Health inspection·October 18, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives or provide resident's an opportunity to formulate an advance directive for nine of 16 residents reviewed for advance directives (Residents 5, 14, 18, 20, 53, 61, 112, 126, and 238). Findings include: Clinical record review for Resident 61 revealed a physician's order dated [DATE], indicating the resident was a full code, which would include CPR (cardiopulmonary resuscitation). Other than an order for resuscitation, there was no evidence Resident 61 was provided written information on advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare for a resident that may be incapacitated and not able to make decisions) or assisted with the opportunity to formulate advance directives regarding treatment in the event Resident 61 could not make decisions regarding her health care. An interview with the Director of Nursing on [DATE], at 9:48 AM confirmed the above information regarding Resident 61. Clinical record review for Resident 5 revealed a physician's order dated [DATE], for a DNR (Do not resuscitate). Other than an order for a DNR, there was no evidence Resident 5 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. Clinical record review for Resident 14 revealed a physician's order dated [DATE], for a DNR. Other than an order for a DNR, there was no evidence Resident 14 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event he could not make decisions regarding his health care. Clinical record review for Resident 112 revealed a physician's order dated [DATE], indicating the resident was a full code, which would include CPR. Other than an order for resuscitation, there was no evidence Resident 112 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event he could not make decisions regarding his health care. Clinical record review for Resident 126 revealed a physician's order dated [DATE], for a DNR. Other than an order for a DNR, there was no evidence Resident 126 was provided written information on Page 1 of 23 395616 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. Clinical record review for Resident 238 revealed a physician's order dated [DATE], indicating the resident was a full code, which would include CPR. Other than an order for resuscitation, there was no evidence Resident 238 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. Interview with administrative staff on [DATE], at 12:13 PM confirmed the above noted information related to Residents 5, 14, 112, 126, and 238. Clinical record review for Resident 18 revealed a physician's order dated [DATE], indicating the resident was a DNR. Other than an order for a DNR, there was no evidence Resident 18 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. Clinical record review for Resident 20 revealed a physician's order dated [DATE], indicating the resident was a DNR. Other than an order for a DNR, there was no evidence Resident 20 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. An interview with the Director of Nursing on [DATE], at 12:09 PM confirmed the above information regarding Resident 20. Clinical record for Resident 53 revealed a physician's order dated [DATE], indicating the resident was a DNR. Other than an order for a DNR, there was no evidence Resident 53 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event she could not make decisions regarding her health care. An interview with the Director of Nursing on [DATE], at 10:03 AM confirmed the above information regarding Residents 18 and 53. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 395616 Page 2 of 23 395616 10/18/2024 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 observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment on three of four nursing units (Unit 1, 2, and 3; Residents 14, 18, 23, 86, 106, and 116). Findings include: Observation of Resident 106's room on October 15, 2024, at 12:47 PM revealed the resident was out of bed in her specialty chair. The chair had dried food, dried spills, dust, and debris on the arms of the chair and metal frame. The sheets on the resident's bed were observed with brown stains and food crumbs on the bed. The flooring was observed with dried liquid spots and black smudges. A fall mat folded at the front of the room was covered in dust, debris, and dried liquid spills. Two tray tables observed in the room contained dried food, dried spills, and a significant amount of adhesive residue all around the perimeter of the tray tables. Significant crumbs and debris were observed on the floor around the air conditioning unit. The corner of the wall near the resident's bathroom door was cracked and chipped with drywall exposed. The flooring of the bathroom was blackened, and debris buildup was observed along the bathroom wall edges and flooring door strip to an adjoining room. The floor strip between tiles from the bathroom to Resident 106's room was missing with a gap between the two types of tiles. The gap was filled with dirt and debris. A follow up observation of Resident 106's room on October 16, 2024, at 9:44 AM revealed the resident was out of bed with the bed made. The sheets remained with brown stains and the other room observations noted above remained unchanged. An observation of Resident 116's room on October 16, 2024, at 9:24 AM revealed the room flooring was dull and dirty with crumbs, blackened spots, and streaks throughout