Health inspection·August 16, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 21 residents reviewed (Resident 8). Residents Affected - Few Findings include: Review of Resident 8's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated July 1, 2024, that indicated the facility assessed him an having a urinary catheter (a tube that is inserted into the bladder to drain urine). There was no documented evidence in Resident 8's clinical record to indicate that he was utilizing a urinary catheter. Interview with the Administrator on August 15, 2024, at 9:38 AM confirmed Resident 8 did not utilize a urinary catheter. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 9 395571 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility failed to provide care and services to maintain optimal communication for one of one resident reviewed (Resident 74). Residents Affected - Few Findings include: Clinical record review for Resident 74 revealed that he had a history of a CVA (Cerebrovascular accident, a loss of blood flow to the brain that causes brain tissue damage). An annual MDS (Minimum Data Set, an assessment completed by the facility at intervals to determine care needs of the resident) indicated that Resident 74 had unclear speech and was usually understood and understands. Review of the care areas determined that he had a communication problem, and that the facility would develop a plan of care related to this. Review of his current care plan revealed that he had a care plan problem that indicated he had difficulty with communication due to speech and language deficits related to a CVA. The goal was that he would express his daily wants and needs. The interventions indicated to ask simple yes and no questions and give him time to respond. Review of Resident 74's Speech therapy (ST) Discharge summary dated [DATE], (this was the last time ST treated him), revealed that he had a CVA in January 2022. He was seen by ST at other entities prior to admission to the facility. The ST discharge summary indicated that the recommended communication strategies for Resident 74 were an AAC (Augmentative and alternative communication device- speech generating devices, a tablet or laptop that helps someone with a speech or language impairment to communicate). She also indicated that the tablet she was using to work on his communication was no longer in his room, and his sister indicated that she took it home with her and she was unsure if the sister was going to bring it back. There was no further follow-up from ST related to Resident 74's AAC device. Her discharge summary also indicated that the staff are reporting that Resident 74 is getting frustrated at times when trying to communicate, although she did not witness this. The concerns related to Resident 74's communication were brought to the attention of the NHA (Nursing Home Administrator) on August 14, 2024, at 2:15 PM. An interview with NHA on August 16, 2024, at 12:49 PM revealed that she had just talked to Resident 74's sister, and she confirmed that she did take the AAC device home because Resident 74 was not using it. The NHA indicated that that no other devices were offered or being used at this time to optimize Resident 74's communication. The facility failed to provide care and services to optimize Resident 74's communication. 28 Pa. Code 211.10 (c)(d) Resident care policies 395571 Page 2 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for seven of eight residents reviewed (Residents 18, 42, 58, 59, 60, 71, and 88). Findings include: Clinical record review for Resident 18 revealed a current care plan for staff to provide a restorative nursing program (RNP) to prevent contracture(s) which included: AAROM (active assisted range of motion, movement of the body to maintain a resident's ability) to their BL (bilateral) arms at the shoulders, elbows, wrists, and fingers. Do a slow progressive stretch and monitor for discomfort for up to 30 repetitions by shift. PROM (passive range of motion) to their BLLE (lower legs at the hips, knees, and ankles for flexion, extension, abduction (moving away from the middle of the body), adduction (moving closer to the middle of the body), and ankle pumps, slowly and gently up to 20 repetitions by shift. Review of task documentation for Resident 18 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to their BLUE at the shoulders, elbows, wrists, and fingers. Do a slow progressive stretch and monitor for discomfort for up to 30 repetitions by shift. Evening Shift: July 5, 6, 8, 17, 18, 19, 22, 23, 26, 28, 30, and 31, 2024 August 1, 10, and 12, 2024 PROM to their BL legs at the hips, knees, and ankles for flexion, extension, abduction, adduction, and ankle pumps, slowly and gently up to 20 repetitions by shift. Evening Shift: July 5, 6, 8, 17, 18, 22, 23, 26 28, 30, and 31, 2024 August 1, 10, and 12, 2024 Clinical record review for Resident 42 revealed a current care plan for staff to provide a RNP which included: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. AAROM to BLUE at the shoulders, elbows, wrists, and fingers three times 10 repetitions by shift. 