Health inspection·September 14, 2023

F 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to post contact information for the Pennsylvania Department of Health on the nursing units or the main bulletin boards. Residents Affected - Some Findings include: Observation on Villa [NAME] Garden Level, Villa [NAME] Garden Level, Villa [NAME] Garden Level, Villa [NAME] Courtyard Level, Villa [NAME] Courtyard Level, Villa [NAME] Courtyard Level, Villa [NAME], and Villa [NAME] nursing units on September 14, 2023, at various times during the day revealed that there were no postings of contact information for the Pennsylvania Department of Health. An interview with the Nursing Home Assistant Administrator on September 14, 2023, at 2:39 p.m. confirmed that there was no posting of the Pennsylvania Department of Health information on the nursing units or on the main bulletin board. The facility failed to provide residents with access to the Pennsylvania Department of Health. 28 Pa. Code 201.29(a)(b)(c)(j) Resident rights. Page 1 of 22 395539 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that information on how to file a grievance or complaint was available to residents or their representatives without asking. Findings include: The facility's Grievance Process policy, dated October 11, 2022, indicated that anyone may file a grievance anonymously if they chose to do so. During an interview with a group of residents on September 12, 2023, at 2:00 p.m. the residents indicated that they would like to be able to file a grievance or make a statement about something that interests them on a grievance form and that they would like to remain anonymous in doing so; however, they are not aware of any way to file a grievance without giving it to staff. Interview with the Nursing Home Assistant Administrator on September 14, 2023, at 3:49 p.m. revealed that the facility's grievance forms were located behind each nursing station, and that nurses could give the forms to the residents and that the residents could hand the forms to the nurses in an envelope or they could take them to the Nursing Home Assistant Administrator's office; however, the door to her office is secured with an alarm and staff would be aware of any resident entering that hallway. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(i) Resident rights. 395539 Page 2 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 49 residents reviewed (Residents 22, 101, 103). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that if the resident had a fall since admission, entry or re-entry, or a prior assessment, then Section J1800 was to be coded (1) Yes, and Section J1900 was to be completed. If the resident had a fall with no injury since admission, entry or re-entry, or a prior assessment then J1900A was to be coded with the number of falls. If the resident had a fall with an injury (skin tears, abrasions, lacerations, superficial bruises, hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900B was to be coded with the number of falls. If the resident had a fall with a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900C was to be coded with the number of falls. Nursing notes, dated September 13, 2023, at 10:07 a.m. and 4:43 p.m. revealed that Resident 22 was found lying on the floor in her room. The resident was in her wheelchair and reported that she reached for something on the floor and fell forward. She reported pain to her face, had a 2 centimeter horizontal abrasion and edema (swelling) to her nose, and a CT-scan at the hospital revealed that she had a nasal fracture. A quarterly MDS assessment for Resident 22, dated November 3, 2022, revealed that Section J1800 was coded zero (0), indicating that the resident did not have a fall since admission, entry or re-entry, or the prior assessment and Section J1900C was coded as (0), indicating that the resident did not have a fall and a fracture. Interview with the Director of Nursing on September 14, 2023, at 12:50 p.m. confirmed that Resident 22's fall and fracture on September 13, 2022, was not captured on the quarterly MDS assessment of November 3, 2022, and should have been. The RAI User's Manual, dated October, 2019, revealed that Section O0100 was to be completed with the resident's special treatments, procedures, and programs, and Section O0100C was to be coded for the use of oxygen. Column (1) was to be checked if oxygen was used while not a resident of the facility within the last 14 days, and column (2) was to be checked if oxygen was used while a resident of the facility within the last 14 days. Physician's orders for Resident 101, dated August 24, 2023, included an order for the resident to receive oxygen at 2-5 liters per minute (flow rate) via nasal cannula (tubes that deliver oxygen into the nostrils) to ensure that the oxygen concentration (percentage of oxygen in blood) was greater than 90 percent every shift. The resident's Medication Administration Record (MAR) for August 2023 indicated that the resident used oxygen daily at 2-5 liters per minute from August 25 through 31, 2023. However, an admission MDS assessment for Resident 101, dated August 31, 2023, revealed that Section O0100C, Column 2 was not checked to indicate that the resident used oxygen during the 14-day assessment period. 