Health inspection·March 7, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and review of clinical records, it was determined that the facility failed to ensure that residents are afforded the right to make choices about aspects of their lives that were significant to them, including medication treatment options, for one resident out of 13 sampled (Resident 30). Findings include: Review of the clinical record revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and vitamin deficiency. An admission MDS (minimum data set-federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 17, 2024, revealed that the resident was cognitively intact with a BIMS (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 14. Interview with Resident 30 on March 5, 2024, at approximately 9:45 AM revealed that the resident stated that she has been requesting specific medications that she had received in the past. She stated that she was prescribed Neurontin for bipolar disorder by her psychiatrist in the community and that she felt as though she was doing much better when receiving that medication. The resident mentioned that she has been experiencing increased anxiety, especially prior to going for debridement treatment on her wounds, and in the past she would receive the antianxiety drug Ativan, as needed, which she no longer receives. The resident also expressed concerns that she was no longer taking vitamin D and a multivitamin (MVI) supplements. The resident stated that she has voiced these concerns to multiple facility staff members but her concerns have not been addressed. A review of the resident's medication administration record (MAR) for the month of March 2024 revealed that the resident was not current prescribed any the above medications or vitamin supplements that she mentioned during the interview, Neurontin, Ativan, Vitamin D, or multivitamin. An interview conducted on March 5, 2024, at approximately 10:30 AM with Employee 3, a nurse aide, confirmed that the resident has mentioned her medication concerns in the past. She stated that she was unaware of the resident's increased anxiety, but would convey the resident's complaints to the licensed nurse. Page 1 of 23 395285 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM revealed that Resident 30 was scheduled to see a behavioral health specialist in the community on April 18, 2024, at 1:00 PM to evaluate the resident's mental health and review the resident's medications. Interview with the Nursing Home Administrator (NHA) and DON on March 7, 2024, at 1:45 PM, confirmed that the facility failed to demonstrate that the resident was timely afforded the right to participate in making choices about health care and treatment options. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 201.18 (e)(1) Management 395285 Page 2 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 timely consult with the resident's physician regarding the potential need to alter treatment due to repeated refusals of medication administration prescribed for one resident out of 12 sampled (Resident 8). Findings include: A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired. Nursing notes dated between January 1, 2024, through the end of survey March 7, 2024, revealed Resident 8 was refusing at least one prescribed medication on a daily basis. There was no documented evidence that the facility had consulted the resident's attending physician regarding the resident's repeated and ongoing refusal of prescribed medications, which was confirmed during interview with the Director of Nursing on March 7, 2024, at approximately 12:50 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services 395285 Page 3 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

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 review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely assess declines in skin integrity, consistent with professional standards of practice, for for two residents out of 13 sampled residents with pressure ulcers (Residents 15 and 27). Residents Affected - Some Findings include: According to Title 49 Chapter 21 49 Pa. Code § 21.145. Functions of the LPN § 21.145. Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and the patient ' s health care team members to seek guidance when: (i) The patient ' s care needs exceed the licensed practical nursing scope of practice. (ii) The patient ' s care needs surpass the LPN ' s knowledge, skill or ability. (iii) The patient ' s condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance. (2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures. (3) An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act. Resident assessment is outside the scope of an LPN. However, at the time of the survey ending March 7, 2024, the facility was utilizing an LPN to conduct resident pressure wound assessments. A review of a facility policy entitled Pressure Sore Strategies and Treatments that was reviewed by the facility on January 24, 2024, indicated that documentation was to include weekly assessment and charting. The assessment is to include the specific skin problem, location, wound characteristics and drainage. Review of Resident 15's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included hypertension (high blood pressure), type II diabetes (is a condition results from insufficient production of insulin, causing high blood sugar), and shortness of breath. Resident 15's plan of care initiated on October 19, 2021, at 7:58 a.m., identified that the 395285 Page 4 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident was at risk for developing skin breakdown due to comorbidities (more than one illness at once) with planned interventions that included to document changes in skin condition and report to charge