Health inspection·January 30, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents (Residents R1, R18, R27, and R32). Findings include: Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/24, indicated diagnoses of hemiplegia, affecting right side (medical condition that causes paralysis or weakness on one side of the body), diabetes mellitus, and hypertension. Review of Resident R1's clinical record revealed that the resident was transferred to the hospital on 8/27/24. Review of Resident R1's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 8/27/24. Review of the clinical record revealed Resident R18 was admitted to the facility on [DATE]. Review of Resident R18's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and retention of urine. Review of Resident R18's clinical record revealed that the resident was transferred to the hospital on [DATE]. Review of Resident R18's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 10/8/24. Review of the clinical record revealed Resident R27 was admitted to the facility on [DATE]. Review of Resident R27's MDS dated [DATE], indicated diagnoses of congestive heart failure, respiratory failure with hypoxia and diabetes mellitus. Page 1 of 21 395605 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R27's clinical record revealed that the resident was transferred to the hospital on 9/1/24. Review of Resident R27's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 9/1/24. Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's MDS dated [DATE]/25, indicated diagnoses of high blood pressure, hyponatremia (too little sodium in the blood), and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of Resident R32's clinical record revealed that the resident was transferred to the hospital on 1/16/25. Review of Resident R32's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 1/16/25. During an interview on 1/29/25, at 10:30 a.m. Secretary Employee E3 confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four of four residents as required. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights. 395605 Page 2 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review and staff interviews it was determined that the facility failed to follow physician orders for one of seven residents (Resident R23) and failed to provide appropriate treatment and care by failing to ensure timely notification to the physician of significant weight loss and failing to implement physician orders in a timely manner for one of seven residents (Resident R36). Residents Affected - Few Findings include: Review of facility policy Physician Notification dated 5/23/24, indicated attending physicians will be notified of changes in resident conditions, incidents involving resident injury, or have the potential for needing physician interventions. Review of facility policy Weight Loss Prevention dated 5/23/24, indicated to update MD (physician) and obtain orders as needed. 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 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE §483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record indicated that Resident R23 was admitted to the facility on [DATE], with diagnosis that included congestive heart failure, cerebral palsy (group of disorders that affect movement, muscle tone, and posture due to damage or abnormal development of the brain during or shortly after birth) and asthma. Review of Resident R23's physician orders dated 7/19/24, indicated that Resident R23 was ordered Empagliflozin Oral Tablet 10 MG (milligrams) 1 tablet by mouth. Review of Resident R23's MAR (medical administration record), the following was not administered: Empagliflozin 1/20/25, 1/19/25, 12/21/24, 12/7/24, 12/6/24. Review of Resident R23's clinical nurse notes indicated medications awaiting med to be delivered from pharmacy and resident R23 did not receive on 1/20/25, 1/19/25, 12/21/24, 12/7/24, 12/6/24. 395605 Page 3 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/30/25, at 11:00 a.m. the Director of Nursing confirmed that resident did not receive the medication on the above days and the physician was not notified. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record indicated that the physician was not made aware of Resident R36's 9.12% weight loss until 11/1/24. Review of Daily Progress note dated 11/1/24, indicated Resident R36 experiences frequent increased stomach residual necessitating need to hold/stop feeding and had significant weight loss noted in 30-day period 119.5 to 108.6. The physician documented, Weight loss noted - needs full nutritional assessment and perhaps a change in substrate (tube feeding formula). Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. 395605 Page 4 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0684 Review of the above order indicates this is a decrease in amount of formula to be administered. Level of Harm - Minimal harm or potential for actual harm Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Residents Affected - Few Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. During an interview on 1/29/25, at 1:45 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 stated, I caught the weight loss in October when I was filling out that portion of the MDS. Usually, the Registered Dietitian would be who catches weight loss and makes recommendations. I round with the physician and made him aware of the weight loss on November 1st and the physician gave a verbal order to change her tube feeding formula. It wasn't changed to a different formula until December 12th because we had to use up her current tube feeding supply, we can't return anything. During an interview on 1/29/25, at 1:45 p.m. LPNAC Employee E4 confirmed that the facility failed to provide appropriate treatment and care by failing to ensure timely notification to the physician of significant weight loss and failing to implement physician orders in a timely manner as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 395605 Page 5 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0692 Provide enough food/fluids to maintain a resident's health. 