Health inspection·February 2, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, and staff interview, it was determined that the facility failed to act upon identified declines in bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 36). Findings include: A review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and muscle weakness. A review of Resident 36's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2023, revealed that the resident was occasionally incontinent of bladder and always continent of bowel. A review of Resident 55's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was now frequently incontinent of bladder and occasionally incontinent of bowel. There was no documented evidence at the time of the survey ending February 2, 2024, that the facility had acted upon the decline in the resident's bowel and bladder continence and developed and implemented an individualized plan to decrease episodes of incontinency and restore normal function to the extent practicable for this resident. Interview with the Nursing Home Administrator on February 2, 2024, at approximately 2:00 PM confirmed that the facility failed to address the resident's increase in incontinency with an individualized plan to improve the resident's function and prevent further decline. 28 Pa. Code 211.12 (d)(5) Nursing services Page 1 of 6 395067 395067 02/02/2024 Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued use of multiple psychoactive medications, including antipsychotic and duplicate drug therapy for anxiety disorder, prescribed for one resident out of five sampled residents (Resident 73). Findings include: A review of Resident 73's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included anxiety, dementia with behavioral disturbance, Lewy body dementia [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], osteoarthritis [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], and repeated falls. A review of the resident's clinical record physician's orders revealed the following orders: November 9, 2023, Pimavanserin Tartrate Oral Capsule 34 MG [Nuplazid is in the drug class of antipsychotics that is used to treat the symptoms of a certain mental/mood disorder (psychosis) that might occur with Parkinson's disease.] Give 1 capsule by mouth one time a day related to unspecified dementia with behavioral disturbance. November 11, 2023, Sertraline HCL (antidepressant used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to unspecified anxiety disorder. December 12, 2023, Buspirone HCL (anti-anxiety medicine) Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to anxiety disorder. December 13, 2023, Seroquel Oral (antipsychotic used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) Tablet 25 MG Give 1 tablet by mouth at bedtime related to neurocognitive disorder with Lewy bodies. December 16, 2023, Ativan (an antianxiety medication used to treat anxiety) Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to unspecified anxiety disorder and December 30, 2023, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed (PRN) for increased anxiety/agitation related to unspecified anxiety disorder. A review of the facility's consultant pharmacist's consultation report dated January 3, 2024, identified that Resident 73 had experienced multiple falls that occurred on 11/22/2023, 11/23/2023, and 12/20/2023. A comprehensive review of the medical record was conducted and identified that the following medications may contribute to falls: Two (2) antipsychotics: Nuplazid 34 mg daily and Seroquel 25 mg twice per day for Lewy Body dementia. Ativan 0.5 mg once daily and every eight (8) PRN for anxiety (PRN dose not administered prior to any fall). Sertraline 25 mg daily for anxiety, and Buspar 5 395067 Page 2 of 6 395067 02/02/2024 Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509

F 0758 mg three times per day for anxiety. Level of Harm - Minimal harm or potential for actual harm The pharmacist requested that the attending physician evaluate these medications as possibly causing or contributing to falls, deducing/discontinuing as appropriate and that if the therapy was to continue it would be recommended that the prescriber document an assessment of risk versus benefits, indicating that the medication is not believed to be contributing to falls in Resident 73; b) the facility interdisciplinary team ensures ongoing effectiveness and potential adverse consequences. Residents Affected - Some A review of the attending physician's progress notes dated January 6, 2024, noted that Resident 73 was receiving Sertraline (Zoloft) and buspirone (Buspar) and Seroquel for the resident's mood. There was no documented evidence that attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder. A review of the physician's response dated January 16, 2024, revealed that a physician extender, a certified registered nurse practitioner, and the resident's attending physician) addressed the pharmacist's recommendations and decreased the resident's dose of the antipsychotic drug Seroquel dose to 25 mg at bedtime and increased the resident's antidepressant Zoloft to 50 mg oral daily. Through survey ending February 2, 2024, there was no documented evidence provided that the resident's attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder and that the physcian had thoroughly evaluated the combination of these medications and their potential side effects that may be negatively affecting the resident. Interview with the Director of Nursing (DON) on February 2, 2024, at 10:24 AM, confirmed that Resident 73's attending physician failed to document an evaluation of potential adverse consequences, including an assessment of the resident's condition and documented the clinical necessity of each psychoactive drug, including antipsychotics and duplicate drug therapy for anxiety disorder, in maintaining or improving the resident's function and abilities. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.2 (d)(3) Medical Director. 28 Pa. Code 211.5(f) Medical records. 395067 Page 3 of 6 395067 02/02/2024 Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policy and incident reports, and staff interviews it was revealed that the facility failed to assure that one of 18 residents reviewed was free of a significant medication error (Resident 81), which compromised the resident's clinical condition and required corrective treatment to reverse the effects of the error. Residents Affected - Few Findings include: A review of the facility's current pharmacy policy and procedures last reviewed January 2024, revealed that facility staff should only prepare medications for one resident at a time. Staff should verify each time a medication is administered that it is the correct medication at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. A review of the clinical record revealed that Resident 81 was admitted to the facility on [DATE], with diagnosis to include rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in the blood) and acute kidney failure. A review of an admission MDS assessment dated [DATE], (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed that the resident was moderately cognitively impaired. A facility incident report dated January 10, 2024, at 8 AM , revealed that Employee 1 (LPN) erroneously administered the following medications to Resident 81, which were prescribed for Resident 10: Cymbalta 30mg two tablets (antidepressant medication) Iron 325 mg one tablet (mineral supplement) Metoprolol Succinate ER 25 mg half tablet hold for systolic blood pressure is less then 100 or heart rate less than 60 (blood pressure medication) Procardia XL 30 mg one tablet (blood pressure medication) Senna-S 8.6 mg one tablet (stool softener) Ativan 0.5mg one tablet (anti-anxiety medication that can cause drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision) Buspirone HCL 7.5 mg one tablet hold if lethargic (anti-anxiety medication) Memantine HCL 5mg one tablet (dementia medication) Oxycodone HCL 5 mg one tablet (opioid narcotic pain medication that can cause confusion, shallow breathing, and slowed heart rate) Seroquel 75 mg one tablet (anti-psychotic medication which can cause drowsiness, dizziness, and lightheadedness) 395067 Page 4 of 6 395067 02/02/2024 Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509

