Health inspection·November 30, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument 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 one resident out of 19 sampled (Resident 80). Residents Affected - Some Findings include: A review of the clinical record of Resident 80 revealed a physician's order dated November 9, 2023, for the resident to be discharged to an alternate nursing home on November 10, 2023. A review of Resident 80's Discharge MDS assessment dated [DATE], Section A 2105, indicated that the resident was discharged to an acute care hospital. Interview with the facility's RNAC (registered nurse assessment coordinator) on November 29, 2023, at approximately 11:22 a.m. confirmed that the MDS Assessment for Resident 80 was not accurate with respect to the resident's discharge location. Page 1 of 14 395104 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policy and clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for two residents out of two sampled (Residents 72 and 74) to promote normal bowel activity to the extent practicable. Residents Affected - Some Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Management / Laxative Protocol, last reviewed by the facility March, 2023, indicated that if there is no bowel activity noted for 3 days, the laxative protocol will be implemented by the charge nurse and nutritional interventions to improve natural bowel function may be introduced. A laxative, suppository or fleets enema will be given as ordered by the attending physician. This protocol will be initiated on the following residents includes; a resident who has not had a bowel movement in 3 days. The protocol is as follows: Milk of Magnesia (MOM) 30 cc by mouth (po), as needed (prn), with AM medication pass, if no results within 12 hours, use Dulcolax suppository, if no results from suppository, administer fleets, if no results after the use of fleets, notify physician for further orders. A review of the clinical record revealed that Resident 72 had physician orders dated August 1, 2023, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 cc by mouth every 24 hours as needed for constipation in the morning if no BM (bowel movement) in 3 days; -Dulcolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally every 24 hours as needed for constipation if MOM is ineffective in 12 hours; -Fleet Enema 7-19 gm/118 ml (Sodium Phosphates), insert 1 application rectally every 24 hours as needed for constipation if Dulcolax ineffective in 12 hours. Review of Resident 72's Documentation Survey Report v2 revealed staff documented NA or 2, and also multiple bland entries. Interview with Employee 2, ADON, on November 29, 2023, at approximately 10:20 AM, confirmed that the blanks indicated the task had not been completed or that staff failed to document; 2 indicates no bowel movement occurred, and the NA indicates the task is not applicable. Resident 72's bowel activity noted on the Documentation Survey Report v2 for September 2023, revealed that he did not have a bowel movement on September 24, 25, 26, and 27, 2023. Review of Resident 72's Medication Administration Record (MAR) for September, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. 395104 Page 2 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident's Documentation Survey Report v2 for October 2023, revealed that he did not have a bowel movement on October 1, 2, 3, and 4, 2023; did not have a bowel movement on October 13, 14, 15, and 16, 2023; and did not have a bowel movement on October 18, 19, 20, and 21, 2023. Review of Resident 72's Medication Administration Record (MAR) for October, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time periods without a bowel movement to promote bowel activity. A review of the clinical record revealed that Resident 74 had physician orders dated July 3, 2023, and October 8, 2023, for the following bowel regimen: - Milk of Magnesia (MOM) Suspension 400 mg/5 ml (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for constipation in the morning if no BM (bowel movement) in 3 days; -Dulcolax Suppository 10 MG (Bisacodyl), inset 1 suppository rectally every 24 hours as needed for constipation if MOM is ineffective in 12 hours; The resident's Documentation Survey Report v2 for September 2023, revealed that he did not have a bowel movement on September 11, 12, 13, and 14, 2023. Review of Resident 74's Medication Administration Record (MAR) for September, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. The resident's Documentation Survey Report v2 for November 2023, revealed that he did not have a bowel movement on November 13, 14, 15, and 16, 2023, and he did not have a bowel movement on November 20, 21, 22, and 23, 2023. Review of Resident 74's Medication Administration Record (MAR) for November, 2023, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time periods without a bowel movement to promote bowel activity. During an interview with the Nursing Home Administrator (NHA) on November 29, 2023, at approximately 1:50 PM, the NHA was unable to provide evidence that physician ordered bowel protocol was consistently carried out for Residents 72 and 74 during the above time frames without bowel activity. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records 395104 Page 3 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility policy, and staff interviews it was determined that the facility failed to consistently provide necessary care and services to prevent the development of a pressure sore for one resident (Resident 9) out of 19 sampled residents. Residents Affected - Few Findings include: Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of current facility policy entitled Pressure Ulcer Protocol Assessment/Prevention last reviewed by the facility May 2023, revealed that upon discovery of all wounds, an investigation will be initiated. Physician will be notified and family if applicable. A plan of care will be established to address prevention and treatment. The charge nurse will notify the wound care nurse of all skin break downs. The wound care nurse will assess the area on the next business day. All residents' skin will be inspected weekly by the charge nurse and documented on the treatment record. Any resident found at risk will have preventative measures instituted. Any resident found with a Stage 1-4 pressure area will have his/her physician notified, protocols reviewed and implemented treatment per physician orders. A review of Resident 9's plan of care for risk for impaired skin integrity due to impaired mobility, incontinence last revised July 21, 2022, revealed planned interventions that included to apply Desitin to buttock/sacral area in the morning and in the evening, apply skin prep and allevyn to both heels as ordered and evaluate, encourage resident to frequently shift weight, turn and reposition every 2 hours and as needed, monitor bony prominence for redness, monitor nutritional status, monitor resident's nutritional status, utilize pressure relieving devices on appropriate surfaces, pressure reduction surface to both bed and chair. A review of a Quarterly Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was severely cognitively impaired, does not walk, and was dependent on staff for toileting and transfers. Review of the clinical record revealed that Resident 9 was diagnosed with COVID-19 on October 26, 2023, and her meal consumption declined in the days leading up to, and after the diagnosis. 395104 Page 4 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the clinical record revealed that on November 2, 2023, nursing staff identified a bruise measuring 2 cm x 1 cm on the resident's left shin. Review of facility investigation dated November 3, 2023, at 1 PM revealed that the facility's wound care nurse was called to Resident 9's room to evaluate the skin integrity of the resident's left hip. The wound care nurse identified SDTI (suspected deep tissue injury: a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) which measured 7 cm x 6 cm. There was no mention of a concern with the resident's left shin. Further review of the investigation revealed that a low air loss mattress was to be applied to the bed. The facility's investigation did not identy the potential contributing factors to the development of left hip suspected deep tissue injury. Review of Resident 9's weight revealed that on August 17, 2023, the resident weighed 128.8 pounds. On November 6, 2023, the resident weighed 118.0 pounds, an 8.4% weight loss in less than 90 days/ 3 months. There was no evidence that the facility's dietitian was notified of changes in the resident's skin condition and increased nutritional needs to promote healing or the resident's significant weight loss increasing the resident's risk for skin breakdown and potential deterrent to healing. Observation of Resident 9 on November 27, 2023, at approximately 10 AM revealed the resident awake and sitting in resident lounge/dining area in her wheelchair. The resident was observed leaning to the left while in the chair. Interview with Employee 1, Registered Nurse, on November 28, 2023, at approximately 10 AM, revealed that she had identified what appeared to be a bruise on Resident 9's hip days before the SDTI was identified. According to Employee 1, the bruise was the size of the tip of her pinky finger. Employee 1 further stated that nurse aide staff had reported that Resident 9 favors her left side and confirmed that she did not report the bruised area when first observed. Observation of Resident 9 on November 29, 2023, at approximately 8:15 AM, revealed that she was in the resident lounge/ dining area in her wheelchair. The resident was again observed leaning to the left while in chair, the same side as her identified pressure injury. Observation of the resident's left hip on November 29, 2023, at approximately 1:30 PM, in the presence of Employee 1, RN, and the wound care nurse revealed that the area measured approximately 3 cm x 1.5 cm, the wound bed was covered with eschar (dark, crusty dead tissue). There was no drainage, the surrounding skin was flesh tone, and wound edges were intact. The facility was unable to demonstrate that the development of the resident's left hip pressure ulcer was unavoidable based on the lack of documented evidence that the facility had implemented resident specific interventions to address potential contributing factors, to include the resident's positioning in the chair, to prevent skin breakdown. Interview with the Assistant Director of Nursing (ADON) on November 29, 2023, at approximately 1:30 PM confirmed to identify potential cause/contributing factors for the development of Resident 9's deep tissue injury. The ADON further confirmed that the nursing staff failed to timely notify the dietitian of significant changes in the resident's weight and decline in meal consumption increasing the resident's risk for skin breakdown. 395104 Page 5 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no evidence that the facility explored potential seating arrangements due to the resident favoring her left side while seated in her wheelchair. Interview with the Nursing Home Administrator on November 30, 2023, at approximately 2:30 PM confirmed that the facility failed to demonstrate the implementation of individualized measures to prevent development and promote healing of a pressure ulcer for a resident with identified risk for skin breakdown. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (a)(d) Resident care policies 395104 Page 6 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

