Health inspection·August 10, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 48 resident rooms (Resident 33, 36, 37, 39, 51, and 53 rooms). Residents Affected - Some Findings include: Observation in Resident 36's room on August 7, 2023, at 11:19 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 36's room on August 8, 2023, at 10:49 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 53's room on August 7, 2023, at 11:25 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 53's room on August 8, 2023, at 9:46 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 39's room on August 7, 2023, at 11:39 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 39's room on August 9, 2023, at 11:41 AM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 37's room on August 7, 2023, at 11:46 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 37's room on August 8, 2023, at 12:25 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 51's room on August 7, 2023, at 11:51 AM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Page 1 of 16 395721 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Additional observation in Resident 51's room on August 8, 2023, at 12:31 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Observation in Resident 33's room on August 7, 2023, at 1:14 PM, revealed that the heating unit contained a thick layer of grey, fuzzy substance in the front grate and more grey, fuzzy substance inside the top portion where air is blown into the room. Additional observation in Resident 33's room on August 8, 2023, at 12:27 PM, revealed that the heater remained with the same amount of grey, fuzzy substance. Interview with Employee 4 (Maintenance Director) on August 9, 2023, at 09:36 AM, revealed there is no cleaning schedule or record for cleaning heaters in skilled nursing. Employee 4 further revealed the heaters in skilled nursing have not been formally cleaned to his knowledge since he has worked at the facility, and he has worked at the facility for three years. Interview with Nursing Home Administrator on August 10, 2023, at 10:39 AM, revealed she would expect the heaters to be clean and a cleaning schedule to be in place. 28 Pa. Code 201.18(e)(2.1) Management 395721 Page 2 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, employee record review, and staff interviews, it was determined that the facility failed to ensure thorough background checks for new employees were conducted for three of five employee records reviewed (Employees 1, 2, and 3). Residents Affected - Few Findings include: Review of facility policy, titled Criminal Background [C]hecks last revised June 20, 2017, revealed that in section titled Standard stated, To ensure that all applicants for employment and former employees reapplying for employment to [the] skilled nursing facilities have criminal background checks. It is the policy of Paramount Health Resources, Inc. to conduct criminal background checks in accordance with state and federal guidelines. Further review of the aforementioned policy revealed that in section titled Implementation subsection, 3. Facility Response stated, .If applicant has not resided in the state of Pennsylvania for the past 2 year's they are sent for fingerprinting for an FBI clearance. Review of Employee 1's employee record on August 9, 2023, at approximately 10:30 AM, revealed that Employee 1 was hired by the facility on June 1, 2023. Review of Employee 1's employee record revealed that, at the time of hire, Employee 1 was not a resident of Pennsylvania. Further review of the employee record revealed no Federal Bureau of Investigation (FBI) fingerprint background check was conducted for Employee 1 prior to hire or starting at the facility. During a staff interview on August 9, 2023, at approximately 12:30 PM, Employee 6 (Human Resource Manager), confirmed that there was no FBI Background check on Employee 1. During a staff interview on August 10, 2023, at approximately 10:30 AM, Nursing Home Administrator (NHA) confirmed there was no FBI background check completed on Employee 1. During the interview, NHA revealed it was the facility's expectation that an FBI background check was completed for Employee 1. Review of Employee 2's employee record revealed that Employee 2 was hired as a Licensed Practical Nurse (LPN) on July 27, 2023. Review of Employee 2's employee record revealed no documented evidence that the facility performed a license verification within the Pennsylvania Department of State system to ensure Employee 2's LPN license was in good standing and without adverse action at the time of hire. Review of Employee 3's employee record revealed that Employee 3 was hired as a Nurse Aide (NA) on July 27, 2023. Review of Employee 3's employee record revealed no documented evidence that the facility performed a Pennsylvania NA Registry verification to ensure Employee 3's NA registration was in good standing without adverse action at the time of hire. During a staff interview on August 10, 2023, at approximately 12:25 PM, NHA and Director of Nursing 395721 Page 3 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0606 Level of Harm - Minimal harm or potential for actual harm (DON) confirmed that there was no documented evidence of Employee 2's license being verified and of Employee 3's NA registry being verified. During the staff interview, the