Health inspection·June 2, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records and facility documentation and staff and family interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 12 residents (Resident R42). Residents Affected - Few Findings include: Review of theInvestigation of Incidents and Accidents Education, sheet, dated 5/24/23, revealed when an unusual incident, injury/bruise (whether or not the origin is known) .the supervisor /charge nurse or appropriate department head will initiate and document an investigation of the accident or incident. 3. Notification of the physician, responsible party, Director of Nursing and Administration will be done promptly. 9. If a resident has an injury/bruise of unknown origin, witness statements will be obtained from the staff who cared for the resident and those who were on the unit or in contact with the resident for the 48-72 hour period prior to the discovery of the injury/bruise. Review of Resident R42's clinical record revealed an admission date of 10/12/21 with diagnoses that included lumbar disc degeneration, difficulty walking, diabetes, anxiety and intellectual disabilities. During an observation on 5/30/23, at 1:30 p.m., Resident R42 was noted with a black, purple and yellow discolored area on the lateral aspect of the left upper arm approximately two inches by one inch in size. During an interview with Resident R42's family member on 5/30/23, at 4:55 p.m., the family member stated that they had not been notified by the facility of the bruise but noticed the bruise a couple of days ago. There was no evidence documented that an investigation was completed regarding the left upper arm bruise. During an interview on 5/31/23, at 12:02 p.m., the Director of Nursing confirmed that Resident R42's bruise was not reported by staff and there was not an investigation completed related to Resident R42's bruise of unknown origin. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 6 396071 396071 06/02/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 review of clinical records and facility policy and staff interview, it was determined that the facility failed to ensure that the care plan review was completed and reviewed with the resident and/or resident representative for two of 12 residents reviewed (Residents R2 and R18) Findings include: Review of the Care-Planning Resident Participation policy, dated 5/24/23, revealed the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care conferences .the facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Review of Resident R2's clinical record revealed an admission date of 11/27/20 with diagnoses that included heart failure, diabetes, difficulty swallowing, poor circulation, anxiety and hypertension. Review of the clinical record revealed that Resident R2 had a Quarterly Minimum Data Set (MDS-periodic review of resident care needs) on 8/17/22 and an Annual MDS review on 2/13/23. There was no evidence that a care plan meeting occurred, who attended or an explanation why the resident or resident representative was not present. Review of Resident R18's clinical record revealed an admission date of 1/6/22, with diagnoses that included heart problems, diabetes, lung problems and schizoaffective disorder. Review of the clinical record revealed that Resident R18 had a Quarterly MDS review on 1/02/23 and 4/01/23. There was no evidence that a care plan meeting occurred, who attended or an explanation why the resident or resident representative was not present. During an interview on 6/01/23, at 9:10 a.m., the Director of Nursing confirmed there was no evidence found that a care plan meeting was held for Resident R2 from the 8/17/22 Quarterly review or the 2/13/23 Annual review and confirmed that Resident R18 lacked evidence that a care plan meeting was completed on the Quarterly review dates of 1/02/23 and 4/01/23. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3) Nursing services 396071 Page 2 of 6 396071 06/02/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility employee records and staff interview, it was determined that the facility failed to complete performance reviews of Nurse Aides (NA) at least once every 12 months for the past year from July 2022 through June 2023. Residents Affected - Some Findings include: Upon request, no records or evidence of performance reviews for all NAs from July 2022, through June 2023, was provided for review. During an interview on 6/02/23, at 12:25 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding completed performance reviews for NAs as required every 12 months. 28 Pa. Code 201.20(a)(d) Staff development 396071 Page 3 of 6 396071 06/02/2023 Clepper Manor 959 East State Street Sharon, PA 16146

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 a review of closed records, facility policy, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of two closed records reviewed (Resident R45). Findings include: Review of the facility policy, entitled Discarding and Destroying Medications, dated 5/24/23, indicated if a resident is transferred to another facility, or dies while he or she is in lawful possession of controlled substances, the facility may dispose of the controlled substance(s) by depositing in the authorized on-site receptacle. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. Required documentation of the medication disposal on the medication disposition record included the signature(s) of at least two witnesses, the quantity disposed, and reason for disposition. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. Review of Resident R45's clinical record revealed admission to the facility on 3/29/23. Resident R45 ceased to breathe on 4/09/23. Review of Resident R45's closed record revealed a lack of evidence of four Percocet 5/235 milligrams (mg) tablets (narcotic pain medication) upon destruction of Resident R45's narcotic medication on 4/18/23. The facility received eight Percocet tablets on 4/09/23 for Resident R45 and the facility nursing staff destroyed four of the eight Percocet tablets on 4/18/23, leaving four Percocet tablets unaccounted for. During an interview on 6/02/23, at 12:30 p.m. the Director of Nursing confirmed there were discrepancies of the number of Percocet 5/325 mg tablets received then destroyed, as evidenced by the controlled drug receipt/record/disposition form. The controlled drug receipt/record/disposition form revealed a quantity of eight were received on 4/09/23, and a quantity of four were destroyed on 4/18/23. The DON confirmed that there was no evidence or record of the other four Percocet 5/325 mg tablets, and the facility failed to implement procedures to keep accurate and safe disposition of controlled medication records for Resident R45. 28 Pa. Code 211.9(a) Pharmacy services 28 Pa. Code 211.12(d)(3)Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 396071 Page 4 of 6 396071 06/02/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of facility records and staff interview, it was determined that the facility failed to assure required attendance of the Medical Director and Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings quarterly for the meeting records reviewed from 7/27/2022 to 5/24/2023. Residents Affected - Many Findings include: Review of the QAPI Committee Attendance Records revealed that the facility holds QAPI meetings monthly. Committee Members are required to attend and sign quarterly attendance sign-in sheets for the required quarterly meetings. Upon review of the QAPI Committee Attendance Records from 7/27/2022, to 5/24/2023, it was revealed that the Medical Director did not attend for five months from 9/21/2022, to 1/25/2023. The Infection Preventionist did not attend for six months between 12/28/2022, to 5/24/2023. During an interview on 6/2/2023, at 12:37 p.m. the Nursing Home Administrator confirmed that both the Medical Director and the Infection Preventionist did not attend the QAPI committee meetings as required. 28 Pa. Code 201.18(e)(1)(2)(3) Management 396071 Page 5 of 6 396071 06/02/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from July 2022 through June 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from July 2022 through June 2023, was provided for review. During an interview on 6/02/23, at 11:40 a.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(c)(d) Staff development 396071 Page 6 of 6