Health inspection·December 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on a review of grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two of the 13 residents sampled (Residents 15 and 16) and four of the six residents interviewed during a resident group interview (Residents 2, 36, 45, and 206). Findings include: A review of grievances filed with the facility revealed a grievance dated October 19, 2023, lodged by a resident indicating that the resident rang her call bell prior to receiving lunch. A review of facility lunch times revealed that the latest lunch delivery time was scheduled for 12:00 PM. The grievance did not indicate what time the resident's lunch was delivered on this date, but noted that staff delivered lunch, encouraged the resident to eat, and then turned off the resident's call bell without addressing the needs. The resident indicated that she rang the call bell again; staff responded, and informed the resident that they would be back in 10 minutes to address her care needs. The grievance indicated that at 1:00 PM, the resident notified the social services department that she was still waiting for assistance from staff. A grievance was filed by a family member on behalf of a resident on October 23, 2023, indicating that her family member's call bell wasn't being answered in a timely manner. During an interview on December 12, 2023, at 9:40 AM, Resident 15 stated that it sometimes takes an hour for staff to respond to her call bell when she needs care. The resident explained that long wait times for care are especially a problem during the dayshift. Resident 15 indicated that she understands that the facility is understaffed and doesn't like to complain but the long waits negatively affect her quality of life in the facility. During an interview on December 12, 2023, at 9:55 AM, Resident 16 stated that it takes too long to get help when she rings her call bell for assistance. She explained that the wait times for staff to provide care are the longest in the afternoon before the residents eat. Resident 16 indicated that after she rings her call bell, staff come into her room, turn off her call bell light, and eventually come back, but it can take an hour before she is provided the care needed. During a resident group interview on December 13, 2023, at 10:30 a.m., four residents in attendance stated that they have concerns about the untimeliness of staff's response to residents' calls for assistance (Residents 2, 36, 45, and 206). Page 1 of 22 395092 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the resident group interview on December 13, 2023, at 10:30 AM, Resident 2 stated that it can take an hour or two hours for staff to respond to her call bell and provide assistance. Resident 2 explained that it is a problem because there are not enough nurse aides to provide timely resident care. During the resident group interview on December 13, 2023, at 10:30 AM, Resident 36 stated that staff do not respond quickly when she rings her call bell for assistance. Resident 36 explained that when certain nursing staff are working, it can take an hour before she is provided care when requested. During the resident group interview on December 13, 2023, at 10:30 AM, Resident 45 stated that nursing staff are busy during the morning and night shifts. She explained that the facility only has a few nurse aides to assist the residents, and it takes 20 to 30 minutes for staff to provide her care after she rings her call bell. During the resident group interview on December 13, 2023, at 10:30 AM, Resident 206 stated that she expects to wait at least an hour for staff assistance if she rings her call bell during lunch time. Resident 206 explained that the wait times for staff are the longest on the weekends. She stated that she needs assistance to use the bathroom, and when staff do not respond timely, she becomes incontinent. During an interview on December 14, 2023, at approximately 10:00 AM, the Nursing Home Administrator (NHA) and Regional Nurse Consultant (RNC) verified that all residents at the facility should be treated with dignity and respect for their personal needs. The NHA and RNC were unable to explain why residents are reporting untimely staff responses to residents' calls for assistance, which is negatively affecting their quality of life in the facility. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 201.18 (e)(1) Management 395092 Page 2 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure a resident's right to be fully informed of and participate in his or her treatment for one out of the 13 residents sampled (Resident 39). Residents Affected - Few Findings include: Clinical record review revealed Resident 39 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of lung and brain (cancer or abnormal cells that divide uncontrollably leading to tumors in the brain and lungs) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 7, 2023, revealed that Resident 39 has severe cognitive impairment with a BIMS score of 4 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates cognition is severely impaired). A clinical record review revealed an Alleged Incapacitated Person Final Decree dated September 15, 2022, indicating that Resident 39 was adjudicated incapacitated and that Resident 39's guardian shall have the authority to authorize and consent to medical treatment and surgical procedures necessary for Resident 39's well-being. A physician order order was noted to consult with hospice dated December 7, 2023 A physician order initiated on December 7, 2023, to receive ceftriaxone sodium injection solution reconstituted 1 GM (antibiotic medication) with instructions to inject 1 gram intramuscularly every 24 hours for pneumonia for 5 days Documentation from the hospice provider, Form HOSP 3-004 Patient/Family Informed Consent, was signed on December 7, 2023 by Resident 39's guardian and noted that Patient and Family Role with Hospice: I understand that I may participate in making decisions regarding the type and frequency of services provided and included in the hospice plan of care. I further understand that the hospice team is not intended to take the place of the family but rather to support the primary caregiver and family in caring for the patient. I have also been encouraged to participate with the interdisciplinary team in the development and ongoing review of my hospice plan of care. On December 8, 2023, Resident 39's guardian elected to initiate Medicare hospice benefits through the hospice provider while the resident remained at the facility. Nursing noted on December 10, 2023, at 1:14 PM that hospice nurse states that the resident is actively dying, and this (ceftriaxone sodium injection) is providing no comfort. Physician aware of the same. Physician orders were noted to admit Resident 39 to hospice care on December 11, 2023. 