Inspection·December 16, 2022

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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents did not receive psychotropoic medications unless necessary and that non-pharmacological interventions were attempted before the use of a PRN (as needed) psychotropic medication for two of five residents reviewed (Residents 88 and 90). Findings include: Review of facility policy Psychotropic Medications, reviewed March 2021, revealed that residents do not receive psychotropic medications pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the medical record. Non-pharmacological interventions (such as behavioral interventions) are considered and used/care planned when indicated, instead of, or in addition to, medication to assist in the allevation of target behaviors. Review of Resident 88's admission MDS (Minimum Data Set - periodic assessment of resident needs) of March 28, 2022, included diagnoses of CVA (cerebrovascular accident - stroke) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Review of Resident 88's physican's order dated April 20, 2022, reveale an order for Hydroxyzine HCl (medication used to treat anxiety) 25 milligrams one tablet every six hours as needed for anxiety. Review of Resident 88's September 2022 Medication Administration Record (MAR) revealed that PRN Hydroxyzine HCl was administered 18 times. Further review of the clinical record failed to reveal behaviors documented prior to the administration on 15 of 18 occasions. Review of the October 2022 MAR revealed that Hydroxyzine HCL was administered eight times. Further review of the clinical record failed to reveal behaviors documented prior to the administration on six of eight occasions. Review of Resident 88's physician's order dated August 9, 2022, revealed an order for Trazodone (antidepressant medication used to treat sleep disorders) 50 milligrams 0.5 tablet at bedtime as needed for insomnia. Review of Resident 88's September 2022 MAR revealed that PRN Trazodone was administered 17 times. Review of the clinical record revealed no documented evidence that alternate interventions were attempted prior to administration on 14 of 17 occasions. Review of Resident 88's October 2022 MAR revealed that PRNTrazodone was administered 10 times. Review of the clinical record failed to reveal documented evidence that alternate interventions were attempted prior to administration on 8 of 10 occasions. Interview with the Director of Nursing on December 16, 2022, at 1:30 p.m. confirmed that the reasons for the use of the PRN Hydroxyzine were not documented and non-pharmacological interventions were not documented for the use of PRN Trazodone for Resident 88. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395857 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ephrata Manor 99 Bethany Road Ephrata, PA 17522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 90's diagnosis list revealed Alzheimer's Disease (An irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Dementia (A term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) Review of Resident 90's physician's order dated July 23, 2022, revealed an order for Ativan (A medication to treat anxiety) 0.5 mg, give half a tab (.25mg) every four hours as needed for anxiety, restlessness, and agitation. Review of the August 2022, MAR revealed that Resident 90 was administered the PRN Ativan nine times for increased anxiety. Clinical records revealed no documented evidence that an alternative behavior intervention was attempted before the medication administration. Interview with the Director of Nursing was conducted on December 16, 2022, at 12:30 p.m., and confirmed nondrug intervention was not provided before administering PRN Ativan to Resident 90. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395857 If continuation sheet Page 3 of 3