Health inspection·November 15, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of one resident reviewed (Resident 77). Findings include: Review of clinical record of Resident 77 revealed diagnoses to include Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features. The average IQ of a young adult with Down syndrome is 50, equivalent to the mental ability of an 8- or 9-year-old child). Further review of Resident 77's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated September 23, 2024, with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated September 26, 2024, indicated that, You have evidence of an Intellectual Disability. The Office of Developmental Programs, Department of Human Services has reviewed your information for nursing facility placement and the possibility that you are a person with an ID. Additional ID specialized services are available for individuals who are in a nursing facility. These services can include training, treatments, therapies and related services to help people function as independently as possible. Based on the review of your information the departments determination appears below: You do require ID/MR specialized services. Review of Resident 77's current care plan conducted during the survey ending November 15, 2024, revealed the care plan failed to identify the individual and specific referrals made, or services recommended and/or provided to the resident as the result of the resident's intellectual disability and PASARR II. An interview with the Nursing Home Administrator on November 15, 2024 at 11:00 a.m. confirmed the PA-PASARR-ID II form completed had identified Resident 77 as requiring the need for special services and was unable to provide evidence of coordination of services including care planning. There was no evidence at the time of the survey the facility had timely identified and coordinated Page 1 of 4 395104 395104 11/15/2024 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0644 Level of Harm - Minimal harm or potential for actual harm the provision of specialized services for this resident with the potential to adversely affect the resident's ability to achieve and maintain their highest practicable physical, mental and psychosocial well-being 28 Pa. Code 211.5(f)(iv)(vi) Medical records. Residents Affected - Few 395104 Page 2 of 4 395104 11/15/2024 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of clinical records and controlled drug records, and staff interview, it was determined the facility failed to implement procedures to promote accurate accounting of controlled medications for one resident of 18 residents sampled (Resident 48). Finding include: A review of the clinical record revealed Resident 48 had a physician's order dated October 18, 2024, for Tramadol HCl oral tablet 50 mg (an opioid pain medication), give one tablet by mouth every 8 hours as needed for moderate pain identified by a scale of 5-7 (pain scale, 1-10, 1 least amount of pain and 10 most amount of pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on October 19, 2024, at 9:00 AM, and October 23, 2024, at 2:40 PM, nursing staff signed out a dose of the resident's supply of Tramadol 50 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. A physician order dated October 28, 2024, was noted for Hydrocodone-Acetaminophen oral tablet 5-325 mg (an opioid pain medication combined with a non-opioid pain reliever used to treat moderate to severe pain), give one tablet by mouth every 6 hours as needed for moderate pain (scale 5-7). A review of the controlled substance record accounting for the above narcotic medication revealed that on November 3, 2024, at 1:00 PM, November 6, 2024, at 2:30 PM, November 9, 2024, at 8:15 AM, and November 12, 2024, at 1:00 PM nursing staff signed out a dose of the resident's supply of Hydrocodone-Acetaminophen 5-325 mg. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. During an interview on November 14, 2024, at approximately 11:05 AM, the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medication for Resident 48 and indicated the controlled substance record be documented clearly and accurately. 28 Pa Code 211.5 (f)(x) Medical records. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9(a)(1)(k) Pharmacy services 395104 Page 3 of 4 395104 11/15/2024 Saint Mary's Villa Nursing Hom 516 St. Mary's Villa Road Moscow, PA 18444

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of four resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of the resident food pantry located on the second floor, Extension 31, on November 13, 2024, at 10:50 AM, revealed that inside the refrigerator there was one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water dated October 21, 2024, two opened 46-ounce containers of moderately thick/honey consistency lemon flavored water dated October 23, 2024, one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water dated November 5, 2024, and one opened 46-ounce container of moderately thick/honey consistency lemon flavored water dated November 5, 2024 (manufacturers label noted that after opening, the drinks may be kept up to seven (7) days under refrigeration). Interview with Employee 1 (registered nurse) on November 13, 2024, at 11:00 AM confirmed the observation of the resident food pantry on Extension 31. Observation of the resident food pantry located on the second floor, Extension 33, on November 13, 2024, at 11:05 AM, revealed inside the refrigerator there was one opened 46-ounce container of moderately thick/ honey consistency lemon flavored water dated October 16, 2024, and one opened 46-ounce container of mildly thick/nectar consistency lemon flavored water without an open date. Interview with Employee 2 (registered nurse) on November 13, 2024, at 11:15 AM confirmed the observations of the resident food pantry on Extension 33. Interview with the Nursing Home Administrator and the Director of Nursing on November 14, 2024, at approximately 1:00 PM confirmed the food and beverages in the resident pantry were to be dated when opened and discarded according to manufactures instructions. 395104 Page 4 of 4