395571 Page 3 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0688 Level of Harm - Minimal harm or potential for actual harm Review of task documentation for Resident 42 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. Residents Affected - Some Evening Shift: July 3, 5, 8, 10, 13, 22, 30, and 31, 2024 August 7, 9, 10, 12, and 13, 2024 AAROM to BLUE at the shoulders, elbows, wrists, and fingers three times 10 repetitions by shift. July 3, 5, 8, 10, 13, 22, 30, and 31, 2024 August 7, 9, 10, 12, and 13, 2024 Clinical record review for Resident 58 revealed a current care plan for staff to provide a RNP which included: AROM to BLLE at the hips, knees, and ankles times 10 repetitions by shift. Review of task documentation for Resident 58 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: Evening Shift: July 5, 7, 8, 13, 14, 16, and 18, 2024 August 1, 4, 7, 10, and 13, 2024 Clinical record review for Resident 71 revealed a current care plan for staff to provide a RNP which included: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. AAROM to BLUE at the elbows, wrists, and fingers for flexion and extension three times 10 repetitions by shift. PROM to BL shoulders three times 10 repetitions for gentle flexion and extension by shift. Review of task documentation for Resident 71 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AAROM to BLLE at the hips, knees, and ankles three times 10 repetitions by shift. 395571 Page 4 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0688 Day Shift: Level of Harm - Minimal harm or potential for actual harm July 4 and 6, 2024 Evening Shift: Residents Affected - Some July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 AAROM to BLUE at the elbows, wrists, and fingers for flexion and extension three times 10 repetitions by shift. Day Shift: July 4 and 6, 2024 Evening Shift: July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 PROM to BL shoulders three times 10 repetitions for gentle flexion and extension by shift. Day Shift: July 4 and 6, 2024 Evening Shift: July 8, 10, 22, 23, 29, 30, and 31, 2024 August 1, 7, 11, 12, and 13, 2024 Clinical record review for Resident 59 revealed a current care plan for staff to provide a RNP which included: AROM to the right and left hips, right knee, and right ankle for flexion and extension 10 times three repetitions by shift. AROM to BLUE at the elbows, wrists, and hands for flexion and extension three times 10 repetitions by shift. AAROM to shoulders for flexion and extension by shift. Review of task documentation for Resident 59 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: 395571 Page 5 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0688 AROM to the right and left hips, right knee, and right ankle for flexion and extension 10 times three repetitions by shift. Level of Harm - Minimal harm or potential for actual harm Evening Shift: Residents Affected - Some July 3, 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 AROM to BLUE at the elbows, wrists, and hands for flexion and extension three times 10 repetitions by shift. July 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 AAROM to shoulders for flexion and extension by shift. July 4, 6, 8, 10, 13, 22, 26, 30, and 31, 2024 August 7 and 10, 2024 Clinical record review for Resident 60 revealed a current care plan for staff to provide a RNP which included: AROM to BLLE at the hips, knees, and ankles for flexion and extension three times 10 repetitions by shift. AAROM to BLUE at the shoulders, elbows, wrists, and fingers, for flexion and extension three times for 10 repetitions by shift. Review of task documentation for Resident 60 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: AROM to BLLE at the hips, knees, and ankles for flexion and extension three times 10 repetitions by shift. Day Shift: July 26, 2024 Evening Shift: July 5, 8, 10, 16, 18, 22, 29, 30, and 31, 2024 August 1, 7, 10, 11, 12, and 13, 2024 AAROM to BLUE at the shoulders, elbows, wrists, and fingers, for flexion and extension three times 395571 Page 6 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0688 for 10 repetitions by shift. Level of Harm - Minimal harm or potential for actual harm Day Shift: July 26, 2024 Residents Affected - Some Evening Shift: July 5, 8, 10, 16, 18, 22, 29, 30, and 31, 2024 August 1, 7, 10, 11, 12, and 13, 2024 Clinical record review for Resident 88 revealed a current care plan for staff to provide a RNP, which included ambulate with a rolling walker with assist of one and use of a gait belt for mobility up to 300 feet by shift. Review of Resident 88's physical therapy discharge summary date July 17, 2024, revealed that they discharged him to RNP for ambulation and ROM with possible transfers. Review of task documentation for Resident 88 revealed that staff did not document completion and/or document previously scheduled (task was completed on a different shift, was not completed during the shift indicated/care planned) completion of the restorative task on the following dates: Evening Shift: July 5, 8, 14, 16, 18, 22, 23, 28, 29, 30, and 31, 2024 August 1, 7, 9, 10, 11, 12, and 13, 2024 Further review of Resident 88's task documentation revealed that they usually accept staff assistance as needed for care and services, with five refusals to ambulate identified throughout July and August 2024. Observation and interview with Resident 88 on August 13, 2024, and 11:35 AM and August 14, 2024, at 8:59 AM revealed that they were dressed and sitting in a wheelchair in their room. They indicated that they have not received therapy recently, but they would like to walk so they could go home. The surveyor reviewed the above information on August 15, 2024, at 2:15 PM with the Nursing Home Administrator and Director of Nursing. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395571 Page 7 of 9 395571 08/16/2024 Muncy Place 215 East Water Street Muncy, PA 17756

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed to follow up with needed dental services for one of two residents reviewed (Resident 39). Residents Affected - Few Findings include: Interview with Resident 39 on August 14, 2024, at 11:56 AM revealed that the facility cancelled her dental appointment today because they didn't stop her blood thinner. Resident 39 indicated that she was supposed to get a tooth pulled and now she must wait until September 2024. Resident 39 also added that the tooth she was supposed to get pulled is now broken and causing her discomfort. Review of the dental consult dated June 4, 2024, indicated that Resident 39 was noted to voice discomfort on her lower tooth, had dental caries (tooth decay) in two teeth, and a large cavity into the nerve on one tooth that could not be fixed. The recommendations from the dentist indicated that Resident 39 should be scheduled to return, to stop blood thinners, treat the caries on two teeth, and extract the tooth with the large cavity. Nursing documentation dated June 4, 2024, at 12:03 PM indicated that Resident 39 returned from her dental appointment, extraction recommended, and follow appointment to be scheduled. Review of the Request for Appointment form dated June 4, 2024, indicated that the facility scheduled Resident 39's follow up appointment for dental extractions and fillings for August 14, 2024, at 8:00 AM. There was no documented evidence in Resident 39's clinical record to indicate that the facility stopped her blood thinners as recommended in the June 4, 2024, dental consult for her August 14, 2024, appointment nor attempted to obtained further information from the dentist after her June 4, 2024, dental appointment regarding the recommendations provided. Interview with the Administrator and Director of Nursing on August 15, 2024, at 11:00 AM confirmed the above findings for Resident 39 and indicated that her next scheduled dental appointment is not until September 23, 2024. 28 Pa. Code 211.15(a) Dental services 395571 Page 8 of 9 395571 08/16/2024 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 observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for one of 21 residents reviewed (Resident 12). Residents Affected - Few Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms, released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. A review of the current physician orders for Resident 12 revealed an order dated July 18, 2024, that noted the resident was on Enhanced Barrier Precautions. The resident also had current orders for tracheostomy (trach, an opening surgically made through the neck into the windpipe through which a tube/cannula allows the passage of air and supplemental oxygen) management three times daily. A review of the current care plan for Resident 12 revealed the resident was on enhanced barrier precautions due to colonization with multi-drug resistant organisms that required the precautions. An intervention included using proper personal protective equipment (gowns, gloves) when performing high-contact activities. Observation outside of Resident 12's room on August 16, 2024, at 8:50 AM revealed a sign on the resident's door frame that indicated the resident was on Enhanced Barrier Precautions and a gown and gloves must be worn for high-contact resident activities. Observation of tracheostomy care for Resident 12 on August 16, 2024, at 9:00 AM revealed Employee 1, respiratory therapist, entered the resident's room with no gown. Employee 1 proceeded to perform tracheostomy care, a high contact resident activity, that included suctioning of the tracheostomy, cleaning around the site, and an inner cannula change. Employee 1 did not utilize a gown and only wore gloves during the high-contact resident activity. An interview with Employee 1 outside of Resident 12's room regarding the sign and required personal protective equipment revealed that the employee should have worn a gown during the care. Employee 1 failed to wear the appropriate personal protective equipment during tracheostomy care for Resident 12. The Nursing Home Administrator and Director of Nursing were notified of the above findings on August 16, 2024, at 1:23 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 395571 Page 9 of 9