Health inspection·June 5, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a residents medication regimen was free from unnecessary psychotropic medications and failed to ensure that residents received adequate monitoring of psychotropic medications for three of five residents reviewed for unnecessary medications (Residents 41, 66, and 67). Findings include: Review of facility policy, titled Psychoactive Drug Monitoring Policy, undated, with a last review date of January 23, 2025, revealed It is the policy of the Skilled Unit of Paramount Nursing and Rehabilitation at Fayetteville, LLC. to monitor Residents who receive antidepressant, hypnotic, antianxiety, or antipsychotic medications. The purpose was identified as to evaluate the effectiveness of the medication and to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. In addition, 1) Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. 2) The continued need for the psychoactive medication is reassessed regularly by the prescriber and the care planning team. If continuation is deemed necessary, this is indicated in the medical record. Effects of the medications are documented as a part of the care planning process. Unless medically contraindicated, periodic dosage reductions are attempted and the results documented. 6) Initiation and dosing of the psychoactive medication follows recommendations for the medical literature, clinical practice guidelines, and regulations and standards. 7) All of the following conditions are satisfied prior to initiation and/or continuation of therapy: a. Possible reversible causes for the resident's distress have been ruled out. b. Use results in maintenance or improvement in the resident's functional status. c. Long-term daily use has been accompanied by unsuccessful gradual dosage reduction. d. The need for and response to therapy are monitored and documented in the resident's medical record. Review of Resident 41's clinical record revealed diagnoses that included generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's current physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet give 2.5 mg (milligrams) by mouth two times a day; sertraline Page 1 of 14 395721 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0605 Level of Harm - Minimal harm or potential for actual harm hydrochloride oral (an antidepressant medication) tablet 25 mg give one tablet by mouth at bedtime; and trazodone hydrochloride oral tablet 50 mg give one tablet by mouth at bedtime, all dated May 1, 2025. All aforementioned medications are classified as psychotropic medications (any drug that affects behavior, mood, thoughts, or perception which includes medications for anxiety and depression as well as antipsychotics). Residents Affected - Some Further review of Resident 41's physician orders revealed that the Resident had been ordered a psychotropic medication since his original admission to the facility on May 9, 2024. Review of Resident 41's clinical record failed to identify side effects that staff should observe for or any documentation of ongoing side effect monitoring of his psychotropic medications. During a staff interview with the Director of Nursing (DON) and Assistant DON on June 5, 2025, at 1:01 PM, the DON indicated that side effect monitoring would be documented in progress notes as staff would only document side effect monitoring if actual side effects were noted to occur. Email communication received from the DON on June 5, 2025, at 1:11 PM, indicated We document adverse effects of all medication, not just psychotropics when side effects occur. The exception to forced documentation is with changes to particular psychotropics, and we are documenting on target symptom leading to increase/decrease etc. Review of Resident 66's clinical record revealed diagnoses that included alzheimer's disease with late onset (memory loss and cognitive difficulties that start after age [AGE]) and anxiety disorder. Review of Resident 66's physician orders revealed orders lorazepam (psychotropic medication) 2 mg/milliliter (ml) 0.5 ml every six hours as needed (PRN) for anxiety related to dementia, with a start date of February 17, 2025; and haloperidol lactate (psychotropic medication) 2 mg/ml 0.5 ml every six hours as needed for agitation/nausea related to dementia, with a start date of February 17, 2025. Further review of Resident 66's physician orders failed to include stop dates for the aforementioned medications. Additional review of Resident 66's clinical record revealed a pharmacy review dated February 26, 2025, with a recommendation to add a 14 day stop date for PRN [as needed] psychotropic medications. Further review of this document revealed the physician marked agreed and signed the form March 4, 2025, but provided no additional order for a stop date. During an interview on June 5, 2025 at 12:29 PM, with the DON, the DON stated it was the facility's expectation that PRN psychotropic medication orders have appropriate stop dates. Review of Resident 67's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included anxiety and depression. Review of Resident 67's current physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet 5 mg oral tablet 5 mg (milligrams) give one tablet by mouth three times a day dated April 8, 2025; clonazepam (an antianxiety medication) oral tablet 0.5 mg Give 0.5 tablet by mouth two times a day, dated May 15, 2025; sertraline (an antidepressant medication) 125 mg (give one 100mg tablet and one 25 mg tablet to equal 125 mg) one time a day, dated April 8, 2025; and trazodone hydrochloride (an antidepressant medication) oral tablet 50 mg give one tablet one 395721 Page 2 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0605 time a day, dated May 14, 2025. All of which are classified as psychotropic medications. Level of Harm - Minimal harm or potential for actual harm