Health inspection·January 9, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were afforded the right to secure and confidential personal and medical records for one of 14 residents reviewed (Resident 18). Residents Affected - Few Findings include: Review of Resident 18's clinical record revealed diagnoses that included quadriplegia (paralysis of both arms and both legs) and tracheostomy status (artificial opening to the trachea [aka windpipe] through which a machine provides breathing assistance). During observations on January 7, 2025, it was observed, from the hallway, that a paper was taped to the wall outside Resident 18's room to the left of the room number sign. It was observed that written on the paper was Resident 18's first name and clinical assessment findings, along with other statements. Written on the paper was the date of January 4, 202[5]. During a staff interview on January 8, 2025, at approximately 1:20 PM, Nursing Home Administrator (NHA) revealed that the paper contained notes written to communicate information for Resident 18's treatment in regard to suctioning Resident 18's tracheostomy. During the interview, NHA revealed it should have been placed on the back of the Resident's door where it would not have been in plain sight from the hallway. 28 Pa code 201.18(b)(2)(3) Management Page 1 of 13 396122 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, clinical record review, and staff interviews, it was determined the facility failed to review and revise the resident's care plan for four of 14 residents reviewed (Residents 2, 26, 29, and 37). Findings include: Review of facility policy, titled Care Plan and Conference, last revised November 30, 2018, read, in part, Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes. Ongoing communication will occur between nursing and RNAC (Registered Nurse Assessment Coordinator) will occur with any change in resident condition. Review of Resident 2's clinical record revealed diagnoses that included dependence on respirator (ventilator) status (when a patient is unable to wean off a ventilator and breathe independently, they become ventilator dependent), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and muscle weakness. Observation of Resident 2 on January 7, 2025, at 10:31 AM, revealed she was lying in bed and had fall mats on both sides of her bed. Observation of Resident 2 on January 8, 2025, at 12:46 PM, revealed she was lying in bed and had fall mats on both sides of her bed. Review of Resident 2's care plan revealed a focus area of The resident is at risk for falls related to medication side effects and history of fall, last revised May 15, 2024, with an intervention for Fall mat to floor on right (door) side of bed, last revised January 21, 2024. Review of Resident 2's clinical record revealed she had an unwitnessed fall on July 13, 2024, with an intervention for bilateral fall mats. Interview with Employee 1 (RNAC) on January 9, 2025, at 10:09 AM, revealed Resident 2's physician order did not get revised to reflect the new order for bilateral floor mats, therefore, the new order did not make it to the care plan to be updated. Interview with the Director of Nursing (DON) on January 9, 2025, at 12:03 PM, revealed she would expect Resident 2's care plan to be updated with her fall intervention from July 13, 2024. Review of Resident 26's clinical record on January 7, 2025, revealed diagnoses included hypertension (elevated/high blood pressure) and bipolar disorder (mental health disorder that causes extreme shifts in mood from depression to manic hyperactivity). Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: CNS [central nervous system] StimulantsAmphetamine-Dextroamphet[[NAME]] . which had an initiation date of March 4, 2024. Review of the Goal section of the care plan revealed the goal of, Resident will be free of adverse reaction to CNS 396122 Page 2 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0657 stimulates administered, which had a revision date of November 26, 2024. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's clinical record revealed that Resident 26's order for Amphetamine-Dextroamphetamine was discontinued on September 20, 2024. Residents Affected - Some During an electronic communication on January 9, 2025, at 12:37 PM, Nursing Home Administrator revealed Resident 26 had a care plan meeting (interdisciplinary meeting utilized to review the plan of care to adjust according to the residents' needs) on November 19, 2024. During a staff interview on January 9, 2025, at approximately 12:50 PM, DON revealed that Resident 26's care plan for CNS stimulants should have been discontinued, at least, during the care plan meeting. Review of Resident 26's physician's orders revealed an order for clonazepam (schedule IV controlled medication used to treat anxiety disorders) 3 mg as-needed every 24 hours for restlessness; clonazepam 1 mg twice a day for anxiety disorder; lorazepam (schedule IV controlled medication used to treat anxiety disorders) 1 mg every six hours as needed for anxiety. Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: Anti-Anxiety Medications, with an initiation date of February 7, 2024. Review of the Interventions section of the care plan revealed only one intervention, which stated, Notify physician for adverse effects of medication, which had an initiation date of February 7, 2024. Resident 26's care plan for anti-anxiety medications did not include additional information such as, but not limited to, target symptoms to monitor, possible non-pharmacological interventions to attempt prior to administration of an as-needed anti-anxiety medication, nor on-going consultation with psychiatric health services. Resident 26 also had a physician order for Seroquel 25 mg (antipsychotic medication used to treat mental health disorders) one time a day for bipolar disorder. Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: Anti-Psychotic medication, with an initiated date of March 11, 2021. Review of the Interventions section of the care plan revealed only one intervention, which stated, Notify physician for adverse effects of medications, which was initiated March 11, 2021. During a staff interview on January 9, 2025, at approximately 12:50 PM, Nursing Home Administrator revealed that Resident 26's care plan did not appear to be individualized. Review of Resident 29's clinical record revealed diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly) and quadriplegia (paralysis that affects all a person's limbs). Observation of Resident 29 on January 7, 2025, at 10:48 AM, revealed bilateral thick fall mats on both sides of the bed. Review of Resident 29's care plan on January 7, 2025, revealed a care plan for falls related to seizure disorder, with an initiation date of May 9, 2024. Resident 29's care plan failed to include bilateral thick fall mats. 396122 Page 3 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of Resident 29's physician's orders revealed an order for bilateral thick fall mats, with an active date of January 8, 2025. Review of Resident 29's care plan on January 8, 2025, revealed bilateral thick fall mats were added to the fall care plan, with an initiation date of January 8, 2025. Residents Affected - Some During an interview with the DON on January 9, 2025, at 12:04 PM, revealed they would have expected Resident 29 to have had an order for the fall mats and would have expected them to have been added to their care plan afterward. DON revealed Resident 29 has had bilateral thick fall mats since the Resident was admitted to the facility in May 2024. Review of Resident 37's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure, and muscle weakness. Review of Resident 37's care plan revealed a focus area of Resident has impaired skin integrity related to blister right lateral heel, last revised March 8, 2024. During an interview with the DON on January 9, 2025, at 12:06 PM, she revealed Resident 37's blister wound has been resolved since March 2024, and she would expect her wound care plan to be revised. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(3) Nursing services 396122 Page 4 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 14 residents reviewed (Residents 9, 14, and 17). Residents Affected - Some Findings include: Review of facility policy, titled Medication Administration, with a last review date of December 31, 2024, revealed Medications are given at the time ordered or within 60 minutes before or after the time for bid [twice a day], tid [three times a day], or qid [four times a day] passes. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), tracheostomy (an opening or incision in the windpipe to relieve an obstruction to breathing), and dependence on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, unable to breathe on their own, or under anesthesia). Review of Resident 9's physician orders on January 7, 2024, revealed an order to apply triple antibiotic ointment to moisture associated skin damage (MASD) at tracheostomy stoma site every shift, dated September 24, 2024. Review of Resident 9's clinical record failed to reveal any progress notes, weekly skin assessments, nursing assessments, or respiratory assessments between September 24, 2024, and January 8, 2025, that included any identified skin damage to their tracheostomy site or otherwise. During a staff interview with the Director of Nursing (DON), Employee 1, and Employee 2 on January 9, 2025, at 10:38 AM, the DON confirmed that she could not find any clinical documentation indicating that Resident 9 had any MASD at their tracheostomy site. She further indicated that Resident 9's physician had assessed their tracheostomy site on January 8, 2025, and noted there was no skin damage noted and discontinued the antibiotic ointment. The DON also indicated that, if a resident had skin issues, that she would expect staff to document them accordingly. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe) and hypertension (high blood pressure). Review of Resident 14's December 2024 treatment administration record (TAR) revealed the following treatment orders: cleanse pressure area to left buttock cleanse with normal saline solution (NSS) cover with calcium alginate and foam border gauze daily, every night shift for pressure area, with a start date of July 5, 2024; treatment for left buttock - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of December 2, 2024; and treatment to left superior thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night for wound care, with a start date of November 13, 2024. Further review of Resident 14's December 2024 TAR revealed the treatment orders above were blank on 396122 Page 5 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0684 December 14 and 18, 2024, indicating they were not completed. Level of Harm - Minimal harm or potential for actual harm Review of Resident 14's November 2024 TAR revealed the following treatment orders: treatment to left superior thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of November 13, 2024; and treatment to left thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of