Health inspection·December 1, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 develop an individualized comprehensive care plan to address a resident's (Resident 27) refusal of care and services to promote the resident's mental, medical, nursing, and psychosocial needs to the extent possible for one out 12 sampled residents. Findings include: Clinical record review revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses which included diabetes and depression. Review of a Neuropsychology Consult dated February 12, 2022, to assess the resident's cognitive functioning and comment on capacity to make informed medical decisions revealed that the resident had unacceptable home conditions prior to admission to the facility. The results of a Neuropsychological exam revealed that the resident had diffuse cognitive dysfunction and on a measure assessing awareness of personal health status and ability to evaluate health problems, handle medical emergencies, and take safety precautions, the resident performed in the impaired range of functioning. At the time of the consult, the resident did not appear to have capacity to make fully informed medical decisions. The impression of the consult noted a diagnosis of an unspecified neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (the 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) and physical behaviors occurred one to three days. A social service noted dated September 27, 2023, indicated that the resident displayed behaviors one to three days a week. The entry indicated that the resident got real upset when his guardian (court appointed) told him his house was sold. Review of a nurses note dated October 9, 2023, indicated that the resident's gastroccult test (detects gastric blood) returned positive and the results were reviewed by the physician with a new order for the resident to go to the emergency department for evaluation. Nursing noted that the resident was refusing to go to the ER. Risks versus benefits were discussed with resident but the resident continued to refuse transfer and the physician was notified. Page 1 of 15 395316 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A nurses note dated October 9, 2023, indicated that the resident's guardian was contacted and made aware of resident's current medical condition. Review of a Rehabilitation Screen dated October 12, 2023, indicated that the resident was dependent for transfers with a Hoyer lift and refuses out of bed positioning. The resident was not appropriate for physical therapy due to poor motivation and refusals to transfer out of bed. A review of the resident's care plan in effect at the time of the survey ending December 1, 2023, revealed no documented evidence that Resident 27's neurocognitive disorder, his limited ability to make informed medical and financial decisions, refusal of medical care, refusals to get out of bed, and behaviors related to having a guardian and the need for his home to be sold were addressed on the plan of care with corresponding interventions to promote the resident's physican and mental health and psychosocial well-being . An interview with the director of social services on November 30, 2023, at approximately 1:00 PM failed to provide documented evidence the facility developed an individualized person-centered care plan to promote the resident's mental, medical, nursing, and psychosocial needs to the extent possible. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395316 Page 2 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review clinical records and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a prescribed bowel protocol for one resident out of 12 sampled (Resident 21) to promote normal bowel activity to the extent practicable. Residents Affected - Few Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). Clinical record revealed that Resident 21 was readmitted to the facility on [DATE] with diagnosis to include dementia. A significant change Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 4, 2023 revealed that Resident 21 was severely, cognitively impaired, required staff assistance for activities of daily living and was frequently incontinent of bowel. Physicians orders dated October 13, 2022, were noted to give 8 oz of prune juice on day 2 with no bowel movement (BM); an order dated July 11, 2023, to give 30 ccs of Milk of Magnesia (MOM) on day 3 with no BM and an order dated July 11, 2023, to insert Biscolox suppository, 10 mg rectally on day 4 with no BM. A review of bowel records revealed that Resident 21 did not have a bowel movement on: -November 5, 2023- day one without a bowel movement -November 6, 2023- day two without bowel movement, Prune juice, 8 oz was ordered but no evidence that it was given to the resident. -November 7, 2023- day three, Prune juice, 8 oz was administered to the resident, 30 ccs of MOM was ordered, but no documented that it was administered to the resident -November 8, 2023- day four, there was no documented evidence of intervention to promote a BM; Biscolox suppository was ordered but there was no evidence that it was administered. -November 9, 2023- day five - no bowel movement or intervention to promote a bowel movement -November 10, 2023- day six, a biscolox suppository was administered and the resident had a bowel movement. November 11, 2023 - day one without a bowel movement 395316 Page 3 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0684 Level of Harm - Minimal harm or potential for actual harm -November 12, 2023 - day two, no BM, no intervention; prune juice was ordered but no evidence that it was administered -November 13, 2023 -day three without a bowel movement; 30 ccs MOM was administered as ordered; however, the resident spit out the medication Residents Affected - Few -November 14, 2023 - on day 4 without a bowel movement - 30 ccs of MOM was administered and not the Biscolox suppository as ordered. During an interview December 1, 2023 at 1 PM, the Director of nursing confirmed that staff failed to consistently carry out physician orders for the bowel regimen prescribed for Resident 21 to prevent constipation and promote normal bowel activity. 