Review of Resident 67's physician order history revealed that she was ordered the buspirone, sertraline, and trazodone on her original admission date of February 13, 2025. Residents Affected - Some Review of Resident 67's clinical record failed to include identified side effects staff should observe for or any documentation of ongoing side effect monitoring of her psychotropic medications. During a staff interview with the DON and Assistant DON on June 5, 2025, at 1:01 PM, the DON indicated that side effect monitoring would be documented in progress notes as staff would only document side effect monitoring if actual side effects were noted to occur. Email communication received from the DON on June 5, 2025, at 1:11 PM, indicated We document adverse effects of all medication, not just psychotropics when side effects occur. The exception to forced documentation is with changes to particular psychotropics, and we are documenting on target symptom leading to increase/decrease etc. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395721 Page 3 of 14 395721 06/05/2025 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 resident assessments accurately reflected the resident's status for three of 25 residents reviewed (Residents 37, 41, and 67). Residents Affected - Some Findings include: Review of Resident 37's clinical record revealed diagnoses that included cerebral infarction (death of brain tissue caused by a disruption in blood flow) and paraplegia (inability to move the lower part of the body). Review of Resident 37's quarterly minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated April 16, 2025, revealed Resident 37 was coded as receiving anticoagulant medication. Review of Resident 37's current and discontinued physician orders failed to reveal Resident 37 had been ordered anticoagulant medication. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on June 4, 2025, at 2:02 PM, it was revealed that Resident 37's quarterly MDS assessment had been coded incorrectly and a modification had been submitted. The NHA stated that it was the facility's expectation that MDS assessments be coded accurately. Review of Resident 41's clinical record revealed diagnoses that include generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's Significant Change MDS with the assessment reference date (last day of the assessment period) of February 26, 2025, indicated in Section N. Medications that he was documented as not receiving an antianxiety medication. Review of Resident 41's Medication Administration Record for February 2025 revealed that he had been administered an antianxiety medication in the assessment period. Review of Resident 41's Significant Change MDS with the assessment reference date of May 3, 2025, indicated in Section N. Medications that he was documented as receiving an anticonvulsant medication. Review of Resident 41's Medication Administration Record for April 2025 and May 2025 failed to reveal any documentation that he had been administered an anticonvulsant medication in the assessment period. During a staff interview with the DON and the Assistant Director of Nursing (ADON) on June 5, 2025, at 11:27 AM, the DON confirmed that Resident 41's MDS assessments were coded incorrectly and that he would expect MDS assessments to be an accurate reflection of a resident during the assessment reference period. Review of Resident 67's clinical record revealed diagnoses that included Parkinson's Disease 395721 Page 4 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements) and restless leg syndrome (condition that causes a very strong urge to move the legs which usually is caused by an uncomfortable feeling in the legs). Review of Resident 67's admission MDS with the assessment reference date of May 20, 2025, indicated in Section N. Medications that she was documented as not receiving an anticonvulsant medication. Review of Resident 67's Medication Administration Record for May 2025 revealed that had been administered an anticonvulsant medication in the assessment period. During a staff interview with the DON and the ADON on June 5, 2025, at 11:27 AM, the DON confirmed that Resident 67's MDS assessment was coded incorrectly and that he would expect MDS assessments to be an accurate reflection of a resident during the assessment reference period. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395721 Page 5 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 18 residents reviewed (Residents 5, 41, and 66). Findings include: Review of the facility policy, titled Care Plan Policy, last reviewed January 23, 2025, read, in part, .to develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs that include, but are not limited to, those identified in the comprehensive assessment . Using the initial plan of care, any updates, the comprehensive assessment and the resultant CAA investigations, the interdisciplinary team will meet with the resident and the resident's family or representative, as appropriate, and develop quantifiable objectives for the highest level of functioning the resident may be expected to attain - physically, mentally, and psychosocially. Review of Resident 5's clinical record revealed diagnoses that included major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities) and generalized anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension). Review of Resident 5's physician orders revealed an order for olanzapine (antipsychotic medication) 5 milligrams (mg) one time a day for major depressive disorder. Review of Resident 5's modification of admission minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), dated December 23, 2024, revealed Resident 5 was coded as receiving psychotropic medication. Further review of the Care Area Assessment worksheet revealed Resident 5 was triggered for psychotropic medications and would be care