Health inspection·January 20, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, employee personnel records, clinical record review, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy pertaining to screening for three of five newly hired employees reviewed (Employees 2, 3, and 4), and investigate the potential for neglect for one of one resident reviewed (Resident 65). Residents Affected - Few Findings include: The current facility policy entitled, Abuse: Prevention, Investigation & Reporting, last revised March 2020, revealed it is the facility guidelines that a resident/situation will be assessed for signs of physical, sexual, mental, or verbal abuse, involuntary seclusion, and neglect. The policy also revealed the facility will screen potential employees, that criminal background checks and employment verifications according to human resources policy are requested for each new employee. Review of the facility policy entitled Employment Verification/Pre-Placement Evaluations/References, dated July 28, 2022, revealed the facility has approved outside background check and employment verification vendors for use by the human resources department. If a role requires education and experience, an education verification and employment verification will be completed, and additional checks and/or clearances may be required depending upon the type of location of the position. Review of Employee 2 (food service attendant), Employee 3 (nurse aide), and Employee 4's (admissions coordinator) personnel record in the presence of Employee 5 (senior human resources consultant), and Employee 6 (human resources generalist) on January 19, 2023, at 2:10 PM confirmed the facility failed to complete reference checks on Employees 2, 3, and 4. Clinical record review for Resident 65 revealed that the facility implemented a chair alarm on March 21, 2022, as an intervention to prevent falls. The facility investigated a concern with Resident 65 falling out of her wheelchair on April 5, 2022, at 4:25 PM, where it was identified that Resident 65 did not have her chair alarm attached to her chair prior to her falling. It was identified that her alarm was still located on her bed at the time of the fall. There was no documentation available that the facility thoroughly investigated Resident 65's fall to include identification of the staff member who failed to implement Resident 65's chair alarm prior to her fall, request the identified staff member's witness statement, report this concern as the potential for neglect to the appropriate agencies, and complete a PB22 (abuse report) if indicated. This surveyor reviewed this information during an interview with the Director of Nursing on January 19, 2023, at 1:21 PM. 483.12(b)(1)-(3) Develop/implement Abuse/neglect Policies Page 1 of 8 395318 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0607 Previously cited 2/3/2022 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures Residents Affected - Few 395318 Page 2 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

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. Based on review of select facility policies, clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding elopement risks for two of 18 residents reviewed (Residents 4 and 64). Findings Include: Review of the policy entitled Wandering/Elopement, last revised September 2022, indicates that the purpose is to identify residents who are at risk for elopement and implement interventions to prevent this. If they are found to be at risk, this will be communicated in the communication book and recorded in their support plan. Review of Resident 4's clinical record revealed nursing documentation dated November 12, 2022, at 1:31 PM, that indicated Resident 4 was missing. Staff searched the facility and outdoors. Staff also was searched for the resident in nearby locations. She was found by Wellsboro Nutrition (2 blocks from the facility) and was accompanied back to the facility. Once returned, Resident 4 stated she should have had warmer clothes. The facility completed a Wander Risk Assessment on November 12, 2022, and indicated that Resident 4 attempted to leave the facility unescorted and has verbalized intent to leave the facility. Comments documented indicate Resident is in an electric wheelchair and goes visiting residents and outside and she does leave the facility without telling staff at times. There was no documented evidence in Resident 4's clinical record to indicate that the facility implemented a plan of care, which would include interventions to monitor Resident 4's risk of elopement. Review of Resident 64's clinical record revealed nursing documentation dated November 7, 2022, at 7:59 PM that indicated the registered nurse was asked to assess the resident after he left the building unescorted. The resident was assessed and asked why he left the building. Resident 64 stated that he was sitting out front and remembered that he likes to take walks, so he stood up and went for a walk. The facility completed a Wander Risk Assessment on November 7, 2022, and indicated that Resident 64 attempted to leave the facility unescorted, and he is cognitively impaired with poor decision making skills. There was no documented evidence in Resident 64's clinical record to indicate that the facility implemented a plan of care, which would include interventions to monitor Resident 64's risk of elopement Interview with the Director of Nursing on January 20, 2023, at 9:41 AM confirmed the above findings and indicated that a plan of care for elopements was developed for both Resident 4 and Resident 64 after this surveyor brought up the concerns. 