nurse, encourage turning and repositioning, and to apply treatments to areas as ordered. A physician order dated August 16, 2023, was noted for Silver Sulfadiazine 1% Cream [(Silvadene) a medication used with other treatments to help prevent and treat wound infections in patients with serious burns], apply topically to the bilateral buttocks prophylactically. A review of a Wound Assessment Report completed by Employee 1, a licensed practical nurse (LPN) and facility's wound care nurse, dated January 10, 2024, revealed that Resident 15 had a new wound, sheering (skin impairment caused by pulling that creates stress on the soft tissue layers (fat and muscle) and could lead to a tearing of the tissue depending on how high the shearing force becomes) to the sacrum that was originally identified on January 7, 2024. Employee 1 noted that the area was to the whole sacral area with skin peeling off and indicated that the resident wanted to be pulled up in the bed causing friction. The area was cleansed, Silvadene (medication is used with other treatments to help prevent and treat wound infections in patients with serious burns) was applied as per TAR (treatment administration record), and no signs or symptoms of infection and that the area would be monitored weekly. Resident 15's clinical record weekly Wound Assessment Report completed by Employee 1, dated January 31, 2024, revealed that the resident continued to have sheering to the coccyx area and no drainage and to continue with Silvadene and monitor weekly. A review of a new wound assessment report completed by Employee 1, dated February 14, 2024, revealed that a new pressure ulcer was identified on February 12, 2024, to Resident 15's right great toe that was indicated to be an unstageable due to suspected deep tissue injury. Employee 1 noted that the resident continued with a red area to the right great toe that measured 0.6 cm in length by 1.0 in width and no signs or symptoms of infection. Bed cradle applied to bed and keep blankets and all pressure off toe and will monitor until healed. Resident 15's clinical record failed to reveal that a registered nurse (RN) timely assessed the newly identified to the sacrum and right great toe and that the identified areas were assessed as per professional nursing standards that included measurements or description of the area, and that weekly wound monitoring was completed. Additionally, the clinical record failed to reveal that the resident's attending physician was timely notified of the new areas and that the resident's care plan for skin breakdown was reviewed and revised for adequacy and continued appropriateness to promote healing and prevent further skin impairments. A review of Resident 27's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pain. A review of a nursing progress note completed by Employee 2, a LPN, dated February 15, 2024, at 9:37 a.m., revealed that Resident 15 had a new reddened area to his left second toe that measured 0.5 cm in length by 0.3 cm in width with and skin prep applied, family aware. Further review of Resident 15's clinical record weekly wound assessment completed by Employee 1, LPN, dated February 28, 2024, at 10:27 a.m., revealing that the reddened area to his left second toe 395285 Page 5 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0686 Level of Harm - Minimal harm or potential for actual harm was now an unstageable area [underneath the discolored surface, this ulcer could be as deep as a stage 3 or stage 4 wound and may also form as a blood blister or be covered with eschar (a dry, dark scab or falling away of dead skin)] that measured 0.5 cm in length by 0.4 cm in width, non-blanchable, with a white center and tender to touch. No signs or symptoms of infection and to continue with skin prep and monitor weekly and as needed until heeled. Residents Affected - Some Resident 15's clinical record failed to reveal documented evidence that a RN assessed the resident's skin impairment to his left great toe and failed to reveal that the facility had promptly reviewed and revised the resident's care plan to assure effective interventions to maintain/improve skin integrity. An interview with the facility's Director of Nursing (DON) on March 6, 2024, at 11:25 a.m., revealed that new pressure injuries and/or skin impairments should be immediately assessed and their origin investigated to plan care accordingly. The DON confirmed that the facility failed ensure timely assessment of newly identified skin impairments by a registered nurse and assessment of healing progress by a registered nurse. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services 395285 Page 6 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and select policy review and interview with facility staff, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for of one resident out of 13 sampled (Resident 7). Findings included: Review of a facility policy entitled Urinary Catheterization care and maintance reviewed February 24, 2024 indicated that, the purpose of urinary catheterization is to facilitate urinary drainage when medically necessary. Urinary catheters should be evaluated every day for the need and removed promptly when no longer necessary. a. On admission to the skilled nursing facility, a resident will be assessed for need for catheterization based on a list of acceptable clinical justification to include, urinary retention that cannot be otherwise teated; The resident is unable to pass urine due to an enlarged prostate; need for accurate output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring; Assistance for the healing of coccyx and sacral wounds stage 3 or greater; comfort or palliative care, if requested by the resident. b. If a resident is catheterized on admission to the facility and does not present with a clinically justifiable reason for catheterization, then the nursing staff will contact the attending Physician either to obtain written clinical justification for the catheter use or an order to remove the catheter. