Health inspection·March 4, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record, review of select facility policies, and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of four residents reviewed (Resident 1) Residents Affected - Some Findings include: The current facility policy entitled Standing Orders for Skilled Nursing Facility, revealed the following orders are initiated from standing orders. The bowel and gastrointestinal (organs that help with digestion) protocol includes nursing staff will administer residents Milk of Magnesia (MOM) 30 milliliters (mL) by mouth on the day shift of day three without a bowel movement. Nursing staff are to administer a Dulcolax Suppository 10 milligram (mg) on the evening shift of day three if the Milk of Magnesia is ineffective. Nursing staff are to administer a Fleet's enema as needed on day four without a bowel movement if no results from the suppository. Nursing staff can administer 15 to 30 mL every two hours for as needed gastrointestinal distress. Clinical record review for Resident 1 revealed the facility initiated a plan of care to address Resident 1's constipation on July 9, 2024. Interventions included that the resident would follow the bowel protocol if constipation occurs. Clinical record review for Resident 1 revealed the following physician orders to promote bowel movements: Milk of Magnesia 400 mg per 5 ml (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as needed (PRN) and administer if no bowel movement by the third day (day shift). Dulcolax suppository (Bisacodyl, a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation for no bowel movement after administration of MOM (evening shift). Fleet's Enema 7-19 gm (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation). Insert 1 applicatorful rectally for no bowel movement by the fourth day (day shift) if no results from administration of suppository or MOM. Review of bowel elimination records for Resident 1 revealed that staff documented no bowel movements for January 28, 29, 30 and, 31, 2025. There was no documentation of Resident 1's bowels from February 1 to 4, 2025. Further review of Resident 1's bowel elimination record revealed that staff documented no bowel movements for February 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, and 18, 2025. Page 1 of 4 395396 395396 03/04/2025 Edenbrook South 101 Leader Drive Williamsport, PA 17701

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Employee 2, assistant director of nursing, on March 4, 2025, at 1:25 PM revealed there was no documentation of Resident 1's bowel movements from February 1 to 5, 2025, because the facility had to use paper documentation during this time due to changes in facility ownership and the bowel movements were not being documented on the nurse aide data collection tool. There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 1 refused, any PRN medications. Further review of Resident 1's clinical record revealed nursing documentation dated February 12, 2025, at 11:14 AM noting that transportation was in the facility to take Resident 1 to a gastrointestinal appointment she made on her own. Resident 1's guardian stated she is not to go to this appointment. Documentation revealed transportation staff stated Resident 1 has to go she has not had a bowel movement in over three weeks. Documentation noted Resident 1 stated, I have not been able to go. Nursing documentation dated February 12, 2025, at 11:59 AM revealed that Resident 1 called 911 due to not being able to go to her appointment due to her guardian's decision. The facility called the guardian and agreed to send her to the hospital. Review of hospital documentation from February 12 to 13, 2025, revealed Resident 1 presented to the emergency department for evaluation of constipation with abdominal pain. Fecal disimpaction was performed in the hospital. Resident 1 was educated on use of Miralax for continued constipation. Nursing documentation dated February 19, 2025, at 10:03 AM noted Resident 1 voiced concerns of a hot broom handle feeling, in her rectum this morning after having a bowel movement. Resident 1 also stated there was blood in the toilet. Nursing documentation on February 19, 2025, at 5:38 PM noted Resident 1 was demanding to go to the hospital, called 911, emergency medical services arrived, and transported Resident 1 to the hospital. Nursing documentation dated February 20, 2025, at 12:49 AM noted Resident 1 was transferred from the emergency room to a medical center for a gastrointestinal consult. Review of the gastrointestinal documentation dated February 20, 2025, revealed a CTE (computed tomography enterography, a noninvasive imaging test that examines the small intestine) was recommended and performed showing small bowel thickening. The documentation revealed that rectal bleeding could be multifactorial but mostly could be from possible solitary rectal ulcer history of constipation requiring disimpaction and the current CTE showing significant stool in the rectum. Resident 1 returned to the facility on February 26, 2025. The facility failed to provide the highest practical care related to bowel management. These findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 4, 2025, at 2:25 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395396 Page 2 of 4 395396 03/04/2025 Edenbrook South 101 Leader Drive Williamsport, PA 17701

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for one of nine residents reviewed (Resident 1). Residents Affected - Few Findings include: The facility policy entitled Resident Height and Weight, last reviewed without changes on January 7, 2025, revealed nursing department staff and the facility dietician will cooperate to prevent, monitor, and provide interventions for undesirable weight variances for residents. A significant weight change is defined as a 5 percent weight change over 30 days, 7.5 percent weight change over 90 days, or a 10 percent weight change over 180 days. Upon admission, and two days following, the nursing department staff will weigh the resident, weekly thereafter for four weeks, and then monthly unless otherwise ordered by the physician, or recommended by the dietitian. Any weight change of five pounds or greater within 30 days will be retaken within 72 hours for verification, and the reweight will be documented in the electronic medical record. If the re-weight verifies a significant, unplanned weight change, this is communicated to the resident's physician, responsible party ,and dietician. This weight change will be assessed and reviewed by the dietician in cooperation with the interdisciplinary team and appropriate interventions will be implemented, reviewed, and revised as needed. Clinical record review revealed the facility admitted Resident 1 on June 21, 2024. Further review of Resident 1's clinical record revealed the following weight assessments: December 13, 2024, 177 pounds January 7, 2025, 174 pounds February 6, 2025, 160 pounds (a 14-pound, 8.04 percent severe weight loss in 30 days) March 1, 2025, 154.5 pounds (a 22.5 pound, 12.71 percent severe weight loss in less than 90 days) Review of Resident 1's clinical record revealed a weight change note dated February 7, 2025, noting Resident 1's current weight was decreased 14 pounds from her prior weight. The registered dietician requested a reweight. The registered dietician had no recommendations at this time. There was no evidence that staff obtained a re-weight or notified Resident 1's physician. Further review of Resident 1's clinical record revealed no assessment of Resident 1's severe weight loss, or any interventions addressing the severe weight loss. Interview with Employee 1 (registered dietitian) on March 4, 2025, at 11:47 AM confirmed these findings. Employee 1 revealed that she was aware of Resident 1's weight loss. She stated that she had been waiting for weight verifications and confirmed that she did not assess and implement interventions to address Resident 1's severe weight loss. 28 Pa. Code 211.10(d) Resident care policies 395396 Page 3 of 4 395396 03/04/2025 Edenbrook South 101 Leader Drive Williamsport, PA 17701

F 0692 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395396 Page 4 of 4