the flooring. An observation of Resident 23's room on October 16, 2024, at 9:32 AM revealed debris/crumbs on the floor beside and under the resident's bed, with a significant amount around the non-slip strips on the floor beside the bed. Fall mats were observed folded up beside the resident's dresser in the front of the room. The fall mats were dusty/dirty and had dried liquid spills on them. The above concerns for Residents 106, 116, and 23 were reviewed with the Nursing Home Administrator and Director of Nursing on October 17, 2024, at 2:25 PM. An observation of Resident 14's room on October 16, 2024, at 11:40 AM revealed the room floor was dull with blackened spots and streaks throughout the flooring. There was dirt along the cove base around the sink. The overbed table along the edge had areas with adhesive material stuck on it. An observation of Resident 86's room on October 15, 2024, at 12:00 PM revealed the floor was dull and dirty with blackened spots and streaks throughout the flooring. There was also dirt noted around the cove base in the room. An observation of Nursing Unit 2 on October 15, 2024, at 11:30 AM revealed the hallway floor was dull and dirty with blackened spots and streaks throughout the flooring throughout the entire hallway. 395616 Page 3 of 23 395616 10/18/2024 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 above concerns for Residents 14 and 86, and the hallway on Unit 2 were reviewed with the Nursing Home Administrator and Director of Nursing on October 17, 2024, at 3:10 PM. Observation of the floor in front of Unit 2's nursing station on October 15, 2024, at 2:48 PM revealed several black sticky areas. A follow up observation on October 16, 2024, at 9:52 AM revealed that black spots remained. Observation of Resident 18's room during an interview on October 15, 2024, at 2:20 PM revealed Resident 18 was seated in her recliner chair. There was a large amount of food on the floor around Resident 18's recliner and along her wall. Resident 18 stated a man just carried a mouse out of my room. A follow up observation of Resident 18's room on October 16, 2024, at 9:54 AM revealed the food remained on Resident 18's floor. The above concerns for Resident 18 and Station II's hallway floor were reviewed with the Nursing Home Administrator and Director of Nursing on October 16, 2024, at 2:05 PM. 483.10(i)(1)(2) Safe, clean, homelike environment Previously cited 11/3/23, 6/10/24, and 8/8/24 28 Pa. Code 201.18 (e)(2.1) Management 395616 Page 4 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0623 Level of Harm - Potential for minimal 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. Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for seven of nine residents reviewed (Residents 5, 14, 35, 79, 87, 104, and 131). Findings include: Clinical record review for Resident 131 revealed that they were transferred to the hospital on August 22, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, and contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The facility did not notify the State Ombudsman of the transfer as required until October 14, 2024. The surveyor reviewed the above information for during an interview with the Director of Nursing on October 17, 2024, at 12:39 PM. Clinical record review for Resident 5 revealed that she was transferred to the hospital on August 18, 2024, after vomiting blood and again on September 10, 2024, related to an infection of her surgical wound. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents noted above. The facility also did not notify the State Ombudsman of the transfer as required until October 14, 2024. Clinical record review for Resident 14 revealed that he was transferred to the hospital on September 13, 2024, due to signs of a possible stroke. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents noted above. The facility also did not notify the State Ombudsman of the transfer as required until October 14, 2024. The surveyor reviewed the above noted information related to Residents 5 and 14, on October 17, 2024, at 12:44 PM with the Director of Nursing who confirmed that there was no evidence that the notice of transfer was provided to the responsible parties. Clinical record review for Resident 35 revealed the resident was transferred to the hospital for a change in condition on April 23, 2024, admitted , and returned to the facility on April 28, 2024. There was no evidence the facility provided written notification regarding the transfer to the resident and the resident's responsible party including the contents list above. The facility also did not notify the State Ombudsman of the transfer until October 14, 2024. Clinical record review for Resident 87 revealed the resident was sent to the hospital for a change in condition on August 24, 2024, admitted , and returned to the facility on August 31, 2024. There 395616 Page 5 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some was no evidence the facility provided written notification regarding the transfer to the resident and the resident's responsible party including the contents list above. The facility also did not notify the State Ombudsman of the transfer until October 14, 2024. In an interview with the Director of Nursing on October 17, 2024, at 12:46 PM it was confirmed the facility had not provided a written notice of transfer with the required contents noted above