Health inspection·March 15, 2024

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records, CMS guidance and facility documentation, and staff interviews, it was determined the facility failed to develop policies and procedures in accordance with CMS (Center for Medicare and Medicaid Services) guidance to protect residents from unacceptable practices of disenrolling residents from the Medicare Health Plans and to ensure all risks of disenrolling are fully explained, both verbally and in writing to the residents, and if applicable, the residents' representative. Residents Affected - Few Finding include: A review of a CMS guidance titled Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment dated October 2021 revealed CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without Part D, Medicare-Medicaid plans, or Programs of All-Inclusive Care for the Elderly (PACE) without the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. Only a Medicare beneficiary, the beneficiary's authorized or designated representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan. Further it is indicated changes in a beneficiary's health care coverage generally must be initiated by the beneficiary or their representative. If a beneficiary or their legal representative requests assistance from the LTC facility in changing the beneficiary's health care coverage, the LTC facility should take the following steps to help ensure changes to a beneficiary's health care coverage comply with regulations regarding enrollment/disenrollment and resident rights: 1) Explain orally and in writing the impact to the beneficiary if they change coverage (e.g., to a stand-alone prescription drug plan (PDP) and Original Medicare, or to a different Medicare health plan). 2) Develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage. At a minimum, information should include the circumstances under which the facility can assist a beneficiary with a plan change. The need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that that the beneficiary and/or the representative understand the information. The need to obtain an attestation signed by Page 1 of 8 395092 395092 03/15/2024 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0574 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change and that the beneficiary or representative (as applicable) received and understood the minimum required information listed above. In cases where beneficiaries request disenrollment from PACE, LTC facilities that are contracted with PACE organizations should work directly with the PACE organization and the participant's interdisciplinary team to ensure the PACE participant receives the information required under the PACE regulations and to coordinate the transition of care, including as specified in their contract requirements. According to the CMS memo if a LTC facility cannot provide documentation of a beneficiary's request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid. Lastly, If the facility has the beneficiary sign documentation regarding their understanding of an enrollment change, CMS will expect to find that the beneficiary's assessed cognitive function also supports an ability to understand this type of information. If CMS becomes aware of enrollment actions that the beneficiary alleges were taken without their request, consent, knowledge, and/or complete understanding, CMS will expect the facility to provide the above noted documentation to support that it appropriately assisted the beneficiary with their choice to change coverage, including that the beneficiary's cognitive function supports such decision-making. Interview with the Nursing Home Administrator on March 15, 2024, at 1:18 PM, confirmed that the facility may initiate discussions about making changes in Medicare Health plans for its residents. The NHA was unable to provide established facility policies and procedures in place at the time of the survey, that outline the facility's process of assisting beneficiaries and their representatives with changing their Medicare health plans, and that assure that residents possess the cognitive ability to make such changes at the given time, and that these changes are initiated by the resident or their representative. 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 201.18 (b)(2)(c)(e)(1)(2) Management 395092 Page 2 of 8 395092 03/15/2024 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 with injury, known unsafe restless behaviors that increased the resident's risk for falls, to prevent a fall with minor injury for one resident out of six sampled (Resident B1). Findings include: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses of dementia, muscle weakness and a history of repeated falls. An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 23, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 2 and required extensive staff assistance with activities of daily living. The resident's care plan, initially dated February 9, 2024, indicated that the resident was at risk for falls related to a history of falling with planned interventions of the placement of an alarm to broda chair when out of bed, a bed alarm-check placement and function every shift, education on transfer and ambulation techniques, keep bed in lowest position, keep environment free of clutter, keep personal belongings within reach, low Bed, matt to floor next to both sides of bed when occupied, place alarm boxes out of resident reach and a PT/OT evaluation as needed Nursing documentation dated February 9, 2024, through February 11, 2024, revealed that the resident displayed restless behaviors, continuing attempts to stand up and out of the wheelchair, bending over while in the chair, displaying unsafe actions of leaning forward in the chair and episodes of agitation during all shifts of nursing duty. The resident was placed at the nurses' stations repeatedly for close staff observation according to nursing documentation, which included nursing entries dated February 10, 2024, at 11:31 AM when nursing noted that the Resident attempted to self transfer and bend over in wheelchair despite several attempts at redirecting, when attempting to redirect, resident becomes agitated and begins yelling, leave me alone, currently at nurses station. A nurses note