DON revealed there was confusion as to who would maintain documentation of License Verification and NA Registry checks at the time. 28 Pa code 201.14(a) Responsibility of licensee Residents Affected - Few 395721 Page 4 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 resident records reviewed (Residents 26 and 37). Residents Affected - Few Findings include: Review of Resident 26's clinical record revealed diagnoses that included Parkinson's Disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Further review of Resident 26's clinical record revealed that they weighed 100 pounds on July 20, 2023; 108 pounds on June 13, 2023; 121 pounds on February 2, 2023; and 121 pounds on January 2, 2023. This indicated a weight loss of approximately 7% from June 2023 to July 2023, and an approximately 17% weight loss between January 2023 and July 2023. Review of Resident 26's July 23, 2023, comprehensive significant change 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) revealed that it was coded to indicate that Resident 26 experienced a weight gain greater than 5% or more in the prior month, or 10% or more in the past six months. Per email correspondence received from the Nursing Home Administrator (NHA) on August 10, 2023, at 8:25 AM, she confirmed that this was a data entry error and revealed that the assessment was fixed and resubmitted. Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, cerebral infarction (or stroke; when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), and hypertension (high blood pressure). Review of Resident 37's nursing tasks revealed a Restorative Nursing Program for Bed Mobility - [Resident 37] will maintain proper bed positioning by turning and repositioning q (q-every) two hours; left side to right side to back with staff assistance x15 minutes daily to remain free of skin breakdown, initiated March 29, 2022, and last revised March 11, 2023. Review of Resident 37's care plan revealed a focus area: [Resident 37] requires assistance with ADL's (Activities of Daily Living) related to decreased mobility, weakness, and Parkinson's disease, last revised December 20, 2021, with an intervention for: Restorative Nursing Program as ordered, created on March 12, 2023. Resident 37's Significant Change MDS, with an assessment reference date (ARD- last day of assessment period) of May 22, 2023, revealed that section M1200. Skin and Ulcer/Injury Treatments under subsection C. Turning/Repositioning Program, Resident 37's assessment was marked No. Interview with Employee 7 on August 10, 2023, at 11:02 AM, revealed Resident 37's turning and repositioning program should have been captured on his Significant Change MDS with ARD May 22, 2023. Interview with the NHA on August 10, 2023, at 12:08 PM, revealed she would expect Resident 37's 395721 Page 5 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0641 restorative nursing program for turning and repositioning every two hours to be accurately coded on his Significant Change MDS with ARD May 22, 2023. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5(f) Clinical records Residents Affected - Few 28 Pa. Code 211.12(d)(5) Nursing services 395721 Page 6 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to have the physician complete a discharge summary, which includes a recapitulation of the resident's stay, for one of two closed records reviewed (Resident 70). Findings include: A review of the closed clinical record revealed that Resident 70 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and sick sinus syndrome (irregular heart rhythm, alternating from slow to rapid heartbeats). Resident was post-hospitalization for placement of a pacemaker (surgically implanted electronic device to stimulate the heartbeat). Further review of Resident 70's clinical record revealed the Resident was discharged to home on May 15, 2023. Resident 70's closed clinical records failed to identify a discharge summary completed by the physician. The only documentation the facility was able to provide was the nurses discharge instructions. The Nursing Home Administrator (NHA) stated the physician initials the nurses discharge instructions. During an interview conducted on August 10, 2023, at approximately 11:15 AM, the NHA was unable to provide evidence that a discharge summary was completed by the physician for Resident 70. Additionally, the facility was unable to provide a policy for Discharge Summary. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services 28 Pa. Code 201.25 Discharge policy 395721 Page 7 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for one of 21 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed diagnoses that included difficulty in walking, cerebral infarction (or stroke; when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and hypertension (high blood pressure). Interview with Resident 37 on August 7, 2023, at 11:44 AM, revealed he had a stroke with right sided weakness and needs assistance with turning and repositioning in bed. Resident 37 also revealed that he only gets turned and repositioned if he rings his call bell and asks to be turned and repositioned. Resident 37's Significant Change Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an assessment reference date (last day of assessment period) of May 22, 2023, revealed that section G0100. Activities of Daily