September 9, 2024. Residents Affected - Some Further review of Resident 14's November 2024 TAR revealed the treatment orders above were blank on November 16, 2024, indicating they were not completed. Review of Resident 14's October 2024 TAR revealed a treatment order to cleanse pressure area to left buttock, cleanse with NSS, cover with calcium alginate and foam border gauze daily every night shift for pressure area, with a start date of July 5, 2024. Further review of Resident 14's October 2024 TAR revealed the treatment order above was blank on October 25, 2024, indicating the treatment was not completed. Review of Resident 14's October 2024 TAR revealed a treatment order for the left thigh, to cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of September 9, 2024. Further review of Resident 14's October 2024 TAR revealed the treatment order above was blank on October 16 and 25, 2024, indicating the treatment was not completed. During a staff interview with the DON on January 9, 2025, at 12:51 PM, revealed that she believed Resident 14's treatment was completed on the dates above, but had careless documentation. DON revealed if the treatment was completed, it should have been documented on the TAR. Review of Resident 17's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), hypotension (low blood pressure), and end stage renal disease (ESRD - condition in which a person's kidneys cease functioning on a permanent basis) with dependence on dialysis(external filtering of the blood performed by a machine by removing the blood and replacing it). Review of Resident 17's physician orders revealed orders for Midodrine HCl Oral Tablet 5 MG [milligram] give three tablets by mouth three times a day related to hypotension. Hold for SBP [systolic blood pressure] greater than 120, dated October 29, 2024; and Insulin Aspartame Injection Solution 100 units/ml [milliliter] Inject as per sliding scale: if 151 - 200 = 1; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400= 5; 401+ = Call Physician, subcutaneously before meals related to Type 2 Diabetes Mellitus, dated October 29, 2024. Review of Resident 17's October 2024 Medication Administration Record revealed that on October 30 and 31, 2024, that there were no documented blood sugars for 6:00 AM, 11:00 AM, or 4:00 PM. All boxes were marked with an X. Review of Resident 17's progress notes revealed a medication administration note on October 30, 2024, at 5:16 PM, related to their ordered 4:00 PM blood sugar check, that indicated Resident 17 was 396122 Page 6 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sleeping, not woken at this time. verbally abusive to staff prior to falling asleep will check blood sugar when she wakes up. Further review of Resident 17's progress notes and Medication Administration record failed to reveal that this occurred. In addition, the review failed to reveal any other nursing progress notes as to why Resident 17's blood sugars were marked with an X on the aforementioned dates and times. Review of Resident 17's November 2024 Medication Administration Record revealed their 6:00 AM ordered blood sugar was blank on November 1, 2024. Review of Resident 17's November 2024 nursing progress notes failed to reveal any documentation as to why their ordered blood sugar was not completed. Review of Resident 17's December 2024 Medication Administration Record revealed their 6:00 AM ordered blood sugar was blank on December 6, 16, 17, 18, and 20, 2024; their 11:00 AM ordered blood sugar was blank on December 15, 16, and 17, 2024; and their 4:00 PM ordered blood sugar was blank on December 15 and 17, 2024. In addition, their blood sugar was documented on December 23, 2024, at 4:00 PM, as being 471. Review of Resident 17's December nursing progress notes failed to reveal any documentation as to why their ordered blood sugars were not completed on the aforementioned dates and times, or that Resident 17's physician was notified of the blood sugar being greater than 401 on December 23, 2024, as ordered. Review of Resident 17's January 2025 Medication Administration Record revealed that on January 3, 2025, at 6:00 AM, their ordered blood sugar test was blank; and that on January 7, 2025, at 9:00 PM, Resident 17's blood pressure was recorded as 134/84 and their dose of Midodrine was administered. Review of Resident 17's January nursing progress notes failed to reveal any documentation as to why their ordered blood sugar was not completed or why the Midodrine was not held as ordered. During a staff interview with the DON, Employee 1, and Employee 2 on January 9, 2025, at approximately 10:16 AM, the DON indicated that she called the nurse who documented Resident 17's blood sugar as being 471 on December 23, 2024, and the nurse said they did not recall Resident 17's blood sugar ever being that high, that they know they would have called the physician, but that they could not clearly recall for sure. The DON indicated that she had no additional information regarding Resident 17's blood sugars not being obtained as per physician orders on the dates and times identified. The DON confirmed that Resident 17 was documented as receiving their Midodrine on January 7, 2025, when it should have been held. The DON said she would expect nursing staff to administer resident medications as ordered or to document why medications were not given as ordered and include all necessary follow-up communication with the physician. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services 396122 Page 7 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

