Health inspection·May 15, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R20). Findings include: Review of facility policy entitled Psychotropic Medication Policy dated 1/21/25, revealed the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication. Review of Resident R20's clinical record revealed an admission date of 3/20/25, with diagnoses that included osteomyelitis (bone infection) of the right ankle and foot, anxiety, and anemia (condition of not enough healthy red blood cells to carry oxygen). The clinical record revealed that on 4/30/25, Resident R20's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 12 hours PRN for anxiety. Review of Resident R20's May 2025 Medication Administration Record revealed that the PRN Lorazepam was used on 5/4/25, 5/5/25, 5/8/25, and 5/9/25. Resident R20's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in May 2025. During an interview on 5/14/25, at 12:09 p.m. the Director of Nursing confirmed that Resident R20's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 2 395341 395341 05/15/2025 Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 20 residents reviewed (Residents R10 and R16). Findings include: Review of facility policy entitled Comprehensive Person-Centered Care Planning dated 1/21/25, indicated The care plans will be reviewed and revised as necessary by the Interdisciplinary Team at least quarterly after each MDS [Minimum Data Set-a periodic assessment of resident care needs] assessment ., or more often as changes occur. Review of Resident R10's clinical record revealed an admission date of 1/3/23, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R10's physician's orders revealed an order for O2 (oxygen) at 2 LPM (liters per minute) NC (nasal cannula oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) routine and PRN (as needed) dated 3/1/25. Review of Resident R10's care plan for alteration in cardio and respiratory lacked an intervention for his/her current use of oxygen. Resident R16's clinical record revealed an admission date of 3/26/19, with diagnoses including Parkinson's disease (a disorder that affects movement related to the central nervous system), major depressive disorder, and moderate intellectual disabilities (limitations to cognitive functioning and skills). Resident R16's clinical record revealed his/her anticoagulant medication Eliquis (a blood thinning medication that reduces the ability to clot) was discontinued on 2/24/25. Resident R16's care plan dated 3/7/25, with a target date of 6/1/25, revealed a care plan was in place related to his/her anticoagulant medication Eliquis. During an interview on 5/14/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that Resident R10's cardio/respiratory care plan was not reviewed/revised to reflect current resident care and services. During an interview on 5/14/25, at 1:45 p.m. the DON confirmed that Resident R16's anticoagulant care plan was not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395341 Page 2 of 2