Living (ADL) Assistance, subsection, A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, Resident 37 was coded as, 3 = Extensive Assistance under performance with Two + persons physical assist under support. Review of Resident 37's nursing tasks revealed a restorative nursing program for Bed Mobility - [Resident 37] will maintain proper bed positioning by turning and repositioning q (q-every) two hours; left side to right side to back with staff assistance x15 minutes daily to remain free of skin breakdown, initiated March 29, 2022, and last revised March 11, 2023. Review of Resident 37's care plan revealed a focus area: [Resident 37] requires assistance with ADL's related to decreased mobility, weakness, and Parkinson's disease, last revised December 20, 2021, with an intervention for: Restorative Nursing Program as ordered, created on March 12, 2023. Review of the clinical record revealed no documentation that Resident 37's restorative program for turning and repositioning every two hours was being implemented. Interview with the Director of Nursing on August 10, 2023, at 10:37 AM, revealed there is no documentation to indicate Resident 37's restorative nursing program for turning and repositioning every two hours was being implemented, and the expectation is for the restorative nursing program to be completed and documented. 28 Pa. Code 211.11 (a) Resident care plan 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services 395721 Page 8 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 21 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record on August 8, 2023, revealed Resident 1 had diagnoses that included neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord, or nerve problem) and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of the physician orders dated August 2023, confirmed that Resident 1 was ordered to have an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Observation of Resident 1 on August 7, 2023, at 11:15 AM, revealed Resident 1's catheter bag and tubing was dragging on the floor while mobile in her wheelchair in the hall. During an interview with the Director of Nursing (DON) on August 9, 2023, at 10:15 AM, the DON confirmed the catheter bag and tubing should never be touching the floor. Observation of Resident 1 on August 10, 2023, while sitting in the Activity Room, revealed the catheter tubing laying on the floor. During an interview with the DON and Nursing Home Administrator on August 10, 2023, they both agreed that they will have to devise a way to prevent the catheter bag and tubing from dragging on the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395721 Page 9 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of 19 residents reviewed (Residents 18 and 20). Residents Affected - Few Findings include: A review of the facility policy, titled Oxygen Therapy last reviewed January 26, 2023, stated oxygen tubing/equipment should be dated when placed into use for the residents. Further review of the policy indicated that a physician's order for oxygen therapy should include the following information: administration modality, liter flow, whether it is continuous or prn (as needed), cleaning schedule, and instructions to change the tubing biweekly. The policy also revealed that the physician order should be reviewed as part of the procedure of administering oxygen therapy. A review of the clinical record for Resident 18 revealed clinical diagnoses that included hypertension (high/elevated blood pressure) and Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of the clinical record revealed that Resident 18 has experienced episodes of coughing and congestion, for which the physician ordered nebulizer treatments. Review of the physician orders dated August 2023, stated, Albuterol Sulfate Inhalation Nebulization 0.63 milligrams/milliliter and to administer 3.0 milliliters every 4 hours as needed for cough and chest congestion with inhalation mask. Observation on August 7, 2023, at 9:30 AM, revealed the inhalation mask lying on the floor in Resident 18's room, and the tubing was not dated. Observation on August 7, 2023, at 1:33 PM, revealed the mask still laying on the floor. During an interview with the Director of Nursing (DON) on August 8, 2023, the DON confirmed that the mask should never be on the floor, and that the tubing should have been dated when placed into use. Review of Resident 20's clinical record revealed diagnoses that included congestive heart failure (CHF weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and shortness of breath. Observations on August 7, 2023, at 11:15 AM, and on August 8, 2023, at 10:00 AM, revealed Resident 20 was receiving supplemental oxygen at a rate of 2 liters per minute via nasal cannula (device that delivers extra oxygen to the nose through soft prongs). Review of Resident 20's nursing progress notes revealed that use of supplemental oxygen was documented on the following dates: July 27, 28, 29, 30, and 31; and August 1 and 3, 2023. Review of Resident 20's current physician orders on August 7, 2023, at 12:58 PM, failed to reveal any active orders indicating the use or rate of use of supplemental oxygen. 395721 Page 10 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator on August 10, 2023, at 12:16 PM, he revealed that the practitioner wrote the hard copy order for oxygen on August 4, 2023, but there was some confusion. The NHA acknowledged that the order should have been in place. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Residents Affected - Few 395721 Page 11 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, clinical record review, and policy review, it was determined that the facility failed to ensure disposal of an unsecured/contaminated (cap missing) medication vial located in one of one medication refrigerator in the medication storage room; and failed adherence to medication expiration (use by dates) for one of two medication carts that affected one resident (Resident 46). Findings include: Review of facility policy, titled Medication Storage in the Facility last reviewed January 26, 2023, stated, Outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, and disposed of according to procedures for medication disposal. Observation on August 8, 2023, at 11:00 AM, revealed the following in the medication refrigerator located in the medication storage room: A box labeled Pneumococcal Vaccine 23 (vaccine indicated for active immunization for the prevention of pneumococcal pneumonia) with one vial remaining in a box that originally contained five vials. The remaining vial was missing the secure cap that covers the rubber top of the vial. The full amount of medication remained in the vial (0.5 milliliters). During an interview with the Director of Nursing (DON) on August 8, 2023, at 11:30 AM, the DON confirmed that the vial of Pneumococcal Vaccine 23 should have been discarded if it was not administered when the secure cap was removed. The DON also stated that he is unsure who removed the secure cap from the vial, but he believed that staff must have realized it was the wrong vaccine after removing the secure cap. A review of the clinical record for Resident 46 on August 10, 2023, revealed diagnoses that included Type 2 Diabetes Mellitus (DM - a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of the August 2023 physician orders for Resident 46 on August 10, 2023, revealed an order for Basaglar KwikPen Solution Pen-Injector 100 Units/Milliliter (Insulin Glargine) inject 10 Units subcutaneously (below the skin into the subcutis layer) daily. Observation of the medication cart for rooms 118-132 revealed the following for Resident 46's insulin medication: Glargine/Basaglar (Insulin) labeled for Resident 46, was placed in the medication cart unused, and without a date that it was removed from the refrigerator. During an interview with Employee 8 (Licensed Practical Nurse) on August 10, 2023, at 10:13 AM, revealed Employee 8 was unable to verify when the insulin was removed from the refrigerator and placed in the medication cart. Employee 8 also confirmed that the insulin should have been dated when removed from the medication refrigerator to inform others that it expires 28 days after removal from the refrigerator. 395721 Page 12 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0761 During an interview with the DON on August 10, 2023, the DON confirmed that the Glargine/Basaglar insulin should have been dated when removed from the refrigerator and placed in the medication cart. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9(a)(1)Pharmacy services Residents Affected - Few 28 Pa. Code 211.12(d)(1)(2)(5)Nursing services 395721 Page 13 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 one of one nourishment areas. Findings include: Review of facility policy, titled 11.0 Food Service- Food Storage/Dry Storage last revised June 7, 2017, revealed Food items should be neatly arranged with labels facing forward, labeled with name, weight or count and date. Review of facility policy, titled 11.0 Food Service- Food Storage/Dry Storage last revised June 7, 2017, revealed Freezer temperature is 0 degrees Fahrenheit (unit of measure) or below at all times .Freezer temperatures are taken daily, each morning and recorded on the Record of Refrigerator and Freezer temperature log. Observation in the main dining area on August 7, 2023, at 9:40 AM, revealed: three containers of Raisin Bran cereal without a date; one container of Krave cereal without a date; one container of Apple [NAME] cereal without a date; one container of [NAME] Krispies cereal without a date; three containers of Cheerios cereal without a date; one container of condiments with ketchup, mustard, mayonnaise, and tartar sauce without a date; and 21 individual jelly containers without a date. Observation in the refrigerator in the main dining area on August 7, 2023, at 9:44 AM, revealed two thawed nutritional shakes without a date; 14 orange juices without a date; four cranberry juices without a date; four prune juices without a date; and 44 individual packs of butter without a date. Observation in walk-in freezer unit on August 7, 2023, at 9:54 AM, revealed: two sealed bags of celery without a date; one open bag of celery without a date; two pans of lasagna without a date; one bag of peppers without a date; one bag of garlic bread open without a date; four packs of waffles without a label or date; one open bag of french fries without a label or date; one open bag of potato wedges without a label or date; and one bag of Salisbury steak without a label or date. Observation of the ice machine in the main kitchen on August 7, 2023, at 10:00 AM, revealed