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records 395316 Page 4 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and resident and staff interviews, it was determined that the facility failed to provide colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) care and services consistent with professional standards of practice for one of one resident reviewed with a colostomy (Resident 27). Findings include: Review of the facility Ostomy Care Policy last reviewed February 21, 2023, indicated that it is the policy of the facility to ensure that residents who require colostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Colostomy care will be provided by licensed nurses under the orders of the attending physician. The frequency of pouch changes and the products required will be noted on the resident's person-centered care plan. The surrounding skin of the colostomy will be monitored for excoriation, abrasion, and breakdown. Changes in the pouching system or frequency of pouch changes will be made, as appropriate. The comprehensive care plan will reflect any special products or pouching techniques needed to prevent or manage any skin breakdown surrounding the colostomy. Clinical record review revealed that Resident 27 was admitted to the facility on [DATE] with diagnoses, which included diabetes and depression. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (the 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) and a colostomy was present. Interview with Resident 27 on November 29, 2023, at approximately 10:00 AM confirmed that he had a colostomy. Resident 27 stated that on occasion the colostomy bag leaks and that the bag does not always seem to seal properly. Review of current physician orders revealed a current order for colostomy care every shift and as needed. Change appliance as needed. Review of Resident 27's care plan initially dated January 12, 2022, revealed that the resident had a colostomy. The care plan failed to include the type of appliance, size of the appliance or wafer, type of collection bag required for colostomy maintenance. The care plan indicated that the nurse aide would provide colostomy care every shift and change the appliance as needed. Licensed nursing staff will notify the physician if the colostomy is not functioning properly. Interview with employee 1 (nurse aide) on December 1, 2023, at 8:50 AM confirmed that she provides care to Resident 27's colostomy, which includes changing the wafer and the colostomy bag. Employee 1 (nurse aide) confirmed that at times the colostomy bag does leak. Interview with the director of nursing on December 1, 2023, at approximately 9:30 AM confirmed the facility failed to provide colostomy care and services consistent with professional standards of 395316 Page 5 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0691 practice and facility policy for Resident 27. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code:211.12(d)(1)(3)(5) Nursing services. Residents Affected - Some 395316 Page 6 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0692 Provide enough food/fluids to maintain a resident's health. 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 interview it was determined that the facility failed to consistently monitor a resident's fluid intake for maintenance of the physician prescribed fluid restriction and to ensure adequate hydration for one resident out of 12 sampled (Resident 4). Residents Affected - Some Findings included: A review of the clinical record revealed that Resident 4 had diagnoses, which included acute and chronic respiratory failure and congestive heart failure. A physician order dated September 6, 2023, was noted for a Fluid Restriction 1800 ml per day distributed per shift: day - 360 cc, evening-360 cc, night-180 cc to equal 900 ccs. The order did not delineate the remaining distribution of 900 ccs of free fluid for this resident to include the amount allotted for medication administration, activites, and hydration at the bedside or as desired by the resident. The resident's care plan, dated March 31, 2023 and revised on September 6, 2023, revealed that the resident had the potential for nutritional problems and included an intervention of 1800 fluid restriction in 24 hours. The breakdown of distribution of the allotted fluids per shift and free fluids with medications and hydration throughout the day was not included on the resident's care plan. A review of a readmission nutrition assessment dated [DATE] revealed Resident 4's estimated 24 hour fluid intake ranged from 1610 ccs to 2013 ccs. A review of the resident's 24 hour fluid intakes dated November 1, 2023 through November 30, 2023 revealed the following noted intakes: November 1, 