the section titled Signature of Nurse completing form and Signature of Nurse giving to driver. This form listed Resident 19's other pharmacy provided medications and indicated the following: Meloxicam 7.5 milligrams 12 tablets Take 1 tab by mouth once daily; Residents Affected - Few Metoprolol Succinate 25 milligrams 27 tablets Take 1 tab by mouth once daily; Venlafaxine ER 150 milligrams 13 tablets Take 1 tab by mouth twice daily; Montelukast 10 milligrams 10 tablets Take 1 tab at mouth at bedtime; Hydroxyzine 25 milligrams 11 tablets Take 1 tablet by mouth every 8 hours as needed; and Seroquel 400 milligrams 10 tablets Take 1 tab at mouth at bedtime. Review of Resident 19's physician orders revealed no order that they could be discharged with their narcotics. Review of Resident 19's clinical progress notes revealed note dated September 14, 2023, at 12:59 PM, which stated (in part) remaining medications were reviewed and sent with Resident. In review of the two Controlled Drug Administration Record Tablet forms, the Pharmacy Return for Credit Request and Resident 19's clinical progress note at discharge, it was found to be unclear what the true disposition of Resident 19's medications. During an interview with the NHA and DON on September 21, 2023, at 10:55 AM, all of the aforementioned concerns were shared. DON indicated that licensed staff should have completed the appropriate section of the controlled substance log and it should have clearly indicated the disposition of the medications. She said that the Resident took the methadone with her. She said she was not sure why she was not given her other medications at discharge. The DON indicated she would look into the concerns a little further. During a follow-up interview with the NHA and DON on September 21, 2023, at 12:10 PM, the DON revealed that she had spoken to the nurse that was there the day Resident 19 was discharged , and that the nurse indicated that the physician gave her a verbal order to send the methadone home with the Resident. The DON again confirmed that the controlled substance log should have been completed with all required information (licensed staff signatures/date/ and clear disposition of medications). At that time, additional information was requested as to why the Resident was not given her other routine medications at time of discharge as per facility policy. Email communication received from NHA on September 21, 2023, at 12:45 PM, included a written statement from a nurse regarding the verbal order they received to send methadone home with the Resident. During a final follow-up interview with the NHA on September 21, 2023, at 1:20 PM, the NHA indicated that she had no other information to provide. Review of Resident 153's clinical record revealed Resident 153 passed away on September 1, 2023. 395613 Page 18 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Resident 153's physician orders at the time of death included active orders for Morphine Sulfate 0.25 ml (opiate/controlled substance) four times a day for pain; lorazepam (antianxiety medication) every four hours as needed for agitation and restlessness; Morphine Sulfate 0.5 ml every two hours as needed for severe pain or shortness of breath; and atropine sulfate (used to reduce salivation) every two hours as needed for secretions. Residents Affected - Few Further review of Resident 153's clinical record revealed no evidence of any final disposition of the aforementioned medications. In an email from the NHA on September 21, 2023, at 1:11 PM, she revealed she was not able to locate any record of medication disposition for Resident 153 following discharge. 28 Pa. Code 211.9(j.1)(3)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395613 Page 19 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the pharmacy regimen review was completed for one of five residents reviewed for unnecessary medications (Resident 80), and failed to act timely upon pharmacist recommendations for two of five residents reviewed for unnecessary medications (Residents 80 and 141) . Findings include: Review of facility policy, titled Medication Regimen Review with a last review date of August 7, 2023, indicated the following: 2. The consultant pharmacist reviews the medication regimen of each resident at least monthly. A more frequent review may be deemed necessary if, for example, the medication regimen is thought to contribute to an acute change in status or adverse consequence or the resident is not expected to stay 30 days. 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate; 7. Recommendations are acted upon and documented by the facility staff and/or the prescriber; and 8. At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director, and director of nursing, at a minimum. Review of Resident 80's clinical record revealed diagnoses that included history of transient ischemic attack (TIA - temporary period of symptoms similar to those of a stroke which generally only lasts a few minutes and leaves no residual effects), cerebral infarct (stroke - damage to the brain from interruption of its blood supply), psychotic disorder with delusions (a mental disorder characterized by a disconnection from reality with an unshakable belief in something that is untrue), diabetes, and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 80's clinical record revealed documentation by the pharmacist that they