Health inspection·October 20, 2023

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 ensure a safe, clean, and homelike environment on four of four nursing units (Applewood unit, Bayberry Unit, Chestnut Unit and Dogwood Unit; Residents 43, 75, 230, 41, 62, and 60). Findings include: Observation of the Bayberry Unit on October 17, 2023, from 10:35 AM through 3:23 PM revealed a strong odor of urine in the hallway, which was stronger near the far end of the hallway and in the room shared by Residents 75 and 43. Observation on October 18, 2023, at 9:57 AM revealed the urine odor continued to be present on Bayberry Unit. During a concurrent interview with Employee 1, housekeeper, about the urine odor in the room shared by Residents 75 and 43, revealed that the room has an odor despite her cleaning. When asked if the room was deep cleaned, Employee 1indicated it has not been deep cleaned in the past month. Employee 2, licensed practical nurse, entered the conversation, and indicated that Resident 43 has a medical problem that also contributed to the odor. Employee 3, nurse aide, indicated that she cleans the mattresses, Residents 75 and 43 recently were provided new mattresses, and that Resident 43 urinates on the floor. Observation of the footboard on Resident 75's bed revealed a three-inch-wide strip the length of the footboard was peeled off exposing particle board. An observation of the privacy curtain for Resident 230 revealed the curtain was soiled with brown spots. An observation of the ceiling above Resident 41's head of the bed revealed that the ceiling had a brown spot that was approximately eight inches. Some of the ceiling was peeling. An observation on October 18, 2023, at 9:52 AM of the fall mat on the floor next to Resident 62's bed revealed the mat had exposed foam in two sections that was approximately 10 inches in length each. The above findings for the environment on Bayberry Unit was reviewed with the Nursing Home Administrator and Director of Nursing in a meeting on October 18, 2023, at 2:25 PM. An additional observation on October 19, 2023, at 11:40 AM on Bayberry Unit revealed the frame of the mechanical lift had a build-up of debris. Concurrently, the surveyor informed the Nursing Home Administrator. Page 1 of 20 395699 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the Dogwood Nursing Unit on October 18, 2023, at 10:09 AM and again on October 19, 2023, at 9:55 AM revealed the following findings in the shower room: A portable oxygen tank on a wheelchair was observed with a nasal cannula attached to the regulator. The oxygen tubing was dated 9/23/23. An interview with the Director of Nursing on October 19, 2023, at 11:06 AM revealed the tubing should be changed weekly. There was a significant amount of dust and debris under the heating vent located in the tub room. A blue pillow was observed with a plastic-like covering. The cover had multiple holes in it which exposed the foam padding. There was a significant amount of dust accumulated on a ceiling vent that was running. Paint was flaking in various areas on the ceiling of the shower stall. A small, brown-colored shelf located along a wall had a substantial build-up of debris and hair on the floor behind it. Observation of the Dogwood Nursing Unit on October 18, 2023, at 10:19 AM and again on October 19, 2023, at 9:55 AM revealed a black-colored coffee cup on the top shelf of the linen cart that was located next to personal hygiene supplies. The cup was filled with multiple packets of sweet'n low, salt, and non-dairy creamers. Observation on the Dogwood Nursing Unit on October 18, 2023, at 10:23 AM revealed the air unit located on the ceiling of the main hallway had a build-up of dust on the vents. Observation of Resident 60's room on October 18, 2023, at 11:06 AM revealed multiple cobwebs on and in the windowsill of the resident's room. A concurrent interview revealed the resident had asked previously to have the cobwebs cleaned, but they were not. Observation of the soiled utility room on Dogwood Nursing Unit on October 19, 2023, at 9:58 AM revealed a significant build-up of multiple cobwebs in the corners of the room and behind a hot water heater. There were multiple small sized, winged insects in the cobwebs and at least four large spiders observed in the various webs. The above findings for the Dogwood Nursing Unit were reviewed with the Nursing Home Administrator and Director of Nursing on October 19, 2023, at 11:13 AM. Observation of Resident 32's room on the Bayberry unit on October 17, 2023, at 3:36 AM revealed a bed controller with wires exposed. There was duct tape near the exposed wires on the controller, but it was no longer covering the wires. Her nightstand