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses to include atrial fibrillation, heart failure and an indwelling foley catheter. admission physicians orders dated December 11, 2023, included an indwelling foley catheter, 16 fr, 10 cc balloon and 1800 cc fluid restriction. A review of a facility form, entitled clinical justification for foley catheter dated December 11, 2023 revealed Urinary catheters are deemed medically necessary for the following reason in the facility: Need for accurate hourly output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring. The form was signed by the resident's attending physician. A review of the residents admission urinary continence evaluation dated December 21, 2023 revealed that the resident was continent of urine. The evaluation findings dated December 21, 2023 indicated that the resident remains continent and incontinent of bowels with a 16 fr/10 cc balloon foley catheter. Will start routine toileting (for bowels) at this time. Monthly physician progress notes dated January 2024 and February 2024 failed to address the ongoing clinical necessity for continued use of the indwelling foley catheter. A review of fluid intake documentation dated December 11, 2024, to the time of the survey ending 395285 Page 7 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few March 7, 2024, revealed that the facility staff documented the resident's daily intake per shift. There was no indication that the resident's hourly urine output was being monitored and documented as noted on the clinical documentation for the foley catheter. The DON confirmed during interview on March 7, 2024, that there was no physician documentation to clinically support the use of the indwelling Foley catheter for accurate hourly urine output measurement for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring. 28 Pa. Code: 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 395285 Page 8 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 13 residents sampled (Residents 8 and 30). Findings include: A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired. Further review of Resident 8's clinical record revealed that the resident exhibited multiple behaviors, including physical aggression with staff and medication and treatment refusals. Resident 8 refused medications on an almost daily basis, throughout the months of January 2024, through end of the survey March 07, 2024, according to a review of nursing progress notes. Review of Resident 8's care plan, initiated by the facility on February 24, 2023, indicated that the resident has behavioral problems. Review of care plan interventions revealed an intervention seek MD/psych consult, as needed, for medication and behavioral management. When reviewed during the survey ending March 7, 2024, the resident's clinical record revealed no documented visits from psychological services and no indication that the resident's physician had been notified of the resident's almost daily refusal of medications. Review of the clinical record revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and opioid dependence (dependence occurs when an opioid drug is used for more than six months to manage pain associated with a medical condition). An admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) A review of the resident's current behavioral care plan dated January 6, 2024, revealed that the resident requires psychosocial interventions for bipolar disorder, opioid dependence, and pain. The planned interventions for the resident's behaviors included seeking physician/psychological consult, as needed, for medication and behavioral management. 395285 Page 9 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with Resident 30 on March 5, 2024, at 10:05 AM revealed that the resident has not received any psychological services since admission to the facility. The resident stated that her psychiatrist retired a few years ago and she has not been able to find another doctor. She stated that her previous psychiatrist prescribed her Neurontin and Ativan, medications, for her bipolar disorder and anxiety, which seemed to help her. She stated that she has been having increased anxiety especially prior to going to wound care to have debridement (a procedure to remove debris, infected/dead tissue from a wound) treatments during her stay at the facility. The resident stated that she has mentioned her concerns to several staff members without any resolution to date. There was no documented evidence that the facility had developed and implemented individualized interventions related to the resident's diagnosed conditions, including psychological services and community substance use services, as noted in the resident's behavioral health care plans. During an interview with the Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM confirmed that Resident 30 had not received any psychological services since admission to the facility. During an interview with the Nursing Home Administrator (NHA), on March 7, 2024, at approximately 10:00 a.m., the NHA was unable to provide evidence that Residents 8 and 30 were being provided the necessary behavioral health services. Refer F561 28 Pa. Code 211.10 (d) Resident care policies 395285 Page 10 of 23 395285 03/07/2024 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. **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 physician failed to act on a drug irregularity the pharmacist identified in the drug regimen of one resident out five of sampled residents (Resident 