had completed an admission Medication Regimen Review, noted irregularities, and to see the report for details on April 26, 2023, and May 7, 2023. In addition, there was documentation by the pharmacist that they had completed a monthly Medication Regimen Review on June 28, 2023, noted irregularities, and to see report for details. Further review of Resident 80's clinical record failed to reveal any documentation by the 395613 Page 20 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pharmacist that a Medication Regimen Review was completed in November 2022, December 2022, or August 2023. Email communication was sent to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 19, 2023, at 12:52 PM, requesting information regarding Resident 80's Medication Regimen Reviews to include recommendations made and the physician follow-up. During an interview with the NHA and DON on September 21, 2023, at 9:43 AM, revealed documentation of a Medication Regimen Review by the pharmacist was again requested for November 2022, December 2022, and August 2023, as well as the pharmacist recommendation reports for April 26, 2023; May 7, 2023; and June 28, 2023, with the physician follow-up. Review of the facility provided Medication Regimen Review report dated June 28, 2023, received on September 21, 2023, at 11:08 AM, revealed that the pharmacist had made a nursing recommendation to change the administration time of Resident 80's metformin (a medication used to manage blood sugar levels) to twice a day with meals instead of administering every 12 hours. This form was signed and dated June 28, 2023. Review of Resident 80's September Medication Administration Record revealed that the metformin was still being administered at 7:00 AM and 7:00 PM. During a follow-up interview with the NHA and DON on September 21, 2023, at 12:15 PM, the NHA and DON both indicated that they could not provide any documentation of a Medication Regimen Review being completed in November 2022, December 2022, or August 2023. The concern identified with the June 28, 2023, not being acted upon was also shared. The April 2023 and May 2023 admission Medication Regimen Review recommendations were again requested. The NHA and DON both indicated that they would look into these concerns for follow-up. During a final interview with the NHA on September 21, 2023, at 1:20 PM, the NHA indicated that she had no other information to provide for the aforementioned concerns identified. Review of Resident 141's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior), anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events), and psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions). Review of Resident 141's clinical progress notes revealed that the pharmacist completed a medication regimen review on June 28, 2023, and made recommendations that time. Further review failed to reveal evidence of what the recommendation was or if the physician reviewed and responded to the recommendation. During an interview with the DON on September 21, 2023, at 12:10 PM, she revealed that she was not able to locate any additonal information concerning the pharmacy recommendation made for Resident 141 in June 2023. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.10(a)(c) Resident care policies 395613 Page 21 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0756 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395613 Page 22 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that as-needed psychotropic drugs were limited to 14 days or had documented rationale and duration for four of five residents reviewed for unnecessary medications (Residents 30, 65, 80, and 141). Findings include: Review of facility policy, titled Antipsychotic Medication Use, revised December 2016, revealed, The need to continue PRN [as-needed] orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Review of Resident 30's clinical record revealed diagnoses including anxiety (a feeling of fear, dread, and uneasiness) and major depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite, and/or daily routine). Review of Resident 30's physician's orders, dated September 18, 2022, revealed a current order for Xanax (antianxiety medication) 0.25 mg to be given every six hours, as needed, that was ordered on August 18, 2022, and was discontinued September 18, 2023. Review of Resident 30's clinical record on September 19, 2023, failed to reveal a rationale documented by the physician to extend use of this medication beyond 14 days. During an interview with the Director of Nursing (DON) on September 20, 2023, at 1:32 PM, she revealed the expectation that the physician would limit the use of the PRN psychotropic medications to 14 days or document the rationale for the extended order, as stated in the facility policy. Review of Resident 65's clinical record on September 18, 2023, revealed diagnoses that included anxiety disorder, major depressive disorder, and neurocognitive disorder with lewy bodies (a progressive dementia that results from protein deposits in nerve cells of brain. It affects movement, thinking skills, mood, memory, and behavior). Review of Resident 65's physician orders revealed an order for lorazepam oral concentrate 2 milligrams/milliliter, Give 0.25 milligram by mouth every four hours as needed for anxiety/restlessness, with a start date of March 3, 2023, and an end date of September 18, 