had a dusting of white powdery substance on it. A fan and a compact disc player located on the nightstand were covered with the white powder. The outside of her garbage can had dried brown spills on it. The privacy curtain between the beds was off some of the hooks. The privacy curtain right inside the door had brown spots on it. Her wheelchair was sitting at the bottom of her bed and appeared very dirty on the frame and inside of the wheels. Observation on October 17, 2023, at 11:40 AM of Resident 66's room on the Applewood unit revealed a pile of drywall dust on the floor behind the headboard of his bed. The wall behind the headboard 395699 Page 2 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was noted to have an area where the drywall was exposed. The windowsill was dirty. The window (right side when looking to the outside), had a big cobweb between the window and the screen that goes across the whole right-side window. Observation of Bayberry unit on October 17, 2023, at 3:30 PM revealed a strong urine odor in the room of Resident 20 and Resident 36. Observation of their rooms on October 18, 2023, at 3:32 PM revealed the strong urine odor was still present. The above findings for Residents 20, 32, 36, and 66 were reviewed with the Nursing Home Administrator and Director of Nursing on October 19, 2023, at 11:13 AM. Observation of the Chestnut Nursing Unit on October 17, 2023, at 11:39 AM, October 18, 2023, at 9:11 AM, and October 19, 2023, at 9:23 AM revealed that upon entering and throughout the hall there was a very strong urine smell. This urine smell intensified when nearing the middle of the hallway. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 2:00 PM. 28 Pa. Code 201.18 Management (e) (2.1) 395699 Page 3 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and resident and staff interview, it was determined that the facility failed to thoroughly investigate, implement interventions to prevent, and report an allegation of potential staff to resident abuse for one of three residents reviewed for abuse (Residents 32). Residents Affected - Few Findings include: Clinical record review for Resident 32 revealed a progress note dated September 15, 2023, at 6:38 AM that indicated when two staff entered Resident 32's room she was heard repeatedly stating, I don't want her in here. Don't let her in here. When the staff asked her who she was referring to Resident 32 replied, Employee 7. When staff asked resident why, she indicated that Employee 7 was mean but did not elaborate further. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on October 19, 2023, at 10:54 AM revealed that the allegation noted above was never reported to them and a full investigation was never done. On October 19, 2023, at 10:54 AM the DON provided the surveyor with statements collected on the same date from the two staff members that had the above encounter with Resident 32. The statement provided to the surveyor that was from Employee 5, registered nurse (RN) indicated that all Resident 32 would say is that Employee 7 was mean. The statement provided to the surveyor that was from Employee 6, licensed practical nurse (LPN) indicated that Employee 7 was mean, and that Resident 32 would not elaborate further. Interview with Resident 32 on October 19, 2023, at 1:14 PM revealed that she is afraid of Employee 7, nurse aide. She indicated that Employee 7 is mean to her and sprays water in her face when she showers her, and it hurts her. She said that Employee 7 is rough with her and takes things from her and won't let her have pizza when it comes on her tray. She also said that she did not want Employee 7 taking care of her. The NHA and DON were made aware of the above noted statements from Resident 32 on October 19, 2023, at 2:48 PM. They indicated that they did not investigate because they did not know about the event. They also indicated that Employee 7 has continued to care for Resident 32 with no further concerns identified. Further interview with the NHA and DON on October 19, 2023, at 2:48 PM confirmed that the facility failed to thoroughly investigate, implement interventions to prevent, and report to the appropriate agencies an allegation of potential staff to resident abuse, for the above incidents noted on September 15, 2023, at 6:38 AM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395699 Page 4 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0688 Level of Harm - Minimal harm or potential for actual harm 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. Based on clinical record review and staff interview, it was determined that the facility failed to complete restorative range of motion programs on four of four residents reviewed (Residents 1, 32, 55, and 68). Residents Affected - Some Findings include: Clinical record review for Resident 32 revealed a progress note dated October 6, 2023, at 7:17 AM that indicated she is receiving occupational and physical therapy and her restorative nursing program will be discontinued. Further clinical record review for Resident 32 revealed that she was on a nursing rehab program for passive range of motion (PROM) to her bilateral upper extremities (BUE) that was discontinued on October 6, 2023. The program order did not indicate specific days or times it was to be completed. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on October 19, 2023, at 2:40 PM confirmed that Resident 32's PROM did not indicate what days or times it was to be completed. They also indicated that the Restorative nurse aide only works part-time, 3 days a week and the understanding is that if the PROM program is in the nurse aide task, then the nurse aides should be doing it. Review of Resident 32's documentation for her PROM program for the dates of August 6, 2023, to October 4, 2023, revealed that she only received the program 23 days out of 60 days reviewed. Review of occupational therapy evaluation and plan of treatment notes for September 26, 2023, indicated one goal was to fit Resident 32 with a splint to the left hand to increase overall range of motion and to improve skin integrity. They also indicated her base line was that her nails were digging into the left palm and nails on digits (fingers) 1-3 on her left hand were leaving marks in her palm. The occupational therapy assessment summary dated September 26, 2023, indicated the reason for occupational therapy was that Resident 32 had a decline in her BUE ROM , increased pain with ROM, and the need for fitting with a new orthotic (a device that supports or corrects the function of a limb, i.e., splint) to the left hand as fingernails have begun to leave marks in the palms of her hand. Interview with the DON and NHA on October 20, 2023, at 9:15 AM confirmed the above noted findings that Resident 32's BUE ROM program was only completed 23 days out of 60 days, and she experienced a decline in her ROM. The facility failed to prevent a decline in ROM to Resident 32's bilateral upper extremities. Clinical record review for Resident 1 revealed a care plan dated June 14, 2023, for staff to provide and encourage gentle active and passive range of motion (AROM/PROM) to bilateral lower extremities with morning and evening care, bathing, and dressing. Review of task documentation for Resident 1 for August, September, and October 2023, revealed that staff did not document completion of the restorative task or documented not applicable on the 395699 Page 5 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0688 following dates: Level of Harm - Minimal harm or potential for actual harm Morning care: August 1, 15, 19, 20, 24, and 29, 2023 Residents Affected - Some September 12, 20, and 25, 2023 October 3, 4, 14, and 15, 2023 Clinical record review for Resident 55 revealed that she was discharged from physical therapy on August 9, 2023, with a recommendation to implement a bilateral lower extremity (BLE, legs) AROM exercise bike, with the resistance setting on four, restorative nursing program (RNP). Review of task documentation for Resident 55 from August and September 2023, revealed that staff did not implement her BLE AROM exercise bike RNP until August 21, 2023, 12 days after Physical Therapy recommended the restorative program, with Resident 55 to complete the RNP three to seven times per week for 15 minutes as needed (PRN) on day shift. The facility discontinued the RNP program on September 8, 2023, 18 days after implementation. Staff documented completion of the restorative task on the following dates: August 23, 2023, tolerated well August 26, 2023, tolerated poorly August 27, 2023, tolerated poorly August 29, 2023, tolerated poorly September 4, 2023, tolerated well September 6, 2023, resident refused Review of Resident 55's restorative nursing documentation dated August 21, 2023, at 1:24 PM confirmed the RNP implementation, noting the program will be attempted and monitored for compliance as resident can have behaviors and at times resist care. Restorative aide educated. Further review of Resident 55's restorative nursing documentation dated September 8, 2023, revealed that staff indicated that Resident 55 was cooperative, with a disagreeable attitude .benefitted from the strengthening program but seems to be overly tired at this time. Will d/c the program at this time with goals met. Review of Resident 55's behavior monitoring for August and September 2023, revealed no behaviors during day shift on the dates the