Health inspection·April 13, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and sanitary environment in resident rooms and common areas in the facility. Findings include: Observations of resident room [ROOM NUMBER] during an environmental tour of the facility on April 11, 2023, at approximately 10:40 AM revealed a brown substance smeared on the wall near the base board located to the right of the resident's bed. An accummulation of leaves, cobwebs and dirt was observed between the window screen and window in the room. Observation of resident lounge/visiting area revealed a large accumulation of spiderwebs in right hand corner of the window located near the ceiling and webs and dirt in the left hand corner of the same window. Observation of resident room [ROOM NUMBER] on April 11, 2023, at 10:00 AM, revealed that the resident safety mats on the floor were heavily soiled with dirt and stained with a dried tan colored substance. Further observation of the room revealed that there was a rotting banana atop the night stand in front of the television. Observation of room [ROOM NUMBER] on April 12, 2023, at approximately 10:30 AM revealed that the heating/AC unit access door was unlatched and open revealing a heavy build of white lint. Interview with the Nursing Home Administrator (NHA) on April 13, 2023, at approximately 2 PM confirmed that the resident environment was to be maintained in a clean and sanitary manner. 28 Pa. Code 207.2(a) Administrator's Responsibility. Page 1 of 19 395285 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and clinical record review it was determined that the facility failed to ensure that residents were free of chemical restraints used to most readily control resident behavior for one resident out 13 sampled residents (Resident 19). Findings include: A review of the clinical record revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) anxiety and chorea-like movements ( Chorea is a movement disorder that occurs in many different diseases and conditions. Dozens of genetic conditions, autoimmune and infectious diseases, endocrine disorders, medications and even pregnancy can have chorea as a symptom. Treatment is based on cause of the chorea). A significant change MDS Assessment (Minimum Data Set - a federally mandated assessment completed periodically to plan resident care) dated March 27, 2023, revealed that Resident 19 was moderately cognitively impaired and exhibited physical and verbal behaviors. A review of Resident 19's monthly behavior tracking flow records dated August 2022 through April 2023 revealed that the resident displayed behaviors to include anxiety, restlessness, verbal aggression and throwing objects. A review of the resident's current care plan for the resident's problem of behaviors initiated February 20, 2020 revealed that the Resident requires psychosocial interventions, receives Venlafaxine (an antidepressant medication), Buspirone (an antianxiety medication), Xanax ( a benzodiazepine, anxiety medication) and Depakote (an antiseizure medication used as a mood stabilizer). Resident 19 gets frustrated with staff if they do not immediately understand her or know what she wants. She can be needy at times, and occasionally is restless, verbally aggressive, yells and throws objects. Care planned interventions were to administer medications as per physician orders, encourage activity involvement (type of activity preferred by the resident was not identified) and socialization with others, seek Physician/Psychological consult as needed for medication and behavioral management, provide reading material for the resident and provide one on one if needed. A physician order, nurses notes and monthly Medication Administration Records dated from August 26, 2022 through September 12, 2022, revealed that the resident received Klonopin (an antianxiety agent, Benzodiazepines/Anticonvulsant) ODT (dissolves in the mouth) 0.25 mg, one by mouth twice a day. The medication was increased September 12, 2023 to Klonopin (ODT) 0.5 mg in the AM and 0.25 mg at HS (at bedtime). Nurses notes dated November 28, 2022 at 11:19 A.M. revealed that the certified registered nurse practitioner was aware of the resident's increased behaviors and safety concerns. The CRNP discontinued the Klonopin ODT dose of .5 mg in the AM and .25 mg in the PM and ordered the start Klonopin ODT 0.5 mg by mouth twice a day. A review of nurses notes dated December 14, 2022 at 2:41 P.M. revealed The nurse was walking down 395285 Page 2 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the hall, observed the resident sitting on the edge of her chair. The chair flipped and she fell to the floor. Nursing assessed the resident and no injuries were noted. Nurses note dated December 14, 2023 at 12:50 P.M. revealed that the nursing notified the CRNP that the resident was displaying continued outbursts and yelling. Nursing noted that Resident 19 continued to throw objects and swearing. The CRNP ordered an increase in the resident's dose of Celexa (an antidepressant medication) to 40 mg by mouth every day and also increased the resident's dose of Klonopin (ODT) to .5 mg, by mouth to three times a day. Resident 19 was admitted to the hospital December 15, 2022, and readmitted to the facility on [DATE]. The order for Klonopin (ODT) .5 mg TID was not re-ordered upon the resident's readmission to the facility. Upon readmission to the facility on December 19, 2022, the physician ordered Buspirone HCL (antianxiety medication) 10 mg tablet, give one by mouth twice daily for anxiety. On January 5, 2023 at 12:30 PM, nursing called the physician to Resident 19's room. Resident 19 was flailing her arms and screaming at staff. Nursing noted that the resident was unable to sit still at that time. Redirection given, food and beverages offered, change of scenery given, one to one preformed. Resident continues to flail and scream at staff. New order noted, Haldol (an antipsychotic medication) 1 mg by mouth, give now and Haldol 1 mg by mouth twice a day. A review of a monthly medication administration record (MAR) revealed that Resident 19 received Haldol 1 mg BID daily