395092 Page 3 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further clinical record review failed to find evidence, at the time of the survey ending December 14, 2023, that Resident 39's legal guardian was afforded the opportunity to participate in the treatment decision regarding the discontinuation of the ceftriaxone sodium injection prior to the discontinuation of the antibiotic medication. A medication administration record for December 2023 indicated that Resident 39 did not receive ceftriaxone sodium injection solution reconstituted 1 GM on December 10, 2023. During an interview on December 14, 2023, at approximately 10:00 AM, the Regional Nurse Consultant and Nursing Home Administrator (NHA) were unable to provide evidence that Resident 39's legal representative was afforded the right to participate in the healthcare decision regarding discontinuation of the antibiotic. 28 Pa. Code 201.29 (a)(b) Resident rights. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395092 Page 4 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interview, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for one of three closed resident records reviewed (Resident 51). Residents Affected - Few Findings Include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that discharge assessments-return anticipated (non-comprehensive) be completed no longer than the resident's discharge date + 14 calendar days. A clinical record review revealed that Resident 51 was transferred to the hospital on September 28, 2023. A progress note dated October 4, 2023, revealed that Resident 51 was not returning to the facility. An MDS discharge assessment-return anticipated (non-comprehensive) was not completed for Resident 51 until on November 22, 2023, (41 days overdue). During an interview on December 14, 2023, at approximately 10:30 AM, the Regional Nurse Consultant confirmed that Resident 51's discharge return anticipated MDS assessment was not submitted within the required timeframes. 28 Pa. Code 211.12 (d)(5) Nursing Services 395092 Page 5 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 16 sampled (Resident 20 and 52). Residents Affected - Few Findings include: Resident 20's annual MDS assessment dated [DATE], indicated in Section O - Special Treatments, Procedures, and Programs (K1. Hospice care) that the resident received hospice care while a resident at the facility and within the last 14 days. However, a clinical record review failed to reveal evidence that Resident 20 had received hospice care. Resident 52's Discharge MDS assessment-return not anticipated, dated October 15, 2023, indicated in Section A2105. Discharge Status that the resident was discharged to a short-term general hospital (acute hospital). However, clinical record review revealed a progress note dated October 13, 2023, at 8:08 PM, which indicated that Resident 52 was discharged home with family as planned. A progress note dated October 15, 2023, at 12:34 PM indicated that Resident 52's discharge paperwork was signed and that the resident was transferred to a car by a family member. During an interview on October 14, 2023, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Regional Nurse Consultant (RNC) confirmed that Section O (K1. Hospice care) in Resident 20's annual comprehensive MDS assessment dated [DATE] was inaccurate and Section A2105. Discharge Status in Resident 52's discharge - return not anticipated MDS were inaccurate. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 395092 Page 6 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls and known unsafe behaviors that increased the resident's risk for falls, to prevent a fall with serious injuries, facial and foot fractures, to one resident out of 13 sampled (Resident 46). Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses of dementia, protein anxiety and a history of repeated falls. A Quarterly Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 2, 2023, revealed that the resident was moderately cognitively impaired with a BIMS score of 6 and required extensive staff assistance with activities of daily living. The resident's care plan initially dated June 8, 2023, indicated that the resident was at risk for falls related to impaired decision making and impulsive movements, with initial planned interventions for the use of bed and chair alarms, bed bolsters, maintain needed items within reach, monitor for changes in mobility, take resident for short walks throughout the day, diversional activity items, camera in room for monitoring, and maintain call light within reach, and educate resident to use call light. A review of a facility investigation report dated June 22, 2023, at 3:05 AM, revealed that a nurse aide found the resident sitting on the floor of the resident's room at the end of his bed. The resident's bed alarm was on the bed but not sounding. No injury was sustained, and the resident was unable to state what had happened. Interventions implemented as the result of this fall included replacement of the bed alarm, bed bolsters applied to mattress, and a camera was placed in the resident's room for staff observation, as previously care planned on June 8, 2023. A review of a facility investigation