Health inspection·December 13, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on a review of resident personal fund accounting, clinical record review, and resident, family, and staff interview, it was determined that the facility failed to provide a personal fund quarterly statement for two of two residents reviewed for personal funds concerns (Residents 19 and 40). Findings include: Interview with Resident 19 on December 10, 2024, at 1:41 PM revealed that she had an idea regarding how much money she had in her personal funds account; however, she does not receive a written statement at least quarterly with her personal funds accounting. Clinical record review for Resident 19 revealed a facility Resident Personal Fund Authorization (form signed by a resident to consent to the facility management of the resident's personal fund) with an undated signature by Resident 19 that did not address the facility's obligation to provide quarterly statements that would account for all transactions occurring with the resident's personal fund. The form did not designate who would receive the accounting statement for the fund. Interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2024, at 10:30 AM indicated that staff from the activities department would report the process that ensured Resident 19 received her resident fund statement; however, no staff provided additional information regarding the provision of personal fund statements for Resident 19. Interview with Resident 40 on December 10, 2024, at 12:11 PM revealed that the facility holds money for her in the business office; however, she does not receive a statement on at least a quarterly basis to know how much money she has. Interview with Resident 40's mother who was present during the interview with Resident 40 indicated that she does not get a statement of Resident 40's personal funds. Clinical record review for Resident 40 revealed a Resident's Personal Fund Agreement (updated version of the form signed by a resident to consent to the facility management of the resident's personal fund), that noted a record of all transactions regarding the resident's funds will be maintained by the facility in accordance with generally accepted accounting principles ,and the resident will have access at any time upon request to the above record and will receive an itemized quarterly statement of his/her account. Resident 40 signed this form on April 19, 2023. Interview with the Nursing Home Administrator on December 12, 2024, at 10:25 AM confirmed that the facility has not provided Resident 40 a statement of her personal funds on at least a quarterly basis. Page 1 of 21 395318 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0568 Level of Harm - Minimal harm or potential for actual harm Interview with the Nursing Home Administrator on December 12, 2024, at 2:06 PM confirmed that the facility had no evidence that quarterly statements were given to the resident/responsible party for Residents 19 and 40 until following the surveyor's questioning. 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Some 28 Pa. Code 201.29(a) Resident rights 395318 Page 2 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide the required notification to a resident whose payment coverage changed for one of three residents reviewed for beneficiary notices (Resident 76). Residents Affected - Few Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date. Clinical record review for Resident 76 revealed census documentation that confirmed Resident 76's last covered day of Medicare A services ended June 27, 2024. The facility discharged Resident 76 to his home/self-care. Rehabilitation/Nursing Communication documentation dated June 24, 2024, at 7:52 AM revealed that Resident 76 was deemed independent in the building with an assistive device. Social services documentation dated June 25, 2024, at 10:31 AM revealed that Resident 76 set a date with skilled therapy staff that he would discharge from the facility to home on June 27, 2024. The documentation indicated that Resident 76 was independent in the facility and had no medical equipment or home health needs. There was no evidence that either skilled therapy or social services staff provided Resident 76 a CMS-10123 notice. Interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2024, at 10:25 AM and 2:30 PM, confirmed that the facility had no evidence to indicate that staff provided the CMS-10123 form to Resident 76 whose Medicare A covered services were ending. The interview confirmed that the facility had no evidence that Resident 76 exhausted his available Medicare A covered days. The interview confirmed that Resident 76's discharge from the facility was a planned discharge; with a known plan at least two days before his discharge. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 395318 Page 3 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0641 Ensure each resident receives an accurate assessment. 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 ensure complete and accurate Minimum Data Set (MDS) assessments for one of 20 residents reviewed (Resident 59). Residents Affected - Few Findings include: Review of Resident 59's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 11, 2024, that indicated the facility assessed her as having a Stage 3 (full thickness skin loss that might extend into underlying tissue) pressure ulcer that was present on admission. There were no other skin issues noted on the assessment. An MDS dated [DATE], now indicated that the facility assessed her as having a Stage 3 pressure ulcer that was not present on admission. There were no other skin issues noted on the assessment. Interview with the Administrator on December 12, 2024, at 2:46 PM, confirmed that Resident 59's October 11, 2024, MDS was coded in error for her pressure ulcer status. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395318 Page 4 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 resident and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for two of four residents reviewed for rehabilitation concerns (Residents 24 and 40). Residents Affected - Few Findings include: Interview with Resident 24 on December 11, 2024, at 9:22 AM revealed that he was provided a prosthetic leg following his left leg amputation; however, he was not using it. Resident 24 stated that staff use a mechanical lift to assist him to transfer and he was not walking at all. Resident 24 stated that the skilled therapy department did not have parallel bars (parallel bars are commonly used during physical therapy and rehabilitation, they are used as a support tool to provide a safe way to work on skills like gait training and balance) like he used in another therapy department prior to his admission to this facility, which now prevented him from taking steps with the prosthetic. Discharge summary documentation from physical therapy staff dated August 25, 2023, listed discharge recommendations that included a restorative nursing program and continued use of prosthetic for assistance and increased safety with standing in Return 7500 (assistive mechanical lift device for sit-to-stand and transfer activities). Interview with Resident 24 and his wife on December 12, 2024, at 1:20 PM reiterated that staff never used his prosthetic leg during transfers with the mechanical lift. Resident 24 and his wife reiterated their experience of using parallel bars at another facility; however, the absence of this equipment at this facility has prevented his ability to walk with the prosthetic. Interview with Employee 7 (nurse aide who identified herself as the nurse aide assigned to Resident 24's care on this date) on December 12, 2024, at 1:28 PM revealed that she was not familiar with Resident 24's left lower leg prosthetic; she was not educated on donning it or using it. Employee 7 referenced the electronic plan of care for Resident 24 that would be utilized to determine his resident care needs and confirmed that his care needs indicated two staff should utilize a sit-to-stand lift; however, there was no intervention listed to use a prosthetic device on his left leg. The review confirmed that the directive for two staff to use the sit-to-stand lift started on August 11, 2023. Review of Resident 24's plan of care to address his risk for falls instructed two staff to utilize a sit-to-stand lift. The plan of care did not include the use of a prosthetic. Interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2024, at 10:25 AM and 2:00 PM, revealed that there was no evidence that the facility implemented the physical therapy recommendation for a restorative nursing program with the continued use of a prosthetic limb for Resident 24's standing during transfers with the sit-to-stand lift. Interview with Resident 40 on December 10, 2024, at 12:24 PM indicated that she no longer receives the services of skilled therapy and does not receive restorative nursing services. A physical therapy Discharge summary dated [DATE], indicated that Resident 40's treatment included exercises to pull herself up to a standing position in the hallway to increase her functional 395318 Page 5 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mobility tolerance and increase her lower extremity functional strength. Recommendations upon discharge from skilled services included that Resident 40 would continue with a restorative nursing program. A plan of care entitled, (Resident 40) is on a Restorative Nurse Program, (Resident 40) will participate daily in the RNP (restorative nursing program) with assistance. The goal is to maintain lower extremity strength to reduce fall risk. (Resident 40) will perform pull-to-stands using the hallway railing, making sure nose over toes during both standing and sitting, and receive reminders to breathe. Review of documentation regarding the planned restorative nursing program indicated numerous days when staff documented that the program was not completed because the resident was resting. Staff documented that the program was not completed on 22 of 31 days in October 2024, on 18 of 30 days in November 2024, and on seven of 11 days in December 2024. Staff also documented zero repetitions for zero minutes on three of the nine remaining days in October 2024, on six of the 12 remaining days in November 2024, and one of the four remaining days in December 2024. Interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2024, at 10:25 AM confirmed that the documentation reflected that staff did not consistently complete the restorative nursing program with Resident 40. The facility did not provide documentation that the licensed staff who oversaw the restorative nursing programs identified that Resident 40's restorative nursing program was not completed consistently. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395318 Page 6 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for one of four residents reviewed (Resident 71), maintain a resident's range of motion program for one of four residents reviewed (Resident 14), and failed to provide services to prevent a decline in a resident's range of motion for one of four resident's reviewed (Resident 11). Findings include: Observation and interview with Resident 71 on December 10, 2024, at 1:09 PM revealed she was lying on her bed. Resident 71 stated she was planning on returning home and had finished therapy, but thought she was going to do more therapy to keep her strength to return home, such as walking. Resident 71 indicated she is not to try to walk on her own and needs to use a walker and rely on staff. Resident 71 stated she lies around a lot. Resident 71 stated staff need to walk her to her bathroom. Clinical record review for Resident 71 revealed a request for the resident to have physical and occupational therapy dated October 25, 2024he. The request was then noted to discontinue physical and occupational therapy orders as the resident had just completed 12 weeks of therapy on October 21, 2024, and is on a restorative nursing program for continued ambulation and lower extremity exercises. A review of Resident 71's physical therapy Discharge summary dated [DATE], noted the resident had reached maximum potential and resident and caregiver training with written communication was provided to nursing for both a restorative nursing program for ambulation and standing lower extremity exercises. The discharge recommendations included a restorative nursing program for ambulation in the hallway with a rolling walker and standing exercises at the hallway rail for heel raises, hip abduction, slow marches, and mini squats of two sets of 20 repetitions. The prognosis to maintain the resident's current level of function was good with consistent staff follow-through. A Rehab Services Restorative Nursing/Functional Maintenance Referral form dated October 16, 2024, by the therapist with services to begin on October 22, 2024, noted Resident 71 was to have an ambulation program to maintain the highest functional mobility level and decreased fall risk with special instructions noting the resident was to ambulate with a rolling walker in the hallway 200-300 feet with supervision and contact guard depending on her balance and awareness of surroundings that particular day. It was also noted the resident still has days with unsteadiness, decreased safety awareness, and needs close supervision/contact guard with ambulation. A physician's order dated October 22, 2024, indicated Resident 71 would ambulate with a rolling walker in the hallway 200-300 feet with one assist of supervision/contact guard depending on balance and awareness of surroundings that day, two times daily. There was no evidence of an order for the standing exercises noted above. A review of Resident 71's mobility/ambulation program documentation for October 2024, revealed no documentation of completion for October 22, October 29, and 30, 2024, as staff indicated resident resting. From October 25, 26, 27 28, and 31, 2024, staff documented zero to 50 feet for ambulation and only one time a day was reflected. There was only one time from October 22 - 31, 2024, that Resident 71 was documented as receiving 200 feet of ambulation. 395318 Page 7 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 71's mobility ambulation program for November 2024, revealed the resident was documented as only receiving the program one time a day from November 1 -3, 2024, with only five feet in distance for November 1 and 3. The resident was only ambulated 200-300 feet five times from November 1-30, 2024, with only six documented resident refusals or resident not being available. One occurrence on November 29, 2024, was again noted as resident resting. The remaining scheduled ambulation was documented as zero, five, 10, or 15 feet, with an occasional 50 or 100 feet documented. Review of Resident 71's December 2024, ambulation/mobility program documentation for twice a day revealed the resident was documented as resting on December 1, and 6, 2024, with zero, five and 10 feet documented completion, with only one instance of 25 feet, and one of 50 feet. The resident did ambulate 200 feet on December 1, 2024. There was no evidence to indicate Resident 71's ambulation program to maintain her mobility was completed as ordered as recommended by physical therapy in October 2024. There was no evidence Resident 71's exercise program to maintain her mobility was ordered or completed as recommended by physical therapy in October 2024. There was no evidence to indicate any communication was provided by facility staff to indicate Resident 71 could not complete the program as ordered. A quarterly MDS (minimum data set, an assessment completed at periodic intervals of time to assess resident care needs), dated November 4, 2024, revealed facility staff assessed Resident 71's sections of walking 150 feet was not attempted due to medical condition or safety concerns. There was no evidence Resident 71 had any medical or safety concerns inhibiting her from staff completing the ordered program. The above information regarding Resident 71 was reviewed with the Nursing Home Administrator and Director of Nursing on December 12, 2024, at 10:45 AM. Review of Resident 11's clinical record revealed that the facility readmitted her from a hospital stay on August 28, 2024. A physician's order was obtained for the facility to complete a physical and occupational therapy screen to determine what her care needs were regarding therapy after being