2023. Review of Resident 65's clinical record failed to reveal any physician documentation of the medication evaluation to support the ongoing order for the lorazepam. Review of Resident 65's Medication Administration Records (MAR - form used to document physician orders as well as when and how medications are administered to a resident) for June 2023, July 2023, August 2023, and September 2023, revealed that they have not received any doses of the as-needed lorazepam. During an interview with the DON on September 21, 2023, at 9:50 AM, the DON revealed that she could 395613 Page 23 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not locate any information regarding the evaluation and ongoing order for the lorazepam. She further revealed that she would expect the medication to be reviewed and documentation to be completed regarding the ongoing order for the lorazepam. Review of Resident 80's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities); psychotic disorder with delusions (a mental disorder characterized by a disconnection from reality with an unshakable belief in something that is untrue), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 80's physician orders revealed an order for lorazepam oral concentrate 2 milligrams/milliliter, Give 1 milligram by mouth every four hours as needed for anxiety, agitation and restlessness. Dose 1 milligram = 0.5 milliliters, dated June 4, 2023. Review of Resident 80's clinical record failed to reveal any physician documentation of the medication evaluation to support the ongoing order for the lorazepam. Review of Resident 80's Medication Administration Records for June 2023, July 2023, August 2023, and September 2023, revealed that they have not received any doses of the as-needed lorazepam. During an interview with the Nursing Home Administrator and DON on September 20, 2023, at 2:29 PM, the DON indicated that she could not locate any information regarding the evaluation and ongoing order for the lorazepam. She further indicated that she would expect the medication to have been reviewed and documentation to be completed regarding the ongoing order for the lorazepam. Review of Resident 141's clinical record revealed diagnoses that included anxiety disorder and Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior). Review of Resident 141's September 2023 MAR revealed an order for alprazolam (antianxiety medication) every four hours as needed for anxiety, effective June 28, 2023, and as of September 20, 2023, at 2:19 PM, the order did not have an end date. Further review of Resident 141's clinical record failed to reveal documented rationale for continued use and duration of use of alprazolam beyond 14 days from the effective date of the order. During an interview with the DON on September 20, 2023, at 1:58 PM, she confirmed that the alprazolam order did not have an end date, nor was she able to locate any documented rationale for Resident 141's continued use of alprazolam beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395613 Page 24 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen and five of five nourishment areas. Findings include: Review of facility policy, titled Food Receiving and Storage, last revised March 2023, revealed, Foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date) .All foods belonging to residents must be labeled with the resident's name, the item and the 'use by' date. Review of facility policy, titled Food and Nutrition Services 'Use by' dating guidelines, revealed, Refrigerator-Ready to eat produce and milk, use by 7 days after opening .Frozen Shakes .Use by date of 14 days once thawed .Freezer- Use by date of 3 months after opening and properly closed. Observation of the dry storage area on September 18, 2023, at 9:53 AM, revealed: eight individual jelly packets in a dome that covers meal plates not dated; one package of strawberry gelatin mix not dated; and one flour bin with flour inside labeled August 23, 2021. Interview with Employee 3 (Food Service Director) on September 18, 2023, at 9:56 AM, revealed the staff had just filled that flour bin, and it should be relabeled with the date it was last filled. Observation of one walk-in freezer unit on September 18, 2023, at 9:57 AM, revealed: one pan containing three packages of bologna labeled use by July 16, 2023; one package of beef tips without a date; one bag labeled ground meat dated May 18, 2023; one container of chili dated February 28, 2023; one pack of bacon labeled December 30, 2022; one container of sauce labeled April 24, 2023; one box of popsicles not dated; and one pan of meat sauce not labeled or dated. Observation in the main kitchen on September 18, 2023, at 10:01 AM, revealed: two pans of bananas not labeled or dated; three packages of gravy not dated; one open container of thyme not dated; and one open container of poultry seasoning not dated. Observation of one walk-in refrigerator on September 18, 2023, at 10:08 AM, revealed: two open bags of bread not dated, and two full bags of bread not dated. Observation of the second walk-in refrigerator in the main kitchen area on September 18, 2023, at 10:10 AM, revealed: two onions on a shelf without a date; one container of whole milk open without an open date; one container of chocolate milk open without an open date; one pan of cabbage with a date August 22, 2023, and the cabbage was moldy; one pan of potatoes labeled September 1, 2023; and one container of garlic labeled July 13, 2023. Observation of the second walk-in freezer on September 18, 2023, at 10:13 AM, revealed: one bag of pie crusts not labeled or dated; and one bag of bread labeled April 23, 2023. Observation of the ice machine in the main kitchen on September 18, 2023, at 10:15 AM, revealed no air gap between the drain of the machine and the floor drain. When the surveyor looked inside the ice machine, the sides of the inside of the ice machine were dirty with a black substance. 