report dated July 20, 2023, at 10 PM. revealed that the resident stood up from the chair and proceeded to walk. When the nurse aide heard the resident's chair alarm and went to help him back into the chair, the resident pushed staff away and fell to the floor. Interventions implemented in response to this fall were for staff to take resident for short walks as previously care planned on June 8, 2023. A review of a facility investigation report dated July 21, 2023, at 3 AM, revealed that Resident 46 was found on the floor in his room next to the foot of the bed lying on his left side in front of a puddle of urine. A large hematoma to the left side of his forehead was observed. The resident was unable to state what he was attempting to do. Bolsters were on the resident's bed and staff last checked the resident, a half hour prior, at 2:30 AM. The resident was sent to the emergency room for further evaluation. No injuries/concerns were identified during emergency room evaluation. Interventions implemented upon the resident's return to the facility was for toileting to be offered every hour while awake, a bedside commode to serve as a visual cue to use for meeting toileting needs and a new bed alarm was applied. 395092 Page 7 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0689 Level of Harm - Actual harm Review of an employee witness statement dated July 21, 2023, indicated that a nurse aide heard a loud noise down the East hall while she was at the nurse's station completing computer work. The witness (nurse aide) found Resident 46 on the floor in his room, the (bed) alarm was not ringing, and he had nothing on. Residents Affected - Few A review of a facility investigation report dated July 23, 2023, at 7:20 AM, revealed that another resident notified facility staff that Resident 46 was on the floor in the resident's room. Staff found Resident 46 on the floor next to the bed in his neighbor's room. No apparent injuries were identified. The resident's bed alarm was in place but did not sound. According to the facility's investigation, the bed alarm did not sound off, and the bolsters were on the resident's bed, but (the resident) was able to get around them/ Camera/ child monitor was monitored for safety; however, {the resident's}activity was not monitored when staff was completing assignments. Intervention implemented included placement of a sensor alarm (to the resident's bed). A review of a facility investigation report dated October 3, 2023, at 12:35 AM, revealed that facility staff witnessed Resident 46 walking down the hall, lose his footing, stumble, lose his balance and fall backward onto his bottom. According to investigation, the resident's nonskid socks were turned slightly, preventing the grips from functioning as intended. There was no documented evidence of the development and implementation of measures to prevent future similar falls while ambulating, including assuring the correct placement of the resident's non-skid socks or appropriate non-skid footwear or providing assistance with ambulation as required. Review of facility investigation report dated October 16, 2023, at 7:20 PM, revealed that Resident 46 attempted to sit in a wheelchair located in the hallway, but the wheels of the chair were not locked. The wheelchair rolled enough for the resident to fall, to a seated position on the floor between the leg rests of the wheelchair. No injuries were identified. The resident had been walking independently while being visualized by staff at the time of the fall, despite the resident's fall while independently ambulating that occurred on October 3, 2023. Interventions implemented as a result of this fall were to educate staff that vacant wheelchairs are to have the wheels locked. Review of a facility investigation report dated October 24, 2023, at 1:40 AM revealed that Resident 46 was found in the club room laying on his left side, still in a seated position, with the chair (he had been seated in) also laying on its side on the floor. The resident sustained a bloody nose, swelling to the left side of his forehead, his left eye, and left hand/wrist/fingers. The resident was sent to the emergency room for an evaluation. The findings of CT scan (diagnostic imaging studies) performed in the emergency room revealed a nondisplaced left orbital roof fracture (bones in the eye socket) extending into the anterior and middle cranial fossae and left frontal sinus, barely perceptible left frontal and subdural hematomas, large left periorbital and temporal scalp hematoma, and complex hemorrhagic collections in the left frontal ethmoid maxillary and sphenoid sinuses. Probable nondisplaced medial orbital and orbital floor fractures. Upon the resident's return to the facility on October 24, 2023, a follow-up CT scan was scheduled, along with an eye consultation. Interventions implemented to prevent additional falls as a result of the resident's fall on October 24, 2023, were completion of a therapy screen, a wheelchair alarm, and placing the resident on every 15 minute checks for monitoring of the resident. 395092 Page 8 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0689 Level of Harm - Actual harm The resident's care planned interventions proved ineffective in preventing multiple falls, including alarms and in-room camera monitoring. However, the facility did not develop and implement measures to increase staff supervision and staff monitoring of the resident and the resident's activities out of the resident's room, until after the resident's fall with facial injuries on October 24, 2023. Residents Affected - Few Review of facility investigation report dated November 6, 2023, at 6 PM, revealed that the resident was found laying on the floor, flat on his back in the west hallway, near the medication room. According to the investigation, the resident stated that he didn't fall, I just laid down. Staff assisted the resident to a sitting, then to a standing position, incontinence care was provided. Staff last saw the resident in the main lobby, sitting