Health inspection·November 3, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for one of 28 residents reviewed (Resident 62). Residents Affected - Few Findings include: Interview and observation with Resident 62 on October 31, 2023, at 2:00 PM revealed the resident was sitting in a motorized wheelchair that she can operate on the window side of the bed. The call bell was on the other side of the bed at the head of the bed on the floor. Resident 62 said she would not be able to reach the call bell to pull it off the floor. Resident 62 said that she asked for a clip for the call bell and bed remote as they often fall on the floor. Interview and observation with Resident 62 on November 1, 2023, at 8:43 AM revealed the resident was in bed eating breakfast. The call bell was hanging over the right side of the bedrail out of the resident's reach. Concurrently, the surveyor found Employee 5, nurse aide, in the hallway and informed her the call bell was out of reach. On return to Resident 62's room, the resident showed Employee 5 how she could not reach the call bell. During an interview with the Nursing Home Administrator and Director of Nursing on November 1, 2023, at 2:50 PM the above concerns regarding Resident 62's inability to reach the call bell and lack of clip to prevent the call bell and bed remote from falling on the floor was discussed. 28 Pa. Code 211.12(d)(1)c(2)(3)(5) Nursing services Page 1 of 17 395616 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observations and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable environment on two of four nursing units (Unit 3 and Unit 4; Residents 24, 81, 92, 119, and 124). Findings include: Observation of the Unit 4 Nursing Unit on October 31, 2023, at 12:00 PM and again on November 1, 2023, at 11:44 AM revealed two blue resident chairs in front of the elevators that had various white, dried stains. Observation of Resident 92's sink on November 1, 2023, at 10:47 AM revealed a large eight inch by eight inch damaged area of wall under the sink. The wall directly above the heating / air conditioning unit under the window was damaged and crumbling. Observation of the Unit 4 Nursing Unit shower room on November 1, 2023, at 12:20 PM revealed the following: A shower gurney had a significant accumulation of debris and hair under the white overlying padding. There were also brown colored stains on the blue fabric of the shower gurney underneath the padding. Two Tango shower chairs had a significant accumulation of hair in each wheel of the chairs. There were dried and brown colored stains on the outside of the commode lid. A used razor with noted white debris and cut hairs was on a shelf above the commode. Two folded towels, two washcloths, and a balled up sheet was noted on top of a plastic storage container. The folded towels and washcloths were on top of a large dried white stain that was located on the plastic storage container. There was a used band aid on the floor. The protective wrapping of a shower wand was peeling off the hose at the base of the handheld wand. There were several strands of the wrap that was peeling off and a sharp piece of plastic near the base of the wand. The bottom of a shower curtain had various black colored stains. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on November 1, 2023, at 2:00 PM. Observation of a resident lift in the hallway on November 2, 2023, at 12:19 PM with Employee 4, registered nurse, on November 2, 2023, at 12:19 PM revealed the base of the lift was covered in a brown colored and dried on crusted substance. 395616 Page 2 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The findings for the lift were reviewed in a meeting with the Nursing Home Administrator on November 2, 2023, at 2:30 PM. Observation of the tub room on Unit 3 on October 31, 2023, at 12:40 PM revealed a bottle of baby shampoo, a bottle of skin protectant, a bottle of skin cleanser, and a bottle of lavender hand soap were on the shelf above the sink. There were no names on these items. Concurrent interview with Employee 6, nurse aide, revealed that these items did not belong there, and she discarded them. Employee 6 revealed that currently there are no residents that take a bath; however, some residents use the toilet in this room. In the adjacent shower room, the bucket that sets below a shower chair was on the floor of the shower and it had a dried yellow substance on the bottom of the bucket. A blue chair mat and blue transfer pad was on the floor of the shower room. Employee 6 indicated that someone may have placed them in there to be washed. The wheels of the shower chair had rust stains. The shower curtain had brown stains and a build-up of a