Health inspection·July 18, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 57). Findings include: Review of Resident 57's clinical record revealed that the resident was discharged from the facility on May 6, 2024. Further review of Resident 57's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 18, 2024 at 11:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record Page 1 of 2 395631 395631 07/18/2024 United Zion Retirement Communi 722 Furnace Hill Pike Lititz, PA 17543

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 clinical records review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indication was provided before administering as-needed anti-anxiety medication for one of 5 residents reviewed (Resident 14). Findings include: Review of Resident 14's physician's order dated June 14, 2024, revealed an order for Lorazepam (anti-anxiety medication) 0.5 mg (milligram) one tablet twice daily as needed for anxiety. Review of Resident 14's June 2024, Medication Administration Records (MAR) from June 15, 2024, until June 26, 2024, Resident 14 was administered as-needed Lorazepam seven times without appropriate indication for use and was administered ten times without attempts to provide a non-pharmacological intervention before administering the medication. Interview conducted with the Nursing Home Administrator on July 18, 2024, at 11:00 a.m., confirmed the facility failed to document evidence of non-pharmacological interventions provided before administering the medication and no appropriate indication for the drug. The facility failed to ensure non-pharmacological interventions were attempted, and appropriate indications were present before administering Resident 14 with as-needed anti-anxiety medication. 28 Pa. Code: 211.12(d)(5) Nursing Services 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services 395631 Page 2 of 2