planned. Review of Resident 5's comprehensive care plan failed to reveal any care planning for psychotropic medication use. During a staff interview on June 5, 2025, at 12:31 PM, with the Director of Nursing (DON), the DON stated it was the expectation of the facility that comprehensive care plans be developed accurately. Review of Resident 41's clinical record revealed diagnoses that include generalized anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. Review of Resident 41's physician orders revealed orders for buspirone hydrochloride (an antianxiety medication) oral tablet give 2.5 mg (milligrams) by mouth two times a day; sertraline hydrochloride oral (an antidepressant medication) tablet 25 mg give one tablet by mouth at bedtime; and 395721 Page 6 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0656 Level of Harm - Minimal harm or potential for actual harm trazodone hydrochloride oral tablet 50 mg give one tablet by mouth at bedtime all dated May 1, 2025. All of which are classified as psychotropic medications (any drug that affects behavior, mood, thoughts, or perception which includes medications for anxiety and depression as well as antipsychotics). Further review of Resident 41's physician orders revealed that he had been ordered at least one psychotropic medication since his original admission to the facility on May 9, 2024. Residents Affected - Some Review of Resident 41's Significant Change MDS assessments dated on February 26, 2025, and May 3, 2025, revealed that he was coded for receiving psychotropic medications. Review of the completed Care Area Assessment worksheet for both of these assessments indicated that Resident 41 triggered for his psychotropic medication use and that this would be care planned. Review of Resident 41's current comprehensive care plan failed to reveal any documentation of his psychotropic medication use. In addition, his full care plan revision history failed to reveal any documentation of psychotropic medication use. During a staff interview with the DON and the Assistant DON on June 5, 2025, at 12:22 PM, the DON confirmed that Resident 41's psychotropic medication use should have been care planned as his two most recent assessments indicated. Review of Resident 66's clinical record revealed diagnoses that included alzheimer's disease with late onset (memory loss and cognitive difficulties that start after age [AGE]) and anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension) Review of Resident 66's physician orders revealed orders for xanax (psychotropic medication) 0.25 mg one time a day; lorazepam (psychotropic medication) 2 mg/milliliter (ml) 0.5 ml every six hours as needed; and haloperidol lactate (psychotropic medication) 2 mg/ml 0.5 ml every six hours as needed. Review of Resident 66's admission MDS dated [DATE], revealed Resident 66 was coded as receiving psychotropic medication. Further review of the care area assessment worksheet revealed Resident 66 was triggered for psychotropic medications and would be care planned. Review of Resident 66's comprehensive care plan failed to reveal any care planning for psychotropic medication use. During a staff interview on June 5, 2025, at 12:31 PM, with the DON, the DON stated it was the expectation of the facility that comprehensive care plans be developed accurately. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395721 Page 7 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 18 residents reviewed (Residents 41 and 67). Residents Affected - Few Findings include: Review of facility policy, titled Care Plan Policy with a last revised date of February 20, 2020, and a last review date of January 23, 2025, revealed The Care Plan will be updated on an ongoing basis by the charge nurse whenever new nursing orders are received and/or any changes in condition with the resident. Review of Resident 41's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 41's physician orders revealed an order for fluid restriction of 2000 ml (milliliters) in 24 hours. Review of Resident 41's care plan revealed in his nutrition care plan an intervention for fluid restriction 1500 ml in 24 hours, dated October 11, 2024; and in his cardiovascular care plan an intervention for fluid restriction 2000 ml in 24 hours, dated April 17, 2025. In an email communication received from the Director of Nursing on June 5, 2025, at 11:44 AM, he indicated that the care plan should have been revised when the fluid restrictions were changed. Review of Resident 67's clinical record revealed diagnoses that included Parkinson's Disease (progressive and irreversible neurological disease that causes decreased control of the nervous system resulting in stiffness, slowing of movement, and uncontrolled bodily movements), repeated falls, and compression fractures (a break in a vertebra [a bone in your spine] which causes the bone to collapse) to the lumbar region of her back. Review of Resident 67's clinical record revealed that she sustained a fall at the facility on April 3, 2025, which resulted in a hospital transfer on April 4, 2025, where she was identified as having a new compression fracture to the lumbar region of her back. Review of Resident 67's current care plan failed to reveal that her new fracture from her fall was included in her care plan. Further review of Resident 67's care plan revealed that she was care planned for a urinary tract infection (UTI) dated March 14, 2025. Review of Resident 67's clinical record failed to reveal any documentation that she was currently being treated for a UTI. 395721 Page 8 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0657 Level of Harm - Minimal harm or potential for actual harm In an email communication received from the Nursing Home Administrator on June 4, 2025, at 3:47 PM, she indicated Resident 67's fall with fracture was not added to the care plan