Health inspection·January 12, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on clinical record review and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for three of 18 residents reviewed (Residents R7, R12, and R26). Findings include: Resident R7's clinical record revealed an admission date of 5/11/22, with diagnoses that included Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), peripheral vascular disease (a slow and progressive circulation disorder), and atrial fibrillation (a type of abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, and weakness and can lead to development of blood clots). Review of Resident R7's Quarterly Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), with an Assessment Reference Date (ARD-a look back period of time for the MDS assessment) of 11/27/23, revealed that Resident R7 was cognitively intact. During an interview with Resident R7 on 1/10/24, at approximately 10:56 a.m. resident reported that he/she was not invited to attend a care plan meeting nor had he/she ever attended one. Resident R7's clinical record lacked any evidence that Resident R7 was invited to or ever attended a care plan meeting. Resident R12's clinical record revealed an admission date of 1/11/23, with diagnoses that included cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), bipolar disorder (an emotional disorder causing extreme high and low mood swings), urinary incontinence (loss of bladder control). Review of Resident R12's quarterly MDS with an ARD of 10/21/23, revealed that Resident R12 was cognitively intact. During an interview with Resident R12 on 1/10/24, at approximately 9:05 a.m. Resident R12 reported that he/she was not invited to attend a care plan meeting nor had he/she ever attended one. Resident R12's clinical record lacked any evidence that Resident R12 was invited to or ever attended a care plan meeting. Page 1 of 10 395550 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident R26's clinical record revealed an admission date of 11/10/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), chronic kidney disease (a gradual loss of kidney function over time), and Difficulty walking. Review of Resident R26's five-day prospective payment system (PPS - sets payment level according to data entered in the MDS) MDS with an ARD of 12/18/23, revealed that Resident R26 was cognitively intact. During an interview with Resident R26 on 1/10/24, at approximately 10:00 a.m. Resident R26 reported that he/she was not invited to attend a care plan meeting nor had he/she ever one. Resident R26's clinical record lacked any evidence that Resident R26 was invited to or ever attended a care plan meeting. During an interview on 1/11/24, at 9:55 a.m. the Social Worker confirmed that there was no evidence of Residents R7, R12, and R26 being invited to, or attending a Care Plan Meeting. 28 Pa. Code 201.29 (a) Resident rights 395550 Page 2 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a complete investigation for an injury of unknown origin in a timely manner for one of 18 residents reviewed (Resident R57). Residents Affected - Few Findings include: Review of the facility policy entitled Resident Incident and Accident Report dated 1/27/23, indicated that, The RN (Registered Nurse) will initiate an investigation for any injury or accident of unknown cause. Review of the clinical record revealed that on 12/12/23, at 10:12 a.m. Resident R57 was having increased leg pain and the physician was notified to obtain an x-ray, an order was received from the physician at 10:38 a.m. to x-ray Resident R57's left hip and leg, the x-ray company was called at 10:52 a.m. and the x-ray was completed at 6:14 p.m. On 12/14/23, at 1:02 a.m. the x-ray results were obtained via telephone which identified an acute left femoral neck fracture and at 9:19 a.m. an order was received to send Resident R57 to the emergency department. He/she was admitted at 5:23 p.m. with a left hip fracture. Resident R57 had a left hip replacement on 12/17/23, and returned to the facility on [DATE], at 12:50 p.m. Review of the clinical record revealed that an investigation for an injury of unknown origin was not initiated in a timely manner after the change in condition and was incomplete. The investigation provided for review lacked evidence that staff interviews were completed individually, did not include names/titles/signatures, and are not date/time stamped. The investigation lacked evidence that it was started timely after the change in condition and did not include staff interviews from shifts prior to the onset. Interview conducted with the Director of Nursing on 1/11/24, at 9:40 a.m. confirmed that an investigation was not initiated in a timely manner related to an injury of unknown origin and was incomplete. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395550 Page 3 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for four of 18 residents reviewed (Residents R30, R25, R34, and R65). Findings include: Resident R30's clinical record revealed an admission date of 5/16/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), congestive heart failure (a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R30's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R25's clinical record revealed an admission date of 10/14/23, with diagnoses that included cellulitis (an infection of the skin), diabetes, and high blood pressure. Review of Resident R25's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R34's clinical record revealed an admission date of 8/2/23, with diagnoses that included high blood pressure, diabetes, and lymphedema (a condition that results in swelling of the leg or arm). Review of Resident R34's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R65's clinical record revealed an admission date of 9/11/23, with diagnoses that included high blood pressure, diabetes, and left femur fracture (a break in the left thigh bone). Review of Resident R65's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. During an interview on 1/11/24, at 9:25 a.m. the Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan was provided to Residents R30, R25, R34, or R65 and/or their representative. 