on couch at approximately 5:45 PM. Prior to that observation, at approximately 5:30 PM, staff observed the resident urinating in the hallway and refused to have his clothes changed. Review of a facility investigation report dated November 8, 2023, at 5:35 AM, revealed that the resident was found on the floor in the nurse's station. There was no documented evidence that staff were present in the nurse's station supervising the resident at the time of the resident's fall as it was noted that staff found the resident on the floor. According to the report, attempts were made throughout the night to place the resident in bed, but were unsuccessful and the resident was resistive/combative with care. According to the investigation dated November 8, 2023, Resident 46 had complained of left leg pain on November 7, 2023, after the unwitnessed incident on November 6, 2023. The physician ordered an x-ray of the left knee, fib/tib, ankle and foot. X-ray results noted a fracture involving the first MTP joint, (joint connects one of your toes (a phalangeal bone or a phalanx) to a long bone in your foot (a metatarsal bone), also noting that the resident had osteoporotic bones. The identified follow-up action included monitoring the resident for pain and medicated as needed and offered rest periods, but did not specifically address the resident's need for increased and direct supervision, and the frequency of the supervision the resident required to prevent repeated falls and injuries. During an interview December 7, 2023 at 1 P.M., the Nursing Home Administrator confirmed that the facility failed to demonstrate that staff consistently provided necessary staff supervision, at the level and frequency required, of resident with increased unsafe behaviors known to staff, and multiple falls, to prevent repeated falls with serious injuries. 28 Pa. Code 211.12 (d)(5) Nursing services 395092 Page 9 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, employee personnel files and facility investigative reports and staff interview, it was determined that the facility failed to provide nursing staff with the necessary skills and competencies to accurately and safely perform medication administration to five residents out of 12 sampled (Residents 11, CR1, 32, 103 and 153) out of 12 sampled. Findings include: A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnosis to include, dementia, muscle weakness and unsteadiness on her feet. 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 Resident 11 was severely cognitively impaired with a BIMS (Brief Interview for Mental Status, is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 7 ( a score of 0 to 7 indicated severe cognitive impairment) and required staff assistance with activities of daily living. A review of a facility medication error investigation report dated November 1, 2023 at 8 A.M., Employee 1 (LPN) erroneously administered the follow medications, prescribed for Resident CR1's to Resident 11: -Apixaban oral tablet 2.5 mg (an anticoagulant medication) for atrial fibrillation -Metoprolol Tartrate oral tablet 25 mg (a medication to treat high blood pressure) -Toresmide oral tablet 40 mg, give 40 MG ( a medication to lower high blood pressure) -Glimepiride oral tablet 1 mg, (a diabetic medication used to lower blood sugar levels) -Synthroid oral tablet 100 MCG ( a medication to treat hypothyroid disease) -Allopurinol 100 mg (a medication for gout) -Calcium 600 mg ( a dietary supplement) -Cholecalciferol 1000 U ( a supplement for Vitamin D deficiency) -Loratadine 10 mg ( for seasonal allergy's) -Multi vitamin The investigation report indicated that Employee 1, LPN should have administered the above scheduled medications as prescribed for Resident CR1 on November 1, 2023 at 7:30 AM, Clinical record revealed that Resident CR1 was admitted to the facility on [DATE] with diagnosis to 395092 Page 10 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0726 include, Hypothroidism, hypertension and diabetes. Level of Harm - Minimal harm or potential for actual harm Resident CR1 had physicians order dated October 22, 2023 for following medications: -Apixaban oral tablet 2.5 mg by mouth two times a day Residents Affected - Some -Toresmide oral tablet 40 mg by mouth in the morning Physicians orders dated October October 20, 2023 revealed; -Synthroid oral tablet 100 MCG by mouth in the morning -Metoprolol Tartrate oral tablet 25 mg by mouth two times a day Physicians orders dated October 21, 2023: -Glimepiride oral tablet 1 mg by mouth daily -Allopurinol 100 mg (a medication for gout) -Calcium 600 mg ( a dietary supplement) -Cholecalciferol 1000 U ( a supplement for Vitamin D deficiency) -Loratadine 10 mg ( for seasonal allergy's) -Multi vitamin At the time of the survey ending December 14, 2023, there was no documented evidence that the facility had evaluated Employee 1's medication administration skills and competencies, or provided re-education to the employee, following the above medication error that occurred on November 1, 2023. A review of a facility medication administration error investigation dated November 16, 2023 revealed that Resident' 32's visitor reported to facility nursing staff that medications were left in the resident's room, which was shared with Resident 11. The visitor inquired if Resident 32 needed to take the medications. Employee 1 (LPN) then informed the visitor that the medications were not for Resident 32. The report noted that Employee 1 (LPN) had recently committed a medication error in the facility (November 1, 2023). A witness statement dated November 23, 2023, from Employee 1 (LPN) revealed that the employee stated I pulled {Resident 11}'s Keflex (antibiotic ) medication, (which was placed in a plastic medication cup) and {Resident 32}'s carpilevadopa ( antiparkinsons medication, also placed in a plastic medication cup) and placed {Resident 11's} medication cup on {Resident 32's} dresser and gave Resident 32 her pill. {Resident 32's} grandaughter picked up {Resident 11's} medication cup off the