to Resident 35 or Resident 87 and their responsible party or notified the State Ombudsman until October 14, 2024. Clinical record review for Resident 79 revealed the resident was transferred and admitted to the hospital for a change in condition on May 22, May 29, June 30, and July 29, 2024. There was no evidence the facility provided written notification regarding the transfer to the resident and the resident's responsible party including the contents list above. The facility also did not notify the State Ombudsman of the transfer until October 14, 2024. Clinical record review for Resident 104 revealed the resident was transferred and admitted to the hospital for a change in condition on August 26, 2024. There was no evidence the facility provided written notification regarding the transfer to the resident and the resident's responsible party including the contents list above. The facility also did not notify the State Ombudsman of the transfer until October 14, 2024. In an interview with the Director of Nursing on October 17, 2024, at 12:44 PM it was confirmed the facility had not provided a written notice of transfer with the required contents noted above to Resident 79 or Resident 104 and their responsible party or notified the State Ombudsman until October 14, 2024. 28 Pa. Code 201.14 (a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights 395616 Page 6 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for seven of nine residents reviewed for hospitalizations (Residents 5, 14, 35, 79, 87, 104, and 131). Findings include: Clinical record review revealed that Resident 131 was transferred to the hospital on August 22, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 5 was transferred to the hospital on August 18, 2024, and September 10, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 14 was transferred to the hospital on September 13, 2024, and September 10, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review for Resident 35 revealed the resident was transferred to the hospital for a change in condition on April 23, 2024, and admitted . Clinical record review for Resident 87 revealed the resident was sent to the hospital for a change in condition on August 24, 2024, and admitted . There was no evidence the facility provided written information to Resident 35 or Resident 87 and their responsible party regarding a bed hold upon transfer out to the hospital. The surveyor reviewed the above information for Residents 35 and 87 during an interview with the Director of Nursing on October 17, 2024, at 12:39 PM. Clinical record review revealed that Resident 79 was transferred to the hospital on May 22, May 29, June 30, and July 29, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 104 was transferred to the hospital on August 26, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The surveyor reviewed the above information for Residents 79 and 104 during an interview with the Director of Nursing on October 17, 2024, at 12:44 PM. 395616 Page 7 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0625 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(f) Resident rights Residents Affected - Few 395616 Page 8 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for two of two residents reviewed (Residents 78 and 86). Findings Include: Clinical record review for Resident 78 revealed an annual MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) dated September 6, 2024, that indicated it is somewhat important to him to have books, newspapers, and magazines, to listen to music, to be around pets, keep up with the news, and to do his favorite activity. Review of Resident 78's current care plan entitled, adjustment to group living/activities related to new admission failed to address any of the activities that were somewhat important to him or identify what his favorite activity was to incorporate it into his activity plan. Clinical record review for Resident 86 revealed an annual MDS dated [DATE], that indicated it is somewhat important to him to attend groups and to do his favorite activity. Review of Resident 86's current care plan entitled, adjustment to group living/activities related to new admission failed to identify what his favorite activity was to incorporate it into his activity plan. Interview with Employee 3, Activity Director, on October 18, 2024, at 11:15 AM confirmed the above noted findings related to Resident 78 and 86's care plan. The facility failed to implement a person center care plan to maintain the highest practicable care for Residents 78 and 86. 28 Pa. Code 211.12(d)(5) Nursing services 395616 Page 9 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide care and services identified to reduce a resident's decline in ADL's (activities of daily living) for three of three residents reviewed (Residents 29, 34, and 128). Residents Affected - Some Findings include: Clinical record review for Resident 29 revealed that she had a diagnosis of a stroke which affected her left side. There was a current physician's order for staff to complete a restorative nursing program (RNP) of ADL tasks for self-grooming with set up and upper body dressing with extensive assist. Review of Resident 29's task documentation revealed that staff did not complete the RNP self-grooming task on the following dates: Day Shift: July 1, 4, 5, 14, and 25, 2024 August 2, 3, 5, 24, and 31, 2024 September 