Health inspection·October 27, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) bag for one of 27 residents reviewed (Resident R78). Findings include: Review of a facility policy entitled, Catheter, Urinary Bag, Care of dated 8/16/23, indicated, Maintain the dignity of the catheterized resident by concealing the urinary bag from public view in a privacy bag . Review of Resident R78's clinical record revealed an admission date of 9/11/23, with diagnoses that included Urinary Tract Infection; Resistance to Multiple Antibiotics, (occurs when bacteria change in a way that makes antibiotics less effective against them); Benign Prostatic Hyperplasia, (the flow of urine is blocked due to the enlargement of prostate gland); and Obstructive and Reflux Uropathy, (urine cannot flow through the urinary tract due to an obstruction and backs up into the kidneys). Observations on 10/24/23, at 10:18 a.m., and 10/25/23, at 10:18 a.m. revealed Resident R78 laying in his/her bed and with his/her urinary drainage bag visible from the hallway without a privacy bag. During an interview on 10/25/23, at 10:22 a.m. Registered Nurse Employee E3, confirmed that the catheter drainage bag should be covered to ensure resident privacy and dignity. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing Services Page 1 of 6 395292 395292 10/27/2023 Wesbury United Methodist Commu 31 North Park Ave Ext Meadville, PA 16335

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of 27 residents reviewed (Resident R4). Residents Affected - Few Findings include: Review of facility policy entitled Confidentiality and Non-Disclosure Policy dated 8/16/23, indicated a secured computer application will not be left unattended while signed on. During observation of medication administration for Resident R4 on 10/24/23, at 4:10 p.m. Licensed Practical Nurse (LPN) Employee E1 prepared medications for a resident from Village Center Hall medication cart parked in the middle of hall in front of the resident room with the computer open sitting on top of medication cart. LPN Employee E1 then proceeded into resident room to administer medications to a resident in the room, after administering medication the nurse walked over to the roommate behind a privacy curtain. LPN Employee E1 did not cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E1 was unable to view the computer on top of the medication cart parked in the middle of the hallway outside the resident room. During an interview on 10/24/23, at the time of the observation, LPN Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover resident/medication information that was on the computer on top of the medication cart. Employee E1 also confirmed that resident information is to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395292 Page 2 of 6 395292 10/27/2023 Wesbury United Methodist Commu 31 North Park Ave Ext Meadville, PA 16335

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of four neighborhoods (Town Square). Residents Affected - Few Findings include: Review of a facility policy entitled Cleaning of Resident Wheelchairs dated 8/16/23, indicated that all wheelchairs are to be cleaned quarterly and daily as needed by housekeeping personnel. Observation on 10/25/23, at 10:22 .a.m. revealed Resident R32's wheelchair was soiled with dried liquid substances that also had a build-up of some debris on the left side of the wheelchair and on the left larger wheel. Observation also revealed that Resident R32's wheelchair's bilateral armrests were cracked, peeling, and torn. During an interview on 10/25/23, at 10:25 a.m. Registered Nurse Employee E3 confirmed that Resident R32 had damaged wheelchair armrests with cracked, peeling and torn protective covering and that the left side of the wheelchair was dirty and in need of cleaning. 28 Pa. Code 201.18(b)(1) Management 395292 Page 3 of 6 395292 10/27/2023 Wesbury United Methodist Commu 31 North Park Ave Ext Meadville, PA 16335

