Health inspection·August 31, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and documents, and staff interviews it was determined that the facility failed to maintain a clean, homelike environment for two resident rooms (rooms [ROOM NUMBERS]). Findings include: Review of a facility policy entitled Cleaning and Disinfecting Residents' Rooms dated 4/28/23, indicated that floors will be cleaned on a regular basis, when spills occur, and when visibly dirty, and that window curtains will be cleaned when these surfaces are visibly contaminated or soiled. Review of three months of Resident Council Meeting notes revealed: 6/13/23, two of nine residents in attendance confirmed that their rooms were not being cleaned daily. 7/11/23, four of eight residents in attendance confirmed that their rooms were not being cleaned daily, and eight of eight residents confirmed that their curtains were dirty. Observation of room [ROOM NUMBER] on 8/28/23 at 12:40 p.m. revealed items on the floor between the beds that included two clear plastic lids with straws, a greeting card, pepper packet, tissue, a French fry, a sock and plastic tabs from an incontinence product under one of the beds. Observations of room [ROOM NUMBER] on 8/29/23, at 11:18 a.m. and 8/30/23, at 11:48 a.m. revealed one clear plastic lid with a straw on the floor in the same location between the beds, the sock and incontinence product plastic tabs remained under the bed. Observations of room [ROOM NUMBER] on 8/29/23, at 9:35 a.m. and 8/30/23, at 11:44 a.m. revealed several areas of brown substance/stain on the privacy curtain that separated the beds in the room. During an interview on 8/31/23, at 9:40 a.m. Housekeeping Director confirmed room [ROOM NUMBER] was not cleaned under the bed properly and that the above items were under resident's bed and should have been captured with cleaning; that the privacy curtain in room [ROOM NUMBER] was soiled and should have been replaced; and that when staff are performing daily cleaning, the privacy curtain should be checked for cleanliness. During an interview on 8/31/23, at 9:54 a.m. the Nursing Home Administrator confirmed that the rooms should be cleaned daily to prevent items being left under the beds and on the floors, and that the Page 1 of 6 395607 395607 08/31/2023 Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254

F 0584 soiled privacy curtain should have been changed out. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 5(e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 395607 Page 2 of 6 395607 08/31/2023 Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for unauthorized access of treatments on one of five medication carts (A/B Cart). Findings include: Review of a facility policy entitled, Specific Medication Administration Procedures dated 4/28/23, indicated that medication carts are to be locked at all times unless in use and under direct observation of the nurse. Observation on 8/30/23, between 9:10 a.m. and 9:35 a.m. revealed that Registered Nurse (RN) Employee E1 prepared medications from the A/B cart parked in the hall across from room [ROOM NUMBER] and proceeded into room [ROOM NUMBER] to administer medications to a resident lying in bed near the window on the far side of the room, pulled the privacy curtain between the beds (blocking the view from the hallway) and did not securely lock the A/B cart which was left out of sight of RN Employee E1. During an interview at that time RN Employee E1 confirmed that he/she should have locked the cart before going into the resident room. During an interview on 8/30/23, at 10:08 a.m. the Director of Nursing confirmed that medication carts are to be secured when not in use and out of direct sight of staff. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395607 Page 3 of 6 395607 08/31/2023 Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of clinical records and facility documents, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident's food preferences were honored for one of eight residents reviewed (Resident R63). Findings include: Review of Resident R63's clinical record revealed an admission date of 4/28/23, with diagnoses that included Type 2 Diabetes Mellitus (a condition caused by a problem in the way the body regulates and uses sugar as energy), Chronic Obstructive Pulmonary Disease (COPD, a long-term condition in which a person experiences increasing breathlessness and cough caused by deteriorating air passages in the lung.), generalized anxiety disorder, (a condition where a person experiences excessive, ongoing nervousness and worry that are difficult to control and interfere with day-to-day activities.), and affective mood disorder (a mental mood disorder that affects a person's emotional state and normal activities). Review of Resident R63's care plan entitled, Nutritional Status dated 4/30/23, included a planned Intervention/Task entitled, Honor Food Preferences. Review of a facility document, provided on 8/30/23, revealed Resident R63's Food Dislikes included green beans, s. tomatoes, spinach, peas, and no sauce. During interviews on 8/28/23, 8/29/23 and 8/30/23, Resident R63 confirmed that he/she is served foods that he/she does not like, and that he/she has told the facility many times of his/her food dislikes but continues to receive these disliked items on his/her meal trays, and he/she loves spinach and hates peas! Observation on 8/30/23, at 12:15 p.m. revealed Resident R63's meal tray ticket included that spinach was to be served, and his/her dislikes included no stewed tomatoes, spinach, peas, green beans, and spaghetti sauce. Observation of the lunch meal tray included peas on his/her plate. During an interview on 8/30/23, at the time of the observation the Director of Nursing confirmed Resident R63 had peas served on his/her lunch plate, and that his/her meal ticket contained peas as a disliked food and that peas should not have been on the resident's tray. 28 Pa. Code 201.18(b)(1)(2) Management 395607 Page 4 of 6 395607 08/31/2023 Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254

