Health inspection·July 25, 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. Based on observations, clinical record review and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 32 residents reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula.Review of Resident 1's clinical record revealed no care plan for oxygen use.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have a care plan for oxygen use.483.21 Develop/Implement Comprehensive Care PlanPreviously cited 8/22/2428 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/22/24 Page 1 of 7 395400 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to maintain acceptable parameters of nutritional status for two of three residents reviewed (Residents 4 and 22). Findings include:Review of facility policy, Weight Assessment and Intervention revised September 2008, revealed monthly weights will be completed no later than the 7th day of the month. Additionally, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.Review of Resident 4's clinical record revealed that the resident weighed 150.0 pounds on April 28, 2025. The resident was admitted to the hospital on [DATE], and readmitted to the facility on [DATE].Review of a weight warning note on May 9, 2025, revealed a weight of 181.3 pounds and indicated a suspected discrepancy in weight. A reweight was requested. Review of the clinical record revealed a reweight of 135.0 pounds was obtained on May 20, 2025 (11 days later).Interview with Employee E3 on July 24, 2025, at 9:40 a.m. confirmed that Resident 4's reweight was not completed timely after the readmission discrepancy.Review of Resident 22's clinical record revealed that the resident weighed 96.8 pounds on February 1, 2025 and 88.4 pounds (decrease of 8.4 pounds or 8.7% decrease) on March 5, 2025. Review of weight warning note of March 6, 2025, indicated suspected significant weight change and a reweight was requested. Review of the clinical record revealed that a reweight of 85.6 pounds was obtained on March 19, 2025 (14 days later).Review of Resident 22's clinical record revealed a weight of 92.6 pounds on April 8, 2025 (increase of 7.0 pounds or 8.3% since previous weight). There was no documented evidence that a reweight was obtained.Review of Resident 22's clinical record revealed a weight of 81.0 pounds on May 15, 2025 (decrease of 11.6 pounds or 12.5% since previous weight). Review of weight warning note of May 16, 2025, revealed suspected significant weight change from previous month and a reweight was requested. A reweight of 78.6 pounds was obtained on May 21, 2025 (5 days later).Interview with Employee E3 on July 24, 2025, at 11:25 a.m. indicated that reweights should be done as soon as possible. Employee E3 indicated that a reweight for Resident 22's April 2025 weight was not completed because the weight change did not trigger for a reweight. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few 395400 Page 2 of 7 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

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 observations, clinical record review and staff interview it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one resident reviewed (Resident 1).Findings include:Observations on July 22, 2025, at 2:20 p.m. and July 24, 2025, at 12:00 p.m. revealed Resident 1 receiving oxygen via nasal cannula (tube that delivers oxygen) at a flow rate of 2.0 liters per minute.Review of Resident 1's clinical record revealed no order for oxygen or respiratory care.Interview with the Director of Nursing on July 25, 2025, at 11:23 a.m. confirmed that Resident 1 did not have an order for oxygen use.483.25 Respiratory/Tracheostomy Care and SuctioningPreviously cited 3/5/25, 8/22/2428 Pa. Code 211.12(d)(3)(5) Nursing ServicesPreviously cited 8/22/24 Residents Affected - Few 395400 Page 3 of 7 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

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 upon observation, it was determined that the facility failed to ensure adequate and competent staffing levels were maintained to promptly respond to resident call bells on one day of three days of the survey.Findings include:Observation on July 23, 2025, at 12:07 p.m. on the B Wing nursing unit revealed five resident call bells with the lights on and audibly ringing, as well as lunch carts in the hallway that had been delivered to the unit from the kitchen.Observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed four employees gathered in a side room with the door closed.Further observation of the B Wing nursing unit nurses' station on July 23, 2025, at 12:07 p.m. revealed a licensed employee sleeping in front of the computer at the desk.Observation of the B Wing resident call bells revealed the resident call bells remained unanswered and the lunch trays not delivered for approximately 15 minutes.The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 11:30 a.m. 28 Pa. Code 201.18(b)(1)(2)(5)(e)(1) ManagementPreviously cited 8/22/202428 Pa. Code 201.29(c)(4) Resident RightsPreviously cited 8/22/202428 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/22/2024 395400 Page 4 of 7 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and staff interviews it was determined that the facility failed to complete a performance review at least once every 12 months for five of five nurse aides (Employees E4, E5, E6, E7, and E8).Findings include:Review of Employee E4's personnel record revealed a date of hire of October 11, 2023.Review of Employee E5's personnel record revealed a date of hire of May 24, 2023.Review of Employee E6's personnel record revealed a date of hire of June 8, 2022.Review of Employee E7's personnel record revealed a date of hire of September 3, 2019.Review of Employee E8's personnel record revealed a date of hire of October 6, 2021.Further review of the personnel records revealed no evidence that the employees had a performance review at least once every 12 months.Interview with the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 10:10 a.m. confirmed that performance reviews had not been completed for the above employees.28 Pa. Code 201.19(2) Personnel policies and procedures Residents Affected - Some 395400 Page 5 of 7 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