a brown substance on the top of the inside of the machine. Observation in the main kitchen on August 7, 2023, at 10:03 AM, revealed the three-compartment sink with the sanitizer sink filled with water. Employee 5 (Food Service Director [FSD]) was requested to test the sanitizer concentration with testing strips. Upon testing the sanitizer, the surveyor checked the expiration date on the strip container used to test the concentration of the sanitizer, which revealed an expiration date of February 1, 2023. Further observation on August 7, 2023, at 10:05 AM, when the sanitizer water was tested with a strip that was not expired, the strip did not change color; indicating the sanitizer water was not at the appropriate parts per million (unit of measure). Observation of the dry storage area on August 7, 2023, at 10:13 AM, revealed: 15 bags of dinner 395721 Page 14 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rolls, with one open, all without a date; five bags of white bread without a date; four bags of wheat bread without a date; 26 bags of hot dog buns, with one open, all without a date; six bags of hamburger buns, with one open, without a date; one opened bag of macaroni pasta without a date; three containers of Raisin Bran cereal without a date; one container of Krave cereal without a date; two containers of Apple [NAME] cereal without a date; one container of [NAME] Krispies cereal without a date; one container of Cheerios cereal without a date; one opened container of liquid butter without a date; 17 packages of oatmeal cookies, with one open, all not dated; and 28 boxes of fudge round cookies, with three open, all not dated. Observation of the walk-in refrigerator on August 7, 2023, at 10:20 AM, revealed one container of opened potato salad without a date; one opened container of orange juice without a date; and four pans of raw chicken breasts labeled 8-2 to 8-5. Interview with Employee 5 on August 7, 2023, at 10:22 AM, revealed the pans of raw chicken breasts were extra from a meal on August 5, 2023, and should have been used or discarded. Observation of August 2023 dish machine temperature logs on August 7, 2023, at 10:26 AM, revealed wash and rinse temperatures were not recorded on August 1, 2023, for breakfast and lunch; August 2, 2023, for breakfast; and August 4 through 6, 2023, for breakfast and lunch. Further observation of the dish machine temperature logs on August 7, 2023, at 10:33 AM, revealed the wash and rinse temperature recorded were all out of acceptable temperature ranges on the following dates: August 1, 2023, at supper; August 2, 2023, wash and rinse on lunch and supper; August 3, 2023, wash and rinse at supper; wash temperature August 4 through 6, 2023, at supper; and August 4 and 6, 2023, rinse at supper. Observation of the temperature log sheet for kitchen freezers and refrigerators on August 7, 2023, at 10:36 AM, revealed temperatures were not recorded for the outside freezer, walk-in, reach in refrigerator, dining room refrigerator, and dining room freezer on August 1, 2023, in PM; August 2 and 3, 2023, for AM and PM; August 4, 2023, at PM; and August 5 and 6, 2023, in AM. Observation in the main kitchen on August 7, 2023, at 10:47 AM, revealed seven bowls stored right side up on a shelf, and a container of individual butter packets on a counter not dated. Observation in the freezer in the main dining area on August 7, 2023, at 10:50 AM, revealed the following to be melted: 28 magic cup nutritional supplements, 14 sherbet, 23 vanilla ice cream, eight strawberry ice cream, and 36 chocolate ice cream. At that time, Employee 5 tested the temperature of one chocolate ice cream and the freezer temperature to be at 26 degrees Fahrenheit. Observation during initial tour of the activity room pantry area refrigerator on August 7, 2023, at 10:56 AM, revealed: three cranberry juice without a date; four orange juice without a date; one shelf with one container of individual butter packets and a container of individual creamer packets without a date; and two thawed nutritional juice drinks without a date. Further observation of the activity room pantry area on August 7, 2023, at 11:00 AM, revealed: seven bags of cheese crackers without a date; one container of Apple jack's cereal without a date; one container of Krave cereal without a date; two packs of peanut butter crackers without a date; 24 packs of graham crackers without a date; six individual jelly packets without a date; and one container of individual creamer packets without a date. 395721 Page 15 of 16 395721 08/10/2023 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0812 Level of Harm - Minimal harm or potential for actual harm Interview with the Employee 5 on August 7, 2023, at 11:03 AM, revealed that items should be labeled and dated per policy, and discarded once expired. Employee 5 also revealed the bowls should be stored upside down, the test strips should be discarded once expired, the sanitizer water should contain the appropriate parts per million, temperature logs should be filled, kitchen equipment should store food and clean and rinse dishes at proper temperatures, and the ice machine should be clean. Residents Affected - Some Interview with the Nursing Home Administrator on August 9, 2023, at 10:11 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 395721 Page 16 of 16