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to follow physician's orders for treatments for one of 27 residents reviewed (Resident R21). Residents Affected - Few Findings include: Review of a facility policy entitled, Oxygen Therapy and Equipment dated 8/16/23, indicated that Humidified O2 [oxygen] bottles will be changed on a weekly basis by night shift or sooner if needed by any shift when the distilled water is used. Review of Resident R21's clinical record revealed an admission date of 6/30/19, with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath); chronic kidney disease (condition where the kidneys gradually lose their ability to properly filter waste and excess fluids from the blood); and circulatory system disorder, (condition that affects the structural and/or functional abilities of the heart and or the blood vessels, causing fatigue and/or shortness of breath). Review of Resident R21's clinical record revealed a physician's order to Humidify O2 - change weekly and date when in use - Once Weekly for O2 Use. Review of Resident R21's October 2023 treatment record revealed the humidifier bottle was changed on 10/22/23. Observations on 10/25/23, at 11:21 a.m., 10/26/23, at 2:18 p.m., and 10/27/23, at 10:20 a.m. revealed that Resident R21's oxygen humidifier bottle was dated for 10/14/23. During an interview on 10/27/23, at 10:26 a.m. Registered Nurse Employee E3 confirmed that the oxygen humidifier bottle was dated 10/14/23, and was not changed per physician's orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395292 Page 4 of 6 395292 10/27/2023 Wesbury United Methodist Commu 31 North Park Ave Ext Meadville, PA 16335

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of 27 residents reviewed (Resident R12). Residents Affected - Few Findings include: Review of Resident R12's clinical record revealed an admission date of 5/26/23, with diagnoses that included Alzheimer's Disease, (brain disorder that destroys memory and thinking skills and, eventually, the ability to carry out simple tasks); sleep related non-obstructive alveolar hypoventilation, (breathing that is too slow and/or shallow during sleep); and dependence on supplemental oxygen. Review of Resident R12's physician's order dated 5/26/23, revealed oxygen ordered at two liters per minute via nasal cannula (tubing into the nostrils to administer oxygen) every shift. Observations on 10/26/23, at 10:10 a.m. and 10/27/23, at 10:23 a.m. revealed that R12's oxygen concentrator had a significant amount of white dust and white cobweb substances obstructing the concentrator's air inlet port. During an interview on 10/27/23, at 10:26 a.m. Registered Nurse Employee E3, confirmed that the oxygen concentrator air inlet area should not be obstructed with white dust and cobweb substances. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395292 Page 5 of 6 395292 10/27/2023 Wesbury United Methodist Commu 31 North Park Ave Ext Meadville, PA 16335

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to label a multi-dose vial of insulin, and a multi-dose insulin pen (medication to treat elevated blood sugar levels) with the date they were opened in one of three medication carts (300 Hall) and failed to prevent the opportunity for potential unauthorized access of medications on one of four medication carts observed (Village Center Hall). Findings include: Review of a facility policy entitled Medication, Storage of dated 8/16/2023, indicated that medications will be dated when opened, and discarded according to pharmacy policy/procedure. Observation on 10/25/23, at 11:20 a.m. of the 300 Hall medication cart revealed one opened Lantus (long-acting) multi-dose insulin pen, and one opened Humalog (short-acting) multi-dose insulin vial without an open date and labeled to discard after 28 days opened. During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E2 confirmed that insulin should be dated when opened and he/she could not tell when the opened insulin should be discarded. During an interview on 10/27/23, at 12:32 p.m. the Director of Nursing confirmed that the opened multi-dose pen of Humalog and multi-dose vial of Lantus insulin should have been labeled with an open date. Review of a facility procedure entitled, Medication Pass Guidelines dated 8/16/2023, indicated that medication cart is always visible to the nurse or locked. Observation on 10/24/23, at approximately 4:10 p.m. revealed that LPN Employee E1 prepared medications for a resident from Village Center Hall medication cart parked in the middle of hall in front of the resident room. LPN Employee E1 then proceeded into resident room to administer medications to a resident in the room, after administering medication they nurse walked over to the roommate behind a privacy curtain. LPN Employee E1 did not securely lock the Village Center East Hall medication cart. LPN Employee E1 was unable to view medication cart and drawers of the medication cart from behind the privacy curtain while unattended. During an interview on 10/24/2023, at the time of the observation, LPN Employee E1 confirmed that he/she left the medication cart unlocked while it was parked in the middle of the hallway in front of the resident's doorway, which was out of view while he/she was talking with roommate behind privacy curtain. LPN Employee E1 also confirmed that the medication cart was to be locked when out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395292 Page 6 of 6