Health inspection·February 23, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 25 residents reviewed (Resident 31). Residents Affected - Few Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated January 29, 2024, indicated that the resident was understood and could understand, and he required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach. Observations of Resident 31 on February 20, 2024, at 1:05 p.m. revealed that the resident was lying in bed, and the call bell was hanging off the back of the bed onto the floor and was not within his reach. Interview with Licensed Practical Nurse 1 at that time revealed that Resident 31 was capable of using his call bell and it should have been placed within his reach. 28 Pa. Code 211.12(d)(5) Nursing Services. Page 1 of 25 395422 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's attending physician was notified about changes in weight for one of 51 residents reviewed (Resident 19), failed to notify the physician regarding an elevated blood sugar and change in skin condition for one of 51 residents reviewed (Resident 47), and failed to notify the physician of purulent drainage from a resident's nephrostomy tube for one of 51 residents reviewed (Resident 97) . Findings include: The facility's policy regarding weight monitoring, dated February 13, 2024, indicated to record weight and alert the nurse to any significant weight change. When there is a significant variance from the previous recorded weight, the scale should be rebalanced and the resident re-weighed and a licensed nurse is to validate. The nurse is responsible to notify the physician of any significant weight change and to consult with the Director of Dietary Services and/or the dietician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated January 30, 2024, indicated that the resident had a weight loss, was not on a physician-prescribed weight loss program, and the resident had diagnoses that included congestive heart failure (the heart cannot pump blood as well as it should causing fluid to build up in the lungs and lower legs). Physician's orders for Resident 19, dated January 23, 2024, included an order for 40 milligrams (mg) of Lasix (a medication used to treat fluid build-up) daily and 25 mg of Spironolactone (a medication used to treat fluid build-up) daily for 90 days (through April 23, 2024). Physician's orders for Resident 19, dated January 30, 2024, included an order for weekly weights due to weight loss in the hospital. A review of Resident 19's clinical record revealed that the resident's weight on January 8, 2024, (prior to her hospitalization on January 15, 2024) was 173.6 pounds. The resident's weight on readmission on [DATE], was 164 pounds. Her weight on January 31, 2024, was 161.2 pounds; on February 8, 2024, her weight was 158 pounds; on February 14, 2024, her weight was 159 pounds; and on February 21, 2024, her weight was 169.6 pounds. There was no documented evidence that the nurse was alerted to the weight changes, that the weight changes were validated by a re-weight, that the Dietary Director or dietician was consulted, or that the physician was notified about Resident 19's progressive weight loss from January 23, 2024, through February 8, 2024, and her significant weight increase from February 14, 2024, to February 21, 2024. Interview with the Director of Nursing on February 23, 2024, at 1:49 p.m. confirmed that there was no documented evidence that the nurse was alerted to the weight changes, that the weight changes were validated by a re-weight, that the Dietary Director or dietician was consulted, or that the physician was notified about Resident 19's progressive weight loss from January 23, 2024, through February 8, 2024, and her significant weight increase from February 14, 2024, to February 21, 2024. 395422 Page 2 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An annual MDS assessment for Resident 47, dated December 19, 2023, revealed that the resident was cognitively intact and required assistance with daily care tasks. A nursing note for Resident 47, dated February 15, 2024, at 10:10 a.m., revealed that staff reported when turning the resident during daily care the nurse aide noticed a crack in the skin approximately 1.0 centimeter (cm) x 1.0 cm behind the right knee, and she notified the registered nurse. There was no documented evidence that the physician was notified by the registered nurse about the change in skin condition for Resident 47. Interview with the Director of Nursing on February 22, 2024, at 3:02 p.m. confirmed that there was no documented evidence in Resident 47's clinical record that the facility called the physician to notify him about the change in skin condition. A nursing note for Resident 47, dated February 4, 2024, at 3:54 p.m. stated that resident's blood sugar was 411 milligrams/deciliter (mg/dL) and the resident was in bed eating a bag of chips when the blood sugar was taken. The registered nurse was updated and was to inform the physician when the resident's blood sugar was over 400 mg/dL. There was no documented evidence in Resident 47's medical record that the physcian was notified of the resident's elevated blood sugar. Interview with the Director of Nursing on February 22, 2024, at 3:03 p.m. confirmed that the physician was not notified of Resident 47's elevated blood sugar. A quarterly MDS assessment for Resident 97, dated February 2, 2024, revealed that the resident was cognitively impaired, required assistance with daily care tasks, and had a diagnosis of neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). Resident 97's care plan, dated April 28, 2023, indicated to monitor the nephrostomy site for signs and symptoms of infection during care. A nursing note for Resident 97, dated February 12, 2024, revealed that the resident's nephrostomy site (a nephrostomy is a thin catheter that drains urine from the kidney into a bag) had drainage that was greenish and bloody, there was a distinct odor present, and the resident had complaints of pain. The registered nurse was notified of the change in condition of the resident. There was no documented evidence the physician was notified about the change in condition to Resident 97's nephrostomy site. Interview with the Director of Nursing on February 22, 2024, at 2:04 p.m. confirmed that there was no documented evidence that Resident 97's physician was notified about the change in condition of the resident's nephrostomy. 