white substance in spots on the lower section. Observation of the privacy curtain for Resident 81 on November 1, 2023, at 8:52 AM revealed it had multiple stains of various colors. Observation of the privacy curtain for Resident 119 on November 1, 2023, at 9:25 AM revealed it had multiple stains of various colors. Observation of the floor under Resident 24's bed on November 1, 2023, at 10:02 AM revealed black marks in a diagonal pattern. Observation of the privacy curtain for Resident 124 on November 2, 2023, at 9:34 AM revealed multiple stains of various colors. The findings for the environment for the tub/shower room and Residents 81, 119, 24, and 124 were reviewed with the Nursing Home Administrator on November 2, 2023, at 2:00 PM. 28 Pa. Code 201.18 (b)(1)(3) Management 395616 Page 3 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a restorative range of motion therapy program for five of six residents reviewed (Residents 18, 79, 81, 96, and 107). Findings include: Review of Resident 107's clinical record revealed that she was on occupational therapy caseload from July 22, 2023, until August 6, 2023, at which time Resident 107 was discharged from occupational therapy. Review of the occupational therapy Discharge summary dated [DATE], indicated that the occupational therapy discharge recommendations was to establish a restorative range of motion program by implementing active range of motion to Resident 107's bilateral upper extremities. There was no documented evidence in Resident 107's clinical record to indicate that the recommended occupational therapy restorative program was established. Occupational therapy documentation from September 24, 2023, until October 14, 2023, indicated that Resident 107 was on occupational therapy caseload. Resident 107 was discharged from occupational therapy on October 14, 2023. Review of the occupational therapy Discharge summary dated [DATE], indicated that the occupational therapy discharge recommendations was to establish a restorative ADL (Activities of Daily Living) program by implementing active range of motion to Resident 107's bilateral upper extremities. m There was no documented evidence in Resident 107's clinical record to indicate that the recommended occupational therapy restorative program was established. Interview with Employee 4, registered nurse, on November 2, 2023, at 1:30 PM confirmed the above findings for Resident 107 and indicated that Resident 107's restorative programs for both August and October were never initiated. Clinical record review for Resident 79 revealed a current physician's order for the resident to participate with a restorative nursing program. Review of a physical therapy Discharge summary dated [DATE], indicated that the facility established a restorative ambulation program for Resident 79 for him to ambulate daily with his prosthesis and the use a front wheeled walker with one staff assisting and a wheelchair to follow to maintain functional mobility. Review of Resident 79's task documentation dated April 6, 2023, revealed that staff were to provide restorative AROM (active range of motion) to their bilateral upper extremities (BUE) and the right lower extremity (RLE). Review of task and facility documentation for Resident 79 for August, September, and October 2023, revealed that staff did not document completion of or documented not applicable on the restorative task on the following dates: Ambulation August 30, 2023 September 1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, 23, 24, 25, 26, and 30, 2023 October 1, 2, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 27, and 395616 Page 4 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0688 28, 2023 Level of Harm - Minimal harm or potential for actual harm AROM BUE and RLE August 1, 4, 5, 6, 7, 11, 12, 13, 14, 18, 19, 20, 21, 22, 23, 26, 27, 28, and 30, 2023 Residents Affected - Some September 1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, 23, 24, 25, 26, 29, and 30, 2023 October 1, 2, 4, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 27, 28, and 29, 2023 Clinical record review for Resident 96 revealed a current physician's order for the resident to receive restorative ambulation six times per week. Review of Resident 96's task documentation dated July 14, 2023, revealed that staff are to provide restorative AROM to their BUE and bilateral lower extremities (BLE) five times per week. Review of task and facility documentation for Resident 96 for August, September, and October 2023, revealed that staff did not document completion of or documented not applicable on the restorative task on the following dates: Ambulation August 1, 4, 5, 6, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 