Health inspection·January 12, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to respect a resident's right to privacy for two of 19 residents reviewed (Residents 8 and 65). Residents Affected - Few Findings include: Clinical record review for Resident 8 revealed nursing documentation dated January 1, 2024, noting Resident 8 was found on the floor and the nurse noted the baby monitor was in use. Clinical record review for Resident 65 revealed nursing documentation dated December 22, 2023, noting Resident 65 was found on the floor and staff heard the chair alarm going off through the baby monitor at the nurses' station. A review of the facility investigation into Resident 65's fall revealed she is to have a voice monitor when in closed-door isolation. Interview with Employee 1 (assistant nursing home administrator) on January 12, 2024, at 1:30 PM confirmed the facility was utilizing baby monitors (audio amplifiers) in resident rooms. She stated the facility used the baby monitors to amplify the sound of resident alarms. There was no evidence in Resident 8 or 65's clinical records that the facility obtained permission for the baby monitors. The facility failed to protect Residents 8 and 65 right to privacy. 28 Pa. Code 211.12(d)(1) Nursing services Page 1 of 11 395318 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report misappropriation of resident property for one of 19 residents reviewed (Residents 36). Residents Affected - Few Findings include: The facility policy entitled, Abuse, Neglect, Exploitation General Policy, effective June 2022, and last revised in January 2024, revealed that the facility goal is to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves but is not limited to identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and /or misappropriation of resident property is more likely to occur. The facility is responsible to investigate and report cases of possible abuse, neglect including involuntary seclusion, exploitation, and misappropriation of property to external agencies in accordance with the regulation. All facility employees, family members, and volunteers are educated that all alleged or suspected violations involving mistreatment, neglect or abuse including injuries of unknown origin, involuntary seclusion, and misappropriation of resident property are reported immediately to the nurse on duty and/or as well as the Director of Nursing (DON) and/or the Nursing Home Administrator (NHA) to ensure a timely investigation is initiated. The facility will report all alleged violations to the NHA, state agency, adult protective services, and all other required agencies within the specified time frame. Interview with Resident 36 on January 9, 2024, at 12:40 PM revealed that he had 41.00 dollars that he put in a tin on his tray table, and it went missing. He did not remember the exact date or time that this occurred but knew that it was summertime. He said that it was approximately a week from the time he put the money in the tin until he noticed it missing. He said that it was reported to staff, but that he was told that there was nothing they could do about it. He indicated that he talked with the social worker but could not remember her name at the time of the interview. Clinical record review revealed a clinical progress note completed by Employee 4, social services, on August 28, 2023, at 3:43 PM that indicated that Resident 36 reported to social services that he had lost $40.00 in cash. The note indicated that Resident 36 said the last time he saw the money was last week when he had put his bingo money in the tin on his tray table. Employee 4 asked Resident 36 if his sister may have taken the money for his phone bill and he said, 'no because she was the one that gave him the money.' Employee 4 left a voicemail for his sister regarding the money. A clinical progress note dated August 29, 2023, at 11:29 AM by Employee 4 indicated that another voice mail was left for Resident 36's sister asking about the $40.00 in cash that he may or may not have had in his room. There were no other progress notes in the clinical record related to Resident 36's allegation of missing money. Interview with Employee 1, Acting NHA, and Employee 2, corporate consultant, on January 12, 2024, at 9:21 AM revealed that the facility did not further investigate Resident 36's allegation of missing money, and it was not reported to external agencies in accordance with the regulation. 395318 Page 2 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0610 The facility failed to investigate and report the allegation of misappropriation of property for Resident 36. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Residents Affected - Few 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395318 Page 3 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide bathing and dressing assistance for a resident dependent on staff assistance for one of two residents sampled for activities of daily living (Resident 31). Residents Affected - Some Findings include: Observation and interview with Resident 31 on January 9, 2024, at 1:17 PM revealed Resident 31 was out of bed in her personal chair, still in her nightgown. Her hair appeared disheveled. Interview with Resident 31 at this time stated she needs staff assistance to get dressed. Resident 31 stated she prefers to get dressed in comfortable clothes. She stated she does not have a specific shower day, she indicated she lets the staff know when she wants a shower if staff are available. Observation of Resident 31 on January 10, 2024, at 11:40 AM revealed Resident 31 was out of bed, but she was still in her nightgown. Clinical record review revealed the facility admitted Resident 31 on May 23, 2023. A review of Resident 31's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated November 7, 2023, indicated nursing staff assessed Resident 31 as requiring moderate assistance for upper body dressing and dependent on staff for lower body dressing. Staff also assessed Resident 31 as dependent on staff for bathing. A review of Resident 31's task documentation (ADL, activities of daily living charting) revealed the following shower documentation since October 1, 2023: From October 1 to 28, 2023, no documentation of a shower From October 30 to November 17, 2023, no documentation of a shower From December 14 to 31 2023, no documentation of a shower Further review revealed that Resident 31's bathing preference was identified as preferring a shower. A review of Resident 31's current care plan revealed she will be odor-free, dressed, and out of bed daily. Findings were reviewed with Employee 1 (assistant nursing home administrator) and Employee 2 (corporate consultant) during a meeting on January 10, 2024, at 2:00 PM. The facility failed to provide bathing and dressing assistance for a resident dependent on staff assistance. 28 Pa Code 211.11(d)(1)(5) Nursing services 395318 Page 4 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

