Health inspection·September 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation and staff interview, it was determined that the facility failed to promote resident dignity during dining in one of two dining rooms observed (second floor dining room, Resident 14). Residents Affected - Few Findings include: An observation of the second-floor dining room on September 12, 2023, at 12:32 PM revealed Resident 14 reclined in a specialty chair in front of a dining table. A plate of untouched pureed food and three two-handled cups with beverages (identified as thickened water, thickened juice and strawberry Ensure) sat on the table in front of the resident and out of the resident's reach. One cup had an empty thickened juice container. Another resident was observed feeding herself across the table from Resident 14 with her meal almost gone. Residents were seated at other tables in the dining room being assisted by staff or feeding themselves with the majority of their meal complete. As other individuals walked past Resident 14, including the surveyor, Resident 14 was asking everyone if they wanted some of her food. At 12:40 PM a dietary staff member was observed approaching the resident and asked the resident, Aren't you hungry today? Resident 14 responded, I am hungry, but have some. At 12:42 PM Employee 5, nurse aide, sat down beside Resident 14 to assist with feeding the resident. The resident across the table from Resident 14 had stacked all her empty dishes up and was exiting the table. Resident 14 only ate a couple bites of food, and the resident was asked if she wanted dessert, and was offered one bite of which the resident refused. At 12:46 PM Employee 5 stated, Ok, I will take you back to your room, and proceeded to get up from the table and pushed the resident out of the dining room. Resident 14 was not offered any of the three beverages including the Ensure, nutritional supplement. Clinical record review for Resident 14 revealed a quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals of time to assess resident care needs) dated August 24, 2023, that assessed Resident 14 as having a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment and requiring extensive assistance of one person physical assist for eating. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator on September 14, 2023, at 3:20 PM. 28 Pa. Code 201.29(a) Resident rights Page 1 of 9 395571 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information and a resident's right to privacy for four of six residents (Residents 12, 17, 46, and 75). Residents Affected - Few Findings include: Observation of the medication pass for the first floor [NAME] hallway on September 14, 2023, at 9:07 AM with Employee 3, licensed practical nurse, revealed an almost full trash receptacle attached to the side of the medication cart. Observation of the trash receptacle revealed an empty medication card for Resident 12 that noted the resident's name and the prescribed dose of Metformin (a medication used to help control high blood sugar). Observation of the trash receptacle revealed an empty medication card for Resident 17 that noted the resident's name and the prescribed dose of Jardiance (a medication used to control high blood sugar in people with diabetes). Observation of the trash receptacle revealed an empty medication card for Resident 46 that noted the resident's name and the prescribed dose of Eliquis (a medication used to prevent blood clots from forming). Observation of the trash receptacle revealed an empty medication card for Resident 75 that noted the resident's name and the prescribed dose of Jardiance. A concurrent interview with Employee 3 confirmed the tops of the packages that included the resident's name and prescribed medication information should be removed and shredded and not thrown in the regular trash. The above findings for Residents 12, 17, 46, and 75 were reviewed with the Nursing Home Administrator on September 14, 2023, at 2:30 PM. 28 Pa. Code 211.12(d)(1) Nursing services 395571 Page 2 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 302). Residents Affected - Few Findings include: The facility's medication error rate was 6.06 percent based on 33 medication opportunities with two medication errors. Observation of Resident 302's medication administration pass on September 14, 2023, at 8:55 AM revealed Employee 3, licensed practical nurse, administered the resident's medications that included Levothyroxine (a medication used to treat thyroid problems) 50 mcg (micrograms). The labeling on the Levothyroxine medication instructed the user to take the medication on an empty stomach a half hour to one hour before breakfast, and at least four hours before an antacid/iron/or vitamin or mineral supplement. The medication was also administered with Ferosul (a type of iron supplement) and the resident's additional morning medications. Observation of Resident 302, at 8:55 AM during receipt of her medications revealed that the resident was eating breakfast that included eggs, hash browns, cereal, and milk. Review of the medication guidelines attached to the order in the electronic health record for the Levothyroxine included a how to section that noted that Levothyroxine is usually once daily on an empty stomach, 30 minutes to one hour before breakfast. Clinical record review for Resident 302 did not specify or provide clarification if the resident was allowed to take the medication with the iron supplement and during breakfast. Further observation of Resident 302's medication administration pass revealed Employee 3 administered Senexon-S (a combination medication used to treat and prevent constipation). Clinical record review for Resident 302 revealed the resident was to receive two Senna (a medication used to treat and prevent constipation) 8.6 milligram (mg) tablets once daily with morning med pass and not the combination medication Senexon-S that was administered. An interview on September 14, 2023, at 2:30 PM with Employee 6, registered nurse, confirmed that the Senexon-S and Senna are two different medications and would have to check about the administration time for the Levothyroxine. An interview with Employee 6 on September 15, 2023, at 12:57 PM revealed that staff clarified with the resident after the surveyor questioning that she usually took the Levothyroxine earlier than her other medications and the time of administration would be changed. Employee 6 further indicated that the resident may have been confused upon initially questioning her. However, there was no evidence that staff clarified the labeling on the medication card regarding administration (take the medication on an empty stomach a half hour to one hour before breakfast, and at least four hours before an antacid/iron/or vitamin or mineral supplement) with the pharmacist or physician. The above information for Resident 302 was reviewed with the Nursing Home Administrator on September 15, 2023, at 1:15 PM. 395571 Page 3 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0759 28 Pa. Code 211.9(a)(1) Pharmacy services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few 395571 Page 4 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

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 observation and staff interview, it was determined that the facility failed to properly store and secure medications on two of three nursing units (First Floor [NAME] Hall, Second Floor; Residents 54 and 12). Findings include: Observation of Resident 54's room on September 12, 2023, at 11:11 AM with Employee 4, Respiratory Therapist, revealed an unlocked cabinet on the left wall as you enter the room that contained the following medications that were identified as Resident 54's: Albuterol HFA (an inhaler used to treat or prevent lung diseases), Atrovent HFA (an inhaler used to help with difficulty breathing in people with lung disease), and Flovent HFA (an inhaler used to treat asthma). Concurrent interview with Employee 4 confirmed that the medications should be stored in the locked medication cart of a locked cabinet. The Nursing Home Administrator was made aware of the concerns related to medication security on September 14, 2023, at 2:45 PM. The facility failed to secure Resident 54's medications as noted above. Observation of the medication pass for the First Floor [NAME] Hallway on September 14, 2023, at 9:00 AM with Employee 3, licensed practical nurse, revealed the following regarding the medication cart: The glucometer (a medical device used to measure the amount of glucose in blood) had several cards kept in the plastic storage case with the device. The laminated card for Resident 12 had a quarter-sized dried reddish, brown colored stain on the card. A pill crusher on top of the cart had a significant accumulation of a black colored substance under the area of the device where the pills are crushed. The coating of the device was starting to come off and flake in the area where the pills are placed to be crushed. A drawer holding the medication cards had paper debris on the bottom and an unidentified small, orange-colored round pill in the bottom of the drawer. A second drawer holding medication cards had paper debris on the bottom and an unidentified half tablet white in color and two round brown colored pills on the bottom of the drawer. A concurrent interview with Employee 3 reported that staff should be discarding any pills that fall into the drawer. The above information regarding the medication cart was review with the Nursing Home Administrator on September 14, 2023, at 2:30 PM. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals 395571 Page 5 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0761 Previously cited deficiency 10/07/2022 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Residents Affected - Few 395571 Page 6 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

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. Based on observation and staff interview, it was determined that the facility failed to prepare, store, and serve food in a sanitary environment and maintain equipment in proper working order in the facility's main kitchen. Findings include: An observation of the main kitchen on September 12, 2023, at 10:28 AM with Employee 2, food service manager, revealed the following: The concrete block wall in the dish room area under the garbage disposal and extending to the dish machine prewash area contained peeling paint and some blackened areas on the wall. Food service staff were observed running racks of dishes through the dish machine, the final rinse was observed to not exceed 166 degrees Fahrenheit. Employee 2 indicated he was not aware of any problems with the dish machine. A review of the temperature checks of the machine for the morning of September 12, 2023, provided by Employee 2, noted the machine final rinse was 180 degrees Fahrenheit, and the acceptable range was 180-195 degrees Fahrenheit. A large open utensil storage rack was located at the end of two production tables. The rack contained multiple spoons, and spatulas hanging off hooks on the rack. Bins were also observed hanging off the side of the rack storing multiple scoops. The bin of