Health inspection·April 2, 2024

F 0637 Assess the resident when there is a significant change in condition 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 a significant change assessment was completed for one of four residents reviewed (Resident 8). Residents Affected - Few Findings include: A review of Resident 8's clinical record on April 1, 2024, revealed diagnoses that included Paraplegia (the inability to voluntarily move the lower parts of the body) and Atrial Fibrillation (irregular and rapid heartbeat). A review of Resident 8's usual weight range prior to January 1, 2024, was documented as 168.3 to 172.0 pounds. A review of the clinical record for Resident 8 on April 1, 2024, revealed Resident 8 had a significant weight loss of 15 % in February 2024. Resident 8's weight on January 1, 2024, was 168.3 pounds, and on February 7, 2024, weighed 143.0 pounds. Resident 8 was diagnosed with a stage 2 pressure ulcer (ulcer involving loss of the top layers of the skin) on February 21, 2024. Resident 8 was weighed again on March 4, 2024, and weighed 134 pounds, an additional 9-pound weight loss. A review of the clinical record on April 1, 2024, revealed no significant change Minimum Data Set (MDS periodic assessment of resident's needs) was ever completed for Resident 8 for weight loss and development of the pressure ulcer. Written correspondence from the facility on April 2, 2024, at 10:55 AM, stated that the facility decided on February 20, 2024, they would continue to monitor, implement interventions, and hold off on developing a significant change assessment. During an interview with the Director of Nursing (DON) on April 2, 2024, at 1:30 PM, the DON confirmed that a significant change assessment should have been completed on Resident 8 for weight loss and development of the stage 2 pressure ulcer. 28 Pa. Code 211.12(d)(3)(5) Nursing services Page 1 of 6 395613 395613 04/02/2024 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on staff interview, policy review, and facility investigation, it was determined that the facility failed to prevent potential accidents/hazards for controlled substances for one nursing unit (B Wing) and a wandering resident (Resident 11). Findings include: A review of the facility policy, titled Controlled Substances, last revised April 2019, Line 4, stated, Access to controlled medications remains locked at all times; and Line 12, C. stated, Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing immediately. A review of the event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse) delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets, 15 milligrams each tablet, of morphine (a non-synthetic narcotic with a high potential abuse and is derived from opium and is used for the treatment of pain). The delivery of the medication occurred on March 24, 2024, at approximately 7:30 PM. Based on Employee 2's statement, the medication bag was placed on the medication cart pole because Employee 2 had to respond to resident wanting to return to bed. Employee 2 stated that, during the shift, she had forgotten the medication was not secured until she saw the pink slip that was delivered with the medication laying on top of her medication cart. Just prior to the end of her shift on March 25, 2024, at 6:00 AM, Employee 2 reached for the medication bag, but the card of morphine was not in the bag. Employee 2 reported to Employee 3 on March 25, 2024, at 6:00 AM, that the morphine card was missing and Employee 3 stated she informed Employee 2 she will have to let the Supervisor know. Employee continued to look for the medications. On March 25, 2024, at 6:35 PM, the Director of Nursing (DON) was notified that the morphine was missing. The DON informed the staff that she would be there in 20 minutes, and also informed the staff to check the rooms of the residents that wander the hall. While the DON was enroute, she received a call from the staff that the morphine card was found in Resident 11's bottom drawer of her bedside stand. Employee 2 added that eight of the morphine tablets were popped out of the card, and all but one tablet was found in the drawer and on the floor. The DON arrived and continued the search for the final morphine tablet, but it was never found. Resident 11, along with her roommates, were assessed and there was no change in status. Resident 11 had a BIMS (brief interview of mental status) of three, and unable to be interviewed. Resident 10, who resides in the room and had a BIMS of 15, denied seeing Resident 11 with the medication. Resident 14, who resides in the room, had a BIMS of 11 and denied seeing Resident 11 with the 395613 Page 2 of 6 395613 04/02/2024 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0689 medication. Level of Harm - Minimal harm or potential for actual harm Resident 15, who resides in the room, had a BIMS of 5 and not able to be interviewed. The physician was notified. Residents Affected - Few Employee 2's employment was officially terminated on March 26, 2024, for gross negligence in failing to secure the narcotics upon arrival to the unit. All licensed staff were re-educated on securing controlled substances at all times. During an interview with the DON on April 2, 2024, the DON confirmed that the policy for securement of controlled substances was not followed and that notification to the DON was not timely. