Health inspection·December 21, 2023

F 0655 Level of Harm - Potential for minimal harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and resident representative for four of 20 residents reviewed (Residents R50, R41, R86, and R89). Findings include: Review of a facility policy entitled, Baseline Care Plan dated 1/02/2023, revealed A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: The initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Resident R50's clinical record revealed an admission date of 3/31/2023, with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Resident R50's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R50 and his/her representative. Resident R41's clinical record revealed an admission date of 10/22/2023, with diagnoses that included chronic respiratory failure, type II diabetes, failure to thrive, heart failure, and repeated falls. Resident R41's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R41 and his/her representative. Resident R86's clinical record revealed an admission date of 5/18/2023, with diagnoses that included type II diabetes, history of falling, and muscle weakness. Resident R86's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R86 and his/her representative. Resident R89's clinical record revealed an admission date of 11/18/23, with diagnoses that included fracture of right hip, muscle wasting and atrophy (loss and breakdown of muscles), lack of coordination, and muscle weakness. Page 1 of 9 395231 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0655 Level of Harm - Potential for minimal harm Residents Affected - Some Resident R89's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R89 and his/her representative. During an interview on 12/21/2023, at 10:30 a.m. the Director of Nursing confirmed that the clinical record of the residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided the residents and his/her representatives upon admission to the facility. 28 Pa. Code 211.10(c) Resident care policies 395231 Page 2 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, observations, and resident representative and staff interviews, it was determined that the facility failed to develop and implement a comprehensive activity program for one of three resident care units observed (Memory Care Unit Three). Residents Affected - Some Findings include: Review of facility policy Activity Program dated 1/02/23, revealed This facility provides activity programs that are designed to meet the needs of residents with a range of cognitive and physical levels of functioning. 1. Activity programs are designed to encourage individual participation and are geared to the needs and preferences of residents in the facility. 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning of the programs, which may include self-directed activities. 3. Our activity programs consist of individual, small and large group activities that are designed to meet the needs and interests of residents and may include such things as: a: exercise, movement to music, pool b: Stimulating activities such as current events, trivia, word games, movies c: Field trips away from the facility such as shopping, going to the park, going out to eat, attending local events d: Spiritual programming as requested by the residents e: Creative activities, such as arts and crafts, painting, writing, music, f: Occasionally special activities such as birthday and holiday parties, outside entertainment and theme events g: activities may be scheduled per resident interest as a one-time event or more often 4. Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents, and family members may also provide activities. 395231 Page 3 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observations on 12/18/23, between 11:00 a.m. and 4:00 p.m.; on 12/19/23, between 9:30 a.m. and 12:00 p.m.; and on 12/20/23, between 8:45 a.m. and 1:00 p.m. revealed no evidence of resident activities being conducted on the Memory Care Unit. During an interview on 12/19/23, at 12:45 p.m. Resident R35's Representative indicated there have not been activities for residents of the Memory Care Unit for months but was supposed to have a facility employee start doing activities on 12/01/23, but this has not occurred. During an interview with Employee E2 on 12/20/23, at approximately 10:30 a.m. it was confirmed that activities have not been taking place consistently for the residents of the Memory Care Unit for numerous days. During an interview with Employee E3 on 12/20/23, at approximately 11:00 a.m. it was confirmed that activities have not been occurring consistently due to the facility employee responsible for the Memory Care Unit was working on other responsibilities at the facility. During an interview on 12/21/23, at 10:15 a.m. the Nursing Home Administrator confirmed that an activity program was trying to be initiated, but due to staffing concerns, the staff responsible for the Memory Care Unit activities have not been able to do them as planned. 28 Pa. Code 211.10(d) Resident care policies 395231 Page 4 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to ensure urinary catheter (tube inserted into the bladder to drain urine) care was completed and urinary output was documented per physician orders for one of 20 residents reviewed (Resident R50). Findings include: Review of the facility policy entitled Use and Care of Urinary Catheter Guidelines, dated 1/2/2023, revealed Catheter care will be done per facility policy and as needed. Drainage bags will be emptied every shift and as needed. Review of the facility policy entitled Medication and Treatment Orders, dated 1/2/2023, revealed Treatment orders will be documented in PCC (Point Click Care) and on the Treatment Administration Record (TAR). Resident R50's clinical record revealed an admission date of 3/31/2023, with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Review of Resident R50's physician's orders dated 4/01/2023, revealed an order for foley (type of catheter) catheter care every shift and physician's orders dated 4/25/2023 to document foley output every shift. Review of R50's TAR completed by the Licensed Nurses for November 2023 and December 2023 revealed his/her foley catheter care was not completed every shift per physician's orders on 11/05/2023, 11/08/2023, and 12/01/2023, and urinary output was not documented every shift per physician orders on 11/01/2023, 11/02/2023, 11/03/2023, 11/04/2023, 11/05/2023, 11/06/2023, 11/08/2023, 11/11/2023, 11/12/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023, 11/29/2023, 12/01/2023, 12/04/2023, 12/07/2023, 12/09/2023, 12/10/2023, and 12/11/2023. During an interview on 12/20/2023, at 11:29 a.m. the Director of Nursing confirmed that the clinical records lacked evidence that catheter care was being completed per physician orders and lacked evidence that urinary output was being documented per physician orders for resident R50. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395231 Page 5 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