26, 28, and 30, 2023 September 1, 2, 3, 4, 6, 7, 8, 9, 10, 15, 17, 18, 20, 23, 24, 25, 26, and 30, 2023 October 1, 4, 7, 8, 9, 13, 14, 15, 18, 19, 20, 21, 27, 28, and 29, 2023 AROM BUE and BLE August 1, 4, 5, 6, 7, 11, 12, 13, 14, 17, 18, 19, 20, 21, 22, 23, 26, 28, and 30, 2023 September 1, 2, 3, 4, 6, 7, 8, 9, 10, 11,13, 15, 17, 18, 20, 23, 24, 25, 26, 29, and 30, 2023 October 1, 2, 4, 5, 7, 8, 9, 10, 13, 14, 15, 18, 20, 21, 23, 24, 27, 28, and 29, 2023 Interview on November 1, 2023, at 9:35 AM and 10:34 AM with the Director of Nursing (DON) acknowledged that there was not a frequency indicated for Resident 79's and 96's restorative programs, but facility policy was for staff to complete a resident's restorative program six times per week. The DON acknowledged that resident restorative programs were not being completed. The surveyor reviewed the above information on November 2, 2023, at 2:15 PM, with the Nursing Home Administrator. During an interview with Resident 81 on October 31, 2023, at 11:08 AM the resident revealed that she was unable to walk, and staff use a mechanical lift to get her out of bed. When asked if staff help her exercise, she said no. Resident 81 pointed to her right side indicating she is unable to move her arm and leg. Review of a physical therapy Discharge summary dated [DATE], for Resident 81 revealed that the 395616 Page 5 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident was discharged the day prior and recommended a restorative nursing program of active range of motion to the bilateral lower extremities at all joints and in all planes of motion (in all directions) daily. Prognosis for Resident 81 to maintain her current level of function was identified as good with consistent staff follow-through. Review of an occupational Discharge summary dated [DATE], for Resident 81 revealed the recommendation of a restorative nursing program for active range of motion to the bilateral upper extremities. Prognosis for Resident 81 to maintain her current level of function was excellent with consistent staff support. There was no documented evidence in Resident 81's clinical record to indicate that the recommended physical therapy and occupational therapy restorative programs were established. During an interview with Employee 3, registered nurse consultant, on November 2, 2023, at 1:00 PM confirmed the above findings for Resident 81 that the restorative nursing programs for Resident 81 was never initiated. Review of the physician orders for Resident 18 revealed an order for Resident 18 dated March 20, 2023, that noted the resident may participate with restorative nursing programs. Review of the current care plan for Resident 18 revealed the resident has a potential for decreased function in activities of daily living (ADLs) / functional abilities due to the resident's balance being compromised, debility, fatigue, and immobility. A review of the tasks for Resident 18 revealed the resident has an AROM program to the bilateral upper and lower extremities. A restorative program note for Resident 18 dated October 30, 2023, at 2:40 PM revealed the resident .participates in AROM to bilateral upper and lower extremities needing visual and verbal cues to follow along. Review of task and facility documentation for Resident 18 for September and October 2023, revealed that staff did not document completion of or documented not applicable on the restorative task on the following dates: September 2, 3, 4, 5, 6, 7, 8, 9, 10, 16, 23, 24, 25, 26, 29, and 30, 2023. October 1, 2, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 19, 20, 21, 22, 24, 28, 29, 31, 2023. An interview with Employee 8, Restorative Aide Manager Lead, revealed that Resident 18 did have a current AROM program. However, the missing days noted on the documentation and the days marked NA revealed the program was not completed for those days. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services 395616 Page 6 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of six residents reviewed (Resident 114). Residents Affected - Few Findings include: A review of current physician orders for Resident 114 revealed an order dated August 24, 2023, that noted oxygen via nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) at two liters per minute to keep the resident's oxygen saturation above 90 percent. Another physician order dated August 24, 2023, instructed staff to change the oxygen equipment every Thursday on night shift for infection control purposes change oxygen equipment every Thursday on 11-7 every night shift every Thu for infection control. The current care plan for Resident 114 revealed the resident has a potential