scoops was directly beside an industrial size countertop mixer. A metal rack hung from the ceiling above the same preparation area with multiple ladles hanging from the rack. The utensils were used in food preparation and serving and were uncovered and stored open to the potential contamination of dust, debris, and food splatter. Employee 1, cook, was observed filling beverages in the main kitchen. Employee 1 had a full moustache and beard, which appeared greater than one half inch in length, and no beard covering was present. At 11:40 AM on September 12, 2023, Employee 2 indicated maintenance staff were working on the dish machine and adjusting the water temperature booster and the machine was reaching 178 degrees Fahrenheit. At 1:30 PM Employee 2 indicated the machine was set up to utilize a chemical for sanitizing should the final rinse temperature not meet the 180-195 degrees Fahrenheit. An observation of a sink/garbage disposal in the production area of the main kitchen on September 14, 2023, at 12:38 PM revealed the wall behind the garbage disposal contained several pipes running to the sink. The wall contained peeling paint, dirt buildup, and dried food debris. The above information was reviewed with the Nursing Home Administrator on September 14, 2023, at 3:20 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 395571 Page 7 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on select review of policies, observation, and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia). Residents Affected - Few Findings include: A review of the Water Management Plan provided by the facility revealed a section titled a Roadmap for Responding to Legionella Environmental Test Results - Example. The document noted that, No Legionella positivity or concentration threshold correlates directly with disease. In its Legionella toolkit, the CDC.gov (Centers for Disease Control and Prevention) emphasizes, there is no safe amount or type of Legionella, and the presence of any Legionella should trigger response activities.' Review of facility documentation dated June 1, 2023, revealed the facility SNU PT Sink tested positive for Legionella feeleii with a concentration of 10.0 CFU/ml (colony forming unit per milliliter). Per the Nursing Home Administrator (NHA), this was the Skilled Nursing Unit Physical Therapy sink located on the second floor. Review of facility documentation dated August 10, 2023, revealed the facility SNU - Beauty Shop Restroom tested positive for Legionella feeleii with a concentration of 5.0 CFU/ml. Per the NHA, this was the bathroom located adjacent to the beauty shop in the basement of the facility. Interview with the NHA and Employee 7, maintenance staff, on September 14, 2023, at 1:00 PM confirmed that the facility was aware of the positive results. Employee 7 reported that housekeeping staff flush the commodes and sinks daily in each resident room. Documentation was provided for the previous three months that noted that this was performed in the occupied and unoccupied resident rooms. However, there was no documentation provided to indicate these actions were being taken to protect residents, staff, and/or visitors from the specific areas that tested positive. An interview with the NHA on September 15, 2023, at 1:04 PM revealed that the SNU - Beauty Shop Restroom was still being used by staff and visitors. However, residents were not supposed to be using the bathroom and beauty shop staff typically escort them to their beauty shop appointment since residents are not supposed to be in the basement alone. Observation of the SNU - Beauty Shop Restroom on September 15, 2023, at 1:45 PM confirmed the restroom was in the basement of the facility adjacent to the beauty shop. The door was closed, unlocked, and accessible to anyone passing by. A concurrent interview with Employee 7 revealed that he was unsure what specific remediation, flushing, or retesting, was done to protect anyone that may use the restroom after the restroom tested positive. Observation of the SNU PT Sink on September 15, 2023, at 2:06 PM revealed the sink was in the therapy room on the second floor at the end of a resident area. The sink was still in use and easily accessible and an unidentified therapy employee confirmed that residents still utilize the sink to wash dishes. A concurrent interview with Employee 7 revealed that the aerator was removed from the sink's faucet upon testing positive. An interview with the NHA on September 15, 2023, at 2:15 PM revealed that the positive areas have 395571 Page 8 of 9 395571 09/15/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0880 not been retested and the NHA will call the company to have retesting completed as soon as possible. Level of Harm - Minimal harm or potential for actual harm Employee 7 revealed the facility currently has a chlorine dioxide injection system (a system to help control Legionella). A proposal was provided by the facility dated July 31, 2023, that addressed a secondary disinfection system for the potable hot water. The proposal indicated if the facility would like to proceed to email or call the supplier with a purchase order. There was no evidence provided of further action taken with this. Residents Affected - Few The facility failed to implement further immediate strategies (shutting off water or restricting access or retesting) at the positive test sites to prevent the potential spread of waterborne pathogens to residents, staff, or visitors that may utilize or encounter the positive-tested areas. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 395571 Page 9 of 9