from January 5, 2023, through January 18, 2023. A review of nurses notes dated January 18, 2023, at 2:23 PM revealed that nursing noted that Resident 19 continued with agitation, restlessness and the physician was made aware. A new order was noted to discontinue the Haldol and order Depakote ( an antiseizure medication sometimes used as a mood stabilizer) 250 mg by mouth three times a day. A nurse's note dated February 8, 2023 at 9:57 A.M. revealed that Resident 19 displayed increased anxiety and restlessness. Nursing noted that the resident was yelling out and throwing things. Refused meals and liquids this morning due to increased anxiety. Re approached. Dark area provided. Resident taken for a walk. No good effects noted. The physician was notified and a new order noted for Xanax (an antianxiety medication) 0.5 mg, take 2 tabs by mouth now and Xanax 0.5 mg, take 2 tabs by mouth every day. Nursing noted on February 9, 2023 at 2:33 P.M., that Resident 19 displayed increased anxiousness and restless movements this afternoon. Refused lunch. Yelling out. Dark quiet area provided. No good effects noted and the physician was made aware. A new order was noted for Xanax 0.5 mg, give 2 tabs by mouth now. A nurses note dated February 10, 2023 at 2:49 revealed that Resident 19 was extremely agitated and unruly, cussing, flailing her arms and legs. Staff placed the resident in a broda chair. The resident was repeatedly trying to bounce in her chair and get out of her chair. Resident very animated, will not calm down. Nursing noted on February 10, 2023 at 4:36 A.M., that Resident 19 displayed unrelenting episodes of agitation and restlessness with acting out and inability to calm down after repeated measures were tried. Nursing noted that the resident has an indwelling urinary catheter and was provided catheter care. Resident does not appear to understand about the catheter and lack of need to be toileted for 395285 Page 3 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some urination although this was repeatedly verbalized to her. Resident was put into her broda chair and placed at the nurses station but kept trying to [NAME] herself out of the chair. Nursing called the physician regarding the resident's behaviors and the physician ordered Xanax 0.5 mg by mouth now. Resident 19 was admitted to the acute care hospital and readmitted to the facility on [DATE]. Upon readmission the physician ordered Xanax .5 mg by mouth every 8 hours as needed for 14 days. A pharmacy request to the physician dated February 20, 2023, revealed that the pharmacist requested that the physician re-evaluate the resident's need for Xanax 0.5 mg, every 8 hours by mouth as needed. The physician re-ordered Xanax 0.5 mg every 8 hours as needed every 14 days beginning February 20, 2023. On March 18, 2023, the pharmacist requested that the physician re-evaluate the resident's need for Xanax 0.5 mg, every 8 hours by mouth as needed. The pharmacist noted Please note that renewal of an as needed order requires a physician explaination and documentation. Based on the narcotic order sign out sheet, it may be appropriate to make Xanax a straight order at bedtime. The physician response was noted by the CRNP dated March 22, 2023, noting Xanax changed to straight order at 2 A.M for anxiety disorder. Nurses notes dated March 21, 2023 at 3:58 A.M. revealed that PRN Xanax 0.5 mg tablet given after continuous attempts to calm resident. Nurses notes dated March 21, 2023, at 1:33 PM revealed that the 14 day, as needed, Xanax order was reevaluated by Physician with a new order noted, Xanax 0.5 mg by mouth every day at 2 A.M. There was no documented evidence at the time of the survey of a documented physician evaluation regarding the resident's need for the administration of the Xanax at 2 AM daily. In response to the resident's behaviors nursing staff notified the physician/physician extender and multiple psychoactive medications were ordered and administered to this resident concurrently. There was no documented evidence at the time of the survey that the facility had used the least restrictive alternative for the least amount of time, that the prescribing practitioners had conducted ongoing re-evaluation of the need for the medications and consistently demonstrated these drugs were not used for staff convenience to most readily control the resident's behavior with least amount of staff effort. The facility administered multiple psychotropic drugs including Klonopin, Buspar, Depakote, Haldol, and Xanax to control the resident's behaviors. An interview with the Director of Nursing on April 13, 2023, at approximately 12:00 PM confirmed that the resident's clinical record lacked documented evidence that the staff and prescribing practitioners had identified and addressed to the extent possible, potential underlying causes for the resident's behaviors and had attemped to rule potential causes for the resident's behaviors to include possible physical causes such as pain or potential adverse consequences associated with the resident's current medication regimen or possible environmental factors, such as staffing levels, over stimulating noise or activities, under stimulating activities, alteration in the resident's customary location or daily routine, temperature of the environment, and crowding to ensure the medical necessity 395285 Page 4 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0605 of the administration of these psychoactive drugs. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan Residents Affected - Some 28 Pa. Code 211.8 (b) Use of restraints 28 Pa. Code 211.2(a) Physician Services . 