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 review of information submitted by the facility, select facility policy and reports and clinical records and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 12 sampled residents. Findings include: Review of facility policy entitled Elopement, last reviewed by the facility April 2023, indicated it is the policy of the facility to promote resident safety through prevention of elopements, while allowing residents as much physical freedom as possible and to initiate a facility-wide search (including the grounds) immediately upon discovery of a missing resident. When residents who are identified as at risk to leave the facility unattended cannot be located on the unit, or any resident is identified as missing from the facility, the following procedure will be implemented: The charge nurse will notify the nursing supervisor on duty. The nursing supervisor will assign specific areas to be searched to specific staff. 1) will be assigned to search all areas within the unit including closets, bathroom, utility rooms, etc. 2) will be assigned to search all other areas in close approximation of where the resident was last seen. 3) will be assigned to search outside perimeters of the facility. 4) will search the ancillary areas. The nursing supervisor will notify the Administrator and the Director of Nursing as soon as the search has commenced. Observation of a posting located at the first-floor nurse's station on January 30, 2024, at approximately 11 AM revealed that the posting indicated that when a [door] alarm sounds, check panel to see which door is sounding. Silence alarm by pressing 1 2 3 4, call the extension, or check the area of the alarm. If it is clear, reset the alarm. Always remember to reset! The doors are not alarmed if system is not reset. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included dementia unspecified severity with agitation, depression, and anxiety. According to the resident's MDS assessments, the resident was severely cognitively impaired. An Elopement Risk assessment dated [DATE], revealed that the results did not identify Resident 1 to be at risk for elopement. The resident's annual MDS assessment dated [DATE], indicated that Resident 1 had not experienced behaviors or wandering but was severely cognitively impaired with a BIMS score of 5. 395104 Page 7 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's clinical record revealed that the resident was receiving physical therapy from October 26, 2023, to November 22, 2023, due to a recognized changes in resident's ambulatory status, wheelchair mobility, and transfer status. According to the therapy documentation, Resident 1 made progress exhibiting improved core and bilateral lower extremity (BLE) strength and control, improved transfers and improved transfer ability. The resident had also accepted a wheelchair for mobility on nursing unit to decrease fall risk and propels wheelchair with BLE with supervision with good endurance. The resident was discharged from physical therapy to nursing care and restorative nursing program on November 22, 2023. Review of information submitted by the facility revealed that on December 4, 2023, at 6:30 PM, nursing staff recognized that Resident 1 was not in her room on the unit. At 6:35 PM a community member passing the facility found Resident 1 on the main road leads to the driveway entrance of the facility, picked up the resident in their car, and then contacted the police. The police contacted then facility, The facility reviewed video surveillance as part of their investigation, which was also reviewed by the surveyor on January 30, 2024, in the presence of the Nursing Home Administrator. When reviewed at the time of the survey ending January 30, 2024, the video showed Resident 1 had self-propelled herself in her wheelchair off the nursing unit and entered the second-floor elevator at 6:17 PM. The resident took the elevator to the basement level where she propelled herself through the hallway and opened the beauty shop exit door, which tripped the facility's alarm. Resident 1 then self-propelled through the opened therapy department door, and is no longer seen on the video. Further observation of the video surveillance revealed that s facility staff member responded to the location of the alarm, opening the beauty shop exit door and looking outside, and searched the immediate area, which included the unoccupied therapy room, but didn't find anyone in the vicinity. The staff member then returned to the nursing unit without looking outside. Resident 1 was then seen again on video surveillance footage walking outside the facility and down the facility driveway leading away from the building to the main access road where she was then out of video surveillance range. Observation conducted on January 30, 2024, of the the location where it was believed Resident 1 had exited the facility, revealed a flight of concrete stairs that the resident had to climb to get to the back parking lot of the building. According to interview the Nursing Home Administrator on January 30, 2024, the resident had left her wheelchair in the therapy department and independently walked up the flight of stairs. Upon return to the facility, Resident 1 was assessed with no injuries identified. The physician ordered the resident to be sent to the emergency room for further evaluation, with no concerns identified. Facility investigation determined that Resident 1 may have been looking for her old room. The resident's room was recently changed on November 8, 2023, to place her closer to the nurse's station due to frequent falls and