in the hospital. There was no documented evidence in Resident 11's clinical record to indicate that the facility completed the screens as ordered by her physician. Review of Resident 11's clinical record revealed an MDS dated [DATE], that indicated the facility assessed her as having no range of motion limitations to either her upper or lower extremities. An MDS dated [DATE], indicated that the facility now assessed Resident 11 as having limited range of motion to both sides of her upper and lower extremities. There was no documented evidence in Resident 11's clinical record to indicate that the facility implemented interventions after identifying her decline in range of motion. Interview with the Administrator on December 13, at 10:52 AM confirmed the above findings for Resident 11. Interview with Resident 14 on December 10, 2024, at 2:06 PM revealed that she had a CVA (stroke, brain damage secondary to abnormal blood supply or trauma in the brain) approximately six months earlier that resulted in deficits to her left arm and leg. Resident 14 said that she does not receive services from skilled therapy. Resident 14 stated that, they (nursing staff) say they're going to (perform exercises with her) but they never do. 395318 Page 8 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0688 Level of Harm - Minimal harm or potential for actual harm Clinical record review of a care plan developed by the facility for Resident 14 indicated that she has the potential for injury, trauma, and falls related to cognitive impairment and history of CVA with left weakness. Interventions listed in the care plan included: to encourage participation in therapy for strengthening and maintain function, assist Resident 14 to attain/maintain her highest practicable level of physical or psychological well-being, and provide appropriate restorative nursing programs (RNP) as indicated. Residents Affected - Some A physical therapy (PT) Discharge summary dated [DATE], listed recommendations that included an RNP for lower extremity AROM (active range of motion) and AAROM (active assisted range of motion) to maintain knee and ankle flexibility range for proper sitting. The surveyor requested any evidence that the RNP program for Resident 14's range of motion was implemented per the PT discharge summary recommendations during interviews with the Nursing Home Administrator on December 12, 2024, at 2:00 PM, and December 13, 2024, at 10:10 AM and 12:15 PM. Interview with the Nursing Home Administrator on December 13, 2024, at 12:15 PM confirmed that the facility had no evidence that the RNP program was implemented for Resident 14. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395318 Page 9 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for one of two residents reviewed for supplemental oxygen concerns (Resident 15). Residents Affected - Few Findings include: Observation of Resident 15 on December 10, 2024, at 11:41 AM revealed that she wore supplemental oxygen via a nasal canula (flexible tubing with small prongs on one end that are positioned in the nares to administer a supply of oxygen) that was attached to a wall flow meter (metered device used to control the flow of compressed medical oxygen from a wall supply) that was set at three liters per minute. Interview with Resident 15 on the date and time of the observation indicated that she believed her oxygen liter flow was to be set at three liters per minute. Clinical record review for Resident 15 revealed an active physician order for staff to administer supplemental oxygen at two liters per minute, to check oxygenation saturations (SPO2, pulse oximeter, an assessment done by a small device applied to the tip of a finger to assess the amount of oxygen in the blood) three times daily, and to keep saturations at or above 90 percent. A plan of care developed by the facility to address Resident 15's risk for ineffective breathing related to a recent hospitalization and her diagnoses of chronic respiratory failure (lungs cannot remove enough carbon dioxide or take in enough oxygen) and COPD (damage to airways with inflammation that limits airflow into and out of the lungs) listed interventions that included to check and record oxygen saturations every eight hours and as needed when oxygen was in use and to administer oxygen per the physician's order. Observation of Resident 15 on December 12, 2024, at 1:35 PM revealed her supplemental oxygen supply via the wall flow meter was set at three liters per minute. Interview with Employee 8 (licensed practical nurse) on December 12, 2024, at 1:35 PM indicated that she believed Resident 15's physician orders for supplemental oxygen permitted her to titrate the liter flow based on Resident 15's oxygen saturation assessments. Review of Resident 15's physician orders confirmed that the active physician order did not permit staff to titrate the oxygen liter flow. Employee 8 went to Resident 15's room to correct the liter flow to two liters per minute as her physician orders directed. The surveyor reviewed the above concerns regarding Resident 15's oxygen administration during an interview with the Nursing Home Administrator and the Director of Nursing on December 12, 2024, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395318 Page 10 of 21 395318 12/13/2024 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 observations, 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 related to call bell response time for two of 20 residents reviewed (Resident 38 and 71). Findings include: In an interview with Resident 71 on December 10, 2024, at 1:24 PM the resident stated she doesn't have much notice for needing to use the bathroom and relies on staff to get her there as she needs assistance to ambulate to the bathroom. Resident 71 stated it takes staff a long time to get there as she will ring the bell and wait. Resident 71 indicated she waited one hour and 5 minutes recently. A review of call bell activation logs for Resident 71 from November 27 - December 11, 2024, revealed the following (total minutes reflect time in seconds from reports): December 3, 2024, call bell activated at 1:03 PM, response at 1:20 PM, 16 minutes. December 6, 2024, call bell activated at 9:24 PM, response at 9:46 PM, 21 minutes. December 8, 2024, call bell activated at 10:50 AM, response at 11:05 AM, 15 minutes. December 11, 2024, call bell activated at 6:52 AM, response at 7:27 AM, 34 minutes. Out of 91 activations. A call bell response time over an hour was not identified for Resident 71, although the resident did have wait times of 15 minutes or greater in the time frame noted above. In an interview with Resident 38 on December 11, 2024, at 12:09 PM the resident stated she has to wait for staff to get her a bed pan or to get changed, when she rings her bell, or if staff does come, in the morning she will sit in a soaked bed later. A review of call bell activation logs for Resident 38 from November 20 - December 11, 2024, revealed the resident has had several call bell response times greater than 15 minutes, or bell response where multiple activations completed and shut off in a short time frame, not meeting the resident needs, as follows (total minutes reflect the call duration which may have included seconds): November 22, 2024, call bell activated at 7:06 AM response at 7:21 AM, 15 minutes. November 22, 2024, call bell activated at 7:01 PM response at 7:54 PM, 53 minutes. November 25, 2024, call bell activated at 7:47 AM, response at 8:11 AM, 23 minutes. November 25, 2025, call bell activated at 6:22 PM, response at 6:39 PM, 16 minutes. November 28, 2024, call bell activated at 8:32 AM, response at 8:53 AM, 20 minutes. Call bell activations were also listed as 8:14 AM, with response at 8:20 AM, then 8:23 AM, response at 8:31 AM prior to the 20-minute bell at 8:32 AM. 395318 Page 11 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0725 December 5, 2024, call bell activated at 2:56 PM, response at 3:18 PM, 22 minutes. Level of Harm - Minimal harm or potential for actual harm December 6, 2024, call bell activated at 7:44 PM, response at 8:11 PM, 26 minutes. December 7, 2024, call bell activated at 7:31 AM, response at 7:53 AM, 22 minutes. Residents Affected - Few December 7, 2024, call bell activated at 6:39 PM, with response at 7:40 PM, one hour and one minute. December 8, 2024, call bell activated at 7:46 AM, response at 8:02 AM, 16 minutes. Call bell had been activated directly before at 7:43 AM and shut off at 7:44 AM prior to being reactivated again at 7:46 AM. December 8, 2024, call bell activated at 11:24 AM, response at 12:01 PM, 37 minutes. December 8, 2024, call bell activated at 12:53 PM, response at 1:08 PM, 15 minutes December 9, 2024, call bell activated just after 1:00 PM, response at 1:16 PM, 15 minutes. December 10, 2024, call bell activated at 9:34 PM, response at 9:56 PM, 22 minutes. Although Resident 38's call bell activation could not be directly correlated to incontinence due to facility staff indicating timing of nurse aide documentation may not be directly at the time someone is toileted, several long call bell wait times were evident in the time frame reviewed above for the resident. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing on December 12, 2024, at 2:00 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services 395318 Page 12 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of two residents reviewed for behaviors(Resident 12). Findings include: Clinical record review for Resident 12 revealed the following current physician orders: Ativan 0.5 milligram (mg) PO (by mouth) BID (twice daily), initially ordered September 26, 2023 Ativan 2 mg PO q HS (hour of sleep), initially ordered December 16, 2023 Ativan 1 mg PO PRN (as needed) q 4 hours (every four hours) for restlessness/anxiety for 120 days, initially ordered on October 29, 2024 Antianxiety Drug Monitoring TID (three times daily) for anxiety/insomnia Resident 12 had the potential to receive 9 mg of Ativan in a 24-hour period after October 29, 2024. Task documentation dated September 16, 2024, revealed that the hospice social worker (SW) noted that Resident 12 was in her room (verbally) rambling, won't open her eyes, talk, or touch, and won't answer questions. On October 16, 2024, Resident 12's physician assessed her and indicated no significant change in her overall condition since last visit, with no staff concerns. On October 20, 2024, at 7:55 PM staff noted Resident 12 chanting during and after dinner. Staff found her feet over the side of bed. Resident 12 was repositioned and had no further concerns. On October 29, 2024, the hospice SW noted that Resident 12 was in the hall, restless, scooting out of her chair. The SW assisted with transferring Resident 12 back to bed with Resident 12 having a firm grip on the SW's hand. The SW noted no PRN Ativan, with the last dose of (routine Ativan) at 9:00 AM. The SW contacted a hospice registered nurse (RN) and added a PRN dose addition