395539 Page 3 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing on September 14, 2023, at 12:50 p.m. confirmed that Section O0100C, Column 2, was not coded accurately on Resident 101's MDS assessment of August 31, 2023. The RAI User's Manual, dated October 2019, indicated that Section C of the MDS was to be completed for each resident to identify his/her cognitive status. Section C0100 was to be coded No (0) or Yes (1) depending on whether a Brief Interview for Mental Status (BIMS) should be attempted with the resident and coded in Sections C0200 through C0500. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The RAI User's Manual also indicated that if a resident did not answer a question, or all responses were nonsensical, then the BIMS interview was to be stopped after Section C0300 (day of the week), a dash was to be coded in the remaining sections of the interview, a (99) was to be entered in Section C0500, and then a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The RAI User's Manual, dated October 2019, indicated that the intent of Section D (mood) was to address mood distress. Section D0100 was to be coded No (0) if the mood interview should not be conducted because the resident was rarely/never understood and coded Yes (1) if the resident mood interview should be conducted because the resident was able to be understood, and the interview was to be coded in Sections D0200, D0300 and D0350. Section D0500 (staff assessment of mood) was to be completed when a resident could not communicate, refused, or was unable to participate. A significant change MDS for Resident 103, dated August 7, 2023, revealed that the resident was understood and could understand others. However, Section C0100 was coded with a (0), indicating that the BIMS interview was not attempted with the resident. Section D0100 was coded with a dash (0), indicating that the mood interview was not attempted with the resident. Interview with the Social Worker responsible for completing Section C and D on the MDS on September 14, 2023, at 8:52 a.m. confirmed that she inaccurately coded the MDS. 28 Pa. Code 211.5(f) Clinical records. 395539 Page 4 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for four of 49 residents reviewed (Residents 44, 45, 69, 70). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated August 12, 2023, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had a Stage 2 pressure ulcer (partial thickness wound). A physician's order for Resident 44, dated September 13, 2023, included an order for the resident to have medi-honey paste applied to her right upper buttock and covered with gauze once daily. There was no documented evidence that Resident 44's care plan, most recently revised August 12, 2023, included specific and individualized interventions related to her Stage 2 pressure ulcer. An interview with the Assistant Director of Nursing on September 14, 2023, at 3:20 p.m. revealed that there was no care plan in place for Resident 44's Stage 2 pressure ulcer and there should have been. The facility's policy regarding care plans, dated October 11, 2022, revealed that the facility would develop a written plan of care that was individualized for each resident's daily care routines and will be available to staff personnel who have the responsibility for providing care or services to the resident. Physician's orders, dated July 25, 2023, included orders for Resident 45 to have oxygen 2 liters per minute at bedtime and 2-5 liters per minute via nasal cannula as needed for shortness of breath. There was no documented evidence that a care plan was developed to address Resident 45's care needs related to oxygen use. Interview with the Director of Nursing on September 13, 2023, at 3:11 p.m. confirmed that Resident 45 had oxygen, and a care plan that addressed the resident's needs related to oxygen use was not developed. A quarterly MDS assessment for Resident 69, dated August 11, 2023, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and that he used oxygen. Physician's orders for Resident 69, dated August 4, 2022, included an order for the resident to receive oxygen via nasal cannula. There was no documented evidence that Resident 69's care plan, most recently revised August 11, 2023, included specific and individualized interventions related to his use of oxygen. Interview with Assistant Director of Nursing on September 14, 2023, at 1:20 p.m. confirmed that Residents 69's care plan was not individualized regarding the resident's use of oxygen and it should have been. 395539 Page 5 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A quarterly MDS assessment for Resident 70, dated June 23, 2023, indicated that the resident was cognitively intact and required assistance from staff for his daily care needs. A physician's order for Resident 70, dated March 2, 2023, included an order for the resident to receive 30 milligrams (mg) Mirtazapine (anti-depressant) daily. There was no documented evidence that Resident 70's care plan, most recently revised June 23, 2023, included specific and individualized interventions related to his depression. Interview with Assistant Director of Nursing on September 14, 2023, at 1:20 p.m. confirmed that Resident 70's care plan was not individualized regarding the resident's use of an anti-depressant and it should have been. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. 395539 Page 6 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for seven of 49 residents reviewed (Residents 10, 36, 47, 48, 49, 62, 69). Findings include: The facility's policy regarding care plans, dated October 11, 2023, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 31, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care needs. Resident 10's care plan, dated June 30, 2023, indicated that the resident was medicated with Lovenox (an anti-coagulant); however, the medication had been discontinued. Interview with the Director of Nursing on September 12, 2023, at 2:41 p.m. confirmed that Resident 10's care plan should have been updated to reflect the Lovenox having been discontinued. A physician's order for Resident 36, dated May 4, 2023, included an order to discontinue the resident's catheter. However, the resident's current care plan, dated August 20, 2023, still included a goal and interventions to address the use of an indwelling urinary catheter. An interview with Registered Nurse Supervisor 4 on September 13, 2023, at 11:07 p.m. confirmed that Resident 36's care plan was not revised to reflect that her catheter was discontinued. An interview with the Director of Nursing on September 13, 2023, at 11:52 a.m. confirmed that Resident 36's catheter was removed from the TAR (Treatment Administration Record); however, the resident's care plan was not updated to reflect that the resident no longer had a catheter in place and the care plan should have been updated. A significant change comprehensive MDS assessment for Resident 47, dated July 24, 2023, indicated that the resident was rarely or never understood, rarely or never understood others, and required extensive assistance from staff for her daily care needs. Resident 47's care plan, most recently revised July 24, 2023, included a care plan for the resident to receive anti-psychotic medication; however, the medication was discontinued in July 2023. Interview with the Director of Nursing on September 14, 2023, at 1:10 p.m. revealed that Resident 47's care plan should have been updated to reflect the discontinuation of antipsychotic medications and it was not. A physician's order for Resident 48, dated June 6, 2023, included an order to discontinue the residents' PICC (peripherally inserted central catheter, a long catheter inserted in the arm for long-term medications) line. However, the resident's current care plan, dated August 10, 2023, still included a goal and interventions to address the use of a PICC line. 395539 Page 7 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with Registered Nurse Supervisor 4 on September 13, 2023, at 11:07 p.m. confirmed that Resident 48's care plan was not revised to reflect that her PICC line was discontinued. An interview with the Director of Nursing on September 13, 2023, at 11:52 a.m. confirmed that Resident 48's catheter was removed from the MAR (Medication Administration Record); however, the resident's care plan was not updated to reflect that the resident no longer had a PICC line in place and the care plan should have been updated. An annual MDS assessment for Resident 49, dated August 28, 2023, indicated that the resident was cognitively impaired and required assistance from staff for her daily care needs. A physician's order for Resident 49, dated May 25, 2023, included an order for the resident's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) line to be discontinued. Resident 49's care plan, most recently revised August 28, 2023, revealed that she had a midline in her left arm. Interview with the Director of Nursing on September 13, 2023, at 1:06 p.m. revealed that Resident 49's care plan should have been updated to reflect the discontinuation of her midline and it was not. A quarterly MDS assessment for Resident 62, dated June 8, 2023, indicated that the resident was cognitively intact and required assistance from staff for her daily care needs. A physician's order for Resident 62, dated June 13, 2023, included an order for the resident to have soft gloves to both hands at all times. Observations of Resident 62 on September 11, 2023, at 2:26 p.m. revealed that she was wearing white, soft cotton gloves. Observations of Resident 62 on September 13, 2023, at 11:26 a.m. revealed that after bathing, the resident was dressed with white cotton gloves. Interview with Licensed Practical Nurse 5 on September 11, 2023, at 2:26 p.m. revealed that Resident 62 wears the gloves to prevent her from scratching herself. Interview with Nurse Aide 1 on September 13, 2023, at 11:26 a.m. revealed that Resident 62 wears the white gloves because she scratches herself a lot. There was no documented evidence that Resident 62's care plan, most recently revised June 8, 2023, included specific and individualized interventions related to her use of soft gloves. An interview with the Assistant Director of Nursing on September 14, 2023, at 11:26 a.m. revealed that Resident 62 did not have a care plan for the use of the white gloves and that she should