and that the UTI from March was removed. She further indicated that she would expect the fracture to have been added to the fall care plan and the UTI removed from the care plan after resolving. Residents Affected - Few 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services 395721 Page 9 of 14 395721 06/05/2025 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 - Some 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 facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure urinary catheter care was completed for three of four residents reviewed with urinary catheters (Residents 1, 21, and 41). Findings include: Review of the facility policy, titled Prevention of Catheter Associated Urinary Tract Infections, last reviewed January 23, 2025, under Catheter Care section stated, daily catheter care should be documented in the resident's EHR (electronic health record). Review of Resident 1's clinical record revealed diagnoses that included obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed) and type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy). Physician orders dated August 2024 through June 2025 identified that Resident 1 had an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Physician orders also stated catheter care was to be performed daily on every shift. Review of Resident 1's Treatment Administration Record revealed no evidence that catheter care was completed by staff until September 11, 2024. During a staff interview with the DON on June 5, 2025 at 12:20 PM, the DON confirmed there was no documentation of catheter care for Resident 1. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. Review of Resident 21's clinical record revealed diagnoses that included retention of urine (a urinary tract disorder that occurs when urine flow is obstructed) and cerebral palsy (congenital disorder of movement, muscle tone, or posture). Physician orders dated February 2025 through June 2025 identified that Resident 21 had an indwelling urinary catheter in place with a 16 French catheter and 10 milliliter filled balloon to maintain placement. Physician orders also stated catheter care was to be performed daily on every shift. Review of Resident 21's care plan revealed foley catheter care to be completed every shift and as needed, effective February 20, 2025. Review of Resident 21's Treatment Administration Record revealed catheter care was not present and being signed off by staff as completed every shift. During a staff interview with the DON on June 5, 2025 at 12:20 PM, the DON confirmed there was no documentation of catheter care for Resident 21. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. Review of Resident 41's clinical record revealed diagnoses that included urinary retention and 395721 Page 10 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0690 unspecified disorder of the urinary system. Level of Harm - Minimal harm or potential for actual harm Review of Resident 41's physician orders revealed orders for a foley catheter 18 French 30 cc and catheter care every shift, dated May 1, 2025. Residents Affected - Some Further review of Resident 41's clinical record revealed that he has had the foley catheter since his original admission to the facility on May 9, 2024. During a staff interview with the DON and the Assistant Director of Nursing on June 5, 2025, at 12:22 PM, the DON confirmed that he could not locate any documentation indicating that Resident 41 received catheter care every shift, and that he would expect catheter care to be documented every shift. The DON added that he modified the templates/order templates on June 4, 2025, so that staff document that catheter care is performed each shift as required. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395721 Page 11 of 14 395721 06/05/2025 Paramount Nursing and Rehab at Fayetteville, LLC 6375 Chambersburg Road Fayetteville, PA 17222

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 18 residents reviewed (Resident 37). Residents Affected - Some Findings include: Review of Resident 37's clinical record revealed diagnoses that included paraplegia (inability to voluntarily move the lower parts of the body) and depression (persistent feeling of sadness, loss of interest, or both, that interferes with daily life activities). During an interview with Resident 37 on June 2, 2025 at 12:09 PM, Resident 37 revealed that at the age of 19 he was the only survivor of a plane crash. Resident 37 also revealed he was severely injured in the crash, which resulted in him being paralyzed from the waste down. Further review of Resident 37's clinical record failed to reveal documentation that any trauma screening had been done. Email communication with the Nursing Home Administrator on June 4, 2025, at 12:50 PM, revealed Resident 37 had not had a trauma screening completed. During an interview on June 5, 2025, at 12:27 PM, with the Director of Nursing (DON), it was revealed that the facility had not been completing trauma screenings and created a policy the prior day (June 4, 2025) for trauma informed care. The DON stated it was the expectation of the facility that residents be screened for trauma. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services 395721 Page 12 of 14 395721 06/05/2025 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. Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in one of one nourishment refrigerators. Findings include: Review of facility policy, titled Food Storage/Refrigerators, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 5. Foods must be stored in appropriate containers; covered, labels, and dated. 6. All food items must be stored 6 inches off the floor. Review of facility policy, titled Food Storage/Dry Storage, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 1. All foods or food items not requiring refrigeration shall be stored at least 6 inches off the floor and 18 inches from the ceiling. 