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 review of facility policies and procedures and observation, it was determined that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered for one of three medication carts reviewed (B Wing Medication Cart).Findings include:Based upon facility policy and procedure titled Storage of Medications revealed Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Review of facility policy and procedure titled Administering Medications revealed The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of package insert instructions for Humalog Insulin (medication used to treat high blood sugar levels) Pens revealed unopened Humalog pens should be stored in the refrigerator.Further review of package insert instructions for Humalog Insulin Pens revealed that once opened, Humalog can be kept at room temperature for up to 28 days. Review of package insert instruction for Lantus Insulin (medication used to treat high blood sugar levels) revealed Lantus Insulin should be used within 28 days after opening.Review of package insert instructions for Insulin Aspart (Novolog insulin) (medication used to treat high blood sugar levels) revealed that Insulin Aspart expires 28 days after opening.Review of package insert instructions for Insulin glargine (medication used to treat high blood sugar levels) revealed Insulin glargine must be discarded 28 days after opened. Observation of the B Wing Medication Cart on July 24, 2025, at 11:00 a.m. revealed a Humalog Insulin Pen opened on June 20, 2025, with no expiration date. The expiration date for this Humalog Insulin Pen would have been July 17, 2025, 28 days after opening the pen. Further observation revealed an unopened and undated Humalog Insulin Pen in the medication drawer.Further observation revealed two open and undated insulin aspart pens.Further observation revealed one open and undated insulin glargine vial. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing ServicesPreviously cited 8/22/2024, 3/5/2025 395400 Page 6 of 7 395400 07/25/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based upon review of facility policy and procedure, observation and clinical record review, it was determined that the facility failed to ensure proper infection control procedures were followed during medication administration observation and pressure ulcer wound treatments for three of three residents observed (Resident 6, Resident 22 and Resident 136.)Findings include: Residents Affected - Some Review of facility policy and procedure titled Administering Medications revealed “Staff follows established facility infection control procedures (e.g. handwashing, aseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.” Observation of Medication Administration on July 22, 2025, at 11:44 a.m. revealed Licensed Employee E9 placing medication pills for administration into Licensed Employee E9’s ungloved hands and then placing the medication pill into the medication cup for administration. Observations on all days of the survey revealed no system in place to communicate to staff that resident required enhanced barrier precautions. Additionally, no PPE (personal protective equipment) was readily available to staff providing high contact care. Review of resident 6’s progress notes on July 24, 2025, revealed resident had a stage III pressure ulcer to the sacrum (bone at the bottom of the spine). Observations of Resident 6’s room showed no indication of enhanced barrier precautions being communicated to staff entering the room. No PPE was observed to be available to staff providing care to Resident 6. Observation of Resident 6’s wound care on July 25, 2025, at 11:28 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. Review of Resident 22’s progress note of July 15, 2025, revealed resident had a stage II pressure ulcer (wound with partial thickness skin loss) to the sacrum (triangular bone at the base of the spine). Observation of Resident 22’s wound care on July 25, 2025, at 10:17 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. Review of resident 136’s progress notes on May 6, 2025, revealed resident had a stage III pressure ulcer to the sacrum (wound full-thickness skin loss) to the sacrum (triangular bone at the base of the spine). Observations of Resident 136’s room showed no indication of enhanced barrier precautions being communicated to staff entering the room. No PPE was observed to be available to staff providing care to Resident 136. Observation of Resident 136’s wound care on July 24, 2025, at 9:40 a.m. revealed Licensed Employee E10 failed to utilize Personal Protective Equipment during the wound dressing change. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 25, 2025, at 11:00 a.m. 395400 Page 7 of 7