have. A quarterly MDS assessment for Resident 69, dated August 11, 2023, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and that he had multiple wounds. A review of Resident 69's care plan, most recently revised August 11, 2023, revealed that the resident had cellulitis (skin infection) of the right ankle, and that he was receiving a wound treatment on his right great toe. A review of the resident's Treatment Administration Record (TAR), dated September 2023, indicated that the resident was no longer receiving treatment for cellulitis on his right great toe. An interview with the Assistant Director of Nursing on September 14, 2023, at 2:15 p.m. confirmed 395539 Page 8 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0657 Level of Harm - Minimal harm or potential for actual harm that Resident 69's care plan should have been updated to reflect the discontinuation of cellulitis and right great toe treatments. 28 Pa. Code 211.11(d) Resident care plan. Residents Affected - Some 395539 Page 9 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 49 residents reviewed (Resident 36). Residents Affected - Few Findings include: The facility's policy on following physican's orders, dated October 11, 2022, revealed that the purpose is to accurately and completely act in accordance with physican orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated August 2, 2023, indicated that the resident was cognitively impaired; required total assistance for bed mobility, transfers, and dressing; had diagnoses that included, stroke, heart disease and joint contratures; and had a current care plan that included interventions to monitor for edema. Physician's orders for Resident 36, dated August 23, 2019, included an order for the resident to wear bilateral TED hose (stockings to prevent blood clots) on in the morning (a.m.) and off in evening (p.m). Observations of Resident 36 on September 11, 2023, at 12:05 p.m. and September 12, 2023, at 12:11 p.m. revealed that the resident was in her bed and her TED hose were not on. Resident 36's Treatment Administration Record (TAR) for August 2023 revealed that her TED hose were documented as off on August 6, 7, 9, 13-15, 20-22, 26-31, 2023. The TAR for September 2023 revealed that her TED hose were documented as off on September 2-12, 2023. There was no documented evidence that Resident 36 refused to wear her TED hose or that staff caring for the resident updated the registered nurse of her refusal. Interview with Nurse Aide 1 on September 12, 2023, at 2:06 p.m. revealed that she did not put on Resident 36's TED hose because she was told that the resident does not wear them. Interview with Licensed Practical Nurse 2 on September 12, 2023, at 12:12 p.m. revealed that Resident 36 is able to let staff know if she wants the TED hose on, and that there should be documentation that she refused. Interview with the Registered Nurse Supervisor 3 on September 12, 2023, at 2:40 p.m. revealed that it was not communicated to her that the resident did not want to wear the TED hose, so they could update the physican or care plan her for refusal. Interview with the Director of Nursing on September 13, 2023, at 12:02 p.m. confirmed that Resident 36 did not have her TED hose on as ordered by the physican, and there was no documentation of refusal. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395539 Page 10 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that preventative pressure ulcer interventions were applied as recommended and care planned for one of 49 residents reviewed (Resident 36). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a residents abilities and care needs) for Resident 36, dated October 11, 2022, revealed that the resident required extensive assistance for daily care tasks and was at risk for pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure) due to limited mobility and contractures. Occupational Therapy care notes, dated September 29, 2022, indicated that Resident 36 would benefit from a positioning device in the left hand. Restorative care notes, dated October 19, 2022, indicated that Resident 36 has pain issues and could only tolerate gentle joint mobilization. Therefore, it was recommended that a rolled wash cloth be placed in the left hand at all times, only to be removed for hygiene purposes. Current care plans indicated that Resident 36 would have a rolled wash cloth in her hand to maintain skin integrity. Observations on September 11, 2023, at 10:51 a.m. and September 12, 2023, at 12:03 p.m. revealed that Resident 36 was lying in her bed, morning care was completed, and a sign on the wall behind her bed indicated that the resident must have a rolled wash cloth in her left hand after hand hygiene. Resident 36 did not have a rolled wash cloth in her left hand. Interview with Licensed Practical Nurse 2 on September 12, 2023, at 12:15 p.m. confirmed that morning hygiene was completed and a rolled wash cloth should have been in Resident 36's left hand as indicated in the sign above her bed. Licensed Practical Nurse 2 then placed a rolled wash cloth in the resident's left hand. Interview with the Director of Nursing on September 13, 2023, at 12:03 p.m. confirmed that a rolled wash cloth should have been in Resident 36's left hand as care planned and recommended by restorative care. 28 Pa. Code 211.12(d)(5) Nursing services. 