395285 Page 5 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview it was determined that the facility failed to include a recapitulation of the residents' stay in the discharge summary of one of two closed records reviewed (Resident 42). Findings include: A review of the closed clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses impaired ambulation and generalized weakness and after care and therapy post hospitalization. The resident was discharged to an assisted living facility on January 20, 2023. A nursing note dated January 20, 2023 at 11:20 AM revealed that Resident 42 was picked up at the facility by her daughter, noting that the resident was going to a personal care home. There was no documented evidence of a recapitulation of the resident's stay to include, nursing discharge instructions, a review of therapy services received while a resident at the facility, and a discharge summary, dietary discharge instructions, social services summery while a resident at the facility and corresponding discharge instructions, any upcoming physicians appointments and a summary of activities noted during the stay at the facility. An interview with the Nursing Home Administrator on April 13, 2023 at approximately 1 p.m., confirmed that a recapitulation of Resident 42's stay had not been completed. 28 Pa. Code 211.5 (f) Clinical records. 28 Pa. Code 201.25 Discharge policy 395285 Page 6 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

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 incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized fall prevention interventions planned to meet resident's safety and supervision needs based on known risk factors, history of falls and displays of unsafe behaviors to prevent falls for two residents (Resident 10 and 33) resulting in a serious injury, a fractured hip, to one resident (Resident 10) and failed to maintain an environment free of potential accident hazards in one resident's room (Resident 26) out of 13 sampled residents. Findings include: The facility policy entitled Falls dated as reviewed March 29, 2023, indicated that a care plan will be developed to address the resident's specific factors which may contribute to the resident's risk for falls. At the beginning of each shift, all nurse aides will participate in walking rounds where they will also check to be sure safety alarms are in place and functioning appropriately. If a resident should sustain a fall, the resident will be re-evaluated by the Physical Therapist for new recommendations to prevent further falls. Review of Resident 10's clinical record revealed admission to the facility on September 3, 2020, with diagnoses to have included senile dementia [is a group of symptoms that affects memory, thinking and interferes with daily life], anxiety, depressive disorder, and general deconditioning. The resident's care plan to address the resident's safety needs, initiated on September 3, 2020, indicated that the resident would remain safe and free from falls and injury with noted interventions that included assist of one with transfers, orient to call system as needed, bed to floor - locked in position and bilateral pressure alarm mats and bilateral floor mats. Review of Resident 10's quarterly Minimum Data Set (MDS a federally mandated standardized assessment process completed periodically to plan resident care), dated October 12, 2022, revealed that the resident was moderately cognitively impaired. The resident required extensive assistance of two plus-person physical assistance for bed mobility and transfers and required total dependence of two plus persons physical assist with toilet use. The resident was not steady and only able to stabilize with staff when moving from seated to standing position and with surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident was always incontinent of bladder and bowel. The MDS also noted that the resident had fallen in the last month and had fallen in the last 2-6 months without fracture related to a fall in the last 6 months. A facility Incident Investigation Form dated November 4, 2022, at 7:40 AM, revealed that Resident 10 had an unwitnessed fall in the doorway of her room. Employee 1, a nurse aide, reported that the resident was walking down the hallway and that she helped her to get into her chair. Resident 10 climbed out of her chair and walked towards her room, into the doorway, and fell. The sustained a 4.0 cm x 4.0 cm scrape to her right knee and a 2.0 cm x 2.0 cm bruise on her left lower leg. The planned preventative measure was for the resident not to be left in the hallway near her room and the resident should be either in her room, or the dining/activities room, or by the nurse's station. The investigation form noted that the resident's safety plan of care was updated. There was no indication that therapy performed a re-evaluation after Resident 10's fall on November 395285 Page 7 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0689 4, 2022, as indicated in the facility's Fall policy. Level of Harm - Actual harm Review of Incident Investigation Form dated November 9, 2022, no time indicated, revealed that the resident had a witnessed fall in the dining room. The investigation noted that the witness to Resident 10's fall was Resident 26. Resident was severely cognitively impaired with a BIMS score 6. However, Resident 26 stated that she witnessed Resident 10 slide out of her chair and land on the floor of the dining room. Resident 26 stated that she tried to help Resident 10 get up and off the ground, but she could not help her. Additionally, Resident 26's witness statement indicated that someone picked her up and took her maybe to the bathroom but she did not know the name of the staff member who picked Resident 10 up from the ground. Residents Affected - Few The Incident Investigation Form further revealed that the Director of Activities saw Resident 26 flailing her arms and pacing back and forth and went to investigate the situation. When the Director of Activities arrived at the area where the residents were assembled, at the other end of the activities/dining room, Resident 10 was sitting on the edge of her Geri Chair and presumed that she climbed back into her chair before she arrived at the area and assisted Resident 10 to sit back in her chair to prevent a fall. The Activities Director assumed that Resident 10 was about to fall out of her chair and did not realize that she already had fallen and was getting herself back into her chair when observed. There was no evidence that the resident's chair alarm was in place and sounding. The facility's investigation