2023--1530 mls November 2, 2023--1230 mls November 3, 2023--1320 mls November 4, 2023--900 mls November 5, 2023--730 mls November 6, 2023--900 mls November 7, 2023--1200 mls November 8, 2023--2340 mls November 9, 2023--900 mls November 10, 2023--1340 mls 395316 Page 7 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0692 November 11, 2023--1000 mls Level of Harm - Minimal harm or potential for actual harm November 12, 2023--1020 mls November 13, 2023--1080 mls Residents Affected - Some November 14, 2023--1520 mls November 15, 2023--1160 mls November 16, 2023--1020 mls November 17, 2023--984 mls November 18, 2023--1240 mls November 19, 2023--1470 mls November 20, 2023--860 mls November 21, 2023--960 mls November 22, 2023--900 mls November 23, 2023--1160 mls November 24, 2023--1000 mls November 25, 2023--1140 mls November 26, 2023--1320 mls November 27, 2023--840 mls November 28, 2023--1220 mls November 29, 2023--1290 mls November 30, 2023--1230 mls Review of Resident 4's November 2023 Medication Administration Records, reflecting the amount of fluid consumed by resident with medications, and Task Documentation Reports, noting the fluid consumed by resident with meals, revealed was no documented evidence that staff were consistently monitoring and calculating the resident's daily fluid with medications and meals, to ensure adherence to the physician ordered fluid restriction and also to assess if the resident was consuming sufficient fluid to maintain adequate hydration. Interview with the director of nursing on December 1, 2023 at 1 P.M., confirmed the lack of documented evidence that the facility had consistently monitored and calculated daily total fluid intake to 395316 Page 8 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0692 evaluate adherence to the fluid restriction and evaluating the resident's hydration status while fluids are restricted. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5 (f) Medical records Residents Affected - Some 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395316 Page 9 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 provide person-centered pain management consistent with professional standards of practice for one resident out of 12 sampled (Resident 4). Residents Affected - Some The findings include: A review of the facility's current Pain Management policy, last reviewed by the facility on October, 2023, revealed that the facility must ensure that pain management is provided to residents who require such services, consistanet with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Clinical record revealed that Resident 4 was readmitted to the facility on [DATE], with diagnoses to include rheumatoid arthritis, chronic pain and opioid dependence. An annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that Resident 4 was cognitively intact, required staff assistance for activities of daily living and occasional pain relieved by medication. The resident had physician orders dated September 15, 2023, for Acetaminophen Tablet 325 mg 2 tablets by mouth every 6 hours as needed for mild pain (pain scale 1-3, on a 1, least pain to 10, most pain scale) and June 5, 2023, oxycodone HCL Oral Tablet 5 MG ( a narcotic, opiod pain medication) Give 1 tablet by mouth every 4 hours as needed for severe pain (7-9) and Gabapentin (an antiseizure medication sometimes used for chronic pain) Oral Capsule 300 MG, Give 1 capsule by mouth four times a day related to CHRONIC PAIN SYNDROME dated September 11, 2023. A review of medication administration records (MAR) revealed that Resident 4 received the Oxycodone 5 mg narcotic opioid pain medication as follows: August 2023 - 24 doses September 2023 - 21 doses October 2023 - 0 doses November 2023 - 17 doses A review of medication administration records (MAR) revealed that Resident 4 received the non-narcotic pain medication, Acetaminophen 325 mg, 2 tablets as follows: August 2023 - 2 doses September 2023 - 19 doses October 2023 - 9 doses 395316 Page 10 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0697 November 2023- 2 doses Level of Harm - Minimal harm or potential for actual harm Further review of the resident's October 2023 medication administration record (MAR) revealed that staff administered Acetaminophen 325 mg, 2 tablets on Residents Affected - Some November 26, 2023 at 9:48 A.M. for a pain rating of 5 November 27, 2023 at 9 A.M for a pain rating of 4, October 15, 2023 at 10:23 A.M. for a pain rating of 5, October 24, 2023 at 10:18 A.M for a pain rating of 4, September 5, 2023 at 8:45 A.M. for a pain rating of 5, September 7, 2023 at 12:47 P.M. for a pain rating of 5 September 7, 2023 at 5:19 P.M. a pain rating of 7 September 12, 2023 at 9:08 A.M. for a pain rating of 5, September 13, 2023 at 12:19 P.M. a pain rating of 5 September 14, 2023 at 1:22 P.M. a pain rating of 6 September 17, 2023 at 5:26 P.M. a pain rating of 4 September 19, 2023 at 10:19 A.M. for a pain rating of 4 September 27, 2023 at 12:13 P.M. a pain rating of 4 August 26, 2023 at 09:48 A.M. for a pain rating of 5 August 27, 2023 at 09:00 A.M. for a pain rating of 5 Staff administered Tylenol for pain rated outside the physician prescribed parameters of pain rated from 1-3 A review of the resident's comprehensive pain assessment dated [DATE] revealed, Resident 4 had frequent pain, rated at 8 and it was relieved by pain medication. A review of a comprehensive pain assessment dated [DATE] revealed, Resident 