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 observation, clinical record review, and staff interview, it was determined that the facility failed to medically justify and evaluate the clinical necessity for a urinary catheter for one of three residents reviewed for catheter use (Resident 65) and implement appropriate services for one of three residents reviewed for catheter use (Resident 26). Findings included: Clinical record review revealed the facility admitted Resident 65 on August 21, 2023, without an indwelling urinary catheter (insertion of a tube into the bladder to remove urine) . Resident 65 was admitted to the hospital from [DATE] to 15, 2023, and a Foley catheter was placed in Resident 65 due to terminal illness. An observation of Resident 65 on January 9, 2024, at 10:55 AM revealed a catheter remained in place. A review of Resident 65's clinical record revealed a Physician Notification/Order Request Form, dated November 22, 2023, indicating the nurse requested the physician add a diagnosis of obstructive uropathy. Further review of Resident 65's clinical record revealed no documentation of the clinical necessity for Resident 65's catheter. The facility did not receive a verbal physician's order for Resident 65's catheter until December 16, 2023. An interview with Employee 6 (acting director of nursing) confirmed these findings. She revealed the facility had no further documentation supporting the clinical necessity for Resident 65's urinary catheter. An observation of Resident 26 on January 9, 2024, at 1:30 PM revealed the resident was lying in bed. A catheter bag with tubing attached was observed hanging from a piece of metal at the bottom of the resident's bed frame, with most of the catheter bag unhygienically lying directly on the floor of the resident's room. The above finding regarding Resident 26 was reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant on January 10, 2024, at 2:00 PM. A follow-up observation of Resident 26 on January 12, 2024, at 10:23 AM revealed the resident was in bed with a catheter bag hanging from a metal piece on the lower foot portion of the bed frame with the side of the bag lying directly on the floor. The January 12, 2024, findings for Resident 26 were concurrently reviewed with Employee 1, and Employee 2. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services 395318 Page 5 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 42). Residents Affected - Few Findings include: Clinical record review for Resident 42 revealed a current diagnosis of Chronic Post Traumatic Stress disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). During an interview with Resident 42 on January 12, 2024, at 9:13 AM upon discussion of her PTSD diagnosis, the resident stated being asked the same questions over and over and having staff she doesn't know triggers her stress. Resident 42 did not elaborate on any other details of her trauma. Clinical record review for Resident 42 revealed an active plan of care for the resident for PTSD, which included interventions of psychiatry/psychology as ordered, encourage to maintain relationships with family and friends, and monitor for signs of and symptoms of depression and anxiety. There was no evidence in Resident 42's plan of care to indicate what individualized specific events may retraumatize the resident, how facility staff can prevent/minimize triggers from occurring, or how to help the resident cope with any trauma related responses to events. There was no evidence facility staff identified what Resident 42's specific triggers were that may retraumatize the resident or implemented measures into the resident's plan of care as to how facility staff can prevent/minimize triggers from occurring for the resident. The above information was reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant, on January 12, 2024, at 12:05 PM. They indicated no additional information was available for Resident 42 regarding her PTSD. 28 Pa Code 201.24 (e)(4) Resident care plan 28 Pa Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.16(a) Social services 395318 Page 6 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on the review of facility documentation and staff interviews, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of resident tracheostomy and catheter care. Findings include: A review of the facility documentation revealed that the facility had nine residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea). A request for nursing staff competencies for tracheostomy and catheter care revealed the facility was unable to provide any. An interview with Employee 6 (acting director of nursing) on January 12, 2024, at 12:27 PM confirmed the facility could provide no documentation that ensured nurses have specific competencies and skill sets to care for the residents' needs listed above. 