28 Pa. Code 211.12(d)(1)(3) Nursing Services. 395422 Page 3 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of clinical records and grievance records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance regarding dietary complaints. Findings include: The facility's policy regarding complaint and grievances, dated February 13, 2024, indicated that residents should have reasonable expectations of care and services and the facility should address those expectations in a timely, reasonable, and consistent manner. The grievance log from December 2023 revealed that there were three grievances from the resident council meeting on December 10, 2023, regarding residents not receiving food that they requested, receiving tiny portions of food, and hair found in the soup. Education was provided to dietary. The grievance log from February 2024 revealed that the rice was undercooked, foods that were to be served cold were being served on the hot plates, the dietary department ignores resident requests, portions were small, food was not palatable and was terrible, poor food quality, and residents were served the wrong consistency. The dietary staff were re-educated about these concerns to resolve them. A meeting with a group of residents on February 21, 2024, at 11:30 a.m. revealed that the residents continue to be dissatisfied with the quality and palatability of the food served at the facility. The group has made complaints to dietary regarding food services, but there have been no changes. Interview with the Nursing Home Administrator on February 23, 2024, at 11:48 a.m. confirmed that there are many grievances regarding food and re-education has been ineffective to resolve food complaints. 28 Pa. Code 201.29(i) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Services. 395422 Page 4 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for three of 51 residents reviewed (Residents 7, 42, 68). Findings include: The facility's policy on care plans, dated February 13, 2024, indicated that a comprehensive, individualized, person-centered plan of care would be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 29, 2023, indicated that the resident was cognitively intact, required moderate to substantial assistance with care needs, and was frequently incontinent of bowel and bladder. An urology consult for Resident 7, dated January 4, 2024, indicated that the resident has a cystoscopy (a procedure to diagnose a treat urinary tract problems) to remove a urethral stent (a tiny tube that holds open the ureters-tubes that carry urine from the kidneys to the bladder). Physician's orders for Resident 7, dated January 4, 2024, included an order for the resident to receive 250 milligrams (mg) of Keflex (an antibiotic) at bedtime, status post cystoscopy with stent removal for six months (through July 4, 2024). There was no documented evidence that a care plan was developed to address Resident 7's need for long-term antibiotic therapy. An interview with the Director of Nursing on February 23, 2024, at 9:28 a.m. confirmed that Resident 7 did not have a care plan for long-term antibiotic therapy and should have. A significant correction MDS assessment for Resident 42, dated February 2, 2024, revealed that the resident was dependent for care needs, was cognitively impaired, and was incontinent of bowel. Observations on February 20, 2024, at 11:33 a.m. revealed that Resident 42 was on contact precautions for Clostridium difficile (C. diff) (a highly contagious infection of the colon). Progress notes for Resident 42, dated February 13, 2024, revealed that the resident's stool tested positive for C. diff. and the resident's room was changed with contact precautions initiated. Physician's orders for Resident 42, dated February 13, 2024, included an order for the resident to receive 500 mg of Metronidazole (an antibiotic) three times a day for 10 days. There was no documented evidence that the resident had a care plan in place to address the C. diff infection with antibiotic and contact precautions. Interview with the Director of Nursing on February 22, 2024, at 3:02 p.m. confirmed that there was no comprehensive care plan in place to address Resident 42's C. diff infection with antibiotic and 395422 Page 5 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0656 contact precautions. Level of Harm - Minimal harm or potential for actual harm A quarterly MDS assessment for Resident 68, dated January 23, 2024, indicated the resident was cognitively impaired, required substantial assistance to dependent with care needs, used oxygen, and had a diagnosis of congestive heart failure (the heart cannot pump blood as well as it should) and respiratory failure (blood does not have enough oxygen and causes difficulty breathing). Residents Affected - Few Progress notes for Resident 68, dated December 13, 2023, revealed that the resident's pulse