also noted that the activities aide, that was working on November 9, 2022, at the time Resident 10's fall was on lunch from 1:45 PM until 2:15 PM. There was no evidence of any staff supervising these residents assembled in the dining/activities room, including Resident 10, who was unsupervised at the time of the fall. Review of Employee 2's, Activity Aide, statement dated November 11, 2022, at 9:00 AM, revealed I was on my lunch break at 1:45 PM to 2:15 PM and when I came back at 2:15 PM, Resident 26 told me that Resident 10 fell out of her chair and how scared she was. Employee 2 noted that she asked Resident 10 about the fall and Resident 10 confirmed that she fell out of her chair. Employee 2's statement indicated that the incident happened in the dining/activity room and that Resident 10 did not report any pain until 6 PM that evening when she took the resident to the bathroom. On November 9, 2022, the resident complained that her right leg was bothering her and Employee 2 reported the incident to the charge nurse, Employee 5, a night shift RN. Review of a statement that was completed by Employee 3, a nurse aide, dated November 9, 2022, and signed by the employee on November 12, 2022, revealed that Resident 10 kept telling us she fell earlier. Employee 3 noted that she didn't witness the fall, but when she took the resident to the bathroom around dinner time the resident had more trouble standing and turning to go to the bathroom. The resident told Employee 3 that she had fallen earlier that day and that her leg hurt a little bit. According to Employee 3's statement Resident 10 claimed that she fell on the previous shift and the two girls had picked her up. The resident also stated that one girl had a ponytail and glasses and the other girl she couldn't remember. Employee 3's statement noted that the resident was not in a ton of pain, just said that her leg hurt. Employee 5 contacted the Director of Nursing (DON) at 8:15 PM on November 9, 2023, and reported that she checked Resident 10 over and that there was discomfort to the resident's leg, but the resident was able to lift the leg, and no deformities were noted to the leg. The preventative measure planned was to apply a pressure sensor alarm in the resident's chair. 395285 Page 8 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0689 Level of Harm - Actual harm Residents Affected - Few An Incident Investigation Form dated November 10, 2022, (no time indicated) revealed that Resident 10 had an unwitnessed fall in her room the night prior (November 9, 2022 - the same date as the resident's fall in the dining/activity room witnessed by Resident 26) and didn't report the fall to any staff until November 10, 2022, in the afternoon. Resident 10's attending physician assessed the resident and indicated that the resident stated that she had right leg pain and that she had fallen last night and put herself back into bed. Resident 10 was given a PRN (as needed) Tylenol and the attending MD ordered an X-ray of her right hip and femur. There was no indication of any alarms sounding at the time of the resident's reported fall from bed on November 9, 2022, although the resident's care plan identified that bilateral pressure alarm mats were to be placed on the resident's bed and floor mats on the sides of the bed. Review of the radiology report November 10, 2022, at 12:54 PM, revealed that the impression of the x-ray was an acute impacted fracture of the right femoral neck. At that time, Resident 10's attending physician ordered the resident be sent to the Emergency Department. Review of nursing documentation dated November 11, 2022, at 1:20 AM, revealed that Resident 10 was admitted to the acute care hospital and that the resident was to have a pre-op evaluation for repair of the right hip. Review of Resident 10's alarm monitoring records dated November 2022 revealed that the resident had a pressure sensitive alarm in place on the chair and bed, which were noted to be functioning at the time of her two falls on November 9, 2022. Interview with Employee 4, a unit clerk, on April 12, 2023, 1:00 PM, reported that Resident 10 had alarms in place prior to her falls on November 9, 2022, and prior to sustaining the fracture. Employee 4 confirmed that the facility's alarm records reflected that staff documented alarms were already in place and functioning at the time of the resident's fall. Employee 4 was unable to explain why the incident report noted the addition of a chair alarm on November 9, 2022, since it was already care planned and documented as in place. During an interview with the Nursing Home Administrator (NHA) on April 12, 2023, at 2:23 PM, it was revealed that the facility was unable to determine which staff members, if any, were in the dining/activity room supervising the residents at the time of Resident 10's fall from her chair in that area on November 9, 2022. The NHA confirmed that the facility failed to ensure supervision of a resident with a history of falls to prevent a fall with major injury, a fracture. Also, the NHA reported that based on the information gathered and staff statements obtained regarding Resident 10's two falls on November 9, 2022, the facility was not able to identify the staff members who may have assisted the resident back into her chair when she was on the floor in the dining/activity room and whether an alarm was present on the resident's chair at the time as noted on the alarm monitoring records. The NHA also verified that the facility failed to re-evaluate Resident 10 after each fall as indicated in the facility's Fall policy. Clinical record review revealed that Resident 33 was admitted to the facility on [DATE] with diagnoses to include after care following a fracture. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was 395285 Page 9 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0689 Level of Harm - Actual harm Residents Affected - Few moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status a tool used to screen and identify the cognitive condition of residents) and was independent for transfers, locomotion and toileting. A review of a facility incident investigation report dated March 16, 2023 at 12:40 P.M. revealed that staff observed Resident 33 in the hallway outside her room. Employee 5 (RN unit manager) heard Resident 33 yell out and fall to the floor, hitting her elbow. Employee 5 assessed the resident and helped the resident back to her bed. The resident was instructed to be more careful when walking. The resident, when interviewed, stated there was a chair in the hallway for me to sit on. When I was walking to the chair, I was holding onto the door and then the handrail, but the floor in my room and the hallway was so slippery that I fell. I had these socks (non-skid) on and still fell on my butt and hit my elbow. The facility investigation noted that the floor of Resident 33's room was found to be very dirty and slippery and outside of the resident's room, a slippery residue was found on the floor. The non-skid socks the resident wearing at the time of the fall were found to be worn and were replaced after the fall. A review of nursing documentation dated March 16, 2023 at 9:23 P.M. revealed, Resident 33 complained of right pelvic pain. She was noted to be very unsteady on her feet, her knees were buckling. The physician was notified and bilateral hips and pelvis xrays were ordered and completed. There were no fractures noted at that time. There were no additional interventions developed or implemented at that time to prevent falls to address the resident's unsteadiness during ambulation. A review of a nurses note dated March 17, 2023, at 9:21 P.M. revealed, Resident 33 was walking poorly, needed assistance to walk. A review of an incident report dated March 19, 2023, at 10:20 A.M. revealed Resident 33 was self ambulating to the bathroom. ( The bathroom is located across the hallway from the resident room. It is a communal resident bathroom) The resident began yelling out and her roommate rang her call bell. Employee 6, a nurse aide, stated that she went into the bathroom and found Resident 33. Resident 33 stated that she fell in the doorway of the bathroom while trying to get back to bed. The resident stated that she was able to get up from the floor and sat back on the toilet. Employee 6 called the licensed nurse who assessed the resident. Resident 33 was complaining of right knee and right hip/pelvis pain. Resident 33 was noted with unsteady ambulation. Upon assessment, the resident's right knee was reported with swelling and she was complaining of discomfort. The Physician was called and the resident was sent to the emergency room. A review of an xray report dated March 19, 2023 revealed, subtle nondisplaced fractures of the right sacral area and right pubic bones, but no acute fracture. New interventions planned after this fall were a therapy evaluation for transfer and ambulation status. There was no evidence at the time of the survey that interventions were implemented after the resident's March 16, 2023, fall and observed unsteadiness and difficulty ambulating on March 17, 2023, to include a therapy screening or evaluation for ambulation as noted in facility policy. Staff 395285 Page 10 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0689 observed that Resident 33 exhibited unsteady ambulation and transfers and the resident incurred another fall 3 days later. Level of Harm - Actual harm Residents Affected - Few During an interview March 13, 2023 at 11 A.M., the Director of Nursing confirmed that the facility failed to ensure the resident's non-skid socks were in good condition and not worn/threadbare, and that the resident was not timely referred to therapy for ambulation screening, as noted in facility policy, following the resident's fall on March 16, 2023, and prior to the resident's fall on March 19, 2023, which the resident also incurred while ambulating. Observation of resident room [ROOM NUMBER] on April 11, 2023, at 10:40 AM revealed that Resident 26 presently resided in the bed located by the door of this room. Resident 26, the resident assigned to the bed by the door, was fully ambulatory, but not present in the room at the time of the observations. Continued observation revealed that maintenance/hardware supplies were observed on the overbed table and unoccupied bed located by the window, on the window sill, and the floor of resident room [ROOM NUMBER]. On the overbed table, there was a glass framed wall plate with a side of the glass exposed, 4 white pieces of wood with loose screws, a black basket, and a white cable with ends exposed. There was a long piece of wooden wall molding on top of the unoccupied bed. On the window sill there were 4 metal shelf brackets, hard plastic baseboard molding, and a plastic outlet wall cover. On the floor beside the unoccupied bed there were pieces of grey plastic baseboard molding. Interview with the Nursing Home Administrator on April 12, 2023, at approximately 11:00 AM confirmed that the maintenance items left unattended in resident room [ROOM NUMBER] were a potential accident hazard to Resident 26, the ambulatory resident currently residing in that room. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 207.2 (a) Administrator's responsibility 28 Pa. Code 211.11 (d)(e) Resident care plan 395285 Page 11 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 interviews with staff, it was determined that the facility failed to provide therapeutic social services to promote the psychosocial well-being of two of 13 residents reviewed (Resident 26 and Resident 4). Residents Affected - Some Findings include: A review of Resident 26's clinical record revealed admission to the facility on April 10, 2019, with diagnoses which included depression, neuralgia (pain due to a damaged nerve), and anxiety. A Quarterly MDS (Minimum Data Set, an assessment completed periodically to plan resident care) dated September 12, 2022, revealed that Resident 26 was severely cognitively impaired. A nursing note dated February 6, 2023, at 10:04 PM, revealed that the resident became agitated after having her room temporarily changed to allow maintenance staff to perform painting and necessary repairs to the room. According to the nursing