395539 Page 11 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's plan of care was followed for fall prevention and transfers for one of 49 residents reviewed (Resident 29). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated August 9, 2023, revealed that the resident was cognitively impaired, required extensive assist with daily care needs including transfers, and had diagnosis that included dementia. A fall care plan, dated July 6, 2023, revealed that the resident was to be transferred as a two-person assist or stand-up lift as needed. Nursing note for Resident 29, dated August 1, 2023, at 5:51 a.m. revealed that the resident was transferring off the toilet with a nurse aide when she lost her balance. The nurse aide then lowered the resident to the floor. Interview with the Assistant Director of Nursing on September 14, 2023, at 1:45 p.m. confirmed that Resident 29 was transferred with one assist and not a two-person assist for transfers as care planned. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395539 Page 12 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of six residents reviewed (Resident 19). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated August 18, 2023, revealed that the resident was moderately cognitively impaired, required limited to extensive assistance from staff with daily care needs, and had a colostomy (a hole (stoma) in the abdominal wall which allows waste to leave the body). Physician orders, dated May 23, 2023, included an order for the stoma area and peristomal area (area around stoma) be cleansed with warm water, dried thoroughly, and a new appliance applied. The order did not include how frequently the appliance was to be changed. A care plan, dated May 24, 2023, indicated that the resident had a colostomy and the ostomy bag was to be changed when it was loose or leaking, and staff were to change the flange (secures pouch to the body) as needed. Review of the Treatment Administration Records (TAR's) for Resident 19 for July, August and September 2023 revealed there was no documented evidence that the Resident 17's colostomy appliance was changed. Interview with Registered Nurse 6 on September 14, 2023, at 2:31 p.m. revealed that Resident 19's colostomy appliance was a one-piece system and needed to be checked and changed each shift, and confirmed that there was no evidence that the resident's colostomy appliance was being changed. Interview with the Director of Nursing on September 14, 2023, at 2:25 p.m. confirmed that there was no documented evidence when Resident 19's colostomy appliance was changed. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395539 Page 13 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 policies, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor a resident's weight as ordered by the physician for one of 49 residents reviewed (Resident 111). Residents Affected - Some Findings include: The facility's policy regarding weighing residents, dated October 10, 2022, indicated that the purpose was to determine weight gain or loss, as changes in weight are frequent indicators of the resident's condition. A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated May 5, 2023, revealed that the resident was severly cognitively impaired, had diagnoses that included Alzheimer's and dementia, and required staff to set up her meals. Current care plans indicated that the resident was at potential risk for altered nutritional status related to her dementia diagnosis. Physician's orders for Resident 111, dated January 6, 2023, revealed that the resident was to be weighed weekly. Resident 111's weight records revealed that her weight was taken on January 4, 2023; April 16, 2023; May 14 and 28, 2023; July 9, and 23, 2023; August 6, 2023; and September 11, 2023. Registered Dietician notes, dated January 6, 2023, at 6:20 p.m., indicated that due to recent weight loss and continued inadequate intake, she recommended weekly weights and supplemental protein drinks with breakfast and lunch. Furthermore, she indicated that the resident's diagnosis of Alzheimer's and dementia likely had a negative impact on her food intake. An interview with the Registered Dietician on September 14, 2023, at 1:13 p.m. indicated that she would expect to see weekly weights documented as ordered by the physician. An interview with the Director of Nursing on September 14, 2023, at 1:30 p.m. confirmed that Resident 111 was not weighed according to the physician's order. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 395539 Page 14 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure oxygen tubing and concentrator filters were changed as ordered by the physician for two of 49 residents (Residents 69, 91). Residents Affected - Few Findings include: A quarterly MDS assessment for Resident 69, dated August 11, 2023, indicated that the resident was cognitively impaired, required assistance from staff for his daily care needs, and that he used oxygen. Physician's orders for Resident 69, dated August 6, 2022, included an order for the resident's air filter on the oxygen concentrator to be cleaned every Saturday night and to change the oxygen tubing at that time. Observations of Resident 69's oxygen tubing on September 11, 2023, at 1:35 p.m. and again on September 14, 2023, at 10:05 a.m. revealed that his oxygen tubing was dated September 2, 2023 and should have been changed September 9, 2023. Interview with Licensed Practical Nurse 5 on September 14, 2023, at 10:55 a.m. revealed that Resident 69's oxygen tubing should have been changed on September 9 and it was not. A quarterly MDS assessment for Resident 91, dated June 22, 2023, revealed that the resident used oxygen and had diagnoses that included chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). Physician's orders for Resident 91, dated June 4, 2020, and July 8, 2021, included an order for the resident to receive continuous oxygen at 2-5 liters per minute (lpm - flow rate) via nasal cannula (tubes that deliver oxygen into the nostrils) and to titrate (adjust the flow rate) as needed to ensure an oxygen concentration/pulse oximetry (percentage of oxygen in blood) that was equal to or greater than 90 percent every shift, to change the oxygen tubing every Saturday on night shift, and to change the air filter on the oxygen concentrator every Saturday on night shift. Observations of Resident 91 on September 11, 2023, at 10:59 a.m. revealed that the resident was receiving oxygen at 3 lpm via nasal cannula. Resident 91's TAR's for July and August 2023 revealed that there was no documented evidence that the resident's oxygen tubing and concentrator filter were changed as ordered on July 22 and August 12, 2023. Interview with the Director of Nursing on September 14, 2023, at 1:10 p.m. confirmed that there was no documented evidence that Resident 69 and 91's oxygen tubing and/or concentrator air filters were changed as ordered by the physician on the mentioned dates and times. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395539 Page 15 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication errors for two of 49 residents reviewed (Residents 51, 72). Residents Affected - Some Findings include: The facility's policy regarding Medication Administration, dated October 11, 2022, indicated that prescribed medications were to be safely administered in accordance with the physician order and manufacturer's specification. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated July 27, 2023, revealed that the resident was cognitively intact, required staff assistance for daily care tasks, and medicated with an anticoagulant (blood thinner). The resident's care plan, most recently updated on July 27, 2023, revealed that the resident medicated with an anticoagulant and was to be medicated per physician's orders. Physician's orders for Resident 51, dated July 31, 2023, included an order for the resident to receive 2 milligrams (mg) coumadin (blood thinner) alternating every other day with 1 mg coumadin. Review of Resident 51's Medication Administration Record (MAR), dated August 2023, revealed that the resident did not receive coumadin as ordered on August 6, 2023; August 15, 2023; and August 24, 2023. Interview with the Assistant Director of Nursing on September 14, 2023, at 3:07 p.m. revealed that she was not sure why Resident 51 did not receive her coumadin on August 6, 15, or 24, as ordered by the physician, but that she should have. An annual MDS assessment for Resident 72, dated August 18, 2023, revealed that the resident was moderately cognitively impaired and required extensive to total staff assistance for daily care tasks. Physician's orders for Resident 72, dated April 10 and August 10, 2023, included an order for the resident to receive 5 milligrams (mg) of Midodrine three times daily for low blood pressure and to hold the medication if the resident's systolic blood pressure (top number - pressure during heart beat) was greater than 130 millimeters of Mercury (mmHg) or the diastolic blood pressure (bottom number - pressure when heart is at rest) was greater than 70 mmHg. Resident 72's Medication Administration Record (MAR) dated May, June, July, August and September 2023 revealed that the resident's diastolic blood pressure was greater than 70 mmHg at 6:00 a.m. on May 5 and July 26; at 8:00 a.m. on May 11, and June 4 and 6; at 2:00 p.m. on June 5, July 22 and August 14; and at 8:00 p.m. on June 9, July 14, 27 and 28, and September 2, 2023. The medication was administered to the resident instead of being held per the physician's order. Interview with the Director of Nursing on September 14, 2023, at 2:25 p.m. confirmed that Resident 72 received the Midodrine on the mentioned dates and times and it should have been held. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395539 Page 16 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure that dietary staff wore hair coverings that completely covered their hair. Findings include: The facility's policy regarding hair restraints for dietary employees, dated October 11, 2022, revealed that hair nets were to be worn at all times, and that all the hair should be placed under the hairnet. Observations in the [NAME] Courtyard dining area on September 11, 2023, at 12:34 p.m. revealed that Dietary Aide 7 was plating food items, which included pulled pork and sweet potatoes fries, with a hairnet on that did not fully cover her hair. Approximately three to four inches of hair tendrils fell down on both sides of her head onto her collar. Observations in the [NAME] Courtyard dining area on September 13, 2023, at 8:53 a.m. revealed that Dietary Aide 8 was plating food, which included pancakes, toast, bacon and eggs, with a hairnet on that did not fully cover her hair. Approximately four inches of hair on each side of her forehead and approximately two inches of hair tendrils on both sides of her head were outside the hairnet. Interview with the Director of Dietary on September 13, 2023, at 9:15 a.m. confirmed that Dietary Aide 7 and Dietary Aide 8 should have been wearing hairnets that completely covered their hair. 28 Pa. Code 211.6(f) Dietary services. 395539 Page 17 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 49 residents reviewed (Resident 97). Findings include: The facility policy for medication administration subcutaneous insulin, dated October 11, 2022, indicated that after the insulin is administered staff are to document the injection on the Medication Administration Record (MAR) along with the site. The diagnosis record for Resident 97, dated July 25, 2023, included chronic kidney disease and diabetes (disease that results with too much sugar in the blood). Physician's orders for Resident 97, dated August 9, 2023, included an order for Novolog insulin (fast acting insulin) to be provided four times a day based on the sliding scale coverage order. For a blood sugar of 201-250 mg/dL give 2 units of Novolog insulin; for a blood sugar of 251-300 mg/dL give 4 units of Novolog insulin; for a blood sugar of 351-400 mg/dL give 8 units of Novolog insulin; for a blood sugar of 401-450 mg/dL give 10 units of Novolog insulin; and if the blood sugar is greater than 450 mg/dL give 10 units of Novolog insulin, recheck blood sugar in two hours and follow sliding scale coverage protocol. The MAR for Resident 97 for August 2023 indicated that Novolog insulin was administered with the p.m. blood sugar check on August 11, 2023, for a blood sugar of 296 mg/dL; August 14, 2023, for a blood sugar of 214 mg/dL; on August 16, 2023, for a blood sugar of 277 mg/dL; on August 17, 2023, for a blood sugar of 263 mg/dL; on August 19, 2023, for a blood sugar of 274 mg/dL; on August 20, 2023, for a blood sugar of 326 mg/dL; on August 21, 2023, for a blood sugar of 263 mg/dL; on August 23, 2023, for a blood sugar of 327 mg/dL; on August 26, 2023, for a blood sugar of 210 mg/dL; on August 30, 2023, for a blood sugar of 250 mg/dL; and on August 31, 2023, for a blood sugar of 242 mg/dL (11 times). The MAR for Resident 97 for August 2023 indicated that Novolog insulin was administered with the 4:00 p.m. blood sugar check on August 11, 2023, for a blood sugar of 273 mg/dL; on August 14, 2023, for a blood sugar of 227 mg/dL; on August 17, 2023, for a blood sugar of 234 mg/dL; on August 19, 2023, for a blood sugar of 274 mg/dL; on August 20, 2023, for a blood sugar of 302 mg/dL; on August 21, 2023, for a blood sugar of 230 mg/dL; on August 23, 2023, for a blood sugar of 272 mg/dL; on August 28, 2023, for a blood sugar of 303 mg/dL; and on August 30, 2023, for a blood sugar of 260 mg/dL (9 times). The MAR for Resident 97 for August 2023 indicated that Novolog insulin was administered with the 11:00 a.m. blood sugar check on August 10, 2023, for a blood sugar of 235 mg/dL; on August 11, 2023, for a blood sugar of 227 mg/dL; on August 12, 2023, for a blood sugar of 298 mg/dL; on August 16, 2023, for a blood sugar of 237 mg/dL; on August 17, 2023, for a blood sugar of 210 mg/dL; on August 18, 2023, for a blood sugar of 241 mg/dL; on August 19, 2023, for a blood sugar of 265 mg/dL; on August 20, 2023, for a blood sugar of 310 mg/dL; on August 21, 2023, for a blood sugar of 228 mg/dL; on August 22, 2023, for a blood sugar of 244 mg/dL; on August 23, 2023, for a blood sugar of 275 mg/dL; on August 29, 2023, for a blood sugar of 211 mg/dL; and on August 30, 2023, for a blood sugar of 206 395539 Page 18 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0842 mg/dL (13 times). Level of Harm - Minimal harm or potential for actual harm The MAR for Resident 97 for August 2023 indicated that Novolog insulin was administered with the 7:00 a.m. blood sugar on August 12, 2023, for a blood sugar of 244 mg/dL; on August 20, 2023, for a blood sugar of 206 mg/dL; and on August 21, 2023 for a blood sugar of 225 mg/dL (3 times). Residents Affected - Some The MAR for Resident 97 for September 2023 indicated that Novolog insulin was administered with the evening (p.m.) blood sugar check on September 6, 2023, for a blood sugar of 286 mg/dL; on September 7, 2023, for a blood sugar of 249 mg/dL; on September 8, 2023, for a blood sugar of 282 mg/dL; and on September 11, 2023, for a blood sugar of 268 mg/dL (4 times). The MAR for Resident 97 for September 2023 indicated that Novolog insulin was administered with the 4:00 p.m. blood sugar check on September 2, 2023, for a blood sugar of 243 mg/dL; on September 4, 2023, for a blood sugar of 330 mg/dL, and on September 11, 2023, for a blood sugar of 230 mg/dL (3 times). The MAR for Resident 97 for September 2023 indicated that Novolog insulin was administered with the 11:00 a.m. blood sugar check on September 2, 2023, for a blood sugar of 206 mg/dL and September 8, 2023, for a blood sugar of 237 mg/dL (2 times). There was no documented evidence in the clinical record of the actual amount of insulin that was provided to the resident at these times. Interview with the Director of Nursing on September 12, 2023 at 2:13 p.m. confirmed that there was no documented evidence of the amount of insulin provided on these dates and the nurse should be documenting it on the MAR. 28 Pa. Code 211.5(f) Clinical records. 395539 Page 19 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