dated February 11, 2024 at 10:50 PM revealed that the resident was at nurses station sitting in a wheelchair, stood up, the was alarm sounding, multiple staff members shouted for her to sit down as they ran toward her however she fell backwards onto floor striking occipital area of head on floor. She was laying on her right side crying and began rubbing her left groin and hip area. As a result of this fall from the wheelchair on February 11, 2024, when the resident was at the nurse's station for observation, she sustained a comminuted right introchanteric femur fracture (right hip fracture). Following hospitalization for treatment of the hip fracture, Resident B1 was readmitted to the facility on [DATE] at 12:05 PM. A nurses note dated February 16, 2024 at 6 PM, revealed that While resident was sitting in her Broda chair in the lobby by the nurses station, she leaned forward and the chair tipped over and she fell out landing on her L (left) side, hitting the left side of her forehead. Assessed for injuries. Large hematoma (similar to a bruise, but the damage that causes it occurs in larger blood vessels. It 395092 Page 3 of 8 395092 03/15/2024 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0689 Level of Harm - Minimal harm or potential for actual harm can lead to swelling, discoloration) L side of forehead seen. Clip alarm pulled off when she leaned forward and was not sounding. The physician was called and made aware of fall. new order noted to give Seroquel (an antipsychotic medication) 25 mg po now then Seroquel 25 mg po BID for anxiety/agitation. It was noted that Resident B1 just returned to the facility from the hospital this afternoon (February 16, 2024 at 12:05 PM). and that She is confused and not easily redirected. Residents Affected - Few A nurses note dated February 16, 2024 at 6:41 PM, after the resident's fall with minor injury, revealed that the new interventions to prevent further falls implemented were the placement of a Pommel Cushion on the Broda chair along with front Anti-Tippers by maintenance man. Nursing noted that the resident was resting quietly at present under close observation. Along with a physician order dated February 16, 2024 at 5:15 PM, for Seroquel Oral Tablet, Give 25 mg by mouth two times a day for agitation/anxiety and Give 25 mg by mouth one time only for anxiety/agitation now. A review of a February Medication Administration Record revealed that Seroquel 25 mg was given to Resident B1 on February 16, 2024 at 7:04 PM, after the resident's fall. After the resident's fall on February 16, 2024, the resident's care plan was updated to include, Anti-Tippers to front of broda chair along with elevating leg rests and a pommel cushion The resident had a fall on February 11, 2024, while seated in a wheelchair at the nurse's station, which resulted in a fractured hip. Following hospitalization for treatment of the resident's hip fracture, and upon the resident's return to the facility on February 16, 2024, the resident was placed in a Broda chair, in the the lobby by the nurse's station, and sustained another fall resulting in a hematoma. The facility was aware that placing the resident at the nurse's station proved ineffective in preventing the resident's fall on February 11, 2024, but employed the same intervention on the day the resident returned to the facility on February 16, 2024, and the resident leaned forward in the chair and fell. The facility failed to demonstrate the provision of individualized effective fall prevention measures, including sufficient staff supervision, at the level and frequency required, to prevent another fall, with minor injury under similar circumstances as a prior recent fall. At the time of the survey ending March 15, 2024, the DON and NHA were unable to provide evidence that the facility had provided effective safety measures and staff supervision to prevent his resident's fall on February 16, 2024. 28 Pa. Code 211.12 (d)(5) Nursing services 395092 Page 4 of 8 395092 03/15/2024 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 - Few 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, employee records, nurse staffing, and incident reports and staff interview, it was determined that the facility failed to provide nursing staff with the necessary skills and competencies to fully assess and monitor a resident for signs of injury after an unwitnessed fall for one resident out of six sampled (Residents B2). Findings include: According to the Commonwealth of Pennsylvania, Pennsylvania code, Title 49. Professional and vocational standards, Chapter 21, State Board of Nursing, 21.145 functions of the LPN; (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. A review of the clinical record revealed that Resident B2 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes, hypertension and atrial fibrillation. A physician orders dated November 9, 2023, was noted for Eliquis (an anticoagulant medication) 2.5 mg by mouth twice a day for atrial fibrillation (a rapid, irregular heart rhythm) A review of the resident's quarterly minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 22, 2023, revealed Resident B2 was cognitively intact with a BIMS score (The Brief Interview for Mental Status (BIMS) is a structured evaluation aimed at evaluating aspects of cognition in elderly patients) of 13, required limited assistance from staff for activities of daily living and utilized a walker for ambulation. A nursing note dated February 27, 2024, at 02:40 AM revealed that Staff heard a loud noise, nurse aide and writer (Employee 1, agency LPN) responded and found resident on the floor at the entrance of her room, lying on the floor with her head and left shoulder against the door blocking entrance to the room. On observation, no open areas, resident was awake and alert with episodes of confusion, not her baseline. Vital signs were obtained and emergency medical services was notified, order to transfer to ED obtained by MD, resident being monitored by staff while awaiting for EMS. A review of a SNF to hospital transfer form dated February 27, 2024 at 2:40 AM revealed that after the fall, Employee 1 (agency LPN) obtained vital signs but did not conduct neuro check data collection in response to an unwitnessed fall (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness). An