Health inspection·November 22, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 10 residents reviewed (Residents R1, R2, R7, R8, R10, R11, and R12). Findings include: Review of facility policy entitled Care Plans dated 8/9/23, indicated The care plan will be reviewed, evaluated, and updated at a minimum of every 90 - days. Resident R1's clinical record revealed an admission date of 4/23/23, with diagnoses that included Multiple Sclerosis (MS - a degenerative disease that affects the nerves disrupting the signals between the brain and body), Traumatic Brain Injury (TBI - injury to the brain caused by trauma), and Epilepsy (neurological disorder resulting in seizures). Review of Resident R1's comprehensive care plan revealed that of the eight care plans present, eight had an outstanding target date (a date that the resident's care plan must be updated by) of 7/23/23. Resident R2's clinical record revealed an admission date of 11/18/23, with diagnoses that included Metabolic Encephalopathy (condition when brain function is disturbed due to disease), Hypothyroidism (disorder when the thyroid gland does not produce enough thyroid hormone), and Kidney Failure. Review of Resident R2's comprehensive care plan revealed that of the 15 care plans present, 15 had an outstanding target date of 10/17/23. Resident R7's clinical record revealed an admission date of 11/18/21, with diagnoses that included Epilepsy, Multiple Sclerosis, and Dysphagia (difficulty swallowing food and/or liquids). Review of Resident R7's comprehensive care plan revealed that of the 17 care plans present, 17 had an outstanding target date of 9/25/23. Resident R8's clinical record revealed an admission date of 3/15/11, with diagnoses that included Dementia (condition that affects the brains ability to think, remember, and function normally), Peripheral Vascular Disease (disorder that affects the blood flow to your legs), and Cirrhosis of the Liver (a degenerative disease of the liver) Review of Resident R8's comprehensive care plan revealed that of the 17 care plans present, 17 had Page 1 of 3 395728 395728 11/22/2023 Lecom at Snyder Memorial 156 Snyder Memorial Rd Marienville, PA 16239

F 0657 an outstanding target date of 10/12/23. Level of Harm - Minimal harm or potential for actual harm Resident R10's clinical record revealed an admission date of 5/17/19, with diagnoses that included Hypothyroidism, Diabetes, and Dysphagia. Residents Affected - Some Review of Resident R10's comprehensive care plan revealed that of the 17 care plans present, 17 had an outstanding target date of 10/31/23. Resident R11's clinical record revealed an admission date of 5/8/19, with diagnoses that included Dysphagia, Alzheimer's, and Depression. Review of Resident R11's comprehensive care plan revealed that of the 15 care plans present, 15 had an outstanding target date of 11/1/23. Resident R12's clinical record revealed an admission date of 10/23/23, with diagnoses that included High Blood Pressure, Dysphagia, and Stroke. Review of Resident R12's comprehensive care plan revealed that of the 13 care plans present, 13 had an outstanding target date of 11/10/23. During an interview on 11/22/23 at 2:59 p.m. the Director of Nursing confirmed that Residents R1, R2, R7, R8, R10, R11, and R12's care plans were not reviewed and /or revised timely as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395728 Page 2 of 3 395728 11/22/2023 Lecom at Snyder Memorial 156 Snyder Memorial Rd Marienville, PA 16239

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to falls for one of three residents reviewed (Resident R1). Findings include: Review of facility policy dated 8/9/23, entitled Fall Prevention and Fall Management indicated that When a fall occurs the following will be followed by the nurse - Complete a QA Incident Report and Document the assessment of the resident and any orders / interventions in the medical record. Resident R1's clinical record revealed an admission date of 4/23/23, with diagnoses that included Multiple Sclerosis (MS - a degenerative disease that affects the nerves disrupting the signals between the brain and body), Traumatic Brain Injury (TBI - injury to the brain caused by trauma), and Epilepsy (neurological disorder resulting in seizures). Investigation into Resident R1's fall history revealed there was no evidence in Resident R1's clinical record of a fall occurring on or around 10/13/2023. Interview with Director of Nursing (DON) on 11/21/2023, at approximately 11:47 a.m. revealed that although he/she was not present at the time of the fall, Resident R1 was in the Nursing Home Administrator's (NHA) office when he/she attempted to stand on his/her own and fell. Phone interview with NHA confirmed that this did occur and that the Emergency Medical Service (EMS) were present and that EMS assisted Resident R1 to the stretcher, treated a skin tear that was sustained and transported Resident R1 to the emergency room due to an unrelated issue. During an interview on 11/21/2023, at approximately 12:00 p.m. the DON confirmed that the clinical record should contain a progress note or an incident report related to the fall and that Resident R1's clinical record lacked evidence of either one being completed. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395728 Page 3 of 3