exercise bike RNP was completed. The facility completed Resident 55's exercise bike RNP only two times weekly, not three times weekly as implemented between August 21, 2023, and September 8, 2023. Interview with Employee 9, registered nurse, PRN restorative nurse, on October 20, 2023, at 9:58 AM 395699 Page 6 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that the facility had a restorative nurse aide who worked part-time three days per week, indicated that the restorative nurse aide was the only staff member who completed the restorative nurse programs, and confirmed that resident restorative programs are not completed by floor staff if the restorative nurse aide was not available. Employee 9 confirmed Resident 55's exercise bike was to be completed three to seven times weekly and indicated that the task was ordered PRN to allow the restorative nurse aide to not have to complete if she is not available that week. Clinical record review for Resident 68 revealed a current care plan for staff to do gentle PROM BLE during morning and evening care, showers, and dressing. Review of Resident 68's task documentations revealed that staff did not document completion of the restorative task or documented not applicable on the following dates: Morning Care: June 14, 15, 20, and 25, 2023 July 4, 13, and 17, 2023 August 1, 14, 15, 20, 23, and 24, 2023 September 1, 6, 7, and 20, 2023 October 3, 4, 5, 9, 11, 14, and 15, 2023 Evening Care: June 23, 2023 The surveyor reviewed the above information on October 19, 2023, at 2:00 PM, with the Nursing Home Administrator and Director of Nursing. 483.25(c)(2)(3) Increase/prevent Decrease in Rom/mobility Previously cited 10/14/2022 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395699 Page 7 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

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 review of select facility policy and procedures, clinical record review, review of facility documents, and staff and resident interview, it was determined that the facility failed to implement interventions and provide adequate supervision for a resident that smokes (Resident 60). Findings include: A review of the facility Smoking Policy last reviewed without changes on December 19, 2022, revealed that the purpose of the policy is to always provide maximum safety to all residents. It is the intent to provide an environment to allow residents who wish to smoke the opportunity to do so in a safe environment with optimal safety to themselves, other residents, volunteers, visitors, and staff members. Designated supervised smoking times are 9:00 AM to 9:15 AM; 10:30 AM to 10:45 AM; 1:00 PM to 1:15 PM; 3:45 PM to 4:00 PM; and 7:00 PM to 7:15 PM. The policy further noted that residents must be accompanied by staff, family, or properly trained volunteers while smoking. Facility documentation titled Smoking Policy Acknowledgement for Resident 60 dated April 20, 2021, revealed the resident signed the form that acknowledged the resident will adhere to the smoking policies. The form noted a resident smoking assessment was completed and indicated the resident may smoke under the following conditions - supervision is checked. A current care plan for Resident 60 revealed the resident has smoking privileges and noted an intervention that the resident will use a smoking apron, and only smoke during designated times in the designated areas with supervision. A physician's order noted Resident 60 may smoke per facility policy. Documentation dated August 31, 2023, at 11:00 AM revealed Resident 60 was found by staff on his left side on the smoker's patio. He reportedly had lost his balance and had fallen. The resident was having pain in the left upper extremity. The resident was transported to the hospital. Documentation dated August 31, 2023, at 11:46 AM revealed the resident was found to be lying on his left side after reportedly falling. The resident was noted to be a smoker that goes outside regularly for smoking breaks. The resident was .complaining of left shoulder/arm pain. The resident was supported by staff and maintained on his left side and transferred to the hospital. Documentation dated August 31, 2023, at 2:04 PM revealed Resident 60 returned from the hospital. Facility documentation dated August 31, 2023, at 11:00 AM revealed an investigation that indicated Resident 60 was found on the ground on the smoker's patio. The documentation noted no witnesses. An interview with the Nursing Home Administrator (NHA) on October 20, 2023, at 10:02 AM revealed Resident 60 was in the designated area smoking and did not have any direct supervision. The NHA revealed the resident was being monitored by staff walking by the smoking area, but