for an altered respiratory status / difficulty breathing / shortness of breath related to the medical history. An intervention is to administer oxygen as ordered. Observation on October 31, 2023, at 11:16 AM and again on November 2, 2023, at 11:57 AM of a chair in the main hallway with Resident 114's name on it revealed a used nasal cannula draped over the back of the chair. The nasal cannula was not bagged or protected from the ambient environment. Observation with Employee 4, registered nurse, on November 2, 2023, at 12:19 PM revealed the same nasal cannula draped over the back of the chair and not bagged or protected from the ambient environment. A concurrent interview with Employee 4 revealed the nasal cannula should be bagged. The above information was reviewed in a meeting on November 2, 2023, at 2:30 PM with the Nursing Home Administrator. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395616 Page 7 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for two of four residents reviewed (Residents 29 and 40). Residents Affected - Some Findings include: The facility policy entitled, Pain Management Guidelines, last reviewed without changes in January 2023, revealed that the facility identified the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to seven, and severe pain was identified as eight to 10. The facility policy entitled, Monitoring Usage of PRN (as needed) Pain Medication, last reviewed without changes on January 2023, revealed that the facility will monitor and review PRN pain drugs bi-monthly. Clinical record review for Resident 29 revealed physician's orders for the following pain medications: Ordered on August 29, 2023, Tylenol 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours PRN for mild pain and Oxycodone 5 mg 1 tablet PO every 6 hours PRN for pain. Review of Resident 29's August, September, and October 2023 MAR (medication administration record, a form to document medication administration) revealed the following: Staff administered the following PRN pain medications: Tylenol 325 mg 2 tablets PO every 6 hours PRN for mild pain September 17, 2023, at 5:56 AM for a pain level of 10. September 23, 2023, at 5:07 AM for a pain level of 5. October 2, 2023, at 2:02 AM for a pain level of 5. October 17, 2023, at 8:02 PM for a pain level of 4. October 19, 2023, at 12:43 AM for a pain level of 4. Oxycodone 5 mg every 6 hours PRN for pain August 30, 2023, at 4:41 PM for a pain level of 3. September 6, 2023, at 12:56 AM for a pain level of 3. September 14, 2023, at 1:40 AM for a pain level of 0. September 10, 2023, at 5:22 PM for a pain level of 2. 395616 Page 8 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0697 October 4, 2023, at 2:07 AM for a pain level of 3. Level of Harm - Minimal harm or potential for actual harm October 12, 2023, at 4:19 AM for a pain level of 3. October 19, 2023, at 12:38 AM for a pain level of 7. Residents Affected - Some October 29, 2023, 6:43 PM for a pain level of 0. Staff did not administer Resident 29's pain medications according to the physician ordered pain scale level(s) nor did they identify the potential for poly pharmacy and administered Tylenol and Oxycodone simultaneously or almost simultaneously in October 2023. Clinical record review for Resident 40 revealed physician's orders for the following pain medications: Ordered on May 12, 2023, Tylenol 500 mg 1 tablet PO every 6 hours PRN for pain. Ordered on August 21, 2023, Norco 5-325 mg 1 tablet PO every 6 hours PRN for moderate to severe pain. Review of Resident 40's August, September, and October 2023 MAR revealed the following: Staff administered the following PRN pain medications: Tylenol 500 mg 1 tablet PO every 6 hours PRN for pain August 21, 2023, at 6:44 PM for a pain level of 4. August 22, 2023, at 1:36 PM for a pain level of 4. September 7, 2023, at 8:16 AM for a pain level of 5. September 23, 2023, at 5:07 AM for a pain level of 5. October 2, 2023, at 2:02 AM for a pain level of 5. October 17, 2023, at 8:02 PM for a pain level of 4. October 19, 2023, at 12:43 AM for a pain level of 4. Norco 5-325 mg every 6 hours PRN for moderate to severe pain August 26, 2023, at 3:08 PM for a pain level of 2. September 7, 2023, at 8:16 AM for a pain level of 5. September 14, 2023, at 1:40 AM for a pain level of 0. September 10, 2023, at 5:22 PM for a pain level of 2. 