Health inspection·August 7, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act, job descriptions, and clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of five residents reviewed (Resident 2). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A job description for registered nurses, undated, indicated that the registered nurse was to ensure that the highest degree of quality care was maintained at all times and was to provide direct nursing care as needed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 3, 2024, indicated that the resident was cognitively impaired, received a diuretic (water pill), and had diagnoses that included heart failure. A nursing note, dated May 22, 2024, revealed laboratory results were reviewed with the Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area), and new orders were received for 40 milligrams (mg) of Torsemide (water pill) twice a day for two days and 20 milliequivalents of potassium chloride (supplement) daily for three days and obtain a basic metabolic panel (BMP-blood test that checks the levels of different substances in your blood) on May 24, 2024. A laboratory result, dated May 24, 2024, was reviewed by the physician, and new orders were received to continue the 40 mg of Torsemide twice a day. A nursing note written by Registered Nurse 2, dated May 24, 2024, at 3:05 p.m. revealed that the laboratory results were reviewed with the physician, new orders were received to continue 40 mg of Torsemide twice a day indefinitely, and that the orders were updated. A CRNP note, dated May 29, 2024, at 8:21 a.m., revealed that Resident 2 was fluid overloaded with 4+ pitting edema (severe swelling) of the lower extremities and that she was currently receiving 40 mg of Torsemide twice a day. The plan was to add 50 mg of Spironolactone daily to the already ordered 40 mg of Torsemide twice a day. Page 1 of 4 395514 395514 08/07/2024 Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2's Medication Administration Record (MAR) for May and June 2024 revealed that the resident did not receive 40 mg of Torsemide twice day from May 25 through June 7, 2024. Interview with the Director of Nursing on August 7, 2024, at 3:32 p.m. confirmed that the registered nurse who reviewed the laboratory results with the physician did not transcribe the new order for Torsemide into the medical record; therefore, the 40 mg of Torsemide twice a day was not administered according to the order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395514 Page 2 of 4 395514 08/07/2024 Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602

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 oxygen was provided as ordered by the physician for one of five residents reviewed (Resident 1). Residents Affected - Few Findings include: The facility's policy regarding oxygen use, dated May 8, 2024, indicated that the facility was to provide oxygen as ordered by the physician. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 4, 2024, revealed that the resident was cognitively intact and received oxygen. A care plan for the resident, dated February 22, 2024, revealed that the resident received oxygen therapy. Physician's orders, dated July 10, 2024, included an order for the resident to receive oxygen at two liters per minute (lpm) every shift for hypoxia (low levels of oxygen in your body tissues). Observations of Resident 1 on August 7, 2024, at 3:11 p.m. and 3:15 p.m. revealed that the resident had oxygen in use via a concentrator (electrical machine that concentrates the oxygen from the air) at a flow rate of five (5) lpm via nasal cannula (tube that delivers oxygen through the nose). Interview with Licensed Practical Nurse 1 at the time of the second observation confirmed that Resident 1's oxygen flow rate was set at five lpm and should have been set at two lpm as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395514 Page 3 of 4 395514 08/07/2024 Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of five residents reviewed (Resident 2). Residents Affected - Some Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 3, 2024, indicated that the resident was cognitively impaired, received a diuretic (water pill), and had diagnoses that included heart failure. A nursing note, dated May 22, 2024, revealed that laboratory results were reviewed with the Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area), and new orders were received for 40 milligrams (mg) of Torsemide (water pill) twice a day for two days and 20 milliequivalents of potassium chloride (supplement) daily for three days and obtain a basic metabolic panel (BMP - blood test that checks the levels of different substances in your blood) on May 24, 2024. A laboratory result, dated May 24, 2024, was reviewed by the physician, and new orders were received to continue the 40 mg of Torsemide twice a day. A nursing note written by Registered Nurse 2, dated May 24, 2024, at 3:05 p.m. revealed that the laboratory results were reviewed with the physician, new orders were received to continue 40 mg of Torsemide twice a day indefinitely, and that the orders were updated. A CRNP note, dated May 29, 2024, at 8:21 a.m., revealed that Resident 2 was fluid overloaded with 4+ pitting edema (severe swelling) of the lower extremities and that she was currently receiving 40 mg of Torsemide twice a day. The plan was to add 50 mg of Spironolactone daily to the already ordered 40 mg of Torsemide twice a day. Resident 2's Medication Administration Record (MAR) for May and June 2024 revealed that the resident did not receive 40 mg of Torsemide twice day from May 25 through June 7, 2024. Interview with the Director of Nursing on August 7, 2024, at 3:32 p.m. confirmed that the registered nurse who reviewed the laboratory results with the physician did not transcribe the order for the Torsemide into the medical record; therefore, the 40 mg of Torsemide twice a day was not administered according to the order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395514 Page 4 of 4