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. Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R41), and failed to ensure PRN orders for psychotropic medications be used only when the medication is necessary to treat a diagnosed specific condition for two of five residents reviewed related to psychotropic medication usage (Residents R76 and R85). Findings include: Review of a facility policy entitled Use of Psychotropic Medication dated 1/2/2023, revealed that PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. and Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Resident R41's clinical record revealed an admission date of 10/22/2023, with diagnoses that included chronic respiratory failure, type II diabetes, failure to thrive, heart failure, and repeated falls. A physician's order dated 11/22/2023, identified to administer Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 4 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of the November 2023 and December 2023 Medication Administration Record (MAR) for Resident R41 revealed that the PRN Lorazepam was used on 11/22/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, 11/20/2023, 12/01/2023, 12/02/2023, 12/03/2023, 12/04/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, 12/09/2023,12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/16/2023, 12/17/2023, 12/18/2023, and 12/19/2023. Review of the November 2023 MAR, December 2023 MAR, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the 17 administrations of Lorazepam in November 2023 and 22 administrations of Lorazepam in December 2023. During an interview on 12/21/2023, at 10:20 a.m. the Director of Nursing confirmed that Resident R41's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and R41's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering Lorazepam. Resident R76's clinical record revealed an admission date of 11/10/21, with diagnoses that included Parkinson's disease (disease of the central nervous system that affects movement), dysphagia (difficulty swalling foods or liquids), muscle wasting and atrophy (a loss and break down of muscle), and dementia (disease of the brain that affects mood, behavior, and decision making). 395231 Page 6 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident R76's clinical record revealed a physician's order dated 4/29/23, Ativan Solution 2 mg/ml [milliliter] (Lorazepam) Inject 0.25 ml intramuscularly every 6 hours as needed for anxiety, agitation 0.5 mg. Resident R76's pharmacy medication regimen review (MRR) dated 11/08/23, revealed This resident has an order for Ativan 0.5 mg IM Q6H PRN for Anxiety/Agitation. This was started 4/29/23. The prescriber must then reassess the patient in order to continue the PRN order. If the medication is to be continued for PRN use, the prescriber must document clinical rationale for extended use AND the duration of treatment. The MRR further lacked evidence of a physician response to discontinue the PRN order as referenced above and/or to continue use with a clinical rationale. Resident R85's clinical record revealed an admission date of 1/30/23, with diagnoses that included fracture of left hip, muscle weakness, unsteadiness of feet, and dementia. Resident R85's clinical record revealed a physician order dated 8/15/23, Ativan oral tablet 0.5 mg (Lorazepam) Give 0.25 mg by mouth every 8 hours as needed for anxiety. Resident R85's pharmacy MRR dated 12/13/23, revealed This resident has an order for Ativan 0.25 mg Q8H PRN for Anxiety/agitation. If the medication is to be continued for PRN use, the prescriber must document clinical rationale for extended use AND the duration of treatment. The physician indicated to discontinue PRN order referenced above. The clinical record lacked evidence, however, that the Ativan 0.25 mg by mouth every 8 hours PRN was discontinued per the physician order documented on 12/13/23. During an interview on 12/21/23, at 10:40 a.m. the Assistant Director of Nursing confirmed that Resident R76's clinical record lacked evidence of a physician response to the pharmacy MRR dated 11/08/23, to discontinue the PRN Ativan 0.5mg IM Q6H PRN and/or continue use with a clinical rationale, and Resident R85's clinical record lacked evidence that the Ativan 0.25 mg by mouth every 8 hours PRN was discontinued per the 12/13/23, physician order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395231 Page 7 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) and tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of three medication carts (Long Cart 2). Findings include: Review of a facility policy entitled, Administering Medication dated 10/01/23, indicated that that the date opened shall be recorded on the container. Observation on 12/18/23, at 3:32 p.m. of the Long Cart 2 revealed an opened multi-dose vial of Novolog insulin without a date when it was opened. At that time, Licensed Practical Nurse Employee E1 confirmed that the multi-dose vial of Novolog insulin did not identify an opened date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 395231 Page 8 of 9 395231 12/21/2023 Hermitage Nursing and Rehabilitation 500 Clarksville Road Hermitage, PA 16148

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 review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was stored and prepared in a safe and sanitary manner related to the walk-in freezer, dry storage area, cooking equipment, and fans in the dishwashing area for one of one main kitchens. Findings include: Review of a facility policy entitled, Sanitary Conditions dated 1/02/2023, revealed that All equipment will be maintained in a clean and sanitary fashion. Observations conducted on 12/18/2023, at approximately 10:05 a.m. of the main kitchen revealed dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove and overhead vents, and two fans in the dishwashing area with a thick layer of dust and a fuzzy substance. During an interview on 12/18/2023, at the time of the observations the Kitchen Manager confirmed that there was dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove and overhead vents, and two fans in the dishwashing area with a thick layer of dust and a fuzzy substance. 28 Pa. Code 201.14(a) Responsibility of licensee 395231 Page 9 of 9