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 policies, clinical records, and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner for one of three residents (Resident R36) and the facility failed to complete initial nutrition assessments for two to seven residents (Resident R29, R49). Residents Affected - Some Findings include: Review of facility policy Weight Loss Prevention dated 5/23/24, indicated Dietitian or Dietitian Tech to evaluate and make recommendations as indicated. Update MD (physician) and obtain orders as needed. 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 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE §483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. 395605 Page 6 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0692 Review of the above order indicates this is a decrease in amount of formula to be administered. Level of Harm - Minimal harm or potential for actual harm Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Residents Affected - Some Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of a Weight Change Note dated 8/13/24, completed by Registered Dietitian (RD) Employee E1 stated, Review of monthly weight status. Per weight 8/1 120# (pounds), resident with trigger for significant weight loss for 6 months (133.5#, -10.1%). Weight stable past 3 months 116-121#. Continue current TF (tube feeding) as ordered/resident tolerates. Continue to monitor weight status for significant change. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in September 2024, October 2024, November 2024, and December 2024. The review of the clinical record failed to reveal any documentation regarding the above weight changes or any nutritional recommendations. During an interview on 1/29/25, at 9:32 a.m. RD Employee E1 stated, I was not employed at the facility between 8/20/24 and 11/6/24. I can't speak exactly to Resident R36's weight loss in September. I was notified through email communication at the beginning of November. My recommendation was to increase her tube feeding rate, but her husband dictates most of her care and had no desire to increase the tube feeding rate. When asked if it is documented in Resident R36's clinical record that her husband refused to have nutritional recommendations implemented, RD Employee E1 stated, Nobody would dare put that in. Review of the clinical record revealed Resident R29 was admitted to the facility on [DATE]. 395605 Page 7 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of fracture of right femur, orthopedic aftercare and atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly). Review of Resident R29's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in October 2024, November 2024, and December 2024. Review of the clinical record revealed Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/10/24, indicated diagnoses of asthma, nonrheumatic aortic stenosis (a narrowing of the aortic valve that occurs when it doesn't open or close properly) and syncope (a sudden and brief loss of consciousness that is caused by a temporary decrease in blood flow to the brain). Review of Resident R49's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in October 2024, November 2024, and December 2024. During an interview on 1/29/25, at 9:44 a.m. RD Employee E1 confirmed that the facility failed to make certain that weight loss was identified and addressed in a timely manner for Resident R36 and the facility failed to assess two residents on admission as required (Resident R29, and R49). 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395605 Page 8 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services for one of four residents (Resident R36). Findings include: Review of facility policy Enteral Therapy dated 5/23/24, indicated the dietitian will assess the resident's nutritional needs and provide consultation to the MD (physician) as indicated. Review of facility policy Weight Loss Prevention dated 5/23/24, indicated Dietitian or Dietitian Tech to evaluate and make recommendations as indicated. Update MD (physician) and obtain orders as needed. 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 2024, indicated the following instructions: - Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days GUIDANCE §483.25(g) Significant weight loss is defined as: 5% or greater in one month 7.5% or greater in three months 10% or greater in six months Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Resident R36's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen. Review of a physician order dated 7/31/24, and discontinued on 9/21/24, indicated to administer Osmolite 1.5 (a type of tube feeding formula) via G-tube (a surgically inserted tube into the stomach to provide nutrition) at 45 cc/hour (milliliters per hour); hold tube feeding daily from 12 a.m. to 4 a.m. 395605 Page 9 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician order dated 9/21/24, and discontinued on 12/13/24, indicated to administer Osmolite 1.5 via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of the above order indicates this is a decrease in amount of formula to be administered. Review of Resident R36's clinical record failed to include documentation to support the change in the tube feeding order. Review of a physician order dated 12/12/24, indicated to administer Nutren 2.0 (a type of tube feeding formula) via G-tube at 40cc/hour; hold tube feeding daily from 12 a.m. to 4 a.m. Review of a Weight Change Note dated 8/13/24, completed by Registered Dietitian (RD) Employee E1 stated, Review of monthly weight status. Per weight 8/1 120# (pounds), resident with trigger for significant weight loss for 6 months (133.5#, -10.1%). Weight stable past 3 months 116-121#. Continue