F 0760 These medications were not prescribed for Resident 81 during the resident's stay, to date, at the facility. Level of Harm - Actual harm A review of a nursing note dated January 10, 2024, at 9:07 AM revealed that Resident 81 was lethargic, sleepy, and only arousable with tactile stimuli (physical touch e.g., sternal rub { firm rub on someone's sternum is a method used when testing an unconscious person's responsiveness}). The resident's blood pressure was 65/36 mm/Hg (a blood pressure of 65/36 is considered a dangerously low blood pressure that can reduce the blood flow to the brain and other organs in the body). The Certified Registered Nurse Practitioner was notified at that time and new orders were obtained. Residents Affected - Few A review of the resident's blood pressures after the medication error on January 10, 2024 were as follows: 9:05 AM - 65/36 mm/Hg 9:22 AM - 70/42 mm/Hg 9:45 AM - 80/46 mm/Hg 9:55 AM - 84/60 mm/Hg 10:00 AM - 80/64 mm/Hg 10:10 AM - 92/40 mm/Hg A review of the Resident 81's January 2024 Medication Administration Report (MAR) revealed that on January 10, 2024, the resident required, and was administered Narcan 0.4 mg/ML (an emergency medication used to treat an opioid overdose) intravenously (through the veins) one time for sedation and Sodium Chloride 0.9% 100 ml intravenously every hour for 2 hours then 60 ml every hour. The facility's investigation report indicated at 8:00 AM on January 10, 2024 Employee 1 entered Resident 81's room to obtain vital signs then exited the room to obtain the resident's medications. While Employee 1 was preparing the resident's medications, other staff entered the room to get Resident 81 out of bed to take her to the dining room. Once Employee 1 had prepared all the medications, she decided not to administer the medications to Resident 81 until the staff were finished getting the resident up out of bed. Employee 1 placed Resident 81's medications off to the side of the med cart to later administration. Employee 1 prepared Resident 10's medications. Once Resident 10's medications were prepared, Employee 1 placed the cup of medications intended for Resident 10 to the side. At approximately 8:10 AM staff brought Resident 81 out of her room. Employee 1 stopped the resident in the hall and grabbed Resident 10's medications and administered Resident 10's medications to Resident 81. Employee 1 realized the error and notified Employee 2, RN (registered nurse) Supervisor. Instead of awaiting further instruction or notifying the physician, Employee 1 then administered Resident 81's prescribed Lasix 40 mg tablet and Potassium 2 0 meq tablet to Resident 81 without identifying if any of these medications may interact with the other medications Employee 1 had erroneously administered to the resident. At approximately 8:30 AM Employee 2 went to the dining room to assess Resident 81 but was met in the hallway by staff, returning Resident 81 to the unit due to a sudden change in 395067 Page 5 of 6 395067 02/02/2024 Green Ridge Care Center 2741 Boulevard Avenue Scranton, PA 18509

F 0760 condition. Level of Harm - Actual harm A review of a witness statement from Employee 1 dated the following day, January 11, 2024, revealed that this nurse stated that other staff came into Resident 81's room to provide care to the resident while she was preparing the resident's medications. The employee stated she labeled the medication cup with the resident's pre poured medications and began preparing Resident 10's medications. Employee 1 indicated that staff brought the resident out of her room to go to the dining room. Employee 1 stated that she stopped the resident grabbed the wrong medication cup, that was poured for Resident 10 and administered the wrong medications to Resident 81. Employee 1 indicated that when the nursing supervisor went to assess the resident, he was met in the hall with by staff returning the resident to her room. Employee 1 stated that Resident 81 at that time was extremely lethargic (sluggish, extremely fatigued, lack of energy). Residents Affected - Few An interview with the Nursing Home Administrator and Director of Nursing on February 2, 2024 at approximately 2:00 PM confirmed that Employee 1 administered the incorrect medications to Resident 81 on January 10, 2024, failing to ensure the resident was free from significant medication errors. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services. 395067 Page 6 of 6