28 Pa Code 201.20(a) Staff development 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services 395318 Page 7 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **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 develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by two of two residents reviewed (Residents 30 and 63). Residents Affected - Few Findings include: Clinical record review for Resident 30 revealed the facility admitted her on July 17, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 30's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 18, 2023, indicated that the facility assessed Resident 30 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 30's care plan revealed a problem for impaired cognitive/communication skills for daily decision making due to a diagnosis of dementia. The interventions included to break tasks into short segments, provide verbal reminders while she is performing self-care, engage in activities that do not require frequent decisions, limit choices to two simple options, assist her to select clothing that is clean and in good repair, fits and is appropriate for the season, and shoes will have non-skid soles and fit well, and to establish a daily routine and post it in her room. Observation of Resident 30s room on January 11, 2024, at 10:10 AM revealed that there was no daily routine posted in her room. Clinical record review for Resident 63 revealed the facility admitted him on April 5, 2023, with diagnosis including Dementia. A review of Resident 63's most recent comprehensive MDS dated [DATE], indicated that the facility assessed Resident 63 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 63's care plan revealed a problem for impaired cognitive skills for daily decision making due to a diagnosis of dementia. The interventions included to break tasks into short segments; provide verbal reminders while he is performing self-care, engage in activities that do not require frequent decisions, limit choices to two simple options, and to establish a daily routine and post it in his room. Observations of Resident 63's room on January 11, 2024, at 10:14 AM revealed that there was no daily routine posted in his room. An interview with Employee 4, social services, on January 12, 2024, at 12:50 PM confirmed that a daily routine was not established and posted in the rooms for Resident 30 or Resident 63, as indicated by their care plan and that the care plans were not person-centered care plans to address their specific needs related to their diagnosis of dementia. The findings were reviewed with Employee 1 (Acting Nursing Home Administrator) and Employee 4 (social services) during a meeting on January 12, 2024, at 12:55 PM. 395318 Page 8 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0744 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.11(d) Resident care plan Residents Affected - Few 395318 Page 9 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food service equipment in a sanitary manner in the facility's main kitchen. Residents Affected - Some Findings include: An observation of the main kitchen on January 9, 2024, at 12:36 PM revealed a large open utensil storage rack was located at the end of a production table in the food preparation area. The tall rack, which extended higher than the production table contained multiple spoons, whisks, spatulas, and ladles, hanging from the rack. The food contact surfaces of the utensils were exposed to dust/debris as well as splatter/splash from items being prepared on the food preparation table. Concurrent interview with Employee 5, dietary supervisor, indicated the utensils were considered clean and available for dietary employees to use in food service and production and it was not expected of the staff to wash/sanitize the utensils before use. An observation in the main kitchen on January 11, 2024, at 11:00 AM revealed dietary staff obtaining utensils from the above utensil rack and placing them in front of pans of food on the steam table where an employee was observed taking the temperatures of the food for lunch service. An observation on January 12, 2024, in the main kitchen at 10:47 AM revealed staff preparing food in the kitchen and setting up the steam table for lunch. Dietary staff was observed obtaining utensils from the open utensil rack carrying it to a preparation table and began using the utensil to place food in bowls without cleaning/sanitizing the utensil first. The above information was reviewed with Employee 1, Assistant Nursing Home Administrator and Employee 2, corporate consultant on January 12, 2024, at 12:10 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 395318 Page 10 of 11 395318 01/12/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to maintain linens in a sanitary manner in the facility's main linen supply storage area. Residents Affected - Many Findings include: In an interview with Employee 6, Assistant Director of Nursing, on January 12, 2024, at 11:30 AM, Employee 6 indicated the facility does not complete any laundering of linens or resident items in the facility and items were sent out of the facility to be laundered. In a concurrent observation of the area, clean linens and laundry are returned to the facility that Employee 6 revealed to be an area through a door in the back service hallway of the facility. Upon entering the door, a storage area behind a metal cage was observed on the left, which contained mattresses and multiple other items. Just past the cage area on the left was a man observed working at a table, multiple tools and equipment were observed in the area, which Employee 6 confirmed was the maintenance shop area. On the left side of the other room after the maintenance shop area, not separated by any walls or rooms, only shelving of maintenance tools and supplies, were several large bins on wheels containing various linens such as towels, wash cloths, blankets, and sheets. Four of the bins containing blankets and towels, were observed stacked 12-18 inches above the top of the bin. A black cover was observed lying over the very top portion of the items completely exposing the linens on all sides until reaching the level that was inside the bin. The bins of linens noted above were also located within 10-20 feet of a set of double doors, which opened to the exterior of the building. During the observation with Employee 6, an employee of the facility was observed entering through the doors and walking past the exposed bins of linens. In a concurrent interview and observation with Employee 7, environmental services, Employee 7 indicated the clean linens are all delivered through the observed double doors and that extra linens were ordered due to a long holiday weekend. Employee 7 indicated that the linens should have all been covered. During the interview with Employee 7, an additional employee was observed entering through the double doors noted above. Employee 7 indicated staff of the facility do enter and exit through the doors located in front of the exposed linen. The above findings regarding the storage of linens were reviewed with Employee 1, Assistant Nursing Home Administrator, and Employee 2, corporate consultant, on January 12, 2024, at 12:05 PM. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 205.26 (d) Linen Storage 395318 Page 11 of 11