dresser and said, I can give this to her (Resident 32) if you want, and I (Employee 1 LPN) said, 'No', its for someone else. 395092 Page 11 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The error resolution was noted as, No meds should be left at the bedside of any resident, only(one) residents meds are taken into the residents room (and administered to the resident). This creates a significant safety concern. A review of a facility employee corrective action form dated November 16, 2023 revealed that the facility gave Employee 1 a verbal warning for the infraction. A review of a medication error report dated November 24, 2023 at 9:09 A.M. revealed, Employee 1 (LPN) was passing medications in the east hall. According to the report Employee 1 removed Lovenox ( a blood thinning medication) injectable medication from the medication cart that was to be given to Resident 153 and administered the injectable medication to Resident 103. The physician was notified and new order noted to hold Resident 103's oral blood thinning medication (Xeralto) for that day. Clinical record review revealed that Resident 103 was admitted to the facility on [DATE], with diagnoses to include, atrial fibrillation. A physician orders dated November 22, 2023, was noted for Xarelto 20 mg, give one tablet in the evening. Resident 153 was admitted to the facility on [DATE], with diagnosis to include, personal history of other venous thrombosis and embolism. The resident had a physician order received November 23, 2023, for Enoxaparin (Lovenox) 40 mg/0.4 ml single use syringe, SQ daily for 5 days. A review of a facility employee corrective action form dated November 28, 2023, revealed that Employee 1 (LPN) was given a final written warning. The document stated that Employee 1 refused to sign the form. There was no evidence that any re education or medication administration competencies were completed with Employee 1 as a result of the medication error. A review of Employee 1's personnel file revealed that she was hired at the facility on September 10, 2022. A review of a yearly medication administration competency dated April 5, 2023, revealed the employee was noted as competent in med administration at that time. During an interview December 13, 2023 at 1 P.M., the Corporate Nurse Consultant confirmed that Employee 1 (LPN) failed to demonstrate competency in medication administration as evidenced by the multiple medication errors in November 2023. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.9 (a)(1)(b)(d)(k) Pharmacy services 395092 Page 12 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to routine drugs and pharmaceuticals to ensure timely medication administration as prescribed for seven residents out of 13 sampled (Residents 20, 31, 39, 103, 153, 203, and 205). Findings include: A clinical record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses to include metachromatic leukodystrophy (a genetic disorder that leads to nervous system impairment), depression, and bipolar disorder. A clinical record review revealed Resident 20 had physician orders for Trazodone Hcl 50 MG (an antidepressant medication) by mouth in the evening for insomnia dated September 21, 2022. A review of Resident 20's May 2023 Medication Administration Record (MAR) dated revealed that staff did not administer Trazodone HCL 50 MG as ordered on May 31, 2023. The MAR noted to see nursing progress note on May 31, 2023, which indicated that the facility as awaiting delivery of Trazodone Hcl tablet 50 MG from pharmacy. A clinical record review revealed Resident 205 was admitted to the facility on [DATE], with diagnoses to include end stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) and gastro-esophageal reflux disease (GERD-a condition where stomach contents are regurgitated into the esophagus). Resident 205 had physician orders for Pantoprazole Sodium Oral Packet 40 MG 40 mg by mouth one time a day for GERD dated December 2, 2023. A review of Resident 205's December 2023 MAR revealed that staff did not administer Pantoprazole Sodium oral packet 40 mg on December 3, December 4, and December 7, 2023 as ordered. The December 2023 MAR noted to see nursing progress notes on December 3, December 4, and December 7, 2023, for the administration of Pantoprazole Sodium Oral Packet 40 MG. A nursing progress note dated December 4, 2023, at 7:50 AM, noted that pharmacy did not send medication (Pantoprazole Sodium Oral Packet 40 MG). Medication (is) not available in (the) e-box. (The) physician made aware. There were no nursing progress notes dated December 3, 2023, and December 7, 2023, addressing the failure to administer Pantoprazole Sodium Oral Packet 40 MG as ordered. Resident 39 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of lung and brain (cancer or abnormal cells that divide uncontrollably leading to tumors in the brain and lungs) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). The resident had a physician order for Ceftriaxone Sodium Injection Solution Reconstituted 1 GM (an antibiotic medication), inject 1 gram intramuscularly every 24 hours for pneumonia for five days, dated December 6, 2023. A review of Resident 39's December 2023 MAR indicated that staff did not administer ceftriaxone sodium injection solution reconstituted 1 GM on December 6, 2023. The MAR indicated to see nursing progress note dated December 6, 2023, which indicated that (Ceftriaxone Sodium Injection Solution 395092 Page 13 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0755 Reconstituted 1 GM) held. New order, waiting for delivery. Level of Harm - Minimal harm or potential for actual harm A clinical record review revealed Resident 203 was admitted to the facility on [DATE], at approximately 2:45 PM with diagnoses to include metabolic encephalopathy (a brain condition that impairs cognitive functioning) and asthma (a condition in which the airways to the lungs become inflamed or narrow making it difficult to breathe). Residents Affected - Some A review of the facility's pharmacy delivery times