attempts to self-rise from her wheelchair. Due to her cognitive impairment, the resident was unable to verbalize why she left the facility or where she was going. Review of witness statement completed by Employee 1, licensed practical nurse, dated December 4, 2023, revealed that she returned from break as the alarm was being disarmed (silenced) by Employee 2, nurse aide. According to Employee 1, Employee 2 stated that the alarm was tripped by the beauty shop 395104 Page 8 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0689 Level of Harm - Minimal harm or potential for actual harm door. Employee 1 then asked Employee 2 to go check the area and when she returned, Employee 2 reported that nobody was downstairs. Then approximately 20 minutes later, the wife of a resident called the unit to inform her that she passed a vehicle who had someone in their car, they assumed it was a resident here [at the facility] so decided to call {the facility}. Immediately I notified my supervisor and performed a head count on my unit. Residents Affected - Few Review of witness statement completed by Employee 2, nurse aide, dated December 4, 2023, revealed that just before dinner trays were picked up on [unit] 28, the door alarm was going off. Employee 2 checked the alarm panel and it read beauty shop. Employee 2 then cancelled the alarm and reset the door. Employee 1 then returned from break and the aides reported the alarm. I went down to investigate why the beauty shop alarm was going off, it was coming from a chair in the physical therapy room. I turned off the alarm and started to call 'hello, anyone down here?' The chemical room door was open, Employee 2 looked inside, no one was there so she closed the door. Employee 2 then returned to the unit after not finding/seeing anyone in the basement. There was no indication that any facility employee went outside to look in the immediate vicinity of the exit door, when no one was immediately visible from the vantage point of looking from the doorway. Interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2024, at approximately 3:00 PM, confirmed that the facility failed to provide necessary supervision and implement effective safety measures for this resident, who left the facility and its grounds unsupervised. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 395104 Page 9 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and staff and resident interviews, it was determined that the facility failed to provide the necessary behavioral health care and services to attain the highest practicable mental and psychosocial well-being of one resident out of the 19 sampled (Resident 8). Findings include: A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses to include anxiety disorder (a mental health disorder involving excessive fear or worry) and osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 12, 2023 revealed that Resident 8 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 13-15 indicates cognition is intact). A review of Resident 8's plan of care, initiated December 8, 2021, revealed that the facility identified that the resident had a mood problem related to anxiety with planned interventions of administering medications as ordered, assisting the resident, family, and caregivers to identify strengths and positive coping skills and reinforce these; monitoring and recording mood to determine if problems seem to be related to external causes; and monitoring, recording, and reporting to the physician patterns, signs, and symptoms of depression, anxiety, and sad mood. A review of Resident 8's Patient Health Questionnaire (PHQ-9 is a tool used to assess the severity and symptoms of depression) dated July 27, 2023, revealed that the resident was at mild risk for depression. Resident 8's care plan related to problem with mood was revised on July 28, 2023, with the planned intervention to have an external provider consult and follow up as indicated. At the time of the survey ending November 30, 2023, there was no evidence that an external provider consultation had occurred. A progress note dated August 20, 2023, at 6:00 PM, indicated that Resident 8 was experiencing feelings of doom and despair. A review of Resident 8' depression screen (PHQ-9) dated September 12, 2023, indicated that the resident was at moderate risk for depression, which was an increase from the resident's prior screen completed on July 27, 2023. Nursing noted on September 12, 2023, at 8:53 AM that Resident 8 had periods of increased anxiety, calls or yells out, and can be demanding with staff. The entry stated that Resident 8 feels tired and restless many days, her appetite is poor, she has trouble sleeping many days, and she has trouble concentrating on things. 395104 Page 10 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on November 27, 2023, at 10:25 AM, Resident 8 stated that she has a terrible case of the blues and sometimes feels like not continuing on with life. There was no evidence that the facility had addressed the resident's behavioral health care needs related to depression and anxiety, and developed and implemented person-centered care plans that include and support the behavioral health care needs for the resident's diagnosed conditions. The facility failed to revise the resident's behavioral health care plan in response to the resident's increased risk for depression noted on September 12, 2023, and signs of increased anxiety nursing noted on September 12, 2023, which was confirmed during interview on November 29, 2023, at approximately 1:00 PM, with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) 28 Pa Code 211.12 (d)(3)(5) Nursing services 395104 Page 11 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of 19 clinical