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. Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that they obtained the required information from the contracted hospice provider for two of 49 residents reviewed (Residents 79,103). Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated December 3, 2015, indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient, physician certification or recertification, and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness). A facility policy, dated October 11, 2022, indicated that documentation of Election Form, Physician Certification, and the care plan are on the medical record and scanned into the Electronic Medical Record under the hospice tab. The current list of diagnoses for Resident 79 included dementia, altered mental status, protein calorie malnutrition, Alzheimer's disease and adult failure to thrive. Physician orders for Resident 79, dated July 18, 2023, included an order for a hospice consult and care from the facility's contracted hospice provider. As of September 12, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice provider's current care plan, a physician certification of terminal illness (a form signed by the resident's hospice physician) specific to each patient, and hospice election form from the hospice provider. Interview with the Director of Nursing on September 14, 2023, at 11:46 a.m. confirmed that the forms were not on the resident's clinical records and indicated that they should have been. A significant change MDS for Resident 103, dated August 7, 2023, revealed that the resident was understood and understands, requires extensive assist for daily care needs, had diagnosis that included heart failure, anxiety, depression, and bipolar (mood disorder), and was receiving hospice services. Physician's orders for Resident 103, dated July 30, 2023, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of September 14, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form, certification of terminal illness form, and resident's hospice plan of care. Interview with Director of Nursing on September 14, 2023, at 11:46 a.m. confirmed that the election of benefits, physician certification, and hospice plan of care for Resident 103 were not on the resident's clinical record. 28 Pa. Code 211.12(d)(3) Nursing services. 395539 Page 20 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 to ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending August 11, 2022, 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 September 14, 2023, identified repeated deficiencies related to accurate Minimum Data Set Assessments, quality of care, safety/accidents, nutrition/hydration status, and complete and accurate medical records. The facility's plan of correction for a deficiency regarding a failure to maintain accurate Minimum Data Set Assessments, cited during the survey ending August 11, 2022, 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 F641, revealed that the QAPI committee was ineffective in correcting deficient practices related to accurate Minimum Data Set Assessments. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending August 11, 2022, 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 F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to quality of care. The facility's plan of correction for a deficiency regarding safety/accidents, cited during the survey ending August 11, 2022, 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 F689, revealed that the QAPI committee was ineffective in correcting deficient practices related to safety/accidents. The facility's plan of correction for a deficiency regarding nutrition/hydration, cited during the survey ending August 11, 2022, 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 F692, revealed that the QAPI committee was ineffective in correcting deficient practices related to nutrition/hydration. The facility's plan of correction for a deficiency regarding complete and accurate medical records, cited during the survey ending August 11, 2022, 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 F842, revealed that the QAPI committee was ineffective in correcting deficient practices related to complete and accurate medical records. Refer to F641, F684, F689, F692, F842. 395539 Page 21 of 22 395539 09/14/2023 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0867 28 Pa. Code 201.14(a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(e)(1) Management. Residents Affected - Some 395539 Page 22 of 22