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 review, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections, consistent with physician orders and the resident's person-centered care plan, for one of five residents reviewed for catheter care (Resident 37). Findings include: Review of facility policy, titled Catheter- Indwelling, last revised November 30, 2021, read, in part, Purpose: To maintain constant urinary drainage, facilitate bladder irrigation, and monitor renal function and contain urinary drainage in seriously ill residents while maintaining a closed system. Criteria: must be documented for strict (foley- catheter) output if ordered by the physician. Review of Resident 37's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and muscle weakness. Review of Resident 37's physician orders revealed orders for the following: Document foley output every shift, with a start date of July 5, 2023. Foley catheter care every shift per policy, with a start date of July 5, 2023. Change foley flush kit every night shift, with a start date of July 18, 2023. Review of Resident 37's care plan revealed a focus area: The resident has the potential for infection related to indwelling catheter. Diagnosis: Obstructive Uropathy with an intervention for, Empty foley catheter and document output every shift, initiated July 4, 2023; Foley catheter care every shift per facility policy, initiated July 4, 2023; and Change foley flush kit every night shift, initiated February 26, 2024. Review of Resident 37's TAR (Medication Administration Record- documentation for treatments/medication administered or monitored) from April 2024 through December 2024, revealed the order to document foley output every shift was not documented as completed 18 times during day shift and 14 times during night shift. Further review of Resident 37's TAR from April 2024 through December 2024 revealed the order for foley catheter care was not documented as completed on April 15 during night shift; May 10 during night shift; June 5 during day shift; August 23 during day shift; August 6, 14, 27, and 28 during night shift; and December 17 and 18 during night shift. Further review of Resident 37's TAR from April 2024 through December 2024 revealed the order to change the foley flush kit was not documented as completed on April 15; August 6, 14, 27, and 28; and December 17 and 18. Review of Resident 37's clinical record revealed she received antibiotic treatment for urinary 396122 Page 8 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0690 tract infections from July 15-22, 2024; and November 3-15, 2024. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on January 9, 2025, at 12:03 PM, revealed she would expect foley output, catheter care, and changing of the foley flush kit to be completed per facility process and physician order. Residents Affected - Some 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396122 Page 9 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary medications for one of one resident reviewed for antibiotic use (Resident 9). Residents Affected - Some Findings include: Review of facility policy, titled Medication Regimen Review and Reporting, with a last review date of December 31, 2024, indicated that a Medication Regimen Review (MRR) is a thorough evaluation of the drug regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication and the consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), tracheostomy (an opening or incision in the windpipe to relieve an obstruction to breathing), and dependence on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, unable to breathe on their own, or under anesthesia). Review of Resident 9's physician orders on January 7, 2025, revealed an order to apply triple antibiotic ointment to moisture associated skin damage (MASD) at tracheostomy stoma site every shift, dated September 24, 2024. Review of Resident 9's clinical record failed to reveal documentation or assessment of any identified skin damage on September 24, 2024, through January 8, 2025. Review of Resident 9's clinical record revealed that the facility's consultant pharmacist had reviewed Resident 9's medication regimen on October 15, 2024; November 12, 2024; and again between December 1-15, 2024, with no recommendations made regarding the ongoing use of the triple antibiotic ointment. During a staff interview with the Director of Nursing (DON), Employee 1, and Employee 2 on January 9, 2025, at 10:38 AM, the DON confirmed that she could not find any clinical documentation identifying that Resident 9 had any MASD at their tracheostomy site, that they should have caught the ongoing antibiotic cream order prior to yesterday, and that it should not have been utilized for this long. She further indicated that Resident 9's physician had assessed their tracheostomy site on January 8, 2025, and noted there was no skin damage noted and discontinued the antibiotic ointment. The DON also confirmed that the monthly consultant pharmacist reviews failed to identify the lack of clinical documentation to support the use of the ongoing antibiotic cream or the overall ongoing use of the antibiotic cream as a concern. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 396122 Page 10 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review and staff interviews, it was determined that the facility failed to ensure the resident was free of unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 26). Findings include: Review of Resident 26's clinical record on January 7, 2025, revealed diagnoses that included hypertension (elevated/high blood pressure) and bipolar disorder (mental health disorder that causes extreme shifts in mood from depression to manic hyperactivity). Review of Resident 26's physician orders revealed orders for clonazepam (schedule IV controlled medication in the drug class of benzodiazepine) 3 milligrams (mg - metric unit of measure) every 24 hours as needed for restlessness for 14 days, with a start date of December 30, 2024, and end date of January 13, 2024. Review of Resident 26's clinical record revealed the as needed clonazepam had been continuously reordered every 14 days over the course of the prior year and beyond. Resident 26 also had a separate, standing order for clonazepam 1 mg two times a day for anxiety disorder (mental health disorder characterized by excessive worry or fear), which was dated September 13, 2024. Review of Resident 26's physician orders revealed that Resident 26 had an order for lorazepam (schedule IV controlled medication in the drug class of benzodiazepine) 1 mg every six hours as needed for anxiety for 14 days, with a start date of December 30, 2024, and end date of January 13, 2024. Review of Resident 26's clinical record revealed the as needed lorazepam had been continuously reordered since October, 2022. Review of available documentation revealed no clinical rationale was documented as to why Resident 26 was receiving duplicative medications of the same drug class with duplicative therapeutic effect. Further, review of a pharmacy recommendation dated November 12, 2024, revealed the consultant pharmacist identified that Resident 26 was receiving Duplicate PRN [as-needed] anxiolytics [anti-anxiety medications] and recommended, Please evaluate and consider consolidating to one. To which the provider checked, Disagree - Perceived risks are outweighed by benefits. Order to remain as is. The response was dated November 19, 2024. Review of Resident 26's clinical record revealed no documented review of the risks and/or benefits of Resident 26 receiving duplicative medications of the same medication class and therapeutic effect. During a staff interview on January 9, 2025, Director of Nursing (DON) revealed the facility was unable to locate a documented rationale for the duplicative medication use at that time. Review of Resident 26's order for lorazepam 1 mg revealed it was to be provided every six hours as needed. 396122 Page 11 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Controlled Drug Record (documentation tool utilized to record the amount of medication, amount administered, and date and time the medication is administered) for Resident 26's lorazepam revealed staff documented administering one tablet of lorazepam on September 25, 2024, at 1:00 PM, then a second administration at 4:00 PM, less than six hours between administration. Review of the electronic medication administration record (MAR - document tool utilized to record when medications or treatments are administered) revealed neither administration recorded on the Controlled Drug Record was recorded in Resident 26's electronic MAR. Further review of the Controlled Drug Record revealed staff documented administering one tablet of lorazepam on October 19, 2024, at 4:30 PM, and then a second administration was documented at 8:00 PM, less than six hours in between doses. Review of the electronic MAR revealed staff did not record the 8:00 PM lorazepam administration. Finally, on October 20, 2024, staff recorded on the Controlled Drug Record administration of the lorazepam at 3:45 PM, then another administration was recorded at 8:00 PM, less than 6 hours between doses. Review of the electronic MAR revealed the 8:00 PM administration was not documented. During a staff interview on January 9, 2024, at approximately 11:30 AM, DON revealed it was the facility's expectation that staff follow the as needed time frame as prescribed by the physician when administering as needed medications. During review of the aforementioned Controlled Drug Record for Resident 26's lorazepam 1 mg tablet, the following was identified: Between the dates of September 14 and 26, 2024, 19 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of October 11 and 28, 2024, 11 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of November 13, 2024, and December 6, 2024, 16 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of December 7 and 25, 2024, 17 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of December 29, 2024, and January 8, 2025, nine tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. During the staff interview on January 9, 2025, at approximately 11:30 AM, DON revealed it was the facility's expectation that staff document on the electronic MAR when medications are administered. Review of Resident 26's clinical record revealed that between November 27, 2024, and December 1, 396122 Page 12 of 13 396122 01/09/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0758 2024, Resident 26 did not have an active order for lorazepam; however, staff administered lorazepam 1 mg tablet on the following dates and time: Level of Harm - Minimal harm or potential for actual harm November 29, 2024, at 12:00 AM Residents Affected - Some November 29, 2024, at 8:00 PM December 1, 2024, at 1:27 AM During the staff interview on January 9, 2025, at approximately 11:30 AM, DON revealed that staff should only administer medication when there is an order by a physician. 28 Pa code 211.9(d)(j.1) Pharmacy services 28 Pa code 211.12(d)(1)(3)(5) Nursing services 396122 Page 13 of 13