incident report dated February 27, 2024, at 2:40 AM, but noted as a late entry and completed February 28, 2024 at 1:17 PM by the DON revealed Staff heard a loud noise, nurse aide and Employee 1 (agency LPN) responded and found resident on the floor at the entrance of her room, lying on the floor with her head and left shoulder against the door blocking entrance to the room. On observation, no open areas, resident was awake and alert with episodes of confusion, not her baseline. Vital signs 395092 Page 5 of 8 395092 03/15/2024 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 - Few were obtained and EMS(emergency medical service) was notified, the Physician was notified. Resident being monitored by staff while awaiting for EMS. According to the incident investigation report, Employee 1, agency LPN, assessed Resident B2 for injury, complaints of left upper arm pain, and noted no dislocation, malformation or injury. The report noted that the resident's Neuros were intact but initially the resident appeared altered and actually appeared to pass out for a few minutes. The resident was transferred to the hospital for evaluation. There was no evidence at the time of the survey ending March 15, 2024, that neuro checks were conducted after Resident B2's unwitnessed fall until the time of transfer to the hospital or that a Registered Nurse had assessed the resident for potential injury and checked the resident's neurological status. Employee 1 contacted the director of nursing (DON) at the resident's time of the fall since the facility had no RN on duty during the night shift of duty. A review of facility nurse staffing documents revealed that two agency licensed practical nurses were on duty February 27, 2024 11 PM to 7 AM shift. The DON did not come to the facility to conduct a professional nursing assessment of the resident when Employee 1 contacted her regarding the resident's fall. Resident assessment is outside the scope of practice of an LPN, according to their practice act. A review of facility documentation, Agency staff orientation guidelines, revealed that Employee 1 (agency LPN) read and signed the form as reviewed and confirming orientation d on November 17, 2023, her first date of employment in the facility. A review of a licensed nurse skills competency checklist provided to the facility by the nurse staffing agency, dated January 20, 2024, indicated that Employee 1 (agency LPN) was proficient in nursing areas to include care of head injuries. There was no documented evidence at the time of the survey ending March 15, 2024, that Employee 1 had conducted neurological monitoring after the fall until the resident's transfer to the ED or that a registered nurse assessed the resident after the fall to include a neurological assessment after Resident B2's unwitnessed fall. An interview on March 15, 2024, at approximately 1:00 P.M. the Director of Nursing (DON) stated that Employee 1, an agency LPN, called her at the time of Resident B2's fall. The DON confirmed that there were two agency LPNs on duty on the 11 PM to 7AM shift when Resident B2 fell. The DON stated that she did not come into the facility to assess Resident B2 and stated that Employee 1 should have completed the neurological assessment, to include neuro checks and Employee 1 should also have completed the incident investigation. During an interview March 15, 2024, at approximately 1:15PM, The Nursing Home Administrator and Director of Nursing confirmed that Employee 1 failed to demonstrate competency regarding neurological data collection after an unwitnessed fall or that a professional nursing assessment of the resident was conducted after the fall. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 395092 Page 6 of 8 395092 03/15/2024 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 demonstrate the clinical necessity for initiation of an antipsychotic drug for one resident (Resident B1) out of six reviewed. Findings included: A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses of dementia, muscle weakness and a history of repeated falls. An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 23, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 2 and required extensive staff assistance with activities of daily living. A review of nursing documentation revealed that the resident displayed unsafe restless behaviors, repeatedly attempting to self-rise and leaning out of her wheelchair from the time of admission February 9, 2024, through the time the resident fell from her wheelchair sustaining a fractured hip on February 11, 2024. The resident was readmitted to the facility from the hospital on February 16, 2024 at 12:05 PM. The resident had another fall on February 16, 2024, at 5:44 PM falling from a Broda chair after again displaying unsafe leaning and attempted self rising. A physician order dated February 16, 2024, at 5:15 PM was noted for Seroquel Oral Tablet, give 25 mg by mouth two times a day for agitation/anxiety and give 25 mg by mouth one time only for anxiety/agitation now. A review of the resident's February 2024 Medication Administration Record revealed that Seroquel 25 mg was given to Resident B1 on February 16, 2024 at 7:04 PM and twice a day thereafter through the time of the survey. There was no documented evidence at the time of the survey ending March 15, 2024, of the clinical indicator, psychiatric diagnosis, or had been prescribed an antipsychotic medication prior to initiation of the antipsychotic drug on February 16, 2024, prescribed for anxiety and agitation. There was no physician documentation of a resident specific information which detailed the clinical justification for the use of the antipsychotic drug was clinically indicated. At the time of the survey ending March 15, 2024, there was no documented evidence of the clinical necessity or clinically supporting diagnosis for use of this antipsychotic medication prescribed for dementia with anxiety/agitation. 28 Pa. Code 211.9(a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.2 (d)(8) Medical director 395092 Page 7 of 8 395092 03/15/2024 Meadow View Rehabilitation & Healthcare Center 225 Park Street Montrose, PA 18801

F 0758 28 Pa. Code 211.5 (f) Medical records Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395092 Page 8 of 8