1, 6, 7, 8, and 16, 2024 October 6, 13, and 15, 2024 Evening Shift: July 7, 2024 August 17 and 26, 2024 September 9, 2024 October 8, 2024 Further review of Resident 29's RNP self-grooming task revealed that staff documented NA (not applicable) on the following dates: Day Shift: July 20, 27, and 28, 2024 August 16, 17, and 19, 2024 September 21, 27, and 29, 2024 395616 Page 10 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0676 Evening Shift: Level of Harm - Minimal harm or potential for actual harm July 21, 2024 August 11 and 15, 2024 Residents Affected - Some September 7, 8, 10, and 19, 2024 October 10, 11, 15, and 16, 2024 Clinical record review for Resident 34 revealed a physician's order from August 29, 2024, through September 26, 2024, for staff to complete an RNP ADL task to provide complete upper body bathing and dressing with limited assist while seated and self-grooming with limited assist. Further review revealed Resident 34 had a current physician's order for the restorative dining program to promote self-feeding. Review of Resident 34's task documentation revealed that staff did not complete the RNP ADL task to provide complete upper body bathing and dressing with limited assist while seated and self-grooming with limited assist on the following dates: Day Shift: August 2, 3, 4, 5, 12, 15, and 31, 2024 September 12 and 16, 2024 Evening Shift: August 17, 2024 September 9 and 12, 2024 Further review of Resident 34's RNP bathing, dressing and self-grooming task revealed that staff documented NA on the following dates: Day Shift: September 2, 2024 Evening Shift: August 8, 11, and 15, 2024 September 7, 8, 10, and 19, 2024 Review of Resident 34's task documentation revealed that staff did not complete the restorative dining program on the following dates: Day Shift: 395616 Page 11 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0676 July 25 and 28, 2024 Level of Harm - Minimal harm or potential for actual harm August 2, 3, 4, 7, 15, 24 and 31, 2024 September 12 and 16, 2024 Residents Affected - Some October 6, 13, and 15, 2024 Evening Shift: July 25, 2024 August 17, 25, and 26, 2024 September 9 and 12, 2024 October 4, 5, 6, and 8, 2024 Further review of Resident 34's restorative dining program revealed that staff documented NA on the following dates: Day Shift: September 2, 2024 Evening Shift: August 8, 15, and 30, 2024 September 7, 8, 10, and 19, 2024 October 1, and 10, 2024 Clinical record review for Resident 128 revealed that there was a current physician's order for staff to complete an RNP ADL task to be seated upright with supervision for upper and lower body bathing, dressing, and self-grooming with supervision. Review of Resident 128's task documentation revealed that staff did not complete the RNP bathing, dressing, and self-grooming task on the following dates: Day Shift: August 30, 2024 September 1, 2, 6, 12, 17, and 20, 2024 October 14 and 15, 2024 Evening Shift: 395616 Page 12 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0676 September 9, 2024 Level of Harm - Minimal harm or potential for actual harm Further review of Resident 128's RNP bathing, dressing, and self-grooming task revealed that staff documented NA on the following dates: Residents Affected - Some Evening Shift: July 21, 2024 August 11 and 15, 2024 September 7, 8, 10, 19, and 24, 2024 October 6 and 8, 2024 The surveyor reviewed the above information during an interview with the Director of Nursing on October 18, 2020, at 10:00 AM. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395616 Page 13 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

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 Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights and vital signs for two of 27 residents (Residents 34 and 123). Residents Affected - Some Findings include: Clinical record review for Resident 34 revealed physician orders for staff to administer and complete the following: From July 11, 2024, to October 14, 2024, check blood pressure (BP) and heart rate (HR) between 11:00 AM and 12:00 PM on Wednesdays. Call the physician if the systolic blood pressure (SBP, when the heart contracts) was less than 100 mmHg (millimeters of mercury) or the HR was greater than 120 BPM (beats per minute) or less than 60 BPM. Call results to the physician once weekly. From August 17, 2024, to October 10, 2024, Nifedipine Extended Release (ER) 24 hour 30 mg (milligrams) two tablets by mouth (PO) daily (QD) for Hypertension. Hold for SBP less than 110 mmHg. On August 6, 2024, Losartan Potassium 50 mg PO every 12 hours for BP. Hold if SPB is less than 110 mmHg. On October 10, 2024, Hydralazine 25 mg PO every eight hours for Hypertension. Hold for SBP less than 120 mmHg. On October 19, 2024, check BP QD and notify provider if SBP was less than 160 mmHg. Review of Resident 34's July, August, September, and October 2024, task documentation (an action intended to improve the resident's health and comfort) revealed the following: Staff did not notify the physician for a HR less than 60 BPM on: July 11, 2024, HR 51 BPM July 18, 2024, HR 58 BPM August 8, 2024, HR 58 BPM Nifedipine ER 10 mg two tablets PO QD. Hold for SBP less than 110 mmHg. Administered Nifedipine ER when SPB was less than 110 mmHg or documented NA(not applicable): September 9, 2024, SBP NA September 20, 2024, SBP 106 September 21, 2024, SBP 108 October 4, 2024, SBP 108 