Health inspection·August 23, 2023

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on clinical record review, staff interview, and review of dietary purchase orders and invoices, it was determined that the facility failed to ensure effective management and execution of the duties and responsibilities of the facility's food and nutrition department to provide enough food in accordance with physician ordered dietary needs for one of six residents reviewed (Resident 3). Findings include: Review of Resident 3's clinical record revealed a physician's order dated March 14, 2023, for the facility to provide her with a gluten free diet. Interview with Employee 2, licensed practical nurse, on August 23, 2023, at 9:15 AM revealed that Resident 3 did not get the breakfast she usually gets every morning. Employee 2 indicated she usually gets two pieces of gluten free toast every morning but stated that the kitchen ran out of the gluten free bread. Interview with Employee 3, dietary manager, on August 23, 2023, at 11:30 AM revealed that the facility ran out of Resident 2's bread starting on August 21, 2023, and that dietary staff did not inform her that the gluten free bread was gone. Employee 3 also indicated that she placed an order to get more of the gluten free bread on August 9, 2023, but that it did not arrive in the August 14, 2023 delivery. Employee 3 indicated that she was not aware that the gluten free bread was not included in the delivery until the surveyor questioned the supply of the bread on August 23, 2023. Review of the facility's purchase order dated August 9, 2023, and invoices dated August 14, 2023, confirmed the above findings and information from Employee 3. Interview with Employee 3 on August 23, 2023, at 10:43 AM revealed that the facility has a food budget of $6.80 per patient day. Employee 3 indicated that the food budget also included paper products and any chemical products that she had to order. Employee 3 indicated that her orders go in on Mondays, that she is not able to order extra, and can only order according to the current census. Further interview with Employee 3 on August 23, 2023, at 11:25 AM revealed that if she orders on a Monday for a census of 127 residents, and if the facility received admissions in the next week, there was a chance the facility would not have enough food to provide meals for the new admissions with the current menu choices. The facility failed to ensure that the dietary department was effectively managed to ensure the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395616 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)