4). Findings include: A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of anxiety disorder, depression, and delusional disorder. A monthly pharmacist medication review dated on May 20, 2023, revealed that the pharmacist identified that the need for Resident 4's attending physician to evaluate the use of opioids prescribed for chronic pain greater than six months. The pharmacist noted that the resident was prescribed an opioid pain medication, Tramadol, 50 mg three times per day for pain since April 25, 2022, and recommended that the physician evaluate/reduce routine analgesic therapy with Tramadol with an end goal of discontinuation when the cause of pain had resolved, or the clinical status had changed. The resident's attending physician failed to act upon the the identified drug irregularity and did not respond to the identified drug irregularity of Resident 4's continued use of an opioid analgesic medication for pain. A pharmacist medication review dated June 10, 2023, indicated that Resident 4 was prescribed Duloxetine [(Cymbalta) a medication used to treat depression and anxiety] 20 mg by mouth daily for depression since June 2022 and recommended that the attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. The attending physician failed to act on the drug irregularity in the resident's medication regimen of the lack of a GDR during the first year in which a resident was prescribed a psychopharmacological medication. A pharmacist monthly medication review dated July 23, 2023, indicated that the resident was prescribed Quetiapine [(Seroquel) a psychotropic medication used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder] 75 mg by mouth in the morning and 50 mg by mouth at bedtime for diagnosis of delusional disorder since July 2020 and recommended that the attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. The attending physician failed to act on the pharmacist's identified drug irregularity of the lack of attempting a GDR of an antipsychotic medication, Seroquel. An interview with the Director of Nursing (DON) on March 7, 2024, at 9:15 a.m., confirmed that Resident 4's attending physician failed to act on the irregularities identified in Resident 4's drug regimen. 395285 Page 11 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0756 Refer F758 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.2 (d)(3)(8) Medical Director. Residents Affected - Some 395285 Page 12 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for six of 13 residents sampled (Resident CR1, 3, 9, 10, 20 and 30). Residents Affected - Some Findings included: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on [DATE], included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections. According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests. There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections. Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, lifelong. A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid. There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE] with diagnosis to include a history of urinary retention and a history of urinary retention. A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity. The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, prophylaxis (to prevent UTIs) with no stop date. admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections. A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, 395285 Page 13 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some but no date or time indicated on the form. The Physician documented ok on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID. An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria). Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs. A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was currently taking Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year. A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily. A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily. The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily. During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by mouth daily and no dose reduction was completed until November 3, 2023. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will 395285 Page 14 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0757 Level of Harm - Minimal harm or potential for actual harm begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time. A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures. Residents Affected - Some A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg. A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, the state is requiring followup for MRSA in the spine. {Resident 10} was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for ??. ( no reason noted). Labs ordered, Infectious disease follow up not needed. There were no additional recommendations on the form. There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline. A review of the clinical record revealed that Resident 3 was admitted into the facility on May 10, 2019, with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection). A review of record titled Newly Diagnosed Infection Report dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound). A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site. A review of a record titled Weekly Skin Documentation Flowsheet from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy. A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily. There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024. A review of the clinical record revealed that Resident 30 was re-admitted into the facility on 395285 Page 15 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some January 12, 2024, with diagnoses including MRSA infection, chronic