current TF (tube feeding) as ordered/resident tolerates. Continue to monitor weight status for significant change. Review of Resident R36's Weight Summary revealed the following documented weights: - 9/2/24: 119.5 lbs (pounds) - 9/30/24 = 108.6 lbs, a loss of 9.12% in one month - 10/1/24 = 108.6 lbs - 10/14/24 = 108 lbs - 11/3/24 = 107.8 lbs - 11/12/24 = 105.9 lbs - 11/25/24 = 107.5 lbs - 12/2/24 = 105.1 lbs - 12/9/24 = 101.5 lbs, a loss of 15% in three months Review of Resident R36's clinical record failed to include documentation that indicated the resident was assessed by the Registered Dietitian in September 2024, October 2024, November 2024, and December 2024. The review of the clinical record failed to reveal any documentation regarding the above weight changes or any nutritional recommendations. During an interview on 1/29/25, at 9:32 a.m. RD Employee E1 stated, I was not employed at the facility between 8/20/24 and 11/6/24. I can't speak exactly to Resident R36's weight loss in September. I was notified through email communication at the beginning of November. My recommendation was to increase her tube feeding rate, but her husband dictates most of her care and had no desire to increase the tube feeding rate. When asked if it is documented in Resident R36's clinical record that her husband refused to have nutritional recommendations implemented, RD Employee E1 stated, Nobody would dare put that in. 395605 Page 10 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R36's clinical record indicated that the physician was not made aware of Resident R36's 9.12% weight loss until 11/1/24. Review of Daily Progress note dated 11/1/24, indicated Resident R36 experiences frequent increased stomach residual necessitating need to hold/stop feeding and had significant weight loss noted in 30-day period 119.5 to 108.6. The physician documented, Weight loss noted - needs full nutritional assessment and perhaps a change in substrate (tube feeding formula). During an interview on 1/29/25, at 1:45 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E4 stated, I caught the weight loss in October when I was filling out that portion of the MDS. Usually, the Registered Dietitian would be who catches weight loss and makes recommendations. I round with the physician and made him aware of the weight loss on November 1st and the physician gave a verbal order to change her tube feeding formula. It wasn't changed to a different formula until December 12th because we had to use up her current tube feeding supply, we can't return anything. During an interview on 1/29/25, at 1:45 p.m. LPNAC Employee E4 confirmed that the facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services as required. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1) Nursing services. 395605 Page 11 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R32 and R36). Residents Affected - Few Findings include: Review of the clinical record revealed Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/1/4/25, indicated diagnoses of high blood pressure, hyponatremia (too little sodium in the blood), and respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). Review of a physician order dated 1/21/25, indicated to provide oxygen at 1 - 2 liters per minute (LPM) via nasal cannula (a lightweight tube that delivers oxygen into the nostrils) continuously. During an observation on 1/27/25, at 11:57 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During an observation on 1/28/25, at 8:57 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During an observation on 1/29/25, at 10:08 a.m. Resident R32 was observed receiving oxygen at 3 LPM via nasal cannula. During this observation, Registered Nurse (RN) Employee E2 confirmed that Resident R32 was receiving oxygen at 3 LPM via nasal cannula. During an interview on 1/29/25, at 10:08 a.m. RN Employee E2 confirmed that the facility failed to provide appropriate respiratory care for Resident R32. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 10/5/24, indicated to administer Ipratropium-Albuterol 0.5-2.5 mg/mL (milligrams per milliliter) inhale orally every 4 hours as needed for congestion. Review of Resident R36's January Medication Administration Record indicated the resident received Ipratropium-Albuterol on 1/4/25, 1/12/25, 1/13/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/24/25, and 1/25/25. During an observation on 1/27/25, at 9:50 a.m. a nebulizer machine (a machine used to deliver aerosolized medications) was observed on Resident R36's bedside table with the attached tubing and aerosolized face mask in a bag in the drawer. Review of Resident R36's physician orders on 1/29/25, failed to include an order to change the nebulizer tubing and aerosolized face mask. 395605 Page 12 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R36's care plan on 1/29/25, failed to include goals and interventions related to the maintenance of equipment for respiratory care and failed to include interventions for procedures to follow in the event of an adverse reaction to respiratory treatments. During an interview on 1/29/25, at 10:10 a.m. Registered Nurse (RN) Employee E2 stated, I don't think there is an order to change the nebulizer tubing, I just know they do it at night on Thursday or Fridays. During an interview on 1/29/25, at 11:16 a.m. the Director of Nursing (DON) stated, Nebulizer tubing is changed Thursday into Friday on the 11 p.m. to 7 a.m. shift, it's changed with the oxygen tubing, that's just how we do it. When asked how would a new employee or agency employee know when to change the nebulizer tubing, the DON stated, It's part of orientation and onboarding, it would be discussed then. During this interview, the DON confirmed that Resident R36 did not have a physician order to change nebulizer tubing and did not have a care plan developed for the administration of aerosolized medications. During an interview on 1/30/25, at 10:01 a.m. the DON was asked to provide the facility's policies and procedures for respiratory care and aerosolized medication therapy. During an interview on 1/30/25, at 10:54 a.m. the DON stated that the facility does not have policies related to respiratory care and aerosolized medication therapy. During an interview on 1/30/25, at 10:54 a.m. the DON confirmed that the facility failed to provide appropriate respiratory care for Resident R36. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.11 (a)(c)(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. 395605 Page 13 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0760 Ensure that residents are free from significant medication errors. 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 record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R50). Residents Affected - Few Findings include: Review of the facility policy Medication Administration) dated 5/23/24 indicated medications and biologicals shall be administered by the same licensed nurse who prepared the dose for administration and will give as soon as possible after being prepared. Review of the clinical record indicated that Resident R50 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly), hypertension and macular degeneration (common eye disease that damages the macula, the central part of the retina responsible for sharp, central vision). Review of Resident R50's physician orders dated 11/23/24 indicated Synthroid (to treat hypothyroidism) Oral Tablet 50 MCG (Levothyroxine Sodium) 1 tablet orally once a day. Review of Resident R50's Medication Administration Record (MAR) indicated that 12/29/24, 12/30/24, 1/21/25 and 1/27/25, staff had documented that the drug was unavailable and not given. Resident R50 had not received the medication for four days. During an interview on 1/30/25, at approximately 11:00 a.m., the Director of Nursing confirmed that the facility failed to make certain significant medications are administered as ordered by the physician. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28Pa. Code:211.9(e)(f)(g)(h) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 395605 Page 14 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews it was determined that the facility failed to employ a qualified Registered Dietitian for one of twelve months (October 2024). Residents Affected - Few Findings include: During an interview with Registered Dietitian Employee E1 revealed she was employed 6/29/21-8/20/24 and didn't start PRN again till 11/6/24. Interview with Nursing Home Administrator on 1/29/25 at 11:00 a.m. indicated the facility had a Registered Dietitian 9/5/24-10/4/24. During an interview on 1/29/25 at 9:00 a.m. the Nursing Home Administrator confirmed that the facility did not employ a qualified Registered Dietitian for one of twelve months as required. 28 Pa. Code 201. 18(e)(1)(6)Management. 28 Pa. Code 211. 6(c) Dietary service. 395605 Page 15 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, documentation review, review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (February 2024 through January 2025) and failed to implement transmission-based precautions for one of four residents (Resident R36). Residents Affected - Few Findings include: Review of the facility policy Legionella Prevention dated 5/23/24, indicated the facility will utilize water management practices to reduce the risk of Legionella in the ice machines by cleaning quarterly, sanitizing, and checking monthly for cleanliness. The policy fails to mention how to prevent Legionella and other microbial growth throughout the facility. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7. Documentation and communication. memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system. -Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. 395605 Page 16 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. -Maintains compliance with other applicable Federal, State and local requirements. Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million). Review of facility policy Contact Precautions dated 5/23/24, indicated contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident's environment. Review of facility policy Enhanced Barrier Precautions dated 5/23/24, indicated the facility will adhere to the CDC guideline recommendations for use of Enhanced Barrier Precautions (EBP) when providing care to residents identified as at risk for multi-drug resistant organisms (MDRO) or to those residents identified as having a MDRO infection. The CDC defines Enhanced Barrier Precautions as: an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and gloves during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Review of the facility provided water management information failed to include specific testing protocols and acceptable ranges for control measures along with a description of the facility's water system using a flow diagram. Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. During an interview on 1/28/25, at approximately 11:30 a.m. the Nursing Home Administrator and Maintenance Supervisor Employee E15 confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility. Review of the clinical record revealed Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/25, indicated diagnoses of anemia (too little iron in the body), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and hyperlipidemia (high levels of fat in the blood). Review of Section H - Bowel and Bladder, Question H0100 indicated the resident has an indwelling catheter. Section K - Swallowing/Nutritional Status, Question K05520B indicated the resident has a feeding tube. Review of Section M - Skin Conditions, Question M0300 indicated the resident has 2 Stage 4 pressure ulcers and 1 unstageable pressure ulcer. 