to what was in the facility chart. Review of facility antianxiety monitoring from October 2024, revealed the Resident 12 had no noted anxiety or anxiousness. There was no other documentation available between September 16, 2024, to October 29, 2024, which indicated Resident 12 had increased rambling, restlessness, and/or signs and symptoms potentially attributed to anxiety to justify adding the PRN Ativan medication on October 29, 2024. Review of Resident 12's October, November, and December 2024, MAR (medication administration record, a form to document medication administration) revealed that the facility administered routine Ativan and PRN Ativan on the following dates: 395318 Page 13 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0758 October 31, 2024, at 12:12 PM staff administered Ativan 1 mg PRN. Level of Harm - Minimal harm or potential for actual harm October 31, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. October 31, 2024, at 7:29 PM staff administered Ativan 1 mg PRN Residents Affected - Some October 31, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 4.5 mg of Ativan within 7 hours, 48 minutes, and 3.5 mg of Ativan within 3 hours on October 31, 2024. November 27, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. November 27, 2024, at 6:00 PM staff administered Ativan 1 mg PRN medication. November 27, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 3.5 mg of Ativan within three hours on November 27, 2024. December 2, 2024, at 4:00 PM staff administered Ativan 1 mg PRN medication. December 2, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. December 2, 2024, at 8:00 PM staff administered Ativan 1 mg PRN medication. December 2, 2024, at 8:00 PM staff also administered Ativan 2 mg routine HS medication. Resident 12 received 4.5 mg of Ativan within 4 hours on December 2, 2024. December 3, 2024, at 5:00 PM staff administered Ativan 0.5 mg Ativan routine BID medication. December 3, 2024, at 7:18 PM staff administered Ativan 1 mg PRN medication. December 3, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 3.5 mg of Ativan within 3 hours on December 3, 2024. December 4, 2024, at 4:00 PM staff administered Ativan 1 mg PRN medication. December 4, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. December 4, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. December 4, 2024, at 8:40 PM staff administered Ativan 1 mg PRN medication. Resident 12 received 4.5 mg of Ativan within 4 hours, 40 minutes on December 4, 2024. December 5, 2024, at 3:30 PM staff administered Ativan 1 mg PRN medication. 395318 Page 14 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0758 December 5, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. Level of Harm - Minimal harm or potential for actual harm December 5, 2024, at 7:30 PM staff administered Ativan 1 mg PRN medication. December 5, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Residents Affected - Some Resident 12 received 4.5 mg of Ativan within 4 hours, 30 minutes on December 5, 2024. December 8, 2024, at 4:00 PM staff administered Ativan 1 mg PRN medication. December 8, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. December 8, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 3.5 mg of Ativan within 4 hours on December 8, 2024. December 11, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. December 11, 2024, at 8:00 PM staff administered Ativan 1 mg PRN medication. December 11, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 2.5 mg of Ativan within 3 hours on December 11, 2024. December 12, 2024, at 4:29 PM staff administered Ativan 1 mg PRN medication. December 12, 2024, at 5:00 PM staff administered Ativan 0.5 mg routine BID medication. December 12, 2024, at 8:00 PM staff administered Ativan 2 mg routine HS medication. Resident 12 received 3.5 mg of Ativan within 3 hours, 31 minutes on December 12, 2024. There was no documentation that staff provided justification for Resident 12's PRN Ativan administration or that non-medicinal interventions were attempted prior to administering the PRN Ativan medications. Review of November and December 2024, pharmacy medication regimen reviews revealed no documentation that identified or addressed the PRN Ativan 1 mg order for 120 days with Resident 12's physician or requested that the physician review Resident 12's PRN Ativan for a potential gradual dose reduction The surveyor reviewed the above for Resident 12 during an interview with the Director of Nursing on December 13, 2024, at 12:15 PM and 1:55 PM. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395318 Page 15 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

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 observation and staff interview, it was determined that the facility failed to ensure locked storage of medication during medication administration pass for one of six residents observed for medication administration (Resident 7). Findings include: Observation of a medication administration pass on December 11, 2024, at 8:38 AM revealed Employee 10 (licensed practical nurse) administered medications to Resident 7. Resident 7 refused to take her Metoprolol medication (medication used to lower blood pressure) because she feared that it would lower her blood pressure excessively. Employee 10 removed the Metoprolol medication from the cup that contained the remainder of Resident 7's scheduled medications. Observation of Employee 10 on December 11, 2024, at 8:42 AM revealed that she put the tab of