venous hypertension with ulcers and local infection of skin and subcutaneous tissue. A review of record titled Newly Diagnosed Infection Report dated October 13, 2023, revealed that there were new orders for Ceftin (antibiotic medication) 500 mg by mouth twice daily for 10 days and Rifampin (antibiotic medication) 300 mg by mouth twice a day for 10 days to treat MRSA in wounds. A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the SSTI met McGeer's criteria by having symptoms of fever (oral temperature greater than or equal to 100.0 degrees Fahrenheit), heat, redness and serous (clear to yellow fluid that leaks out of wound) drainage at the infected site. Further review of the clinical record revealed the resident's temperature was 97.0 degrees Fahrenheit on October 13, 2023, and there was no documentation of this resident having a fever, failing to meet the McGeer criteria for infection. A review of laboratory test results for culture and sensitivity of left ankle wound dated October 13, 2023, at 7:54 AM revealed that the identified organism was resistant to the prescribed Cefuroxime Axetil (Ceftin). A review of the resident's October 2023 MAR revealed that the resident received Ceftin 500 mg by mouth twice daily for 10 days receiving 20 unnecessary doses. A review of record titled Newly Diagnosed Infection Report dated December 31, 2023, revealed that there were new orders for one dose of Vancomycin (antibiotic medication) 500 mg by mouth and one dose of Septra DS (antibiotic medication) for Escherichia coli ([E. Coli] bacteria that produces powerful toxins), extended-spectrum beta-lactamases ([EBSL] enzymes that confer resistance to most beta-lactam antibiotics) Enterobacter (a serious infection known to cause infections affecting parts of the body) and MRSA. Also, a new order to send the resident to the emergency department (ED). A review of undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the resident had heat, redness, swelling and tenderness at the affected site. There was no documentation provided showing evidence that the SSTI criteria was met. There was no corresponding physician documentation to indicate the clinical necessity of initiating antibiotic treatment to treat the resident's suspected SSTI. A review of the resident's December 2023 MAR revealed that the resident received Vancomycin 500 mg by mouth one dose and Septra DS by mouth one dose receiving 2 unnecessary doses. Consultation Notes from the hospital dated January 1, 2024, at 11:08 AM, revealed that the resident was admitted for an infectious disease consultation secondary to venous stasis ulcers. Wound cultures dated December 27, 2023, revealed MRSA plus EBSL E. coli. In summary, there is no cellulitis (bacterial infection of the skin), the wounds have colonized multidrug-resistant organisms ([MDRO] bacteria that resist treatment with more than one antibiotic) due to being in and out the hospital and long-term care facilities. At this point all antibiotic therapy should be discontinued. During an interview March 7, 2024 at 10 A.M, the Director of Nursing (DON) confirmed that the above noted residents were not free from unnecessary medications (antibiotics). 395285 Page 16 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0757 Refer F880, F881 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.2 (d)(3)(5) Medical director Residents Affected - Some 28 Pa. Code 211.5 (f) Medical records 395285 Page 17 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued dose of an antipsychotic drug prescribed for one resident out of five sampled (Resident 4) and failed to attempt a gradual dose reduction of the antipsychotic drug. Findings include: A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included anxiety disorder and delusional disorder. The pharmacist conducted a medication review on July 23, 2023, that indicated that the resident had been receiving the antipsychotic drug Quetiapine (Seroquel - a psychotropic medication used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) 75 mg by mouth in the morning and 50 mg by mouth at bedtime for diagnosis of delusional disorder since July 2020. The pharmacist requested that the resident's attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. At the time of the survey ending March 7, 2024, there was no documentation from the physician to support the lack of attempts at a gradual dose reduction of Resident 4' dose of the antipsychotic drug. An interview with the Director of Nursing (DON) on March 7, 2024, at 9:30 a.m., confirmed that the facility could not provide documented evidence Resident 4's attending physician had documented individualized clinical rationale for Resident 4's ongoing need for the current dosage of Seroquel and the physician had not attempted a gradual dose reduction. 28 Pa. Code 211.2 (d)(3) Medical Director. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.9 (k) Pharmacy services. 