28 Pa. Code 211.12(d)(3)(5) Nursing services 395550 Page 4 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0656 Level of Harm - Minimal harm or potential for actual harm 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 clinical records and staff interviews, it was determined that the facility failed to develop a wound care plan for one of 18 residents reviewed (Resident R34). Residents Affected - Few Findings include: Resident R34's clinical record revealed an admission date of 8/2/23, with diagnosis of hypertension (high blood pressure), peripheral venous insufficiency (a condition where your veins have trouble sending blood from your limbs back to your heart), open wound right lower leg, and lymphedema (a condition that causes swelling which can cause skin break down). Review of Resident R34's treatment record revealed an order to keep dressings clean, dry and intact to both legs, and to elevate bilateral lower extremities when possible. Review of Resident R34's physician orders revealed Resident R34 follows with the wound clinic for peripheral venous wounds to bilateral legs. Review of Resident R34's care plans revealed no evidence of a care plan for peripheral venous wounds to bilateral legs. During an interview on 1/11/24, at 12:21 p.m. the Director of Nursing confirmed that Resident 34's plan of care lacked a care plan for peripheral venous wounds. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395550 Page 5 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

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 review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration and oxygen therapy for two of 18 residents reviewed (Residents R65 and R30). Residents Affected - Few Findings include: Review of facility policy entitled Physician Orders dated 1/27/23, revealed Upon receipt of written or verbal orders by the practitioner, the Registered Nurse (RN) will write and or enter the new order into electronic medical record (EMR). and If a new medication has been ordered . the pharmacy should dispense either via omni cell, routine/scheduled run or via emergency run. Review of Resident R65's clinical record revealed an admission date of 10/14/23, with diagnosis that include urinary tract infection (an infection in the urine), diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), hypertension (high blood pressure), and urinary calculus (kidney stones). Interview with Resident R65 on 1/10/24, at 10:42 a.m. revealed that he/she was told he/she had a urinary tract infection three days prior to starting an antibiotic. Review of Resident R65's clinical record revealed a laboratory report for urinalysis culture and sensitivity (a report that shows the physician what organism is in the urine and what antibiotic would be more effective to treat the infection), report that revealed his/her urine was collected on 1/5/24. On 1/7/24, the urinalysis was received by the facility with the culture and sensitivity report received on 1/8/24. There was no evidence that the physician was notified of these reports. Review of Resident R65's clinical revealed that on 1/9/24, the physician wrote an order on the culture and sensitivity report for Bactrim DS (antibiotic medication to treat a urinary tract infection) one tablet by mouth twice a day for seven days. This physician order of 1/9/24, reflected a delay of two days after the facility received the urinalysis report and one day after the facility received the culture and sensitivity report. Review of Resident R65's medication administration record revealed the antibiotic was not started until 1/10/24, or a period of two days after the culture and sensitivity report was received by the facility and one day after the physician wrote the order. Interview with the Director of Nursing on 1/11/24, at 1:10 p.m. confirmed the antibiotic treatment was not initiated on 1/9/24, as ordered by the physician and that the physician should have been notified promptly when the urinalysis report was received on 1/7/24, and the culture and sensitivity report on 1/8/24, in order to for a physician order to initiate the antibiotic treatment as soon as possible. Review of facility policy entitled, Oxygen Administration & Supply dated 1/27/23, revealed that Disposable humidifiers, tubing, nasal canula or mask will be cleaned weekly by nursing on the 11-7 shift. All equipment will be dated. Do not keep disposable equipment from one episode to the next. Resident R30's clinical record revealed an admission date of 5/16/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with 395550 Page 6 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few symptoms of difficulty breathing, coughing and shortness of breath), congestive heart failure (a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), and diabetes. Resident R30's physician's orders dated for 11/8/23, indicated to change oxygen tubing and humidifier bottle every week on Sunday. Review of Resident R30's December 2023 and January 2024 Treatment Administration Record (TAR) revealed that his/her oxygen tubing was identified as changed on the following dates: 12/10/23, 12/17/23, 12/24/23, 12/31/23, and 1/7/24. Observation on 1/9/24, at approximately 4:13 p.m. and on 1/11/24, at 11:10 a.m. revealed Resident R30's oxygen tubing was dated 12/10/23. This observation identified that the oxygen tubing had not been changed on 12/17/23, 12/24/23, 12/31/23, or 1/7/24 and that the December and January TARs were not accurate. During an interview on 1/11/24, at 11:15 a.m. Licensed Practical Nurse, Employee E4, confirmed that the oxygen tubing was dated 12/10/23, and had not been changed weekly as required and ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395550 Page 7 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

