Health inspection·January 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview it was determined the facility failed to fully develop and revise a person-centered comprehensive care plan to meet the individualized needs of one resident out of 20 sampled (Resident 67). Findings included: A review of Resident 67's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and muscle weakness. A review of Resident 67's POLST (Pennsylvania Orders for Life Sustaining Treatment, a process that helps an individual receive the medical treatment they want, and avoid the medical treatments they do not want, when they are seriously ill or frail) initiated by the facility's Social Worker (SW) and completed with Resident 67's RP (responsible party) dated [DATE], indicated the resident's code status was changed to do-not-resuscitate (DNR a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or if the heart stops beating and comfort care (a specialized patient care approach focused on managing symptoms, relieving pain, and enhancing quality of life. It is typically offered to residents who have experienced multiple hospitalizations, where further medical interventions are unlikely to change the outcome), elected medical interventions for comfort measures, antibiotic use to be determined when infection occurs or with comfort as the goal, and no hydration or nutrition by means of a feeding tube. The POLST form dated [DATE], and a progress note by the Social Worker indicated that the resident's responsible party (RP) had elected a care plan that included do-not-resuscitate (DNR), comfort care, antibiotics for comfort, and no artificial hydration or nutrition by tube. Physician's orders dated [DATE], at 1:15 PM, revealed that the Resident 67's code status was DNR. A review of the resident's comprehensive plan of care, last revised on [DATE], failed to reflect these updated medical treatment goals and interventions. Despite updated physician orders and documentation in progress notes, the care plan did not address the resident's goals for comfort measures only, the selective use of antibiotics, or the decision to forego artificial hydration and nutrition. Page 1 of 4 395357 395357 01/10/2025 Ellen Memorial Rehabilitation and Healthcare Cente 23 Ellen Memorial Lane Honesdale, PA 18431

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE], the Social Worker confirmed that the resident's RP elected comfort measures due to the resident's progressive weight loss and variable meal intake. The Director of Nursing (DON) confirmed that the facility failed to revise the resident's care plan to include the specific medical treatment goals outlined by the POLST form and RP's instructions. The facility failed to incorporate the resident's medical treatment goals for comfort measures only, antibiotics use for comfort, and no hydration or artificial nutrition by tube 28 Pa. Code 211.12 (d)(5) Nursing services 395357 Page 2 of 4 395357 01/10/2025 Ellen Memorial Rehabilitation and Healthcare Cente 23 Ellen Memorial Lane Honesdale, PA 18431

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. Based on a review of clinical records, and staff interview, it was determined the facility failed to implement individualized approaches to prevent declines in bowel continency and restore normal bowel function to the extent possible for one resident (Resident 65) out of 20 residents sampled. Findings include: Review of facility policy entitled Bladder and Continence, last reviewed on January 2, 2025, indicated residents who are identified as having the potential to improve continence, place on a retraining program. According to the policy, upon admission, re-admission, with any significant change, and after urinary catheter removal, a bowel and bladder diary will be completed for a minimum of three days to gather information about the resident's current continence status. Upon review of the data gathered from the diary, a continence evaluation will be completed, and an appropriate toileting program implemented. A review of Resident 65's clinical record revealed admission to the facility on February 23, 2024, with diagnoses which included hypertension (high blood pressure), anxiety, and recurrent urinary tract infections. A review of Resident 65's admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 1, 2024, section H, bowel, and bladder, indicated the resident was frequently incontinent of bladder and frequently incontinent of bowel and was not on a toileting program to manage the resident's incontinence. The resident required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with activities of daily living which included toilet transfer and toileting hygiene. A review of Resident 65's care plan-initiated February 26, 2024, revealed that the resident has an ADL self-care performance deficit related to weakness and need for assist with personal care. There was no evidence the facility had evaluated the resident's bowel and/or bladder habits and status to develop an individualized toileting retraining program to decrease episodes of incontinence. A Continence Evaluation completed on April 9, 2024, indicated that Resident 65 experienced occasional incontinence of both bowel and bladder. Recommendations included routine toileting before and after meals, at bedtime, and as requested, with checks and changes every three hours during the night. Despite this evaluation, there was no evidence that the recommended program was implemented. 28 Pa. Code 211.12 (d)(5) Nursing services. 395357 Page 3 of 4 395357 01/10/2025 Ellen Memorial Rehabilitation and Healthcare Cente 23 Ellen Memorial Lane Honesdale, PA 18431

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice Agency for two residents (Residents 69 and 7). Findings include: A review of Resident 69's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of physician's order dated December 4, 2024, revealed the resident was admitted into hospice services for a diagnosis of end stage Alzheimer's disease. A review of the resident's care plan initially dated October 30, 2024, and last revised November 25, 2024, revealed the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. A review of Resident 7's clinical record revealed she was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of physician's order dated September 19, 2024, revealed the resident was admitted into hospice services for a diagnosis of end stage dementia. A review of the resident's care plan initially dated September 19, 2024, and last revised December 10, 2024, revealed the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis. An interview with the director of nursing on January 8, 2025, at approximately 12:30 pm, confirmed the resident's care plan was not coordinated with hospice services. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.21(c) Use of outside resources 395357 Page 4 of 4