395616 Page 9 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Staff did not administer Resident 40's pain medications according to the physician ordered pain scale level(s) nor did they identify the potential for poly pharmacy and administered Tylenol and Norco simultaneously or almost simultaneously in September 2023. There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters or that the facility identified that multiple medications were available for the same pain parameters. The surveyor reviewed Resident 29 and 40's pain medication information during an interview with the Nursing Home Administrator and Director of Nursing on November 1, 2023, at 2:15 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395616 Page 10 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess the resident for the need for side rails and risk of side rail entrapment for one of three residents reviewed (Resident 28). Findings include: Observation and interview on November 1, 2023, at 11:05 AM revealed Resident 28 had enabler bars (side rails) on both sides of the bed. Resident 28 indicated that he uses the bars to move in bed and help him get out of bed. A safety risk evaluation dated May 12, 2023, revealed the facility assessed Resident 28 as not needing side rails. There was no documented evidence in Resident 28's clinical record to indicate that the facility assessed the resident as having the need for side rails and assessed for entrapment risks. Interview with Employee 3, registered nurse consultant, on November 3, 2023, at 8:30 AM confirmed the above findings for Resident 28 and indicated that the staff completing the assessment did not realize that enabler bars were side rails. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395616 Page 11 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address dementia symptoms displayed by two of four residents reviewed (Residents 107 and 124). Residents Affected - Few Findings include: Review of Resident 107's clinical record revealed that the facility admitted her on July 21, 2023. The facility implemented a diagnosis of unspecified dementia on August 10, 2023. Documentation along with the diagnosis indicated that Resident 107 scored an 18 out of 30 on the St. Louis University Mental Status Examination (SLUMS test, a tool used to screen for various types of dementia). Resident 107's score of 18 out of 30 indicated dementia. A physician progress note dated August 14, 2023, indicated that Resident 107's primary diagnosis was Dementia in Alzheimer's disease with delirium. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 27, 2023, indicated that the facility assessed Resident 107 as having the diagnosis of dementia and cognitive loss. The MDS triggered for the facility to complete a care plan regarding cognitive loss and/or dementia. There was no documented evidence to indicate that the facility developed an individualized person-centered plan to address her known diagnosis of dementia. Interview with Employee 3, nurse consultant, on November 2, 2023, at 11:45 AM confirmed the above findings for Resident 107. Clinical record review revealed Resident 124 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important functions). Review of Resident 124's medications revealed that she was on Donepezil (medication to help a person's memory and thinking) 5 mg (milligrams) daily related to Alzheimer's Disease. Review of a psychiatric consultation for Resident 124 dated October 16, 2023, revealed the resident had limited orientation and cognition (a term for mental processes). Review of Resident 124's care plan revealed that there was no indication that the facility had developed and implemented a person-centered non-pharmacological care plan to address the resident's dementia. These findings were reviewed with the Nursing Home Administrator during an interview on November 2, 2023, at 2:20 PM. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services 395616 Page 12 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 11, 62, and 88). Residents Affected - Some Findings include: The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors. The policy entitled Medication Administration, last reviewed in January 2023, indicates that medications are administered by licensed staff, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer medication as ordered in accordance with manufacturer's specifications. Observation of a medication administration pass on October 31, 2023, at 9:01 AM revealed Employee 1, licensed practical nurse, preparing to administer Insulin Aspart (an injectable insulin to treat diabetes) two units to Resident 11. Employee 1 administered the Insulin Aspart to Resident 11 one hour and 15 minutes after she was served her breakfast. Review of the Insulin Aspart package insert revealed that it is to be administered five to 10 minutes prior to a meal. Interview with Employee 1 at this time confirmed that Resident 11 was served her breakfast prior to 8:00 AM. Observation of a medication administration pass on October 31, 2023, at 