483.21 Develop/Implement Comprehensive Care Plan 395318 Page 3 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0656 Previously cited 2/3/22 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 395318 Page 4 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of two residents reviewed (Resident 51). Residents Affected - Some Findings include: The facility policy entitled, Pain Management, last reviewed without changes in October 2022, revealed that staff will follow a modified pain scale of 1-3 for mild pain, 4-7 for moderate pain, and 8-10 for severe pain to describe and evaluate pain. Clinical record review for Resident 51 revealed physician's orders for the following pain medications: Ordered on June 28, 2021, Acetaminophen Tablet 325 milligram (mg) two tablet by mouth (PO) every 4 hours as needed (PRN) for mild pain, not to exceed 3000 mg per 24-hour period. Ordered on October 6, 2022, Oxycodone 5 mg/Acetaminophen 325 mg one tablet PO every 8 hours PRN moderate to severe pain. Review of Resident 51's November and December 2022 and January 2023 MAR (medication administration record, a form to document medication administration) revealed the following: Staff administered the following PRN pain medications: Acetaminophen 325 mg two tablets PO every 4 hours PRN for mild pain on November 19, 2022, at 4:43 PM for a pain level of 0. Staff administered Resident 51's Oxycodone 5 mg/Acetaminophen 325 mg every 8 hours PRN on the following dates without identifying the resident's pain level: November 1, 2022, at 7:00 AM November 2, 2022, at 7:00 AM November 3, 2022, at 7:30 AM November 4, 2022, at 8:00 AM November 6, 2022, at 12:00 AM November 7, 2022, at 7:00 AM November 8, 2022, at 2:58 PM November 9, 2022, at 7:30 AM November 10, 2022, at 7:00 AM 395318 Page 5 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0697 November 11, 2022, at 6:00 AM Level of Harm - Minimal harm or potential for actual harm November 12, 2022, at 7:30 AM November 12, 2022, at 5:00 PM Residents Affected - Some November 13, 2022, at 7:30 AM November 14, 2022, at 7:30 AM November 15, 2022, at 8:00 AM November 16, 2022, at 8:00 AM November 17, 2022, at 3:41 PM November ,18 2022, at 7:00 AM November 19, 2022, at 3:10 PM November 20, 2022, at 3:00 PM November 21, 2022, at 7:30 AM November 22, 2022, at 7:00 AM November 23, 2022, at 7:30 AM November 25, 2022, at 7:00 AM November 26, 2022, at 7:30 AM November 27, 2022, at 7:00 AM November 28, 2022, at 7:00 AM November 29, 2022, at 7:00 AM November 30, 2022, at 7:00 AM Staff administered Resident 51's Oxycodone 5 mg/Acetaminophen 325 mg one tablet PO every 8 hours PRN moderate to severe pain 4-10 on the following dates: December 1, 2022, at 7:30 AM for a pain level of 3 December 2, 2022, at 7:30 AM for a pain level of 2 December 5, 2022, at 7:00 AM for a pain level of 2 395318 Page 6 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0697 December 6, 2022, at 7:30 AM for a pain level of 2 Level of Harm - Minimal harm or potential for actual harm December 7, 2022, at 7:00 AM for a pain level of 0 December 7, 2022, at 5:00 PM for a pain level of 0 Residents Affected - Some December 9, 2022, at 7:00 AM for a pain level of 2 December 10, 2022, at 7:00 AM for a pain level of 2 December 11, 2022, at 7:30 AM for a pain level of 2 December 13, 2022, at 7:00 AM for a pain level of 2 December 14, 2022, at 7:00 AM for a pain level of 2 December 19, 2022, at 7:00 AM for a pain level of 0 December 21, 2022, at 7:30 AM for a pain level of 2 December 29, 2022, at 7:30 AM for a pain level of 2 December 30, 2022, at 7:30 AM for a pain level of 0 January 2, 2023, at 7:30 AM for a pain level of 2 January 7, 2023, at 4:00 PM for a pain level of 0 January 10, 2023, at 7:00 AM for a pain level of 0 January 13, 2023, at 7:30 AM for a pain level of 0 January 16, 2023, at 7:30 AM for a pain level of 0 January 18, 2023, at 7:00 AM for a pain level of 0 Staff did not administer Resident 51's pain medications according to the physician ordered pain scale level(s). The surveyor reviewed Resident 51's pain information during an interview with the Director of Nursing on January 20, 2023, at 12:14 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395318 Page 7 of 8 395318 01/20/2023 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of call bell response logs, clinical record review, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs for one of 18 residents reviewed (Resident 40). Findings include: Review of Resident 40's Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated November 29, 2022, indicated the facility assessed her as being cognitively intact and needing the extensive assistance of two staff members for toileting. During an interview with Resident 40 on January 17, 2023, at 12:40 PM she indicated that just last evening she had to wait almost an hour for nursing staff to answer her call bell and help her get off the toilet. Resident 40 also indicated that staff will come and answer her call bell but turn it off without helping her and say that they will return but end up never coming back. Review of the facility's call bell logs dated January 16, 2023, revealed that Resident 40's call bell was activated from 6:57 PM until 7:53 PM, for a total of 55 minutes. An additional interview with Resident 40 on January 19, 2023, at 12:21 PM indicated that she had problems with her call bell being answered again last night. Resident 40 indicated that she rang her call bell around 6:30 PM and staff came in and shut it off but didn't help her. Resident 40 stated she had to use the restroom. Resident 40 indicated that when no one came back, she rang the call bell again around 7:00 PM, and waited almost an hour before staff came to help her. Review of the facility's call bell logs dated January 18, 2023, confirmed that Resident 40 rang her bell at 6:29 PM, and it was turned off by 6:40 PM. Resident 40's call bell was again activated at 7:08 PM and was not deactivated until 7:56 PM, for a total of 48 minutes. Interview with the Director of Nursing on January 20, 2023, at 9:41 AM confirmed the above findings for Resident 40. The facility failed to provide sufficient staff to ensure the needs of the residents were met. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services 395318 Page 8 of 8