revealed that the pharmacy scheduled delivery times were Monday through Friday between the hours of 3:30 pm to 6:30 pm and between the hours of 10:00 pm 1:00 am and Saturday between the hours of 8 PM to 11 PM Saturday 8:00 pm - 11:00 pm. The facility's scheduled medication administration times during the 2 PM to 10 PM shift, during which Resident 203 was admitted , were noted as 2:30 PM, 5 PM, 7 PM, 8 PM and 9 PM. Resident 203 had physician orders for Ipratropium Bromide Solution 0.03% (bronchodilator-medication that is breathed in through the mouth to open up the airways to the lungs) spray in both nostrils two times a day for asthma, dated December 11, 2023. Resident 203's December 2023 MAR indicated that Ipratropium Bromide Solution 0.03% was not administered to the resident on December 11, 2023, or December 12, 2023. The MAR noted to see nursing progress dated December 11, 2023, and December 12, 2023, for the administration of Ipratropium Bromide Solution 0.03%, which noted that on December 11, 2023, and December 12, 2023, the facility was awaiting pharmacy delivery of Ipratropium Bromide Solution 0.03%. Resident 203 also had physician orders for Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour (an anticholinergic muscle relaxant medication used to help increase the volume of urine a bladder can hold) 10 mg by mouth in the evening for urinary antispasmodic, dated December 11, 2023. The resident's December 2023 MAR revealed that Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour was not administered on the evening of December 11, 2023. According to the MAR and nursing progress notes dated December 11, 2023, at 5:42 PM the medication was not given as the facility was awaiting pharmacy delivery. Resident 203 had a physician order for Montelukast Sodium Oral Tablet (a medication that prevents and treats the symptoms of asthma and allergies) 10 MG by mouth in the evening for asthma, dated December 11, 2023, which was not administered on the evening of December 11, 2023, as the facility was awaiting pharmacy delivery, according to the resident's December 2023 MAR and nursing progress notes dated December 11, 2023. Clinical record review revealed that Resident 153 was admitted to the facility on [DATE], with diagnosis of history of venous thrombosis and embolism and physicians orders received November 23, 2023, for Enoxaparin (Lovenox) 40 mg/0.4 ml single use syringe, SQ daily for 5 days. A review of the resident's November 2023 MAR indicated that the Lovenox SQ was unavailable on November 23, 2023, and administered to the resident November 24, 2023, through November 27, 2023, for a total of 4 doses of the medication and not the five doses of the injectable medication as ordered. 395092 Page 14 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview December 14, 2023 at 1 PM, the Director of Nursing confirmed that Resident 153 did not receive all five does of injectable Lovenox as prescribed. Clinical record review revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses to include neuropathy (nerve pain). The resident had a physician order dated August 23, 2023 for Gabapentin (Neurontin, a seizure medication sometimes used for nerve pain) 100 mg cap, one three times a day for neuropathy. A review of the resident's November MAR revealed that the resident did not receive Gabapentin as ordered on November 25, 2023 the 6:30 AM, 11 AM. and the 5 PM. because the medication was not available in the facility for administration to the resident as ordered. A review of nurses notes dated November November 25,2023 at 06:29 A.M. revealed electronic Mar Orders Administration Note Gabapentin Oral Tablet, Medication unavailable. A nurses note dated November 25,2023 19:25 eMar - electronic Administration MAR Note Gabapentin Oral Tablet noted call placed to pharmacy, not available at this time. Physician made aware, verbal to hold order times dose. The November 2023 MAR indicated that on November 25, 2023, no doses of Gabapentin 100 mg were available at the facility for administration to the resident. During an interview on December 13, 2023 at 1 PM, the corporate nurse consultant was unable to state why there was no Gabapentin 100 mg available for administration to Resident 31 on November 25, 2023, or confirm that the resident's medication was refilled timely to assure availability for administration as prescribed. During an interview on December 14, 2023, at approximately 10:00 AM the Corporate Nurse Consultant and Nursing Home Administrator (NHA) were unable to provide evidence that the facility administered medication in accordance with physician orders for above residents. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 395092 Page 15 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, select facility policy and medication error reports and staff interview it was revealed that the facility failed to assure that two of seven residents reviewed were free of significant medication errors (Resident 11 and 103). Residents Affected - Few Findings include: A review of a current facility pharmacy policy, dated as reviewed June 20, 2023 revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Prior to administration, staff are to review and confirm medications for each individual resident on the medication administration record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label Medications are administered according to written orders by the physician. A review of the clinical record revealed that Resident 11 was admitted to the facility on [DATE], with diagnosis to include, dementia, muscle weakness and unsteadiness on her feet. 