oximetry (measures blood oxygen levels) was 78 percent on room air (without supplemental oxygen). The respiratory therapist evaluated the resident and oxygen was applied at 3 liters per minute (LPM) via nasal cannula (a small tube that delivers oxygen through the nasal passages). The resident's pulse oximetry increased to 92 percent. The medical director and resident representative were notified. Physician's orders for Resident 68, dated December 13, 2023, included an order for oxygen at 3 LPM via nasal cannula, change tubing, mask, and/or nasal cannula weekly and sooner as needed. Physician's orders, dated January 18, 2024, included an order for oxygen at 3 LPM continuously via nasal cannula with ear protectors on tubing. There was no documented evidence that the resident had a care plan in place to address his need for supplemental oxygen. Interview with the Director of Nursing on February 22, 2024, at 4:02 p.m. confirmed that there was no comprehensive care plan in place to address Resident 68's need for supplemental oxygen. 28 Pa. Code 211.12(d)(5) Nursing Services. 395422 Page 6 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for one of 51 residents reviewed (Resident 29). Findings include: The facility's policy on care plans, dated February 13, 2024, indicated that the comprehensive care plan will be reviewed, updated and/or revised based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each Omnibus Budget Reconciliation Act (OBRA) MDS assessment and as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 3, 2024, revealed that the resident was cognitively intact and required supervision to partial assist with care needs. Clinical record review for Resident 29 revealed that he had a care plan in place for heparin (an anticoagulant or blood thinning medication). The resident did not have an order for heparin or any other anticoagulant. Interview with the Director of Nursing on February 22, 2024, at 4:01 p.m. confirmed the Resident 29's care plan for anticoagulant should have been resolved to reflect the resident was not on an anticoagulant. 28 Pa. Code 211.12(d)(5) Nursing Services. 395422 Page 7 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 51 residents reviewed (Resident 33) and failed to prevent a delay in care for one of 51 residents reviewed (Resident 97) resulting in his hospitalization. Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated February 2, 2024, revealed that the resident was cognitively impaired. A nutritional note for Resident 33, dated December 12, 2023, revealed that the resident was to receive a health shake two times per day to meet her protein needs. Physician's orders for Resident 33, dated December 13, 2023, included orders for the resident to receive a 4-ounce health shake two times per day. Review of Resident 33's Medication Administration Records (MAR) and nursing notes for December 2023, as well as January and February 2024, revealed that staff had documented that the health shake was not available for administration. Interview with the Director of Nursing on February 22, 2024, at 3:25 p.m. confirmed that Resident 33 did not receive the health shakes as ordered by the physician A quarterly MDS assessment for Resident 97, dated February 2, 2024, revealed that the resident was cognitively impaired, required assistance with daily care tasks, and has a diagnosis of neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem). A nursing note for Resident 97, dated October 8, 2023, at 3:05 p.m., revealed that the nephrostomy (a catheter that is inserted in the kidney through the abdomen and allows urine to drain) dressing was loose, there was blood in the drainage bag, and six centimeters of the tube was exposed from the site. The nurse sent a fax to the provider to notify them of the change in condition. A nursing note for Resident 97, dated October 9, 2023, at 7:53 a.m., revealed that six centimeters of the nephrostomy tube was exposed from the site due to sutures being out, and a call was placed to the physician with orders to contact the urologist office. A nursing note for Resident 97, dated October 9, 2023, at 3:23 p.m., indicated that the resident had 180 milliliter (ml) of frank (fresh) red blood in the nephrostomy tube and 100 ml of tea-colored urine in the catheter. A call was placed to the urologist's office and staff were waiting on a call back. A nursing note for Resident 97, dated October 9, 2023, at 3:37 p.m., indicated that the resident needs to be sent to the emergency room due to the bleeding and inability to provide urology care. A nursing note for Resident 97, dated October 9, 2023, at 4:19 p.m., revealed that the resident would need to be sent to Altoona UPMC instead of [NAME] UPMC due to the possibility to staying 395422 Page 8 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0684 overnight and needing to see a urologist. UPMC [NAME] did not have a urologist available at that time. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on February 22, 2024, at 11:43 a.m. confirmed that the physician was not notified timely about Resident 97's changes in condition, which led to her hospitalization and treatment of a blood clot. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395422 Page 9 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of 51 residents reviewed (Resident 42). Residents Affected - Few Findings include: The facility's policy regarding dressing changes, dated February 13, 2024, indicated that all dressings were to be applied to wounds by a nurse, as ordered by the physician to promote healing, and then documented in the medical record. A significant correction Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 2, 2024, revealed that the resident was dependent for care needs, was cognitively impaired, had an indwelling foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), a Stage 2 pressure ulcer (pressure wound with skin loss), a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar), a venous ulcer (ulcers caused by problems with blood flow in the leg veins), and had diagnoses that included peripheral vascular disease (disease reducing blood flow to the legs) and diabetes (disease causing high blood sugar levels). The resident's care plan, revised on January 30, 2024, revealed that staff were to administer treatments as ordered and to monitor for effectiveness. Physician's orders for Resident 42, dated November 12, 2023, included an order for the staff to cleanse the right great toe with betadine (an antiseptic solution used to treat and prevent infection) every day shift and may cover with a dry dressing as needed for drainage. A review of the resident's Treatment Administration Record (TAR) for January 2024 revealed that the resident did not receive the treatment on January 25, 2024, as ordered. Physician's order for Resident 42, dated December 29, 2023, included an order for the staff to cleanse and dry the coccyx, apply exufiber AG (a dressing used on wounds with a high amount of drainage) to the wound bed, and cover with border foam daily. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 9, 2024, as ordered. Physician's orders for Resident 42, dated January 6, 2024, included an order for the staff to cleanse the left hip with soap and water, dry well, apply optifoam gentle (a foam dressing) to the area daily and as needed for soilage and dislodgement. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 18, 2024, as ordered. Physician's orders for Resident 42, dated January 18, 2024, included an order for staff to paint the resident's right heel with betadine and cover with foam dressing every day and evening shift. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 21 and 31, 2024, on the evening shift and on January 25, 2024, on the day shift as ordered. Physician's orders for Resident 42, dated January 18, 2024, included an order for staff to cleanse and dry the coccyx, apply calcium AG (a dressing used to wounds with a high amount of drainage) to the wound bed, and cover with sacral foam daily. A review of the resident's TAR for January 2024 395422 Page 10 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0686 revealed that the resident did not receive this treatment on January 25 and 26, 2024, as ordered. Level of Harm - Minimal harm or potential for actual harm Physician's order for Resident 42, dated January 19, 2024, included an order for the staff to apply santyl (a wound debridement treatment) to the left hip every day shift. A review of the resident's TAR for January 2024 revealed that the resident did not receive this treatment on January 25, 2024, as ordered. Residents Affected - Few Physician's orders for Resident 42, dated January 27, 2024, included an order for staff to irrigate the coccyx with one-forth strength Dakins (a solution used to treat and prevent tissue infections), apply santyl to the wound bed, and cover with sacral foam daily. A review of the resident's TAR for February 2024 revealed that the resident did not receive this treatment on February 14, 2024, as ordered. Interview with the Director of Nursing on February 22, 2024, at 11:26 a.m. confirmed there was no documented evidence that wound treatments were attempted or done to the areas listed above on dates listed above. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395422 Page 11 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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, as well as staff interviews, it was determined that the facility failed to provide suprapubic urinary catheter changes as ordered by the physician for one of 51 residents reviewed (Resident 35). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 8, 2024, revealed that the resident was cognitively intact; was understood; could understand; required partial assistance with dressing, toilet use, and bathing; was independent with bed mobility and eating; had an indwelling catheter (a tube inserted into the bladder to drain urine); and had an active diagnosis of neurogenic bladder (bladder does not function properly due to disease or damage to the central nervous system). A care plan for Resident 35's indwelling catheter, dated February 1, 2024, revealed that she had a suprapubic catheter due to a neurogenic bladder. A nursing note for Resident 35, dated February 10, 2024, at 9:30 a.m., revealed that the consultant physician recommended the resident to have a suprapubic catheter change every two weeks while at the facility. Resident 35 must use a 24 French catheter size. The Medical Director was notified of the recommendation. Physician's orders for Resident 35, dated February 10, 2024, included orders for staff to change the 24 French, 10-millimeter balloon catheter (indicates size of catheter) every two weeks. The catheter must be a 24 French suprapubic tube. A review of Resident 35's Medication and Treatment Administration Records (MAR/TAR) for February 2024 revealed that the catheter was not changed on February 20, 2024, as scheduled. A nursing note for Resident 35, dated February 20, 2024, at 7:00 a.m., revealed that staff were unable to change the catheter this shift and were awaiting delivery of correct size of the catheter per physician's order. Interview with Director of Nursing on February 23, 2024, at 3:33 p.m. confirmed that the catheter was not changed as ordered, because central supply was not notified of the physician's order and the supplies were not ordered. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395422 Page 12 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that weights were obtained and documented as ordered for residents with weight loss for two of 51 residents reviewed (Residents 12, 42) and failed to ensure supplements were provided and documented as ordered for two of 51 residents reviewed (Residents 77, 97). Residents Affected - Some Findings include: The facility's policy for weighing residents, dated February 13, 2024, indicated that weights will be completed as indicated and documented in the clinical record. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired, had diagnoses that included coronary (heart) artery disease and dysphagia (difficulty swallowing foods or liquids), required tube feedings for nutrition, and had weight loss that was not a physician-prescribed weight loss regimen. Current care plans indicated that the resident was at potential risk for altered nutritional status related to her dysphagia diagnosis. Physician's orders for Resident 12, dated December 6, 2023, revealed that the resident was to be weighed every evening shift for three days (December 6, 7, 8, 2023), then every Wednesday on the evening shift for four weeks, (December 13, 20, 27, 2023, and January 3, 2024) then every evening shift, starting on the first and ending on the third of every month (February 1, 2 , 3, 2024). A review of Resident 12's weight record for December 2023 and January and February 2024 revealed no documented evidence that the weights were completed on Friday, December 8, 2023; Wednesday, December 13, 2023; or Friday February 2, 2024, as ordered. A significant correction MDS assessment for Resident 42, dated February 2, 2024, revealed that the resident was cognitively impaired, dependent for care needs, had pressure ulcers, and had a weight loss that was not a physician-prescribed weight loss regimen. Physician's orders for Resident 42, dated January 16, 2024, included an order for 0.5 tablet of 15 milligrams (mg) of Remeron (an antidepressant used to stimulate appetite) at bedtime for weight loss. Physician's orders for Resident 42, dated January 18, 2024, included an order for weekly weights for four weeks every day shift on Thursday to monitor weight due to weight loss. A review of Resident 42's weight record and TAR for January and February 2024 revealed no documented evidence that the weekly weights were completed on Thursday, January 25, 2024, or Thursday, February 8, 2024, as ordered. An interview with the Director of Nursing on February 22, 2024, at 11:26 a.m. confirmed that there was no documented evidence that the weights for Resident's 12 and 42 were completed as ordered on the above dates mentioned, and they should have been. An admission MDS assessment for Resident 77, dated January 14, 2024, revealed that the resident was 395422 Page 13 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some severely cognitively impaired (unable to make sound decisions), able to make himself understood, could understand others, had concerns with pocketing food, required an altered diet, and required staff assistance with meals. Current physician's orders for Resident 77 revealed that the resident was to have a health shake or substitute with meals due to weight loss. A review of the Medication Administration Records (MAR) and nursing notes for Resident 77 for December 2023 and January 2024 revealed that staff documented that the health shake was not available for administration. A quarterly MDS assessment for Resident 97, dated January 20, 2024, revealed that the resident was cognitively intact, was able to make herself understood, could understand others, had weight loss while not on a physician-prescribed weight loss regimen, and had diagnoses that included anemia (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and kidney disease. A nurse's note for Resident 97, dated January 17, 2024, revealed that the dietician recommended a health shake or substitute with meals four times a day and to add a yogurt at bedtime due to weight loss. The physician was made aware of the recommendation and an order was received for a health shake or substitute with meals and to add a yogurt at bedtime due to weight loss. A review of the MAR and nursing notes for Resident 97 for December 2023 and January 2024 revealed that staff documented that the health shake was not available for administration. Interview with Licensed Practical Nurse 2 on February 21, 2024, at 12:17 p.m. revealed that the kitchen provides the health shake, and if the health shake is unavailable, they will make a fortified pudding as a substitute. Interview with the Director on Nursing on February 22, 2024, at 3:25 p.m. confirmed that Residents 77 and 97 did not receive the health shakes as ordered by the physician/dietician and should have received either a health shake or a substitute. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395422 Page 14 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for one of 51 residents reviewed (Resident 95). Residents Affected - Few Findings include: The facility's policy regarding oxygen therapy, dated December 13, 2023, indicated that oxygen was to be administered by licensed staff and in accordance with physician's orders. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated February 16, 2024, revealed that the resident was cognitively intact and had diagnoses that included chronic respiratory failure with hypoxia (a serious condition that causes low blood oxygen). Resident 95's care plan, dated September 1, 2023, indicated that she had difficulty breathing related to respiratory failure. Physician's orders for Resident 95, dated February 9, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 4 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). Observations of Resident 95 on February 11, 2024, at 1:10 p.m., and February 12, 2023, at 12:28 p.m. and 3:35 p.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set between 3.0 and 3.5 liters per minute. Interview with Licensed Practical Nurse 3 on February 22, 2024, at 3:35 p.m. confirmed that Resident 95's oxygen flow rate was set between 3.0 and 3.5 liters per minute, and not 4.0 liters per minute as ordered by the physician. Interview with the Director of Nursing on February 22, 2024, at 9:30 a.m. confirmed that Resident 95's oxygen flow rate should be set at 4 liters per minute continuously as per physician order, and it was not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395422 Page 15 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to verify registry verification prior to allowing individuals to work as a nurse aide for one of five newly hired nurse aides reviewed (Nurse Aide 4). Findings include: The personnel file for Nurse Aide 4 revealed that she was hired by the facility on October 9, 2023. However, there was no documented evidence that the facility verified the nurse aide's standing with the state nurse aide registry until February 21, 2024. Interview with the Nursing Home Administrator on February 22, 2024, at 11:21 a.m. confirmed that Nurse Aide 4 did not have a nurse aide registry check completed prior to her start date and that she should have. 28 Pa. Code 201.29 Personnel Policies and Procedures. 395422 Page 16 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

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 personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for four of five nurse aides reviewed (Nurse Aides 5, 6, 7, 8). Residents Affected - Few Findings include: A list of nurse aides provided by the facility revealed that Nurse Aide 5 was hired on June 20, 2019, and that she was due for her annual performance evaluation in June 2023. Nurse Aide 6 was hired December 21, 2017, and was due for her annual performance evaluation in December 2023. Nurse Aide 7 was hired May 4, 2015, and was due for her annual performance evaluation in May 2023. Nurse Aide 8 was hired September 24, 2015, and was due for her annual performance evaluation in September 2023. There was no documented evidence that the annual performance evaluations were completed as required for Nurse Aides 5, 6, 7, and 8. Interview with the Nursing Home Administrator on February 22, 2024, at 12:07 p.m. confirmed that he could not provide evidence that annual performance evaluations were completed as required for Nurse Aides 5, 6, 7, and 8. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff Development. 395422 Page 17 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 51 residents reviewed (Residents 15, 29). Findings include: The facility's policy regarding controlled drug disposal, dated February 13, 2024, indicated that controlled drugs should be wasted using a commercial controlled drug disposal system signed by two nurses witnessing the destruction of the controlled drug. The facility's policy regarding medication administration, dated February 13, 2024, indicated that the nurse will document on the Medication Administration Record (MAR) immediately prior to administration or immediately post administration based on the preferred individual practice of the nurse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated December 28, 2023, revealed that the resident was cognitively intact, was dependent on staff for care needs, had constant pain, and was receiving controlled pain medication. Physician's order for Resident 15, dated February 28, 2023, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (a narcotic pain medication) by mouth every eight hours as needed for severe pain. Review of Resident 15's controlled drug records for December 2023 and February 2024 revealed that a dose of Oxycodone was signed-out once on February 2, 2024, at 5:00 p.m. However, the resident's clinical record, including the MAR, contained no documented evidence that Oxycodone was actually administered. Physician's orders for Resident 15, dated July 6, 2023, included an order for the resident to receive a 50 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain management and removed per schedule, and an order for a second nurse to witness the disposal of the patch every three days. The MAR and a controlled drug count record for Resident 15, dated December 2023 and January and February 2024 revealed that a 50 mcg Fentanyl patch was applied to the resident on December 15 and 27, 2023; January 2, 2024; and February 4 and 22, 2024. There was no documented evidence that two licensed nurses signed that the old patch was destroyed after removal on that dates listed above. Interview with the Director of Nursing on February 23, 2024, at 3:33 p.m. confirmed that the Oxycodone for Resident 15 was signed out on the narcotic sheet but was not documented as administered on the medication administration record, and confirmed that there was no documented evidence that two licensed personnel performed the destruction of Resident 15's Fentanyl patches as required. A quarterly MDS assessment for Resident 29, dated February 3, 2024, revealed the resident was cognitively intact, required supervision to partial assist with care needs, had a surgical area, and was receiving controlled pain medication. 