documentation, once the resident was temporarily relocated, she became agitated and expressed a desire to leave the facility. Resident 26 then made motions with fingernails to slash wrist and the resident stated to staff that she wanted to kill herself and the staff. The nursing staff immediately provided one-on-one supervision, assessed the resident's physical environment, and suspended maintenance to the resident's normal room and placed her back into her normally assigned room. Despite staff efforts to redirect the resident, she continued to express desire to die, and exit seek. The physician ordered the resident to be sent to the emergency room for evaluation due to negative/suicidal statements. A review of social services documentation dated February 7, 2023, at 2:17 PM, indicated that Resident 26 was upset the night prior about having her room temporarily relocated due to maintenance scheduled for her assigned room. According to the documentation, Resident 26 was initially agreeable to the temporary room change, but then became agitated, expressing the desire to leave the facility, and harm herself and/or staff. Resident returned to the facility after being evaluated by the hospital. The resident did not acknowledge the events of last evening, was cheerful, pleasant, and verbalized no suicidal ideations or any threat to herself or any staff members. Review of clinical record revealed that Resident 26 was evaluated by outside psychiatric services on February 15, 2023, at 930 AM for stated suicidal ideations. The evaluation determined that the resident's current risk factor for suicide was low and that the resident would follow-up with the outside psychiatric services in one month. Recommendations were to add an antidepressant to the resident's current medication regimen. A review of social services documentation dated February 23, 2023, at 2:56 PM, revealed that an invitation was sent to the resident's daughter to attend the next scheduled care plan meeting. There was no documented evidence that the facility's social service worker had reviewed and/or addressed the consulting psychiatric notes/recommendations to ensure that the resident received appropriate services related to recent verbalizations of self-harm and expressions of distress to ensure the resident's current psychosocial needs were met. A review of social services quarterly assessment documentation dated February 28, 2023, at 11:49 395285 Page 12 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some AM, revealed that the resident continued on safety checks by nursing every 2 hours, no suicidal ideations noted, and emotional support and TLC offered as needed. The social service documentation did not address the resident's response to the emotional support and TLC offered. There was no documented evidence that the facility's designated Social Services Director provided therapeutic social services to Resident 26 in response to the resident's increased agitation, self-harm verbalizations and expressions of distress beginning February 7, 2023. Review of Resident 26's care plan for suicidal thoughts/verbalization initiated on February 7, 2023, noted the planned interventions to conduct checks of the resident every shift as directed by physician, schedule psychiatric visits as ordered, contact physician to determine if transfer to ER for emergency treatment warranted if suicidal statement made, assess physical environment for harmful objects and remove those considered to be potentially harmful, contact resident's family regarding verbalized expression, provide for client's basic needs, promoting highest possible level of independent functioning, provide experience/interactions that enhance self-esteem, sense of personal power, safety checks as needed, check room for anything that might be harmful as determined by interdisciplinary care plan team, encourage involvement in life of facility, provide support to resident as needed, one-on-one visits as needed. Review of Resident 26's behavior monitoring flow record dated February 2023 for monitoring of verbally aggressive behaviors revealed that on February 24, 25, and 26, 2023, the resident experienced verbally aggressive behaviors. According to the documentation, the staff attempted redirection, one-on-one, activity, toileting, and food and fluids. All interventions were ineffective to resolve the resident's aggressive behaviors. There was no documentation in the resident's clinical record of the provision of therapeutic social services had been provided to the resident in response to the resident's behavioral symptoms. An interview with the Nursing Home Administrator (NHA) on April 13, 2023, at approximately 2:00 PM confirmed that there was no documented evidence that the facility's social service worker provided therapeutic and medically-related social services to Resident 26 to promote her psychosocial well-being. Review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included Alzheimer's Disease, dementia with psychotic disturbance, unspecified mood disorder, depression, and anxiety disorder. Resident 4's admission Minimum Data Set (MDS) assessment of Resident 4, dated March 23, 2023, revealed that the resident was cognitively intact. Review of nursing progress note completed by Employee 8, a LPN, dated March 20, 2023, at 12:15 PM, revealed that she had been notified by an activity aide that the Resident 4 vocalized that he wanted to kill himself. Employee 8 noted that she immediately assessed the resident and situation and that Resident 4 stated that he was feeling upset and does not like his current situation. The resident stated that he did not have a plan to harm himself. Employee 8 immediately notified the attending physician and was placed on every 30-minute checks, call-bell was removed and provided with a hand bell, and knives were removed from all meal trays for safety. Additionally, review of the attending physician's assessment dated [DATE], at 4:52 PM, revealed that the physician assessed and indicated that Resident 4 did not seem suicidal and was more or less 395285 Page 13 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0745 