2. Items must be stored on a surface, which facilitates thorough cleaning. 4. All items are stored and issued on a first in/first out rotation. All cans must be dated. 7. Any opened items must be dated with the date of opening and tightly recovered to preserve freshness. 9. Any damaged cans or cartons will be refused delivery, credited by the appropriate purveyor, or discarded. These items will be removed from the kitchen storage and placed in the Food Service Manager's office until credited. Review of facility policy, titled Identification of Food Supplies, with a last revised date of June 20, 2017, and a last review date of January 23, 2025, revealed, in part, 1. All food supplies removed from original container must be clearly identified in storage container. 2. Labeling shall contain name of item and date container was opened. Review of facility policy, titled Personal Food/Beverage Storage with a last revised date of June 3, 2025, indicated 1. All foods/beverages will be labeled with the resident name and date when brought into the facility. 2. Outside source, for example: family, friends, etc. will be educated that unconsumed items will be discarded 3 days after the date marked. 3. Nursing is responsible for checking temperatures of refrigerator unit and safe techniques are followed regarding discarding all outdated items. Tour of the kitchen on June 2, 2025, between 9:45 AM and 10:15 AM, with Employee 1 (Dietary Manager) revealed the following observations: Walk-in cooler had a 50-pound bag of onions approximately half full sitting on floor; Ice machine vent on the outside of the upper portion was covered with a moderate amount of fuzzy gray colored debris; Three bay refrigerator had four packages of bagels with no dates indicated; Walk-in freezer had an opened package of peas and an open package of California blend vegetables with no dates indicated and a box of mixed bread items with no dates indicated on any of the packages; Dry storage had three small clear packages of a type of rice type grain with seasoning, which had 395721 Page 13 of 14 395721 06/05/2025 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 no actual labeling of what the item was or any dates; an opened package of elbow noodles dated, but not secured; an opened container of ginger spice with a delivery date December 13, 2023, and no open date indicated; three packages of pork gravy mix with no dates indicated; an opened bag of shredded coconut with no dates indicated; a dented can of cherry pie filling on rack to be used; opened bag of corn flakes and and an opened bag frosted mini wheats with no open date; and two cases of potatoes and one case of oatmeal sitting directly on the floor; and Three-compartment sanitation sink had no test strips noted. During an immediate staff interview with Employee 1 on June 2, 2025, at 10:10 AM, Employee 1 indicated that the bagels in the three bay refrigerator were pulled from freezer that morning; that he was not aware items should not be stored directly on floor; that maintenance cleans the ice machine vents; that all items should be labeled, dated and securely closed; spices are good for one year after opening; and that the facility food provider had indicated dented cans can be used and should not be sent back unless there is an actual puncture or leak noted. He further indicated that he would locate the test strips for the three-compartment sink. Observation of a refrigerator in the Activity Room on June 2, 2025, at 10:16 AM, revealed the presence of a sign on the front which indicated items must be labeled with name and date and that items will be thrown away if noted to be greater than three days old. Inside the refrigerator, there was dried spills noted on the shelves, drawers, and in the bottom of the refrigerator; there were three beverages in facility cups with plastic disposable lids with no names or dates noted; and there a was chocolate dessert labeled with a resident's name dated May 24, 2025. During a staff interview with Employee 1 on June 2, 2025, at 10:21 AM, Employee 1 indicated that nursing staff was responsible for the refrigerator in the activity room. Observation in the kitchen on June 3, 2025, at 11:45 AM, revealed that two containers of test strips for the three-compartment sanitation sink were present. One was unopened with an expiration date June 2026, and the other one was opened but the insert with results grid was missing and, therefore, there was also no expiration date noted. In addition, in the walk-in cooler there was a case of canned gravy sitting directly on the floor. During a staff interview with the Nursing Home Administrator (NHA) on June 3, 2025, at 1:33 PM, the NHA indicated that she thought dietary was responsible for the activity room refrigerator, but indicated that they had just recently changed their facility practice for snacks, which means that this refrigerator was more for outside food brought in for residents. During a follow-up staff interview with the NHA and Director of Nursing on June 4, 2025, at 2:04 PM, the NHA confirmed that she would expect foods to be labeled, dated, and stored properly. She indicated that nursing was responsible for labeling and dating of foods in activity room refrigerator and that dietary would be responsible for cleaning the refrigerator. She also confirmed that the sanitation strips should have expiration date as well as testing guide. She confirmed that could not speak as to the accuracy of the testing that had been documented and, therefore, was not submitting the test logs for review. The NHA also indicated that she had identified concerns in the dietary department prior to survey and that she had made some staffing changes to improve services. 28 Pa. Code 201.18(b)(1)(3) Management 395721 Page 14 of 14