395422 Page 18 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0755 Level of Harm - Minimal harm or potential for actual harm Physician's orders for Resident 29, dated January 3, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for moderate to severe pain. Review of the controlled drug record for Resident 29 for January 2024 revealed that a dose of Tramadol was signed out on January 7, 2024, at 8:55 p.m. and January 14, 2024, at 6:30 p.m. Residents Affected - Some Review of Resident 29's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on February 23, 2024, at 3:03 p.m. confirmed that there was no documented evidence in Resident 29's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395422 Page 19 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician or designee responded timely to a pharmacy recommendation for one of 51 residents reviewed (Resident 15). Findings include: The facility's policy regarding Monthly Drug Regimen Reviews, dated February 13, 2024, indicated that consultant reports have one recommendation per page. The Director of Nursing or designee would contact the physician with any outstanding recommendations, if no response from the physician notify the medical director for further assistance 15-21 days after the reports are available. During the drug regimen review, routine recommendations were to be communicated to the Director of Nursing or the designee, attending physician, and the Medical Director for response and resolution, after the completion of the monthly medication review. Physician's orders for Resident 15, dated April 11, 2023, included an order for the resident to receive one 20 milligram (mg) tablet of Omeprazole delayed release twice a day for gastro-esophageal reflux disease (GERD - heartburn) scheduled at 9:00 a.m. and 5:00 p.m. A monthly pharmacy medication regimen review for Resident 15, dated January 10, 2024, revealed a recommendation for a change in the medication administration times. The medication should be given 30 to 60 minutes before food for optimal control of gastric acidity. There was no documented evidence that the recommendation was addressed by the physician or designee. Interview with the Director of Nursing on February 22, 2024, at 4:45 p.m. confirmed that there was no documented evidence in Resident 15's clinical record to indicate that the physician or designee addressed the January 10, 2024, pharmacy recommendation to change the medication administration time for optimal effectiveness. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 395422 Page 20 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to offer routine dental services for one of 51 residents reviewed (Resident 91). Residents Affected - Few Findings include: The facility's policy regarding dental services, dated February 13, 2024, revealed that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 91, dated December 16, 2023, revealed that the resident was cognitively intact and was dependent on staff for daily care tasks including oral care. An interview with Resident 91's family members on February 21, 2024, at 9:13 a.m. revealed that the resident and her family had requested that she see the dentist for a regular cleaning since she still had all of her own teeth. Observations of Resident 91 on February 21, 2024, at 9:13 a.m. revealed that the resident still had all of her own teeth and that they were in good condition. However, there was no documented evidence that Resident 91 had seen a dentist or was scheduled for an appointment to see the dentist since her admission to the facility in January 2023. Interview with the Director of Nursing on February 23, 2024, at 11:20 a.m. confirmed that Resident 91 had not seen a dentist or had a consult with a dentist since her admission. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services 28 Pa. Code 211.15(a) Dental Services. 395422 Page 21 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on individual resident interviews and an interview with a group of residents, as well as a meal test tray, it was determined that the facility failed to serve food items that were palatable to residents. Residents Affected - Some Findings include: Interview with Resident 7 on February 20, 2024, at 1:01 p.m. revealed that the food was awful and there was nothing good about it. Interview with Resident 11 on February 20, 2024, at 2:00 p.m. and Resident 93 during the initial tour on February 21, 2024, at 10:11 a.m. revealed that the food was bad. Interview with Resident 115 during the initial tour on February 20, 2023, at 11:03 a.m. revealed the food was not palatable as it did not taste good. Resident 115 would frequently order take out or have family bring in food. Interview with a group of residents on February 21, 2024, at 11:43 a.m. revealed that the food was bland, the vegetables were overcooked, and condiments do not come on the trays. Observations of the lunch meal on February 22, 2024, at 12:23 p.m. revealed that food items on a test tray were not palatable to taste. The brussel sprouts were overcooked, mushy and bland. The pureed stuffing and chicken were bland and pasty, and the honey Dijon chicken was bland with no seasoning and not palatable to taste. Condiments were noted on top of the tray carts and were available on resident request per staff interviews. Interview with the Dietary Manager on February 22, 2024, at the time of the test tray, revealed no response to observations of food tasting bland and vegetables being overcooked. Interview with the Dietary Manager and the corporate dietary consultant on February 22, 2024, at 4:30 p.m. revealed that the recipe is followed and the chicken was cooked then brushed with the seasonings then put back in the oven to finish cooking. The blandness of the honey Dijon chicken and pureed food and consistency of the brussel sprouts were addressed again with the Dietary Manager and she stated she could not speak to the individual tastes of the residents and that she seasons the food within the restrictions of the residents. 