seeking attention and that the resident was at a low risk to hurt and/or kill himself. Level of Harm - Minimal harm or potential for actual harm The physician ordered a psychiatric evaluation, and the resident has a scheduled appointment with psychiatric services on April 19, 2023. Residents Affected - Some Further review of Resident 4's clinical record revealed that the social service worker completed a Social Evaluation on March 16, 2023, noting that he was unhappy about placement and wanted to go home now and noted that the resident was very anxious. The social service worker noted Follow-up with patient/family as needed. Further review of the social service worker's social evaluation assessment indicated that an addendum note was added to the evaluation on March 21, 2023. The addendum indicated that Resident 4 had an episode yesterday when the resident stated that he would kill himself and that he did not like it at the facility and was very anxious. Additionally, it was noted that he was frustrated with his hip fracture and that emotional support was offered and accepted and seemed calm that day. Further review of social service's progress notes dated March 22, 2023, at 11:34 AM, revealed that he was very anxious to return to his prior home and that he was frustrated with his current physical status and felt antsy and had a poor appetite and was not sleeping well because of nerves. Additionally, social service progress notes dated March 23, 2023, at 8:44 AM and 3:06 PM, continued to note that the resident felt down, and had trouble falling asleep and staying asleep, felt tired, and had a poor appetite 12-14 days of the last two weeks. The social service worker indicated that the resident was receiving antidepressant medication to manage depression and was prescribed Xanax (a type of drug called a benzodiazepine and used to treat anxiety and panic disorders) to manage his anxiety. There was no further documentation in the resident's clinical record that social services had followed up with Resident 4 after March 23, 2023, until during on site survey ending April 13, 2023, and had consistently provided therapeutic social services to promote the resident's psychosocial well-being and to assist the resident in coping with his current situation and to manage the resident's signs/symptoms of depression. An interview with the Nursing Home Administrator (NHA) on April 13, 2023, at approximately 2:15 PM, confirmed that there was no further documented evidence that the facility's social service worker provided therapeutic and medically-related social services to Resident 4 to promote his psychosocial well-being. 28 Pa. Code 211.5(f)(g)(h) Clinical Records 28 Pa. Code 211.16 (a) Social Services. 395285 Page 14 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on a review of clinical records and staff interview it was determined that the facility failed to ensure that the pharmacist conducted a drug regimen review at least monthly that included a thorough evaluation of the medication regimen of a resident, including a review of the medical record for supporting clinical rationale for the medications prescribed for one resident out of 28 sampled (Resident 28). Findings include: The Monthly Medication Review (MMR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MMR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. A review of Resident 28's clinical record revealed that the licensed pharmacist indicated that there were no irregularities relating to the resident' use of Risperidone 0.5 mg (antipsychotic medication) prescription for a diagnosis of Dementia Behavioral Disturbances on the Chronological Record of Monthly Medication Regimen review (MMR) form dated March 18, 2023. Further review of Resident 28's MMR completed by the pharmacist indicated that no irregularities were identified in the resident's drug regimen during the months of February 20, 2023, January 14, 2023, December 17, 2022, November 19, 2022, October 23, 2022, and September 28, 2022. A review of Resident 28's clinical record failed to indicate an active diagnosis of Dementia or dementia behavioral disturbances. A review of Resident 28's Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 2023, did not indicate an active diagnosis of dementia. A review of Resident 28's clinical record revealed an active order, at the time of the survey ending April 13, 2023, for Risperdal (Risperidone) 0.5 mg Give one tablet by mouth twice daily for anxiety disorder, unspecified. Interview with the Nursing Home Administrator on April 12, 2023, at 10:45 a.m. confirmed that Resident 28 did not have a current diagnosis of Dementia or supporting diagnosis for the use of the antipsychotic drug, Risperdal and the pharmacist failed to identify the irregularity in the resident's drug regimen. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.5(h) Clinical records 395285 Page 15 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

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 observations and a review of select facility policy and staff interviews it was determined that the facility failed to label multi dose medication bottles with open dates to ensure acceptable time frames for use on one medication cart out of two medication carts observed (blue hallway). Findings include: According to the National Association of Boards of Pharmacy, Uniform Prescription Labeling Requirements, indicate that critical information on prescription labels include the Use by date, which is the Date by which medication should be used, not expiration date of medication or expiration date of prescription. During an interview April 12, 2023, at 11 AM, the Director of Nursing stated that multiple dose eye drop bottles are to be discarded 30 days after opening. In addition, nursing staff are to write the date opened on the bottle when first opened for use. Observation conducted on April 12, 2023, at 9:30 a.m. of the blue hallway medication cart revealed 1 bottle of Prednisone-Bromfernac eye drops belonging to Resident 6 with no open date and an opened bottle of Moisture eye drops belonging to Resident A1 with no open date. The observation was confirmed at the time of the observation by Employee 7 (LPN). Interview with Employee 2, Licensed Practical Nurse, at this time, confirmed that the medications were outdated and should been disposed of and not left in the cart for continued resident use. An interview with the Nursing Home Administrator on April 13, 2023, at 2 PM confirmed that the Ophthalmic medication should have had an open date. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (a)(d)(3)(5) Nursing services 395285 Page 16 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 that 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. 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). Review of the current facility policy entitled Policy for Dating Leftovers and Dairy Products indicated that all leftovers will be put in containers or plastic bags and dated and then used within 72-hours. Dry storage area, walk-in coolers and walk-in freezers, and coolers will be checked and logged for cleanliness and for dating of items at the beginning and at the end of operation by the supervisor or designee. Review of the current facility policy entitled Container Policy: Resident Food Storage indicated that resident items are to be placed in a closed container and the container will be labeled with the resident's name, date, and room number. Perishable food will be kept in the unit refrigerator no longer than consumably desirable, as determined by the nursing staff. Observation in the reach-in tray line refrigerator that there was a stainless-steel pan of cherry fruited gelatin that was dated April 7, 2023, and scheduled for service on April 8, 2023, and on April 11, 2023. The food service manager stated that the prepared item should be discarded in 3-days and confirmed that the fruited gelatin should not be served on April 11, 2023 (> 3-day). Observation in the tray line cooler revealed that there was a deep stainless pan of lettuce and 7 containers of foods intended for the salad bar, which were not dated. There were three plastic clamshell containers of scones that were not dated. There were three shallow trays (one pizza, one brussels sprouts, and one with potatoes) that were not dated and a half shallow stainless pain that contained cherry gelatin that was uncovered and open to air. Observations in the walk-in dairy cooler revealed a 5 lb. container of cottage cheese that was opened and dated April 2, 2023. The manager confirmed the container should have been discarded. Observations of the dry storage area revealed a garbage can with trash inside that did not have a lid to cover the trash. In the area that housed snacks and cases of canned soda, there was a bucket on the top shelf of a wired rack and placed underneath an open ceiling tile that exposed a repaired broken pipe. The dietary manager stated there was a broken sewage/waste disposal pipe and that it was repaired and that the bucket was placed there in case of another break. 395285 Page 17 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0812 Level of Harm - Minimal harm or potential for actual harm Observation of the area that housed dietary's paper products revealed that there were several cases of product stored too close to the ceiling. Observation of the walk-in produce cooler revealed that there was a 12.84-ounce bottle of balsamic glaze that was not dated Residents Affected - Many Observation revealed an accumulation of dust in the light fixture and vent grates with cobwebs present on the hood above the stove. The ceiling fan inside of the dish room had an accumulation of dust and debris. During an observation of the unit pantry area on April 11, 2023, at 10:55 AM, revealed that the following concerns were identified: there was a container of cheesecake that was dated March 22, 2023, (expired by 20-days), a jar of nacho dip that was not labeled or dated, an open jar of cheese dip that was not labeled or dated, a packet of sour cream with a manufacturer's expiration date of April 10, 2023 (expired by 4-days), and a quart of half and half with a listed expiration date of January 23, 2023. A significant build-up of ice crystals was observed in the freezer and there was a package of frozen pizza that had significant ice crystals inside of the packaging and was not dated. Interview with the Nursing Home Administrator on April 12, 2023, at 1:15 PM, confirmed that the dietary department and unit pantry area were to be maintained in a sanitary manner and that food/beverages should be stored in a sanitary manner. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa Code 211.6(c) Dietary services 395285 Page 18 of 19 395285 04/13/2023 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on select facility policy review and staff interview it was determined that the facility failed to develop and implement a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of foods. Residents Affected - Some Findings include: Review of the current facility policy entitled Container Policy: Resident Food Storage that was last reviewed by the facility on December 22, 2022, indicated that resident items are to be placed in a closed container and the container will be labeled with the resident's name, date, and room number. Perishable food will be kept in the unit refrigerator no longer than consumably desirable, as determined by the nursing staff. During an observation of the unit pantry area on April 11, 2023, at 10:55 AM, revealed that there were several food items brought in by residents' family/visitors that were kept past the manufacturers' identified expiration date on the packaging. The facility failed to fully develop and implement a policy that addressed sanitary food storage practices for personal food to include expected discard dates. Interview with the regional Nursing Home Administrator (NHA) on April 13, 2023, at 1:30 PM, failed to provide documented evidence that the current facility outside food policy included safe and sanitary storage, handling, and consumption of the food. Refer F812 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(a) Resident care policies 395285 Page 19 of 19