records and resident payor source data, and staff interview, it was determined that the facility failed to offer routine annual dental services for one private payor source resident reviewed. (Resident 24). Residents Affected - Few Findings include: Resident 24 was admitted to the facility on [DATE], with diagnosis to include depression and dementia, and her payor source was private pay. Review of Resident 24's annual MDS dated [DATE] quarterly MDS dated [DATE], April 21, 2023 and July 17, 2023 and annual MDS assessment dated [DATE], all indicated that the resident was severely cognitively impaired. Documentation provided by the facility indicated that the resident was last seen by a Dentist on December 29, 2021. A 2023 Dental Screening Consent Form was completed on December 20, 2022, and indicated that the resident's representitive wanted the resident to have a dental screening. There was no documentation that Resident 24 was offered dental services since December 29, 2021. Interview with the Administrator on November 29, 2023 at 10:30 a.m. confirmed that the facility had no documented evidence that Resident 24 received dental services since December 29, 2021. 28 Pa. Code 211.5 Dental Services 395104 Page 12 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for two Medicaid payor source out of 19 residents sampled. (Resident 66 and 44). Residents Affected - Few Findings include: Review of Resident 66's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 66's quarterly MDS assessments dated February 9, 2023, May 5, 2023 and October 27, 2023, and annual MDS assessment dated [DATE], all indicated that the resident was cognitively impaired. Documentation provided by the facility indicated that the resident was last seen by a dentist on October 26, 2022. A 2023 Dental Screening Consent Form was completed on February 14, 2023 and indicated that the resident's representitive wanted the resident to have a dental screening. There was no documentation in the resident's clinical record that Resident 66 received dental services since October 26, 2022, which was confirmed during interview with the Administrator on November 29, 2023 at 10:30 a.m. Resident 44's clinical record indicated that the resident was admitted to the facility on [DATE], and that the resident's payor source was Medicaid. Review of Resident 24's quarterly MDS assessment dated [DATE], August 25, 2023 and November 15, 2023 and annual MDS assessment dated [DATE], all indicated that the resident was severely cognitively impaired. A 2023 Dental Screening Consent Form was completed on February 17, 2023 and indicated that the resident's resident representitive wanted the resident to have a dental screening. There was no documented evidence the resident's dental screening had been completed as of the time of the survey ending November 30, 2023. 28 Pa Code 211.5 Dental Services 395104 Page 13 of 14 395104 11/30/2023 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's infection control tracking logs and policy and staff interviews, it was determined that the facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility and plan preventative measures accordingly. Residents Affected - Some Findings include: A review of the current facility policy titled Infection Control Program, dated July 27, 2023, revealed that the program's primary objective is to provide an effective facility-wide program for the surveillance, prevention, and control of infection. The program monitors the rates of healthcare-associated infections, uses systems to collect and analyze data, and organizes activities to prevent and control infections in residents and personnel. A review of the facility's infection control data revealed that the facility's infection control tracking did not reflect evidence of the consistent utilization of a comprehensive tracking system to monitor and investigate the causes of all types of infections. There was no evidence the facility was using an infection control tracking system to analyze infection clusters, identify changes in prevalent organisms, or recognize increases in the rate of infection in a timely manner. A review of the facility's infection control data revealed infection tracking logs dated August 2023, September 2023, and October 2023, failed to include resident room numbers, resident units, and the type of pathogen/infectious organism associated with the infection. A review of facility infection control data failed to reveal that the facility evaluated the data for potential patterns of infectious organisms within the facility. The facility analysis report included resident infection by general type but did not include resident location or pathogen. A review of facility analysis reports revealed the following: August 2023: Respiratory infections 1, skin infections 3, dental/oral infections 1, urinary tract infections (with foley) 1, urinary tract infections without foley 2, Scabies 1 September 2023: Respiratory infections 2, skin infections 0, dental/oral infections 0, urinary tract infections (with foley catheter) 2, urinary tract infections without foley catheter 3, conjunctivitis 1 October 2023: Respiratory infections 4, skin infections 4, dental/oral infections 0, urinary tract infections (with foley) 5, urinary tract infections without foley 13, conjunctivitis 1 During an interview on November 30, 2023, at 9:30 AM, the infection preventionist confirmed that the facility's data for the August 2023 through October 2023, did not include sufficient data to identify patterns and implement corresponding interventions to reduce the spread of infection based on the infection tracking. 28 Pa Code 211.12 (c) Nursing services 28 Pa. Code 211.10 (d) Resident care policies 395104 Page 14 of 14