9:08 AM revealed Employee 1 administering Fluticasone (treats allergies) nasal spray to Resident 62. Employee 1 administered two sprays in both of Resident 62's nostrils. Review of Resident 62's clinical record revealed a physician's order dated March 15, 2023, that indicated nursing staff were to administer one spray of Fluticasone once a day. Observation of a medication administration pass on October 31, 2023, at 10:26 AM revealed Employee 2, licensed practical nurse, administering Insulin Aspart four units to Resident 88. Employee 2 administered the insulin almost one hour and 45 minutes prior to his lunch. Resident 88 did not receive his meal tray until 12:07 PM and had not received any other snack or food after the administration. Review of the Novolog package insert revealed that it is to be administered five to 10 minutes prior to a meal. Interview with Employee 2 at 12:10 PM confirmed that she administered Resident 88's insulin too early. Interview with the Administrator and Director of Nursing on November 1, 2023, at 2:00 PM acknowledged the above findings. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395616 Page 13 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Residents Affected - Some Findings include: A tour of the facility's main kitchen with Employee 7 (Interim General Manager of the Kitchen) on October 31, 2023, at 9:10 AM revealed the following: A meat slicer was covered with dust. The dry goods storage area had the following open items that were not labeled with open dates: bag of cream of wheat, a bag of noodles, a bag of thick and easy thickener. There was a large plastic storage container with a white product that Employee 7 identified as flour. There was no label or dates on the product. The oven, steamer, and hot holder appliances had a build-up of dust and debris on the top of each unit. The hot holder had various hot pads that Employee 7 identified as clean. The hot pads had various stains on them. The spice storage area had a large container of parsley flakes and a box of corn starch that were both open with no open date on the products. There were multiple brown colored stains on six of the ceiling tiles on the ceiling above a food prep area. Employee 7 was unable to identify what the stains were from. There was a winged insect flying near the three-basin sink and another winged insect in the housekeeping closet. The housekeeping closet had a dustpan hanging on the wall with the dustpan covered with various waste debris. The wall near the three-basin sink had stuck on debris and dried stains running down the wall. Employee 7 revealed that this is where the garbage can is typically located. There were multiple various sized stainless steel food lids that Employee 7 identified as clean. The lids were in a large plastic basin on a portable cart. The plastic basin had various unidentified debris on the bottom. There was a jagged piece of 1 inch x 1 inch broken plastic on the floor. In the corner area near the walk in cooler and freezer and where the stainless steel lids were being stored was a large accumulation of debris. Closer inspection by the surveyor revealed concerns for mouse droppings. An open and unlabeled bag of what appeared to be French fries was found in the freezer. The floor of the freezer under the storage racks had significant debris that included discarded paper products, large unidentified debris, a discarded container of strawberry sherbet, and three discarded magic cup nutrition cups. 395616 Page 14 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0812 Level of Harm - Minimal harm or potential for actual harm There was a build-up of stains and splash stains noted on the wall surface where the hand sprayer is operated prior to placing items in the dishwasher. There were diffuse dark colored stains on the ceiling above the dishwasher area. Multiple ceiling tiles had the stains and Employee 7 was unable to identify what the stains were. Residents Affected - Some A camera on the ceiling and two fans mounted on the walls near the dishwasher area had a significant build-up of dust. The first aid cabinet top was covered in dust. There were freshly washed cups observed on a mobile cart below it. There was a build-up of a black colored substance and debris along the perimeter of the wall and the floor, which spanned from the dry goods storage area to the area behind the stove. The cabinets in an adjacent room of the kitchen revealed the following: a plastic Tupperware bowl with a lid had a significant amount of moisture in it and it was unknown how long it was in the cabinet without being properly dried, and there was a significant build-up of debris on the shelf holding the