395616 Page 14 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0684 Losartan 50 mg PO every 12 hours. Hold for SBP less than 110 mmHg. Level of Harm - Minimal harm or potential for actual harm Administered Losartan when SPB was less than 110 mmHg, documented NA, or no BP documented: August 18, 2024, at 9:00 PM, SBP 104 Residents Affected - Some September 3, 2024, at 9:00 PM, SBP 108 September 5, 2024, at 9:00 PM, SBP NA September 9, 2024, at 9:00 AM, SBP NA September 13, 2024, at 9:00 PM SBP not documented September 20, 2024, at 9:00 AM, SBP 106 September 20, 2024, at 9:00 PM, SBP not documented September 21, 2024, at 9:00 AM, SBP 108 September 27, 2024, at 9:00 PM, SBP 106 September 28, 2024, at 9:00 PM, SBP not documented September 29, 2024, at 9:00 PM, SBP not documented October 4, 2024, at 9:00 AM, SBP 108 Hydralazine 25 mg PO every eight hours. Hold for SBP less than 120 mmHg. Administered Hydralazine when SBP was less than 120 mmHg, on October 12, 2024, at 10:00 PM, SBP was 118 mmHg. Clinical record review for Resident 123 revealed physician orders for staff to complete the following: BP and HR QD Weights QD Review of Resident 123's May, July, August, and September 2024, task documentation revealed that there was no documentation that staff completed the following: BP and HR daily on: May 16, 2024 June 24, 2024 395616 Page 15 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0684 September 14, 2024 Level of Harm - Minimal harm or potential for actual harm Weights daily on: May 14, 20, and 30, 2024 Residents Affected - Some July 5, 22, and 23, 2024 August 3, 2024 September 14, 2024 The surveyor reviewed the above information during an interview on October 18, 2024, at 9:50 AM with the Director of Nursing. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services 395616 Page 16 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement treatment and services to prevent the development and promote the healing of pressure ulcers for two of five residents reviewed for pressure ulcer concerns (Residents 104 and 14). Residents Affected - Few Findings include: The facility policy entitled Pressure Injury Prevention and Treatment, last reviewed without changes January 2024 revealed each resident will be assessed routinely to prevent skin breakdown, provide appropriate treatment, and monitor healing progress. A Braden Pressure Injury Risk Assessment and identification of primary risk factors will be completed to identify residents individual risk needs related to the development of pressure injury. This assessment will be completed within eight hours of admission, quarterly, annually, and with each significant change in condition. The weekly skin assessment will be completed by the licensed nurse and documented on the treatment administration record. Clinical record review revealed the facility admitted Resident 104 on December 14, 2023. The last Braden Scale for predicting pressure sore risk was completed on January 16, 2024. Nursing staff assessed Resident 104 as a moderate risk. Review of Resident 104's clinical record revealed she returned from the hospital on September 1, 2024, with no pressure ulcers. Nursing documentation dated September 26, 2024, at 1:26 PM revealed the licensed practical nurse was called to Resident 104's room to assess a new wound on her coccyx measuring 2 centimeters (cm) by 1.5 cm. Nursing documentation dated September 26, 2024, at 1:57 PM noted the registered nurse documented she was called to Resident 104's room to assess a worsening area of pressure to the coccyx, noting WHS (wound healing solutions) consulted. Review of skin observation/checks dated October 3 and 10, 2024, revealed Resident 104 is followed by the wound team for her coccyx and no assessment of the area was completed. Further review of Resident 104's clinical record revealed a Skin Wound note dated October 3, 2024, noting Resident 104 was out of the facility and not assessed. The Skin Wound note dated October 10, 2024, revealed Resident 104's coccyx was not assessed. Review of the skin and wound note dated October 17, 2024, noted Resident 104's coccyx measured 1.7 cm by 0.5 cm by 0.1 cm. Interview with the Director of Nursing on October 18, 2024, confirmed these findings indicating Resident 104's coccyx was not assessed from September 26, 2024, to October 17, 2024. Clinical record review for Resident 14 revealed that he was readmitted to the facility on [DATE], from the hospital, with a Stage 1 pressure ulcer (redness of an area but skin is intact) located behind his right ear. Review of a wound assessment dated [DATE], revealed that the area behind his right ear was .50 cm x .20 cm x .20 cm with a scant amount of serous drainage noted. The wound was documented on this 395616 Page 17 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment as a Stage 2 pressure ulcer (a shallow open wound that occurs when the skin breaks through its top layer into the layer below presenting as a shallow open area). The current treatment order that was initiated on September 20, 2024, was to cleanse the right ear pressure area with normal saline and apply Hydrocolloid (moisture retentive dressing) to the base of the wound and change 3 times per week, and as needed for soilage or dislodgement. There was also an order dated October 10, 2024, that indicated to wrap the oxygen tubing with foam for protection above the right ear. Observation