Resident 7's Metoprolol medication in an open plastic cup on top of the medication cart and stated that she would dispose of it at the nurses' station when she was completed with her morning medication administration pass. Employee 10 then began preparing medications for the next resident on her schedule. Observation of Employee 10 on December 11, 2024, at 8:54 AM revealed that she left the medication cart unattended in the hallway to administer medication to Resident 7's roommate. The medication cart (with the unsecured tablet of Metoprolol) was not in Employee 10's view from December 11, 2024, at 8:54 AM to 8:58 AM, while she administered medications and washed her hands in Resident 7's room. Interview with Employee 10 upon her return to the medication cart on December 11, 2024, at 8:58 AM confirmed that she left the unsecured tablet of Metoprolol on top of the med cart while administering medications to Resident 7's roommate. The surveyor reviewed the above concerns regarding medication security during an interview with the Nursing Home Administrator and the Director of Nursing on December 11, 2024, at 1:45 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395318 Page 16 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure routine dental services for one of two residents reviewed for dental concerns (Resident 40). Residents Affected - Few Findings include: Interview with Resident 40 on December 10, 2024, at 12:16 PM revealed that she had natural teeth; however, had not received services from dental professionals in the past year (e.g., for routine prophylactic cleaning of her teeth). The surveyor requested any evidence that Resident 40 received routine dental services in the past year during an interview with the Nursing Home Administrator and the Director of Nursing on December 11, 2024, at 1:45 PM. Clinical record review for Resident 40 revealed a summary report from the facility's contracted dental provider that indicated that Resident 40 last received services from the professional dentist on October 4, 2022 (more than two years ago). The summary report indicated that Resident 40 received professional dental hygienist services on April 26, 2023 (approximately one and one-half years ago). Interview with the Nursing Home Administrator on December 12, 2024, at 10:25 AM confirmed that the facility did not provide routine dental services for Resident 40 in accordance with the State plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395318 Page 17 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of 20 residents reviewed (Resident 12). Residents Affected - Some Findings include: Clinical record review for Resident 12 revealed the following current physician orders: Ativan 0.5 milligram (mg) PO (by mouth) BID (twice daily at 8:30 and 5:00 PM), initially ordered September 26, 2023 Ativan 2 mg PO q HS (hour of sleep, 8:00 PM), initially ordered September 26, 2023 Ativan 1 mg PO PRN (as needed) q 4 hours (every four hours) for restlessness/anxiety for 120 days, initially ordered on October 29, 2024 Morphine 100 mg/5 ml (20 mg/ml) 5 mg/0.25 ml PO q 2 hours for moderated pain 4-7, initially ordered on March 30, 2023 Review of Resident 12's October, November, and December 2024's MAR (medication administration record, a form to document medication administration) revealed that Employee 9, licensed practical nurse, documented the following: On October 30, 2023, at 8:28 PM Employee 9 documented that she administered Resident 12's Ativan 0.5 mg routine BID medication at 5:00 PM, 3 hours, 28 minutes after the administration occurred. On October 31, 2024, at 7:29 PM Employee 9 documented that she administered Ativan 1 mg PRN. At 7:31 PM, 2 minutes later, Employee 9 documented that Resident 12's PRN Ativan administration was effective but indicated that it was effective for 8:29 PM, 58 minutes after the documentation occurred. Employee 9 pre-documented the outcome of Resident 12's PRN Ativan dose. On November 27, 2024, at 6:13 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 6:00 PM. At 6:14 PM, 1 minute later, Employee 9 documented that Resident 12's PRN Ativan administration was effective but indicated that it was effective for 7:00 PM, which was 46 minutes after the documentation occurred. Employee 9 pre-documented the outcome of Resident 12's PRN Ativan dose. On December 2, 2024, at 10:50 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 4:00 PM 6 hours, 50 minutes prior. At 10:51 PM, 1 minute later, Employee 9 documented that Resident 12's 4:00 PM PRN Ativan administration was effective as of 5:00 PM, 5 hours 51 minutes prior. At 10:51 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 8:00 PM, 2 hours, 51 minutes prior. At 10:51 PM, Employee 9 documented that Resident 12's 8:00 PM PRN Ativan administration was effective as of 9:00 PM, one hour, 51 minutes prior. Employee 9 failed to timely document Resident 12's PRN Ativan administration. On December 2, 2024, at 10:50 PM Employee 9 documented that she administered Morphine 5 mg PRN medication for a pain level of 4 at 4:00 PM, 6 hours, 50 minutes prior. At 10:50 PM Employee 9 395318 Page 18 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented that the PRN Morphine administration was effective at 5:00 PM, five hours, 50 minutes prior. Employee 9 failed to timely document Resident 12's 4:00 PM PRN Morphine administration. On December 3, 2024, at 7:21 PM Employee 9 documented that she administered Morphine 5 mg PRN medication for a pain level