Health inspection·December 20, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 23 residents reviewed (Residents 102 and 108). Residents Affected - Few Findings include: Review of Resident 102's clinical record revealed that the facility admitted her with a diagnosis of pneumonia (an infection in the air sacs in one or both lungs) on September 6, 2024. Review of Resident 102's resolved diagnosis list indicated that her pneumonia infection was resolved on October 10, 2024. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated November 15, 2024, indicated the facility assessed her as still having pneumonia. There was no documented evidence in Resident 102's clinical record to indicate that she had a pneumonia infection. Interview with the Administrator on December 19, 2024, at 9:11 AM confirmed that Resident 102's November 15, 2024, MDS was coded in error regarding having pneumonia. Review of Resident 108's closed clinical record revealed an MDS assessment dated [DATE], that indicated Resident 108 was discharged from the facility to a hospital setting. Physician progress note documentation dated November 11, 2024, at 11:29 AM indicated that Resident 108 was discharged home. Interview with the Nursing Home Administrator on December 20, 2024, at 10:58 AM confirmed Resident 108 was discharged home and the November 11, 2024, MDS was coded in error. §483.20(g) Accuracy of Assessments Previously cited 12/1/23 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 6 395767 395767 12/20/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

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 bowel protocol medication administration for one of 23 residents reviewed (Resident 48). Residents Affected - Few Findings include: Clinical record review for Resident 48 revealed a medical provider progress note dated November 4, 2024, at 2:17 PM that indicated she was having difficulty passing stool. Review of Resident 48's bowel elimination records revealed that staff documented no bowel movements for November 27, 28, 29, and 30, 2024, and December 7, 8, 9, 10, or 11, 2024. Clinical record review for Resident 48 revealed the following physician orders to promote bowel movements: Milk of Magnesia Suspension 400 MG (milligrams) per 5 ML (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as needed (PRN) for constipation if no BM (bowel movement) on day four give with the 7-3 shift morning medication pass. Bisacodyl Suppository 10 MG (Dulcolax, stimulant laxative medication administered via suppository form into the rectum to treat constipation by increasing fluid/salts in the intestines) Insert one suppository rectally PRN for constipation if MOM is ineffective on day five. Give with the 7-3 shift morning medication pass. Fleet's Enema 7-19 GM (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation) Insert 1 applicator rectally PRN for constipation if Dulcolax is ineffective administer on day six. Administer with the 7-3 shift morning medication pass. There was no documentation on Resident 48's medication administration record (MAR) indicating that staff initiated her bowel protocol, or that she refused her bowel protocol medications, for the dates noted above. Interview with the Director of Nursing on December 20, 2024, at 9:55 AM confirmed the above noted findings that the facility failed to provide the highest practicable care related to Resident 48's bowel protocol medication administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395767 Page 2 of 6 395767 12/20/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain proper treatment to maintain vision for one of one resident reviewed for vision concerns (Resident 41). Residents Affected - Few Findings include: An interview with Resident 41 on December 17, 2024, at 11:06 AM revealed that she saw the eye doctor a long time ago, and Resident 41stated that she never received her new glasses. Observation of Resident 41's overbed table at this time revealed there was a pair of broken eyeglasses with one of the lenses missing. Review of Resident 41's clinical record revealed see saw Health drive eye care group on June 7, 2024. Health drive recommended new glasses for Resident 41 and to deliver them upon arrival. Interview with the Nursing Home Administrator on December 20, 2024, at 10:52 AM confirmed Resident 41 never received the new glasses ordered on June 7, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395767 Page 3 of 6 395767 12/20/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

F 0699 Provide care or services that was trauma informed and/or culturally competent. 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 identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of two residents reviewed for PTSD (Resident 57). Residents Affected - Few Findings include: Clinical record review for Resident 57 revealed that the facility admitted him on March 1, 2023. Clinical record review for Resident 57 revealed that he had a current diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health disorder that is caused by an extremely stressful or terrifying event). Review of Resident 57's current care plan revealed a care plan problem entitled, has a mood problem related to PTSD and Adjustment disorder and may display moods of being withdrawn from people. Some triggers include not able to go home independently or to be at home with family. The goal and interventions were noted as follows: Resident 57 will have improved mood state through the review date Administer medications as ordered. Monitor/document for side effects and effectiveness. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Discuss with resident, if appropriate about long term care and needing assistance. Provide active listening and support when feeling overwhelmed or upset. Interview with the Nursing Home Administrator on December 19, 2024, at 11:30 AM revealed that Resident 57 was admitted with the diagnosis of PTSD. She stated that they spoke to Resident 57's wife yesterday and that she did not know what triggers him but indicated that he would wake up and go out into another room when he would have issues related to his PTSD, but he would not talk about it. She confirmed that the facility did not ask Resident 57's wife about his PTSD until after the surveyor brought it to their attention on December 18, 2024, at 2:50 PM. The facility failed to identify care plan triggers that may retraumatize Resident 57 related to his diagnosis of PTSD. 28 Pa Code 211.12 (d)(3)(5) Nursing services 395767 Page 4 of 6 395767 12/20/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to maintain the food preparation and dishwashing area in a safe and sanitary manner in the facility's main kitchen. Residents Affected - Few Findings include: An observation of the facility's main kitchen with Employee 1, dietary manager, on December 17, 2024, at 8:25 AM revealed the following: Flooring tiles surrounding the dish machine area were absent of grout with observed liquid and food debris buildup in between the tiles. Multiple vinyl tiles in the kitchen entrance area outside the dish room, surrounding the ice machine and production area inside the entrance area were broken and cracked with dirt and debris buildup. The broken and cracked tiles are susceptible to harboring food/dirt debris presenting sanitation concerns in a food preparation area. The flooring where the tile meets the wall and transition strip from the kitchen to the dish machine room was observed with significant black buildup. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 19, 2024, at 2:30 PM. 483.60 (i)(2) Food storage safe and sanitary Previously cited 1/29/24 28 Pa. Code 201.14(a) Responsibility of licensee 395767 Page 5 of 6 395767 12/20/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 a resident received the pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 5). Residents Affected - Few Findings include: Clinical record review revealed that the facility admitted Resident 5 on December 3, 2018. Review of Resident 5's immunization history revealed no evidence of a recommended pneumococcal vaccine. Review of a Pneumococcal Immunization Informed Consent dated November 18, 2024, revealed Resident 5's responsible party gave the facility permission to administer the pneumococcal vaccination. During an interview with the Nursing Home Administrator on December 20, 2024, at 11:53 AM it was confirmed that there was no documented evidence that Resident 5 was offered the pneumococcal immunization after the facility received the November 18, 2024 consent. 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations Previously cited deficiency 12/1/23 28 Pa. Code 211.12(d)(1)(5) Nursing services 395767 Page 6 of 6