there was no designated staff member responsible for the resident's supervision at the time. The resident was not accompanied by staff, family, or any properly trained volunteers while out smoking as noted in the policy. An interview with Resident 60 on October 20, 2023, at 10:36 AM revealed that it was only himself 395699 Page 8 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0689 Level of Harm - Minimal harm or potential for actual harm and another resident in the designated area at the time of the fall. There were no staff present providing supervision. The above information for Resident 60 was reviewed in an interview with the NHA and Director of Nursing on October 20, 2023, at 10:02 AM. Residents Affected - Few 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/14/22 28 Pa. Code 201.18(b)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395699 Page 9 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0692 Provide enough food/fluids to maintain a resident's health. 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 follow physician orders to maintain acceptable weights regarding nutrition management for one of one resident reviewed (Resident 68). Residents Affected - Few Findings include: Clinical record review for Resident 68 revealed that her weights were as follows: April 20, 2023, 154.2 pounds May 16, 2023, 153.4 pounds May 18, 2023, 153.2 pounds June 15, 2023, 143.6 pounds (9.6 pounds, 6.2 percent weight loss in one month) June 16, 2023, 143.4 pounds July 6, 2023, 134.6 pounds (19.6 pounds, 12.71 percent weight loss in three months) July 7, 2023, 139.4 pounds July 13, 2023, 134.8 pounds July 20, 2023, 134 pounds July 28, 2023, 134.6 pounds August 4, 2023, 135.8 pounds August 10, 2023, 140.4 pounds August 11, 2023, 132.2 pounds (21.2 pounds, 13.8 percent weight loss in three months) August 20, 2023, 141.0 pounds August 23, 2023, 140.2 pounds September 8, 2023, 142.0 pounds September 14, 2023, 139.8 pounds September 23, 2023, 140.2 pounds September 27, 2023, 140.0 pounds October 5, 2023, 141.4 pounds 395699 Page 10 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0692 October 12, 2023, 136.4 pounds Level of Harm - Minimal harm or potential for actual harm October 19, 2023, 136.6 pounds (17.6 pounds, 11.41 percent weight loss in six months) Resident 68's physician ordered the following: Residents Affected - Few On May 9, 2023, for staff to provide her med pass (dietary supplement) 90 milliliters (ml) four times daily (QID). On May 19, 2023, regular diet, texture, and consistency. On July 11, 2023, a speech therapy consultation. On July 18, 2023, regular diet, mechanical soft texture per speech therapy's recommendation. On July 31, 2023, nutrient dense mechanical soft regular diet, and active critical care supplement 1 ounce daily per the registered dietitian recommendation. On September 11, 2023, discontinue active critical care supplement per the registered dietitian. On October 9, 2023, active crucial care 1 ounce daily per the registered dietician recommendation. Review of Resident 68's registered dietitian documentation revealed the following: On May 9, 2023, the dietitian identified that Resident 68's weight had been trending down and most recent weight shows a 7.6-pound loss and added 2 ounces of Med Pass supplement QID. On July 31, 2023, the dietitian noted that Resident 68 had a 19.6-pound (12.7 percent) significant weight loss in 90 days and 23.6 pounds (14.9 percent) weight loss in 180 days and a Stage II pressure ulcer on Resident 68's coccyx. The dietitian recommended an increase in the med pass supplement to 3 ounces (90 ml) QID, though Resident 68 was already on 90 ml of med pass supplement since May 9, 2023, add 1-ounce active supplement daily, and change Resident 68's diet to nutrient dense. On September 10, 2023, the dietitian noted that Resident 68 had a 13-pound (8.4 percent) significant weight loss in 90 days, and 17.4-pound (11 percent) weight loss in 180 days. The dietitian discontinued the active supplement related to a healed pressure injury. On October 9, 2023, the dietitian noted Resident 68 now had 2 pressure injuries to her coccyx and her weight was stable in the past month. The dietitian re-implemented the 1-ounce active supplement daily for wound healing. Review of Resident 68's speech therapy documentation revealed that she received speech therapy from July 12, 2023, through August 9, 2023, for treatment of swallowing dysfunction and was discharged due to reaching her maximum potential in her speech therapy needs. Review of Resident 68's wound documentation revealed that her coccyx wound healed on June 20, 2023, but re-opened on June 27, 2023. The wound healed again on August 14, 2023, but re-opened again on September 26, 2023. 