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 review of a facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in three of three unit refrigerators reviewed (Unit A, Unit B, Dementia Unit). Findings include: Review of facility policy entitled Food Receiving and Storage dated 4/28/23, indicated that open containers are labeled, dated and toxic substances will be stored in separate storage areas from food. Review of facility policy entitled Refrigerators and Freezers dated 4/28/23, indicated that refrigerators and freezers are kept clean and free of debris. Observation on 8/30/23, at 10:45 a.m. revealed a refrigerator in the pantry on Unit A had two foam cups which contained a pudding like substance inside with no labels or dates. The shelves and the door of the refrigerator had a yellow dry substance stuck to them. A plastic container that contained nutritious snacks for residents had a black dry substance on the handles and running down the sides of the plastic container. Additionally, there was a plastic cooler that the facility holds ice in for residents' water that had a dry brown liquid substance on the lid and down the sides. During an interview at the time of observation with the Assistant Director of Nursing (ADON) he/she confirmed that items in the refrigerator should be labeled and dated and that the refrigerator, plastic container containing nutritious snacks, and cooler for ice should be clean. Observation on 8/30/23, at 10:50 a.m. revealed a refrigerator in the pantry on Unit B had one foam cup which contained a pudding like substance inside with no date. The shelves and the door of the refrigerator had yellow and red dry crusty substances stuck to them. Additionally, there was a plastic container that contained nutritious snacks for residents with a black dry substance on the handles and running down the sides of the plastic container. During an interview at the time of observation with the ADON, he/she confirmed that items in the refrigerator should be labeled and dated and that the refrigerator and plastic container containing nutritious snacks should be clean. Observation on 8/30/23, at 10:55 a.m. revealed a refrigerator and freezer on the Dementia Unit with a bottle of salad dressing that was open with no name or date. The refrigerator had a crusty dry white substance on the shelves. The freezer contained ice packs that were used for treatments on residents along with ice cream being stored together. During an interview at the time of observation with the ADON, he/she confirmed that the ice packs were used on resident's bodies and should not be stored in the resident freezer, the salad dressing should have a name and date on it, and that the refrigerator should be clean. 28 Pa. Code 201.14(a) Responsibility of licensee 395607 Page 5 of 6 395607 08/31/2023 Shippenville Nursing and Rehab 21158 Paint Boulevard Shippenville, PA 16254

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain effective infection control during the administration of resident medications for three of five residents observed. Residents Affected - Some Findings include: Review of a facility policy entitled, Specific Medication Administration Procedures dated 4/28/23, indicated that staff are expected to wear gloves if handling medications. Observation on 8/30/23, between 8:40 a.m. and 9:35 a.m. of medication administration revealed Registered Nurse (RN) Employee E1 prepared oral (by mouth) medications and touched individual resident medications with his/her bare hands prior to administering the medications to three of five residents. During an interview at that time RN Employee E1 confirmed that he/she should not handle resident medications with his/her bare hands prior to administration. During an interview on 8/30/23, at 10:08 a.m. the Director of Nursing confirmed that staff are encouraged not to handle medications with their hands, and should wear gloves. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 28 Pa. Code 201.18(b)(1)(3) Management 395607 Page 6 of 6