Health inspection·March 13, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 19 residents reviewed (Resident R60). Findings include: A facility policy entitled, Care Plans, Comprehensive Person-Centered dated 10/29/24, indicated that assessments of residents are on-going and care plans are revised as information about the resident and the resident's condition changes, and the interdisciplinary team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in nursing home residents). Resident R60's clinical record revealed an admission date of 4/09/24, with diagnoses that included long-term kidney disease, sudden kidney failure, and high blood pressure. Review of Resident R60's clinical record revealed a physician's order dated 6/18/24, for removal of his/her dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) catheter (a soft, flexible tube used to access a patient's blood for hemodialysis). A departmental progress note dated 6/21/24, indicated that the dialysis catheter was removed due to Resident R60 no longer requiring dialysis treatment. A care plan entitled end stage renal disease initiated 6/05/24, with the most recent target date of 11/16/24, included interventions to transport Resident R60 to dialysis on Tuesdays and Saturdays at 10:30 a.m., coordinate dialysis care with the dialysis treatment facility, arrange for transportation to and from dialysis, and confer with physician and/or dialysis treatment facility regarding changes in medication administration times/dosages pre-dialysis as needed. Review of Resident R60's MDS's revealed the following: Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Quarterly MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not Page 1 of 6 395594 395594 03/13/2025 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0657 receiving dialysis services. Level of Harm - Minimal harm or potential for actual harm Significant Change in Status Assessment MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Residents Affected - Few Significant Change in Status Assessment MDS dated [DATE], Section O - Special Treatments and Programs, O0110-J2 was coded as not receiving dialysis services. Interview on 3/12/25, at 12:57 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R60's care plan lacked evidence of being updated to reflect the current necessary care and services. 28 Pa. Code 211.5(f)(ii) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395594 Page 2 of 6 395594 03/13/2025 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of clinical records and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of seven residents reviewed for psychotropic medications (Resident R58). Findings include: Resident R58's clinical record revealed an admission date of 4/26/24, with diagnoses that included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), Psychosis (when people lose some contact with reality), anxiety, and high blood pressure. A physician's order dated 2/08/25, instructed staff to administer Lorazepam 0.5 mg by mouth every eight hours PRN for anxiety or agitation, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of Resident R58's MAR revealed he/she received the Lorazepam once on 2/25/25 and 3/04/25. During an interview on 3/13/25, at 8:46 a.m. the Social Worker confirmed that Residents R11 and R58's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395594 Page 3 of 6 395594 03/13/2025 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

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 policy, observations, and staff interview, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms (Units A, C, and D medication room). Findings include: A facility policy entitled, Medication Storage in the Facility-Controlled Substance Storage dated 10/29/24, indicated that Schedule II-V (controlled substances that have an increased risk of resulting in addiction and/or substance use disorder) medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separated from all other medications. Observation on 2/26/25, at 1:26 p.m. of the Unit A, C, and D medication refrigerator revealed one locked compartment that contained two boxes of injectable Lorazepam (controlled substance used to treat anxiety disorders) was affixed to the rack of the refrigerator and that the rack was not permanently affixed inside the refrigerator. During an interview at that time, the Assistant Director of Nursing confirmed that the refrigerator rack was not permanently affixed to the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 395594 Page 4 of 6 395594 03/13/2025 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure fluid intake and urinary output were documented as per physician's orders in the Treatment Administration Record (TAR) and in the Tasks Record for two of three residents reviewed with foley catheters (a medical device with tubing that drains urine from the bladder) (Residents R49 and R83). Findings include: The facility policy entitled Emptying a Urinary Drainage Bag, dated 10/29/24, revealed to empty the urinary drainage bag at least every eight hours and document the amount of urine emptied from the drainage bag. The facility policy entitled Intake, Measuring and Recording, dated 10/29/24, revealed the amount of liquids consumed should be recorded in the resident's medical record. Resident R49's clinical record revealed an admission date of 1/4/25, with diagnoses that included chronic obstructive pulmonary disease (a group of diseases in the lungs that block airflow making it difficult to breath), hypertension (high blood pressure), and chronic kidney disease. Review of Resident R49's physician's orders dated 1/7/25, revealed an order to document fluid intake and foley output every shift. Review of R49's TAR which is completed by the Licensed Nurses for January 2025, February 2025, and March 2025 revealed his/her fluid intake and urinary output were not documented every shift per physician's orders on 1/7/25, 1/8/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/17/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/28/25, 2/13/25, 2/14/25, 2/17/25, 2/18/25, 2/20/25, 2/21/25, 2/22/25, 2/24/25, 3/3/25, and 3/11/25. Review of R49's Tasks Record which is completed by Nursing Assistants from 2/11/25 through 3/11/25, revealed his/her fluid intake was not documented every shift per physician's orders on 2/14/25, 2/17/25, 2/22/25, 2/25/25, and 3/5/25, and urinary output was not documented every shift per physician's orders on 2/14/25, 2/28/25, 3/1/25, 3/4/35, and 3/5/25. Resident R83's clinical record revealed an admission date of 1/31/25, with diagnoses that included rhabdomyolysis (muscle breakdown that damages kidneys due to protein in the blood), weakness, and malignant neoplasm of prostate (cancer of the prostate gland). Review of Resident R83's physician's orders dated 1/31/25, revealed an order to document fluid intake and output every shift. Review of R83's Treatment Administration Record (TAR) which is completed by the Licensed Nurses for February 2025 and March 2025 revealed his/her fluid intake and urinary output were not documented every shift per physician's orders on 2/1/25, 2/7/25, 2/13/25, 2/14/25, 2/15/25, 2/17/25, 2/18/25, 2/20/25, 2/21/25, 2/22/25, 2/24/25, 3/3/25, and 3/11/25. Review of R83's Tasks Record which is completed by Nursing Assistants from 2/11/25 through 3/11/25, 395594 Page 5 of 6 395594 03/13/2025 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed his/her fluid intake was not documented every shift per physician's orders on 2/14/25, 2/17/25, 2/22/25, 2/25/25, 3/5/25, and urinary output was not documented every shift per physician's orders on 2/14/25, 2/28/25, 3/1/25, 3/4/25, and 3/5/25. During an interview on 3/12/25, at 10:46 a.m. the Director of Nursing confirmed that the clinical records lacked evidence that the TAR and Tasks Record documentation were completed per physician's orders for fluid intake and urinary output for Residents R49 and R83 on the dates listed above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395594 Page 6 of 6