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 facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of Bilevel Positive Airway Pressure (BIPAP - a machine that uses pressure to push air into your lungs) and/or CPAP (Continuous Positive Airway Pressure) therapy for one of one residents reviewed for respiratory services (Resident R30). Residents Affected - Few Findings include: Review of a facility policy dated 1/27/23, entitled, AVAPS (Average Volume Assured Pressure Support - a device that provide consistent ventilation support) and BiPAP Therapy indicated Procedure instructions stating, Obtain physician order .). Resident R30's clinical record revealed an admission date of 5/16/23, with diagnoses including respiratory failure with hypercapnia (extreme breathing difficulties demonstrated by increased carbon dioxide levels in the blood), Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), and diabetes (a condition where the body produces insufficient amounts of insulin, causing High blood sugar). Review of Resident R30's clinical record revealed Treatment Administration Record (TAR) dated from 12/10/23, to 1/9/24, that Resident R30 received Continuous Positive Airway Pressure - (CPAP - delivers continuous pressurized air ) or BiPAP therapy on the night shifts of the following dates: 12/10/23-CPAP, 12/11/23-CPAP, 12/12/23-BiPAP, 12/13/23-BiPAP, 12/14/23-BIPAP, 12/15/23-BiPAP, 12/18/23-CPAP, 12/19/23-BiPAP, 12/20/23-BiPAP, 12/24/23-BiPAP, 12/27/23-BiPAP, 12/28/23-CPAP, 12/29/23-BiPAP, 12/31/23-BiPAP, 1/1/24-BIPAP, 1/4/24-BiPAP. Additional review of Resident R30's clinical record revealed that there was no physician's order for application of either CPAP or BiPAP Therapy. Observation on 1/9/24, at approximately 4:13 p.m. revealed Resident R30 had a BiPAP machine sitting on his/her bedside table. When Resident R30 was interviewed if he/she used the BiPAP machine, he /she stated that they use it most nights. During an interview on 1/10/24, at 11:30 a.m. Registered Nurse (RN) Employee E3 confirmed that Resident R30's clinical record lacked a physician's order for BiPAP Therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395550 Page 8 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of facility contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for one of one residents reviewed for dialysis (Resident R39). Residents Affected - Few Findings include: Review of dialysis contract dated 11/28/23, indicated Long Term Care Facility (LTCF) shall timely provide all relevant information to Dialysis Clinic Inc (DCI) regarding the condition and needs of each LTCF patient ., DCI shall provide relevant information regarding each patient's dialysis treatment which may require follow up care or observation by LTCF's staff: and This .communication will occur prior to each and every transfer of a patient to DCI . Resident R39's clinical record revealed an admission date of 11/28/23, with diagnoses that included end stage renal disease (a disease that causes the kidneys not to function properly), diabetes, hypercholesterolemia (high cholesterol), and hypothyroidism (a condition where your thyroid gland [a butterfly shaped organ in your neck] makes too little hormone). Review of Resident R39's physician orders revealed an order for dialysis every Monday, Wednesday, and Friday 8:30 a.m. to 2:30 p.m. Review of Resident R39's clinical record lacked evidence of communication between the facility and dialysis clinic. During an interview on 1/11/24, at 9:24 a.m. the Director of Nursing confirmed there was no evidence of ongoing communication and collaboration between the facility and dialysis clinic. He/she also confirmed that communication should be done with every dialysis treatment. 28 Pa. Code 211.5(f)(viii) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395550 Page 9 of 10 395550 01/12/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (Apple Tree and Hickory Lane medication carts). Findings include: Review of facility policy entitled Storage of Medications dated 1/27/23, indicated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Review of manufacturer's guidelines revealed open Insulin Lispro pens must be used within 28 days after opening or be discarded, even if the pen still contains insulin. Observation of drug storage on 1/9/24, at 3:46 p.m. of the Hickory Lane medication cart revealed a pen of Insulin Lispro with an open date of 12/10/23, which was beyond the expiration date of 28 days after opening. During an interview at the time of observation, Licensed Practical Nurse (LPN) Employee E1 confirmed that the Insulin Lispro pen should have been discarded as it was beyond the 28 days after opening. Observation of drug storage on 1/9/24, at 4:18 p.m. of the Apple Tree medication cart revealed an open bottle of acetaminophen (pain medicine) 500 milligram tablets with a manufacturer's expiration date of 3/2019, which was beyond the manufacturer's expiration date. During an interview at the time of observation, LPN Employee E2 confirmed that the open bottle of acetaminophen had a manufacturer expiration date on 3/2019, and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services 395550 Page 10 of 10