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 Resident 11 was severely cognitively impaired with a BIMS (Brief Interview for Mental Status, is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 7 ( a score of 0 to 7 indicated severe cognitive impairment) and required staff assistance for activities of daily living. A review of a facility medication error investigation report dated November 1, 2023 at 8 AM Employee 1 (LPN) erroneously administered the following medications to Resident 11, which were prescribed for Resident CR1: -Apixaban oral tablet 2.5 mg (an anticoagulant medication) for atrial fibrillation -Metoprolol Tartrate oral tablet 25 mg (a medication to treat high blood pressure) -Toresmide oral tablet 40 mg, give 40 MG ( a medication to lower high blood pressure) -Glimepiride oral tablet 1 mg, (a diabetic medication used to lower blood sugar levels) -Synthroid oral tablet 100 MCG ( a medication to treat hypothyroid disease) The investigation report indicated that the above noted medications were to be administered on November 1, 2023 at 7:30 A.M. to Resident CR1. Clinical record revealed that Resident CR1 was admitted to the facility on [DATE] with diagnosis to include, Hypothroidism, hypertension and diabetes. 395092 Page 16 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0760 A review of Physicians orders dated October 22, 2023 revealed the following medications orders: Level of Harm - Minimal harm or potential for actual harm -Apixaban oral tablet 2.5 mg by mouth two times a day -Toresmide oral tablet 40 mg by mouth in the morning Residents Affected - Few Physicians orders dated October October 20, 2023 revealed; -Synthroid oral tablet 100 MCG by mouth in the morning -Metoprolol Tartrate oral tablet 25 mg by mouth two times a day Physicians orders dated October 21, 2023: -Glimepiride oral tablet 1 mg by mouth daily A review of nurses notes dated November 1, 2023 at 9:26 AM revealed that the nursing staff member (Employee 1 LPN) was passing medications in the south hall. Her medication cart was located outside of resident room S1 while she was dispensing medications for room S2-1. She stated that the prescriptions (packaged in blister packs with instructions and prescription on the label) cards were in the wrong room slot. Employee 1 (LPN) then went into room S-1 to help a nurse aide boost the resident in bed and picked up the medication that was dispensed for S2-1 (Resident CR1) and administered them to the resident in S-1 (Resident 11). The physician was notified and new orders noted to push fluids. RN was in to assess the resident. The physician directed staff that the resident's blood pressure and heart rate were to be taken every 30 minutes and staff to complete alert charting to monitor her blood pressure, heart rate and mentation. The resident was placed in Trendelenberg's position (In the Trendelenberg position, the body is lain supine, or flat on the back on a 15-30 degree incline with the feet elevated above the head. The reverse Trendelenberg position). A review of Resident 11's blood pressure readings post medication administration were noted as follows: November 1, 2023 at 9:15 A.M. 82/32 mmHg November 1, 2023 at 9:30 A.M. 77/29 mmHg November 1, 2023 at 10 A.M. 90/59 mmHg November 1, 2023 at 2 P.M. 90/51 mmHg November 1, 2023 at 3 P.M. 90/41 mmHg November 1, 2023 at 4:10 P.M. 90/56 mmHg November 1, 2023 at 7 P.M. 147/93 mmHg The last recorded blood pressure prior to the medication error was documented as October 26, 2023 at 9:41 PM 118 /66 mmHg. 395092 Page 17 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A medication error report dated November 24, 2023 at 9 AM revealed that Employee 1 (LPN) was passing medication in the east hall. Employee 1 pulled Lovenox (Lovenox is an anticoagulant that helps prevent the formation of blood clots) SQ (A subcutaneous injection uses a short needle to inject a mediation into the fatty tissue layer between the skin and muscle - or right under the skin) that was to be administered to Resident 153 and administered the Lovenox SQ to Resident 103. The physician was notified with new orders noted to hold the Resident 103's Xarelto 20 mg on November 24, 2023. A clinical record review revealed that Resident 103 was admitted to the facility on [DATE] with diagnosis to include, atrial fibrillation. Physician orders dated November 22, 2023, were noted for Xarelto 20 mg, give one tablet in the evening. Clinical record review revealed that Resident 153 was admitted to the facility on [DATE], with diagnosis to include, personal history of other venous thrombosis and embolism. Physicians order received November 23, 2023, for Enoxaparin (Lovenox) 40 mg/0.4 ml single use syringe, SQ daily for 5 days. Resident 153's November 2023 medication administration record indicated that Lovenox SQ was unavailable on November 23, 2023, and administered to the resident on November 24 through November 27, 2023, for a total of 4 doses of the medication, and not the physician ordered 5 doses of the injectable medication, Lovenox. Resident 153 missed a dose of Lovenox 40 mg/0.4 ml. During an interview December 13, 2023 at 1 P.M., the corporate Nurse Consultant confirmed that Employee 1 (LPN) administered the incorrect medications to Resident 11 on November 1, 2023, including 2 blood pressure reducing medications resulting in a decrease in the resident's blood pressure and administered an injectable anticoagulant medication incorrectly to Resident 103 on November 24, 2023. Cross refer F726, F755 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing Services. 28 Pa. Code 211.9 (a)(1)(d)(2) Pharmacy Services. 