salt and pepper shakers. There was an area storing serving bowls that were for resident use and identified as clean by Employee 7 revealed a build-up of dust and debris on the shelving. The above information regarding the main kitchen was reviewed at the time of the findings with Employee 7 and again on October 31, 2023, at 10:00 AM. Observations of the resident dining area on October 31, 2023, at 10:00 AM and again on November 2, 2023, at 11:10 AM revealed an egress door that had various cobwebs near the floor and windowsills, and three dead millipede like pests on the floor. The above information was reviewed in a meeting with the Nursing Home Administrator on November 2, 2023, at 3:01 PM. 483.60 Food Procure, Store/Prepare/Serve - Sanitary Previously cited 12/16/22 28 Pa. Code 201.14(a) Responsibility of licensee 395616 Page 15 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

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 documentation, clinical record review, observation, and staff interview, it was determined that the facility failed to implement measures to prevent the potential spread of infections for one of five residents reviewed for infections (Resident 7) and the main laundry unit of the facility. Residents Affected - Some Findings include: Review of an annual MDS (minimum data set, an assessment tool design to direct the plan of care) for Resident 7 dated August 16, 2023, revealed that the resident was always incontinent (loss of bladder control) of urine. Review of a report of a urine culture for Resident 7 dated August 27, 2023, indicated the resident had under 100,000 colonies/milliliter Escherichia coli ESBL (extended spectrum beta lactamase, chemicals produced due to certain type of bacteria, a person infected with ESBL can be a carrier and spread the bacteria to others, which is difficult to treat with antibiotics) producing organism. The report indicated the person may require isolation (special precautions to prevent the spread of infection) and directed the facility to contact infectious disease service. Clinical record review for Resident 7 revealed no evidence in the physician orders, progress notes, MAR (medication administration record), or TAR (treatment administration record) that the resident was placed on isolation/contact precautions, or the facility contacted infectious disease services. During an interview with the Nursing Home Administrator and Director of Nursing on November 1, 2023, the surveyor reviewed the findings for Resident 7 and the facility indicated that the physician did not order isolation precautions. A follow up interview with Employee 3, registered nurse consultant, on November 2, 2023, at 10:30 AM confirmed that Resident 7 should have been on isolation precautions. Observation on November 1, 2023, at 11:20 AM of the soiled linen room where the facility's dirty laundry is received in the basement by a laundry chute revealed mopheads and towels were on the floor unbagged. Concurrent interview with Employee 10, laundry aide, revealed sometimes the bags break open in the laundry chute. Other clothing items and linen were bagged appropriately and on the floor below the laundry chute. Employee 10 was sorting dirty laundry while wearing disposable gloves. The dirty laundry touched Employee's 10 sweatshirt. The surveyor questioned Employee 10 if gowns were available to prevent cross contamination. The surveyor observed and talked with Employee 10 on Unit 3 earlier that day. Employee 10 acknowledged that she also works on the units and said that she is new to the facility and doesn't know about gowns. Concurrent, observation in the hallway outside of the laundry room in the basement revealed a wheelchair washer. Next to the wheelchair washer were cardboard boxes of resident gowns and sheets that were overflowing onto the floor. A blanket, sheets, and towel were on the floor near the wheelchair washer. Interview with Employee 11, laundry aide, revealed that these linens are rags used to dry the wheelchairs, which is managed by another department. The observations in the dirty linen room and wheelchair washer were reviewed with the Nursing Home Administrator and Director of Nursing on November 1, 2023, at 2:50 PM. 395616 Page 16 of 17 395616 11/03/2023 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0880 The facility failed to prevent the spread of infection by not implementing isolation precautions for ESBL for Resident 7 and by failing to prevent cross contamination in the main laundry area. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a)(b) Responsibility of licensee Residents Affected - Some 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395616 Page 17 of 17