395699 Page 11 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no documentation that indicated the facility's dietitian identified, monitored, and implemented dietary interventions to Resident 68's weight loss and pressure ulcers between May 9, 2023, and July 31, 2023, and July 31, 2023, and September 10, 2023. This surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on October 19, 2023, at 2:00 PM. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services 395699 Page 12 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 and resident and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice for one of one resident reviewed for dialysis concerns (Resident 230). Residents Affected - Few Findings include: Clinical record review for Resident 230 revealed that he was a resident of the facility from August 23, 2023, through September 1, 2023. He was readmitted to the facility on [DATE]. Interview with Resident 230 on October 17, 2023, revealed that he goes to dialysis (a process of purifying the blood of a person whose kidneys are not working normally) on Monday, Wednesday, and Friday. He reported that he has a shunt (a surgically created connection to allow direct access to the bloodstream for dialysis) in his left forearm that does not work so he receives dialysis through a tube in his chest. Resident 230 pointed to a central venous catheter (a small tube inserted in the chest to access blood supply and to provide dialysis) that was partially covered by a dressing in the right upper chest that had two access lumens (tubes to access the bloodstream). Resident 230 reported that when he was here previously, he often missed his lunch because he left for dialysis around noon, and he doesn't eat at dialysis. Resident 230 reported that the staff at dialysis are the only ones to care for the central venous catheter and dressing. Review of Resident 230's physician orders revealed that he did not have an order to go to dialysis including the specific days of the week and there were no orders on care of the central venous catheter. Review of Resident 230's dialysis care plan did not include which days of the week he attends dialysis, what time he leaves and returns to the facility, who provides transportation, if he would require a meal before dialysis, if his central venous catheter site would require monitoring after dialysis, or any emergency procedures if bleeding was noted. Observation on October 18, 2023, at 12:00 PM revealed the resident left for dialysis. Concurrently the surveyor questioned why he did not have lunch. Employee 2, licensed practical nurse, reported that sometimes a packed lunch is provided to the resident to take with him and maybe he took a lunch with him. The surveyor went to the kitchen and reviewed the calendar that was sent to the kitchen listing residents who are scheduled for appointments and if the resident would require a meal delivery at an earlier time. Resident 230 was not listed on this form as needing an early lunch. During an interview with Resident 230 on October 19, 2023, at 8:35 AM it was confirmed that he did not have a lunch served to him prior to dialysis on the day before. During an interview with the Nursing Home Administrator and Director of Nursing on October 20, 2023, at 10:11 AM the above findings were confirmed for Resident 230. 28 Pa. Code: 211.11(a)(c) Resident Care policies 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services 395699 Page 13 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 for the risk of side rail entrapment with the use of side rails for five of 15 residents reviewed for accidents/hazards (Residents 1, 9, 33, 49, and 60). Findings include: Observation of Resident 9 on October 17, 2023, at 11:54 AM revealed the resident had bilateral side rails on the bed. A concurrent interview with Resident 9 revealed the resident utilizes the side rails for positioning purposes. A Nursing Physical Device Review for Resident 9 dated November 8, 2022, revealed the resident uses the bilateral grab bars to aid with bed mobility and repositioning. The facility was unable to provide any documented evidence that the entrapment zones for Resident 9's grab bars were assessed. Observation of Resident 60's bed on October 18, 2023, at 11:06 AM revealed the resident had bilateral side rails. Observation of Resident 60 on October 20, 2023, at 10:36 AM revealed the resident was in bed and had bilateral side rails. A concurrent interview with Resident 60 revealed the resident utilized the side rails to get up and down. A Nursing Physical Device Review for Resident 60 dated November 8, 2022, revealed the resident uses the bilateral grab bars to help with