395092 Page 18 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plan of correction for the deficiencies cited during the survey of December 14, 2023, and the findings of the survey ending February 7, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement plans to correct quality deficiencies related to fall prevention and significant medication errors and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. This plan was to be functional by December 28, 2023. The results of the current survey ending February 7, 2024, identified repeat quality deficiencies related to fall prevention and significant medication errors. In response to the deficiency cited related to resident falls during the survey of December 14, 2023, the facility's plan of correction revealed that the plan included the DON (director of nursing) / designee will audit residents falls during the clinical meeting to verify if interventions were in place including necessary staff supervision to prevent further falls. The audits will be completed weekly for four weeks then monthly for two months thereafter. Results of the audits will be reviewed at Quality Assurance Committee and changes will be made as necessary. However, at the time of the revisit survey ending February 7, 2024, review of clinical records revealed Resident 1 fell in the facility on the morning of January 22, 2024 and again on the morning of January 25, 2024, with the second fall resulting in a fractured arm. sustaining There was no documented evidence the resident's clip alarm was checked for placement and functioning prior to the falls and the alarm was not sounding at the time of either fall. The resident removed the alarm at the time of the fall on January 22, 2024, and staff failed to timely toilet and/or check or change the resident for incontinence prior to the fall on January 25, 2024. In response to the deficiency cited related to significant medication errors during the survey of December 14, 2023, the facility's plan of correction revealed that the plan included the DON / designee will re-educate the licensed nursing staff on the Medication Administration policy including preventing medication errors. Further the DON / designee will conduct random medication competencies for 2 licensed nurses per week to verify they remain competent in medication administration. The competencies will be completed weekly for four weeks then monthly for two months thereafter. Results of the audits will be reviewed at Quality Assurance Committee and changes will be made as necessary. However, at the time of the revisit survey ending February 7, 2024, a review of clinical records revealed that Resident 2 had received Resident 3's Humalog insulin. Resident 2 received 25 units of Humalog insulin instead of the physician ordered 25 units of Levemir insulin. Employee 2 failed to follow facility policy despite being educated on the Medication Administration policy and the facility performing competencies in response to the prior deficiency cited on December 14, 2023, related to medication errors. The facility's QAPI committee failed to identify that the facility had failed to implement their 395092 Page 19 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0867 plan of correction, in a manner consistent with the regulatory guidelines for the deficiencies cited, to ensure that solutions to the problem were sustained. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(c) Nursing services Residents Affected - Some 28 Pa. Code 201.18(e)(1) Management. 395092 Page 20 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, a review of pest control treatment logs and manufacturer's product specifications, and resident and staff interview, it was determined that the facility failed to maintain an effective pest control program as evidenced by observations on one out of the four nursing units (South). Residents Affected - Few Findings include: During a resident group interview on December 13, 2023, at 10:30 AM Resident 206 stated that she has ants in her bathroom in her room. She explained that she has told nursing staff, but the ants are still there. During an observation of resident room South 3 on December 13, 2023, at 11:25 AM, five brown ants were observed on the bathroom floor. A review of facility Pest and Application logs from June 2023 through November 2023 revealed the following: On June 26, 2023, at 10:56 AM, Room South 1 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On June 30, 2023, at 12:59 PM, Room South 3 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On June 30, 2023, at 4:15 PM, Room South 1 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On July 20, 2023 (no time indicated), Room South 2 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On August 31, 2023, at 5:18 PM, Room South 3 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On September 7, 2023, at 11:35 AM, Room South 4 was treated for ants with a dime-sized amount of Maxforce Ant Bait. On October 4, 2023 (no time indicated), Room South 1 was treated for ants with a dime-sized amount of Maxforce Ant Bait. November 2023 Pest and Application Log indicated no application of product. A review of the facility's safety data sheet indicated that the product utilized for ant pest control was MAXFORCE FC Ant Bait Stations (SDS number 102000005016). A review of Maxforce Ant Bait Station label information revealed directions indicating indoor use: for normal infestations, you should use MAXFORCE FC Ant Bait Stations in an average-sized room. For heavier infestations, you will need additional bait stations in each room. If infestation persists beyond two weeks, replace all bait stations where the bait has been completely consumed and relocate 395092 Page 21 of 22 395092 12/14/2023 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bait stations that show no evidence of ant feeding. Inspect all bait stations and replace them as needed for continuous control of ants. A review of Pest and Application logs from June 2023 through November 2023 revealed no description of the ant activity to determine if the infestation was normal or heavy, and the logs contained no evidence that the Maxforce Ant Bait Stations were replaced and/or monitored as needed in accordance with the manufacturer's instructions for use. During an interview on December 14, 2023, at approximately 11:00 AM, the Nursing Home Administrator (NHA) indicated that the director of maintenance oversees the facility's pest control management program. The NHA was unable to provide written policies, procedures, or protocols, which the facility utilizes to maintain an effective pest control program. The NHA acknowledged that ants continued to be observed at the facility and that it is the facility' responsibility to maintain an effective pest management program 28 Pa. Code 201.18(e)(2.1) Management 395092 Page 22 of 22