395613 Page 25 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the A-Wing pantry area on September 18, 2023, at 10:17 AM, revealed: one bin of snacks containing goldfish crackers, oatmeal cookies, and graham crackers not dated; five containers of Fruit Loops cereal not dated; three containers of Raisin Bran cereal not dated; two containers of Frosted Flakes cereal not dated; one bag of individual sugar packets not dated; three individual packs of oatmeal not dated; one container of tea bags and hot chocolate packets not dated; and a drawer containing condiments that included jellies, ketchup packets, salad dressings, butter packets, and syrup packets not dated. Further observation of the A-Wing pantry area refrigerator on September 18, 2023, at 10:26 AM, revealed: one orange nutritional drink with an expiration date of June 27, 2023; and two thawed chocolate shakes not labeled with a date pulled from the freezer. Observation of the B-Wing pantry area on September 18, 2023, at 10:30 AM, revealed: one bin of snacks containing goldfish crackers, oatmeal cookies, and graham crackers not dated; three containers of Fruit Loops cereal not dated; two containers of Raisin Bran cereal not dated; 10 individual packs of oatmeal not dated; 18 thickened tea drink mix packets with use by date of July 15, 2023; two hot chocolate packets with a use by date of February 8, 2023; and three bags of individual sugar packets not dated. Further observation of the B-Wing pantry area freezer on September 18, 2023, at 10:36 AM, revealed: two sherbet frozen dessert not dated; 13 popsicles not dated; and three ice cream cones from an outside source for a resident not labeled with resident's name or use by date. Observation of the C-Wing pantry area on September 18, 2023, at 10:43 AM, revealed: one bin of snacks containing goldfish crackers and graham crackers not dated; two packets of thickened coffee mix with a use by date of July 18, 2021; two thickened tea drink mix packets with use by date July 15, 2023; three thickened tea drink mix packets with use by date March 10, 2023; and one basket of tea bags not dated. Further observation of the C-Wing pantry area freezer on September 18, 2023, at 10:46 AM, revealed: two sherbet frozen dessert not dated; and 13 popsicles not dated. Observation of the F-Wing pantry area on September 18, 2023, at 10:50 AM, revealed: one bin of snacks containing goldfish crackers, fudge cookies, and oatmeal cookies not dated; five containers of Fruit Loops cereal not dated; four containers of frosted mini wheat cereal not dated; 10 thickened tea drink mix packets with use by date March 10, 2023; three hot chocolate packets with a use by date of February 8, 2023; eight thickened coffee packets with a use by date of August 31, 2023; and one drawer containing ketchup and mustard packets, saltine crackers, jellies, sugar packers, and butters not dated. Further observation of the F-Wing pantry area freezer on September 18, 2023, at 10:51 AM, revealed: six sherbet frozen dessert not dated; one chocolate nutritional shake with a use by date of August 5, 2023; two vanilla nutritional shakes with a use by date of June 10, 2023; two vanilla nutritional shakes with a use by date of July 15, 2023; and one vanilla nutritional shake with a use by date of March 25, 2023. Observation of the E-Wing pantry area on September 18, 2023, at 10:55 AM, revealed: one bin of snacks containing goldfish crackers, oatmeal cookies, and graham crackers not dated; one open box of oatmeal cookies not dated; and one drawer containing ketchup, mustard packets, and salad dressings not 395613 Page 26 of 27 395613 09/21/2023 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0812 dated. Level of Harm - Minimal harm or potential for actual harm Observation of the E-Wing pantry area freezer on September 18, 2023, at 10:59 AM, revealed: seven sherbet frozen dessert not dated; five popsicles not dated; four vanilla nutritional shakes with a use by date of July 15, 2023; and one chocolate shake labeled use by August 5, 2023. Residents Affected - Some Observation of the E-Wing pantry area refrigerator on September 18, 2023, at 11:00 AM, revealed: one chocolate nutritional shake not labeled with a thawed date; and two cranberry apple nutritional drinks with a use by date of August 18, 2023. Interview with the Employee 3 on September 18, 2023, at 11:06 AM, revealed she would expect that items to be labeled and dated per policy, and discarded once past the use by date. Interview with the Nursing Home Administrator on September 20, 2023, at 1:47 PM, revealed it was the facility's expectation that expired items are discarded once past the use by date, foods items are labeled and dated per facility policy, and kitchen equipment is utilized and cleaned in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 395613 Page 27 of 27