more independent movement and independent positioning in bed. Observation of Resident 33's bed on October 19, 2023, at 10:00 AM revealed the resident had bilateral grab bars. Concurrent interview with the resident revealed he uses them to help him move in and out of bed. The facility was unable to provide any documented evidence that the entrapment zones for Resident 60 and Resident 33's grab bars were assessed. An interview with the Nursing Home Administrator and Director of Nursing on October 19, 2023, at 12:45 PM revealed that there was no evidence that could be provided to indicate the entrapment zones were assessed as required. Observation of Resident 49 on October 17, 2023, at 11:51 AM, October 18, 2023, and October 19, 2023, at 9:30 AM revealed the resident was bed with bilateral one-quarter side rails observed on the bed. Clinical record review for Resident 49 revealed no documentation that the bilateral one-quarter side rails were assessed for the risk of entrapment. Observation of Resident 1 on October 17, 2023, at 11:43 AM, October 18, 2023, at 9:19 AM, and 395699 Page 14 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0700 Level of Harm - Minimal harm or potential for actual harm October 19, 2023, at 9:25 AM revealed the resident was in bed with bilateral one-quarter side rails observed on the bed. Clinical record review for Resident 1 revealed no documentation that the bilateral one-quarter side rails were assessed for the risk of entrapment. Residents Affected - Some The surveyor reviewed Resident 49 and Resident 1's one-quarter side rail concerns during an interview with the Director of Nursing on October 19, 2023, at 12:45 PM. 483.25 (n) (1) (3) (4) Bed rails Previously cited 10/14/22 28 Pa. Code 211.12 (d)(5) Nursing services 395699 Page 15 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 that a resident's physician made timely physician visits for one of 20 residents reviewed (Resident 47). Residents Affected - Few Findings include: Clinical record review for Resident 47 revealed that the facility admitted him on October 6, 2020. Clinical record review for Resident 47 revealed his attending physician documented a progress note on October 26, 2022, at 11:14 PM that he visited the resident on October 18, 2022. Review of a nursing note for Resident 47 dated July 15, 2023, at 8:30 PM revealed that this was the next time he was seen by his physician since October 2022. There was no corresponding note written by the attending physician. Clinical record review for Resident 47 revealed the next attending physician visit was on September 10, 2023, as written in a progress note by the physician on October 15, 2023, at 10:47 AM. The facility failed to ensure timely (every 60 days) physician visits for Resident 47. During an interview with the Director of Nursing on October 20, 2023, at 12:10 PM it was confirmed that Resident 47 did not have every 60-day physician visits. 28 Pa. Code 211.2 Medical Director (a)(3)(9) 395699 Page 16 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary manager in the absence of a full-time qualified registered dietitian. Residents Affected - Few Findings include: Interview with Employee 4, dietary manager, on October 17, 2023, at 10:58 AM revealed that that there was no full-time qualified registered dietician working on-site and that he was enrolled in a certified dietary manager (CDM) course currently. Review of an email dated January 23, 2023, revealed that Employee 4 received confirmation of enrollment in a CDM. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 18, 2023, at 2:00 PM confirmed that Employee 4 was enrolled in a CDM course and that a qualified dietician was not in the facility full-time. Interview with the NHA and the DON on October 20, 2023, at 10:00 AM revealed that the facility could not provide any documentation that Employee 4 had attended or completed any coursework associated with the CDM course in which he enrolled on January 23, 2023. 28 Pa Code 201.18(e)(1)(6) Management 28 Pa. Code 211.6(c) Dietary services 395699 Page 17 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