28 Pa. Code 211.6(b) Dietary Services. 395422 Page 22 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending March 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 23, 2024, identified repeated deficiencies related to revision of residents' care plans, catheter care, regulations regarding nurse aide annual performance evaluations, and infection prevention and control. The facility's plan of correction for a deficiency regarding revising residents' care plans, cited during the survey ending March 30, 2023, revealed that audits of care plans would be completed, and the results would be reported to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding revising residents' care plans. The facility's plans of correction for deficiencies regarding, catheter care, cited during the survey ending on March 30, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F690, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care. The facility's plan of corrections for deficiencies regarding nurse aide annual performance evaluations, cited during the survey ending March 30, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F730, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding nurse aide annual performance evaluations. The facility's plan of correction for a deficiency regarding infection prevention and control, cited during the survey ending March 30, 2023, revealed that infection prevention and control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with infection prevention and control. Refer to F657, F690, F730, and F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395422 Page 23 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing care for two of 51 residents reviewed (Residents 12, 109). Residents Affected - Few Findings include: The facility's policy regarding catheter care, dated February 13, 2024, indicated that the catheter tubing and drainage bag were to be kept off the floor to prevent catheter-associated urinary tract infections. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated December 13, 2023, revealed that the resident was moderately cognitively impaired and had diagnoses that included acute kidney failure (a condition where the kidneys cannot filter waste from the blood) with dysfunction of the bladder. The resident's care plan, dated February 5, 2024, indicated the use of an indwelling catheter with interventions that included that the catheter tubing and bag should be kept off the floor. Observations on February 20, 2024, at 1:13 p.m. and February 21, at 3:15 p.m. revealed that Resident 12's catheter drainage bag was touching the floor as it hung off the right side of her bed. Interview with Nurse Aide 9 on February 21, 2024, at 3:15 p.m. confirmed that the catheter bag was touching the floor, and it should not have been. Interview with the Director of Nursing on February 21, 2024, at 3:24 p.m. confirmed that Resident 12's catheter bag should not have been touching the floor. The facility's policy regarding the hand washing and hand hygiene, dated February 13, 2024, indicated that alcohol-based hand rub containing at least 62 percent alcohol, or alternatively soap and water, was to be used before and after direct contact with residents, before and after handling clean or soiled dressings, before moving from a contaminated body site to clean body site during resident care, after handling used dressings and contaminated equipment, and after removing gloves. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated February 8, 2024, revealed that the resident was cognitively impaired; was dependent on staff for toileting, hygiene and transfers; and was at risk for pressure ulcers. The resident's care plan, dated February 11, 2024, indicated that she had a Stage II pressure injury on the gluteal cleft (butt crack) related to immobility and staff were to administer treatments as ordered. Physician's orders for Resident 109, dated February 11, 2024, included an order for the gluteal cleft be cleansed, patted dry, peri protect applied to the area, and covered with optifoam. Observations of Resident 109's wound care on February 22, 2024, at 12:46 p.m. revealed that there were two distinct open areas on her gluteal cleft. Licenced Practical Nurse (LPN) 10 removed a urine-soaked brief, provided incontinence care, and removed the soiled dressing. LPN 10 then washed her hands with soap and water and donned clean gloves before cleansing the pressure area with moistened wash clothes and soap. LPN 10 removed her gloves, donned a clean pair without performing hand hygiene, 395422 Page 24 of 25 395422 02/23/2024 Pennknoll Village 208 Pennknoll Road Everett, PA 15537

F 0880 Level of Harm - Minimal harm or potential for actual harm and applied the peri protect with a gloved hand. LPN 10 removed her gloves, donned a clean pair of gloves, applied the foam bordered dressing, and secured the clean brief. Interview with the LPN 10 on February 22, 2024, at 1:15 p.m. confirmed that she did not wash her hands or perform hand hygiene between glove changes and dirty-to-clean tasks. Residents Affected - Few Interview with the Director of Nursing on February 22, 2024, at 3:45 p.m. confirmed that hand hygiene should have been completed between dirty and clean tasks and between glove changes. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395422 Page 25 of 25