4, 2023 rarely had any pain and his pain rating was 0. There was no documented evidence that the facility had evaluated the resident's pain and prescribed regimen for the continued necessity of use of the opioid pain medication after no usage by the resident during 31 days in the month of October 2023, to deter potentially problematic patterns of opioid medication use. 395316 Page 11 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There was no documented evidence of additional pain relieving modalities developed and implemented to address Resident 4's pain and the development and attempts of non- pharmacological interventions to manage the resident's pain prior to the administration of the prn pain medications. During an interview on December 1, 2023, at approximately 12:00 p.m., the Director of Nursing (DON) was unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to administering prn pain medications or evidence of a reassessment of the resident's pain management needs. Refer F756 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 395316 Page 12 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist identified irregularities in the drug regimen prescribed for one of 12 residents sampled (Resident 4). Findings include: Clinical record revealed that Resident 4 was readmitted to the facility on [DATE] with diagnosis to include rheumatoid arthritis, chronic pain and was opioid dependent. An annual Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 29, 2023, revealed that Resident 4 was cognitively intact, required staff assistance for activities of daily living and had occasional pain relieved by medication. The resident had physician orders dated June 5, 2023, oxycodone HCL Oral Tablet 5 MG ( a narcotic, opiod pain medication) Give 1 tablet by mouth every 4 hours as needed for severe pain (rated from 7-9). A review of medication administration records (MAR) revealed that Resident 4 received the prn Oxycodone 5 mg narcotic pain medication as follows: August 2023 - 24 doses September 2023 - 21 doses October 2023 - 0 doses November 2023 - 17 doses Facility documentation revealed that the contracted Pharmacist completed a monthly medication/pharmacy review for Resident 4 during each of the preceeding 12 months. There was no evidence at the time of the survey ending December 1, 2023, that the pharmacist identified any irregularities regarding the resident's use of oxycodone during those months. The pharmacist did not identify the opioid dependent resident's use of multiple doses of Oxycodone during August 2023 and September 2023, and zero usage in October 2023, and the multiple doses again November 2023. There was no documented evidence that the pharmacist had recommended that the physician evaluate the continued necessity of the opioid medication when the resident received no doses of the prn medication during the month of October 2023. During an interview December 1, 2023 at 1 P.M., the Director of Nursing confirmed that the pharmacist did not identify any irregularities related to Resident 4's prn Oxycodone 5 mg usage. 28 Pa. Code 211.5 (f) Medical records 395316 Page 13 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0756 28 Pa. Code 211.9 (k) Pharmacy services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395316 Page 14 of 15 395316 12/01/2023 St Luke's Rehabilitation and Nursing Center 360 West Ruddle Street Coaldale, PA 18218

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **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 maintain accurate and complete clinical records, according to professional standards of practice, by failing to document medication and treatment administration as prescribed for one of 12 sampled residents (Resident 37). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of the clinical record of Resident 37 revealed that the resident was cognitively intact and admitted to the facility on [DATE], with diagnoses to include infection and inflammation reaction due to internal left prosthesis (infection of the left hip replacement) and pyogenic arthritis (an infection in the joint fluid and joint tissues). Further review of the clinical record revealed that Resident 37 had physician's orders dated November 8, 2023, for Vancomycin HCL Intravenous Solution (IV antibiotic used for treatment of potentially life-threatening infections) 1000 mg intravenously every 12 hours for 200 ml/hr over 60 minutes, and PICC line catheter (a long, thin tube that is inserted through a vein in the arm and passed through to a larger vein near the heart) flush with 10 cc NSS (normal saline solution) before and after medications. A review of the November 2023 medication administration record (MAR) for Resident 37 revealed that there was no documented evidence that the medication Vancomycin was administered to the resident as ordered on November 14, 2023, at 10:00 PM. Further review of the November 2023 MAR revealed no documented evidence that the PICC line catheter flush was performed as ordered on November 14, 2023, at 10:00 PM. Interview with the Director of Nursing on December 1, 2023, at 8:35 AM confirmed that the facility's nursing staff failed to consistently and accurately document the administration of prescribed medications, treatments and services to Resident 37 and as a result, the resident's clinical record was inaccurate and incomplete. 28 Pa. Code 211.5 (f) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 395316 Page 15 of 15