395605 Page 17 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a nursing progress note dated 10/10/24, stated, New orders obtained for treatment of Shingles, husband updated. Review of Resident R36's clinical record failed to reveal documentation that the resident was placed in transmission-based precautions for Shingles on 10/10/24, and failed to reveal documentation that EBP were implemented related to Resident R36's wounds and indwelling medical devices. During an interview on 1/29/25, at 10:10 a.m. Registered Nurse (RN) Employee E2 stated, I'm not sure if isolation precautions are in the physician orders or resident care plans, usually I find out by word of mouth. During an interview on 1/29/25, at 11:23 a.m. Infection Preventionist Employee E4 stated, We placed in her Contact Precautions when she had shingles. We don't write orders for isolation precautions; we update the resident care plans to reflect any isolation precautions. During an interview on 1/29/25, at 12:11 p.m. Infection Preventionist Employee E4 confirmed there was no documentation in Resident R36's plan of care to reflect being placed in Contact Precautions for shingles and there was no documentation to implement EBP related to the resident's wounds and indwelling medical devices. During an interview on 1/29/25, at 12:11 p.m. Infection Preventionist Employee E4 confirmed that the facility failed to implement transmission-based precautions as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 395605 Page 18 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on review of facility policy, facility personnel/in-service training records, and staff interview, it was determined that the facility failed to provide training on resident protection from abuse and neglect for one of seven staff members (Employee E8). Findings include: Review of the facility policy Facility Assessment: Staff Training and Competencies dated 5/23/24, indicated that all new staff are trained during the orientation process on designated facility topics. A checklist is completed both on theory and skills material. A checklist is completed again annually on both theory and skills material. Review of the facility policy Prohibition and Prevention of resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property dated 5/23/24, indicated that all employees receive abuse training during general orientation and annually in conjunction with scheduled on-going training. Review of facility provided documents and training records revealed the following staff member did not have documented training on abuse and neglect. Nurse Aide (NA) Employee E8 had a hire date of 4/27/17, failed to have abuse and neglect prevention in-service education between 4/27/23, and 4/27/24. During an interview on 1/29/25, at 2:15 p.m. the Staff Development Coordinator Employee E14 confirmed that the facility failed to provide training on resident protection from abuse and neglect for one of seven staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395605 Page 19 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on review of facility documents, employee education records, and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of seven staff members (Employee E7, E8, E9, E11, and E12) Findings include: Review of the facility policy Facility Assessment: Staff Training and Competencies dated 5/23/24, indicated that all new staff are trained during the orientation process on designated facility topics. A checklist is completed both on theory and skills material. A checklist is completed again annually on both theory and skills material. Review of facility provided documents and training records revealed the following staff members did not have documented training. Nurse Aide (NA) Employee E7 had a hire date of 3/12/20, failed to have QAPI education between 3/12/23, and 3/12/24. NA Employee E8 had a hire date of 4/27/17, failed to have QAPI education between 4/27/23, and 4/27/24. NA Employee E9 had a hire date of 10/23/20, failed to have QAPI education between 10/23/23, and 10/23/24. NA Employee E11 had a hire date of 11/20/22, failed to have QAPI education between 11/20/23, and 11/20/24. Registered Nurse Employee E12 had a hire date of 7/12/16, failed to have QAPI education between 7/12/23, and 7/12/24. During an interview on 1/29/25, at 2:15 p.m. the Staff Development Coordinator Employee E14 confirmed that the facility failed to provide training on QAPI for five of seven staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395605 Page 20 of 21 395605 01/30/2025 St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of facility documents, employee education records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year as required for two out of five Nurse Aide (NA) Employees (Employee E7, and E8) Findings include: Review of the facility policy Facility Assessment: Staff Training and Competencies dated 5/23/24, indicated that all new staff are trained during the orientation process on designated facility topics. A checklist is completed both on theory and skills material. A checklist is completed again annually on both theory and skills material. Review of facility provided documents and training records revealed the following staff members did not have documented training. NA Employee E7 had a hire date of 3/12/20, facility provided information indicated that she had received 8.5 hours of in-services between 3/12/23, and 3/12/24 and did not meet the required 12 hours of in-servicing NA Employee E8 had a hire date of 4/27/17, facility provided information indicated that she had received 5.25 hours of in-services between 4/28/23, and 4/27/24, and did not meet the required 12 hours of in-servicing During an interview on 1/29/25, at 2:15 p.m. the Staff Development Coordinator Employee E14 confirmed that the facility failed to ensure that all NA received a minimum of 12 hours of in-service education training each year as required for two of five NA. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development. 395605 Page 21 of 21