of Resident 14 on October 16, 2024, at 10:15 AM with Employee 4, Licensed Practical Nurse, revealed he was sitting in his stationary chair in his room with his oxygen on. Observation of his right ear and the oxygen tubing revealed that there was no dressing on his right ear and there was no foam wrapped on the tubing. The tubing was laying directly on top of the open area behind his right ear. Concurrent interview of Employee 4 confirmed the above noted findings related to Resident 14's right ear pressure ulcer. The Director of Nursing was made aware of concerns with Resident 14's pressure ulcer on October 17, 2024, at 3:15 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395616 Page 18 of 23 395616 10/18/2024 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 Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of two residents reviewed (Resident 78). Residents Affected - Few Findings include: Clinical record review for Resident 78 revealed the facility admitted him on May 11, 2023, with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 78's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 6, 2024, indicated that the facility assessed Resident 78 as having a diagnosis of dementia and his cognition was moderately impaired. A review of Resident 78's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview with the Director of Nursing on October 17, 2024, at 3:15 PM confirmed the facility had no further documentation that the facility developed and implemented individualized person-centered care plans to address Resident 78's dementia and cognitive loss. 483.40(b)(3) Dementia Treatment and Services Previously cited 12/15/23 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395616 Page 19 of 23 395616 10/18/2024 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 Residents Affected - Many 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 and serve food in accordance with professional standards for food service safety and sanitation to prevent the potential for food borne illness in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on October 15, 2024, at 9:40 AM revealed the following: A large storage area located outside the entrance to the kitchen containing a milk cooler, storage cabinets, bread products and other storage, contained dried food and dirt debris on the flooring under the pieces of equipment and along wall and equipment edges where they meet the floor. An ice scoop was observed stored on the side of the ice machine totally open to air and potential contaminants. The exterior of the convection ovens contained significant dust and debris buildup on the top of the ovens and control panels. The wall behind the oven, fryer, and stove top area contained dried food splatter. The flooring under and behind the equipment contained significant debris. The drain on the front of the steamer contained a large amount of food debris inconsistent with items prepared in the kitchen at the time. A perforated pan stored inverted on the top of the steamer contained dried food stuck to the pan. A slicer was observed uncovered on a countertop. Employee 1, director of dining services, was not sure when the slicer was used last. Dried food was observed in the blade area and beside the controls. A large floor stand mixer was observed not in use and uncovered. Dried food and dust were observed on the metal wire guard at the top of the mixer and the bowl was open and uncovered with the potential to collect dust, debris, and contaminants. Two small floor ramps to a two-door cooler across from the mixer were observed with significant dirt and debris collected along the sides of the ramps. A grid type ceiling vent in the chemical storage room was covered in dust. An additional square metal ceiling vent was blackened and dusty. A sprinkler head next to the vent appeared corroded and dusty. The dry storage area contained multiple brown spotted ceiling tiles. Employee 1 was unsure what the brown spots came from. The following items were observed in the emergency supply room: 395616 Page 20 of 23 395616 10/18/2024 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 Residents Affected - Many A case of corn flakes with a received date of September 28, 2023, and a manufacturer's expiration date of June 20, 2024. A case of crispy rice cereal with a manufacturer's expiration date of July 11, 2024. A box of graham crackers received on September 28, 2023, with no expiration date. Employee 1 was not sure if the product was expired or when it expires. A case of oatmeal cream pies received on September 28, 2023, which Employee 1 indicated were good for one hundred years, by a number code located on the product. Additional numbers on the box also interpreted a code that the product may have expired on June 23, 2024. Employee 1 confirmed he was not sure of the product's actual expiration date. A bottle and one case of cranberry juice cocktail received on September 28, 2023, with a manufacturer's expiration date of August 8, 2024. Two cases of apple juice with a manufacturer's expiration date of May 8, 2024. A follow up observation in the main kitchen on October 17, 2024, at 11:06 AM revealed the following: Multiple square ceiling vents over the production and serving area blackened and contained dust buildup. Staff were observed serving pork, mashed potatoes, and vegetables on the lunch serving line in addition to mechanically altered ground pork, pureed pork, and pureed vegetables. A review of the temperature log sheet of serving temps for the food items revealed there was no evidence the temperature was checked for the ground pork or pureed items that were being served on the line prior to service to assure appropriate temperatures were met. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on October 17, 2024, at 2:55 PM. 483.60 (i)(2) Food store, distribute, maintain, sanitary Previously cited 11/3/23 28 Pa. Code 201.14 (a) Responsibility of licensee 395616 Page 21 of 23 395616 10/18/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for two of five residents reviewed for transmission-based precaution concerns (Residents 19 and 288). Residents Affected - Few Findings include: Review of the facility policy entitled Infection Control Plan, last approved September 6, 2024, indicated the infection control plan is comprehensive in that it addresses detection, prevention, and control of infections among residents and personnel and all staff are responsible for adhering to the plan, policies, and processes regardless of their position. The policy also indicated Transmission-Based Precautions (TBP) are the second tier of basic infection control and are used in addition to standard precautions for patients who may be infected or colonized with certain infectious pathogens for which additional precautions are needed requiring a gown and gloves for room entry and patient care activities where contact precautions are in place, and additionally, droplet precautions require a face mask for room entry and patient care, and airborne precautions require a respirator (N95 mask) for room entry and patient care. An observation of Resident 19's room on October 15, 2024, at 12:30 PM revealed a sign on the exterior of the resident's door frame noting Droplet and Contact precautions for the room noting Resident's 19's bed number. Continued observation revealed two staff members in the hall entering and exiting resident rooms collecting meal trays. The unidentified staff members were observed entering Resident 19's room, assisting the roommate with positioning in bed, and collecting Resident 19's meal tray, exiting the room to the hallway. The staff member with the tray opened the door to a meal delivery cart and placed the tray in the cart and continued to move down the hall to other resident rooms collecting meal trays. The two unidentified staff members observed did not don or doff any mask, gown, or gloves when entering Resident 19's room. The staff member obtained the tray without gloves, touched the meal delivery cart, and continued to other resident room without hand washing or hand sanitizing. Clinical record review for Resident 19 revealed the resident had an active physician's order dated October 15, 2024, for Droplet Precautions: Norovirus 10/11/24 (a group of viruses that causes severe vomiting and diarrhea). An observation of Resident 288's room on October 17, 2024, at 11:41 AM revealed a sign outside the resident's room noting Droplet Precautions with Resident 288's bed number written on the sign. Two visitors were observed in the resident rooms standing over the resident's bed as the resident was consuming lunch. The visitors were not observed wearing any personal protective equipment (PPE) such as gloves, mask, or gown. At 11:59 AM an unidentified facility staff member entered Resident 288's room and was observed walking past the resident's bed, briefly talking with the visitors, and then obtaining a jacket from the roommate's side of the room. The staff member walked out towards the nurse's station and proceeded to give the jacket to another resident. The staff member did not don any PPE to enter the room. At 12:06 PM Employee 2, nurse aide, entered Resident 288's room without donning any PPE, and obtained the resident's meal tray as the visitors were still present in the room with the resident. 395616 Page 22 of 23 395616 10/18/2024 Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employee 2 proceeded to exit the room with the meal tray, open the door to the meal delivery cart, place the tray in the cart, and close the cart door. A concurrent interview with Employee 2 revealed that donning PPE for Resident 288's room was only needed when we change her. Clinical record review for Resident 288 revealed the resident was admitted to the facility on [DATE], and was ordered droplet precautions upon admission for MRSA (Methicillin-resistant Staphylococcus aureus) of the nares. The order also indicated You will be required to follow droplet precautions until nares is resolved. Facility staff failed to follow appropriate donning of required PPE for Resident's 19 and 288 who were ordered droplet precautions while entering the resident's room and exiting the resident's room, touching other high contact surfaces (meal delivery cart) without any further sanitization leading to the potential spread of infection. No staff were observed educating the visitors in Resident 288's room without PPE of the risks or recommended PPE for visitation. The above observations for Residents 19 and 288 were reviewed with the Nursing Home Administrator and Director of Nursing on October 17, 2024, at 2:30 PM. 483.80 Infection control Previously cited 11/3/23 28 Pa. Code 201.18(b)(3)(d)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395616 Page 23 of 23