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395613 Page 3 of 6 395613 04/02/2024 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policy, facility investigation, and staff interview, it was determined that the facility failed to follow procedures to secure controlled medications on one of five nursing units (B Wing). Residents Affected - Few Finding include: A review of the facility policy on April 2, 2024, titled, Controlled Substances, last revised April 2019, stated that any discrepancies in the controlled substance count are documented and reported to the director of nursing (DON) services immediately; controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications; and the DON services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. A review of the facility's event investigation dated March 25, 2024, revealed that Employee 1 (Licensed Practical Nurse) was delivered and reconciled with Employee 2 (Licensed Practical Nurse) a card containing 30 tablets with 15 milligrams each of morphine (a non-synthetic narcotic with a high potential abuse and is derived from opium and is used for the treatment of pain). The delivery of the medication occurred on March 24, 2024, at approximately 7:30 PM. A review of the written statement by Employee 2 revealed that the morphine was never secured per the facility policy. Employee 2 stated that she hung the medication on the pole of the medication cart, and then realized it at the end of the shift the card of morphine was missing. The card of morphine was found approximately 10 hours later in the bottom drawer of Resident 11's bedside stand, who frequently wanders on the unit. Eight of the pills were popped out of the card, and all but one of the pills were found. Resident 11 and her roommates were assessed and no change in status was identified. The physician and pharmacy were notified. Employee 2's employment was terminated on March 26, 2024, for failing to follow policy and failure to secure the morphine upon arrival. All licensed staff were reeducated on the immediate securement of controlled substances, always maintain securement, and to report discrepancies immediately per policy. During an interview with the DON on April 2, 2024, she confirmed that controlled substance should always be secured immediately upon arrival to the nursing units, and that what Employee 2 did was gross negligence and required immediate termination. 28 Pa. Code 211.19(a)(1)Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services 395613 Page 4 of 6 395613 04/02/2024 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review, staff interviews, and policy review, the facility failed to assist the resident in obtaining and emergency dental services for one of 15 residents reviewed (Resident 13). Residents Affected - Some Findings include: Review of the facility's policy, titled Emergency Dental Care, last reviewed April 2007, stated emergency dental care is available on a 24 hour basis. Emergency dental services include services to treat broken, or otherwise damaged teeth. Review of Resident 13's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and dysphagia (difficulty swallowing). Resident 13 was admitted to the facility on [DATE], and discharged to home on February 8, 2024. A review of the closed clinical record nursing note dated September 22, 2023, statesd, lower dentures broken. Resident stated last night staff was cleaning them and accidentally dropped dentures on to the floor causing them to break in half. Call out to RR [Resident Representative] for update. No issues noted with meal this AM. MD made aware. A review of the nutrition note dated October 26, 2023, stated resident has broken bottom dentures and is requesting pureed textures for now from regular textures. Nursing will follow-up to get dentures fixed. No additional progress notes were identified regarding the broken dentures. A review of Resident 13's physician orders during his stay failed to reveal any dental visits for replacement of the dentures. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 1, 2024, they confirmed that the dentures were accidently broken by staff. They also confirmed that Resident 13 was sent to the dentist on December 18, 2023, for a final denture fitting and minor adjustment. The dental practice informed the facility at that time that the dentures are ready for pick-up upon final payment. A review of correspondence dated March 30, 2024, from the dental practice revealed that Resident 13 has been calling the office everyday asking why he has not received his dentures. The dental practice also notified the facility regarding the non-payment and informed the facility they are going to report the concern to the Department of Health. The dental practice stated the dentures were broken on December 13, 2023, but the DON confirmed that the dentures were broken on September 22, 2023. During an interview with the DON on April 2, 2024, the DON provided the correspondence sent by the NHA to the facility's corporate office. It was confirmed that the corporate office has not paid the bill to the dental practice as of April 2, 2024. It was also confirmed that correspondence to corporate by the NHA has been ongoing since the dentures have been ready for pick-up on December 18, 2023. 395613 Page 5 of 6 395613 04/02/2024 Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201

F 0790 During an interview with the DON on April 2, 2024, the DON confirmed that Resident 13's dentures should have been received immediately after his visit and final adjustment. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(g)Responsibility of licensee Residents Affected - Some 28 Pa. Code 211.10(c)Resident care policies 395613 Page 6 of 6