395285 Page 18 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, the facility's infection control data, clinical records and the facility's infection control policy it was determined that the facility failed to develop and implement infection control procedures for tracking and managing chronic infections as evidenced by four of 13 residents sampled (Residents 10, 9, 20, CR1) Residents Affected - Some Findings include: A review of the facility's current infection control policy dated as reviewed by the facility February 24, 2024, revealed that it is the policy of the facility will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The objectives to include, to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual agreement based upon the facility assessment conducted according to and following accepted national standards. A review of facility infection control logs dated from July 2023 through February 2024 revealed that there were four chronic infections treated by ongoing antibiotics among residents of the facility. These logs did not include any attempt to monitor the need for the ongoing use of the antibiotic medications, including evidence that these specific lifelong or chronic infections were reassessed and tracked to determine the need for ongoing antibiotic usage. A review of the facility's infection data dated July 2023 through September 2023, and September 2023 through February 2024 revealed that Residents 10, 9, 20 and CR1 had chronic infections which were identified in the facility's infection data each month. There was no evidence of re-evaluation or scheduled monitoring for these residents identified with chronic infections to evaluate the effectiveness and continued appropriateness of continued prophylactic antibiotic therapy. There was no descriptive information on the resident listings to include diagnostic criteria used. There was no data indicated on the monthly infection control logs indicating periodic assessment or evaluation of any of the four residents on the logs with lifelong/chronic infections requiring daily administration of antibiotic therapy to prevent infections. Interview on March 6, 2024, at 10 AM with the facility Infection Control Nurse confirmed that the facility's current infection control program did not include procedures to address those residents diagnosed with lifelong/chronic infections and clinical criteria to be used to determine best practices for treatment and any monitoring or surveillance related activities that may be required. Refer F881 28 Pa Code 211.10 (a)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(5) Nursing services 395285 Page 19 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by five of 13 sampled residents (Resident CR1, 9, 3, 10 and 20). Residents Affected - Many Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed February 2023, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic steward ship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. There was no evidence at the time of the survey ending March 7, 2024, of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on [DATE], included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections. According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests. There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections. Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, lifelong. A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid. There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE] with diagnosis to include a history of urinary retention and a history of urinary retention. A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity. 395285 Page 20 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, prophylaxis (to prevent UTIs) with no stop date. admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections. A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, but no date or time indicated on the form. The Physician documented ok on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID. An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria). Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs. A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was currently taking Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year. A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily. A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily. The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily. During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by 395285 Page 21 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0881 mouth daily and no dose reduction was completed until November 3, 2023. Level of Harm - Minimal harm or potential for actual harm Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. Residents Affected - Many A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time. A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures. A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg. A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, the state is requiring followup for MRSA in the spine. {Resident 10} was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for ??. ( no reason noted). Labs ordered, Infectious disease follow up not needed. There were no additional recommendations on the form. There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline. A review of the clinical record revealed that Resident 3 was admitted into the facility on May 10, 2019, with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection). A review of record titled Newly Diagnosed Infection Report dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound). A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site. A review of a record titled Weekly Skin Documentation Flowsheet from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of 395285 Page 22 of 23 395285 03/07/2024 Barnes-Kasson County Hospital 2872 Turnpike Street Susquehanna, PA 18847

F 0881 Level of Harm - Minimal harm or potential for actual harm serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy. A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily. Residents Affected - Many There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024. During an interview March 7, 2024 at 1 P.M., the Director of Nursing confirmed that the facility did not implement protocols to monitor antibiotic use that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and a facility-wide system to monitor the use of antibiotics. Refer F757 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.2 (d)(3)(5)(10) Medical director 28 Pa. Code 211.10 (a)(d) Resident Care Policies 395285 Page 23 of 23