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 review of facility documentation, observation, and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of food borne illness in the main kitchen and the facility's pantry. Findings include: Observation of the facility's kitchen on October 17, 2023, at 10:58 AM revealed that facility staff did not document daily food temperatures on the following dates and meals: Breakfast: October 5, 10, 14, and 15, 2023, the egg, meat, and cereal portion of the meal October 7, 8, 11, 12, and 13, 2023, the fruit, milk, and coffee portion of the meal Lunch: October 3, 7, 8, 11, 12, and 13, 2023, the fruit, dessert, milk, and coffee portion of the meal October 5, 10, 14, and 15, 2023, the soup, sandwich, meat/entrée, ground and pureed meat, starch, pureed starch, vegetable, and pureed vegetable portion of the meal Dinner: October 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 16, 2023, the fruit, dessert, milk, and coffee portion of the meal October 14 and 15, 2023, all portions of the meal Further review of the facility's temperature logs revealed the following: There was no temperature monitoring of the facility's walk-in freezer and refrigerator, and the reach-in refrigerator on October 14 and 15, 2023. There was no monitoring of the pot and pan sanitizer concentrations on October 14 and 15, 2023, morning and evening shift. Staff indicated a dash, not a concentration amount as required on October 3, 4, 6, 7, 8, 9, 11, 12, 13, 16, and 17, 2023, morning shift. Further observation of the facility's kitchen on October 17, 2023, at 11:13 AM revealed that there was sliced ham covered with aluminum foil in a shallow pan that was dated October 14, 2023, in the facility's walk-in refrigerator. Interview with Employee 4, dietary manager, on October 17, 2023, at 11:17 AM confirmed that the facility did not have cool down temperature logs for the sliced ham located in the walk-in refrigerator and confirmed that the facility was missing daily food monitoring, freezer, and refrigerator temperatures, and monitoring of the pot and pan sanitizer concentrations. 395699 Page 18 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0812 Observation of the facility's pantry revealed the following: Level of Harm - Minimal harm or potential for actual harm In the cupboards: An opened box of single serve hot cocoa packets with at best before date of May 2023. Residents Affected - Many An opened container of creamy peanut butter with a best buy date of September 20, 2023. A ready to serve can of tomato soup with a use by date of April 28, 2023. In the refrigerator: 2 opened boxes of honey thick apple juice that were stuck to the shelves. One box was dated as opened on October 15, 2023, and the second box was dated as opened on October 17, 2023. Both apple juice boxes had a best by date of August 10, 2023. An open gallon of iced tea with an opened date of August 1, 2023, and a sell by date of September 11, 2023 An open bottle of ketchup with a use by date of July 3, 2023 Concurrent interview with Employee 8, licensed practical nurse, confirmed the observation. This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on October 18, 2023, at 2:00 PM. 483.60(i)(1)(2) Food Procurement. store/prepare/serve Sanitary Previously cited 10/14/22 28 Pa. Code 201.14 (a) responsibility of licensee 395699 Page 19 of 20 395699 10/20/2023 Sweden Valley Manor 1028 East Second Street Coudersport, PA 16915

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **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 obtain outside resources from the palliative care provider for one of 20 residents reviewed (Resident 47). Findings include: Clinical record review for Resident 47 revealed that he was admitted to the facility on [DATE]. A physician ordered palliative care (specialized medical care for people with a serious illness that focuses on providing relief from pain and other symptoms of the serious illness) on June 26, 2021. During an interview with Resident 47 on October 17, 2023, at 3:15 PM the surveyor required staff's assistance to help understand the resident as his voice was very weak. Review of a palliative care consultation for Resident 47 dated June 29, 2023, revealed that the resident has a long history of Parkinson's Disease (a disorder of the central nervous system that includes uncontrollable movements, stiffness, difficulty with balance and coordination, including walking and talking). The resident was struggling with his disease course. He had worsening anxiety, pain with the slightest movement, and requested multiple times for staff to just allow him to die or to sedate him. The resident was tearful throughout the visit. The Palliative Care provider indicated that the resident would be seen within a week in the facility. Clinical record review for Resident 47 revealed that there were no further palliative care consultations since June 29, 2023, and no indications that the facility followed up with palliative care. During a meeting with the Nursing Home Administrator and Director of Nursing it was confirmed that Resident 47 was ordered palliative care and it was not provided since the last visit in June. 28 Pa. Code 201.21(c) Use of outside resources 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395699 Page 20 of 20