of 4 at 7:00 PM, 21 minutes prior. At 7:21 PM Employee 9 documented that the PRN Morphine administration was effective at 8:00 PM, which was 39 minutes after the documentation occurred. Employee 9 pre-documented the outcome of Resident 12's PRN Morphine dose. On December 4, 2024, at 8:40 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 4:00 PM 4 hours, 40 minutes prior. At 8:40 PM Employee 9 documented that Resident 12's 4:00 PM PRN Ativan administration was effective as of 5:00 PM, 3 hours 40 minutes prior. At 8:41 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 8:40 PM, 2 hours, 1 minute prior. At 8:41 PM Employee 9 documented that Resident 12's 8:40 PM PRN Ativan administration was effective as of 9:40 PM, which was 59 minutes after the documentation occurred. Employee 9 failed to timely document Resident 12's 4:00 PM PRN Ativan administration and effectiveness and pre-documented the outcome of Resident 12's 8:40 PRN Ativan dose. On December 5, 2024, at 10:48 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 3:30 PM, 7 hours, 18 minutes prior. At 10:49 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 7:30 PM, 3 hours, 19 minute prior. Employee 9 failed to timely document Resident 12's 3:30 PM and 7:30 PRN Ativan administration. On December 8, 2024, at 6:57 PM Employee 9 documented that she administered Ativan 1 mg PRN medication at 4:00 PM 2 hours, 57 minutes prior. At 6:59 PM Employee 9 documented that Resident 12's 4:00 PM PRN Ativan administration was effective as of 5:00 PM, 1 hour 59 minutes prior. Employee 9 failed to timely document Resident 12's PRN Ativan administration and effectiveness and pre-documented the outcome of Resident 12's 8:40 PRN Ativan dose. This surveyor reviewed the above information during an interview on December 13, 2024, at 1:55 PM with the Director of Nursing. 28 Pa. Code 211.5 (f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395318 Page 19 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide required immunization education for four of five residents reviewed for influenza immunizations (Resident 11, 15, 46, and 59). Residents Affected - Some Findings include: Review of Resident 11's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on November 21, 2024. There was no documented evidence in Resident 11's clinical record to indicate that the facility provided the resident or her responsible party education regarding the risks and benefits of the vaccination. Review of Resident 15's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on October 29, 2024. There was no documented evidence in Resident 15's clinical record to indicate that the facility provided the resident or her responsible party education regarding the risks and benefits of the vaccination. Review of Resident 46's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on October 29, 2024. There was no documented evidence in Resident 46's clinical record to indicate that the facility provided the resident or his responsible party education regarding the risks and benefits of the vaccination. Review of Resident 59's immunization listing revealed that the facility administered the influenza vaccination for the 2024-2025 season on October 29, 2024. There was no documented evidence in Resident 59's clinical record to indicate that the facility provided the resident or her responsible party education regarding the risks and benefits of the vaccination. Interview with Employee 6, infection control preventionist, on December 13, at 10:05 AM confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395318 Page 20 of 21 395318 12/13/2024 Green Home, Inc, The 37 Central Avenue Wellsboro, PA 16901

F 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of newly hired staff and staff interview, it was determined that the facility failed to screen, educate, and offer the COVID-19 vaccine to four of four newly hired employees (Employees 1, 2, 3, and 4). Residents Affected - Some Findings include: Review of the CMS (Center for Medicare and Medicaid Services) memo (QSO-21-19-NH) published May 11, 2021, indicates that the facility is to offer current COVID-19 vaccinations to staff. Employees are to be medically screened for eligibility and educated on the risks and benefits of the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education to staff, and whether the staff member received the vaccine. Review of the facility's new hire list revealed that Employees 1 and Employee 2, both nurse aide trainees, were hired on August 5, 2024. There was no documented evidence to indicate that the facility completed screening, offered the COVID-19 vaccine, or completed education regarding the risks and benefits if applicable. Review of the facility's new hire list revealed that Employee 3, licensed practical nurse, was hired on October 14, 2024. There was no documented evidence to indicate that the facility completed screening, offered the COVID-19 vaccine, or completed education regarding the risks and benefits if applicable. Review of the facility's new hire list revealed that Employees 4, nurse aide, was hired on December 9, 2024. There was no documented evidence to indicate that the facility completed screening, offered the COVID-19 vaccine, or completed education regarding the risks and benefits if applicable. Interview with Employee 5, employee health, on December 13, 2024, at 11:18 AM confirmed the above findings for Employees 1, 2, 3, and 4. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395318 Page 21 of 21