Health inspection·July 28, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) and the October 2019 Resident Assessment Instrument User's Manual (instruction manual for completing the MDS assessments), clinical records, and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for two of 24 residents reviewed (Residents R46 and R84). Residents Affected - Few Findings include: Review of RAI instructions for MDS Section O0100C Special Treatments, Procedures, and Programs Oxygen Therapy indicated to check if the treatments, procedures, and programs were performed during the last fourteen days. Review of RAI instructions for MDS Section O0100J Special Treatments, Procedures, and Programs Dialysis indicated to check if the treatments, procedures, and programs were performed during the last fourteen days. Resident R46's clinical record revealed an admission date of 8/15/22, with diagnoses that included chronic obstructive pulmonary disease (a lung disease that obstructs airflow to the lungs resulting in difficulty breathing), high blood pressure, and anxiety. Resident R46's clinical record revealed a physician's order dated 8/15/22, for oxygen therapy at four liters per minute via nasal cannula (a tube that delivers oxygen to your nose through soft prongs) continuously for difficulty breathing. Staff signage on the treatment record identified the usage of oxygen at four liters per minute by way of nasal cannula for the entire fourteen-day look-back period for Resident R46. Review of Resident R46's quarterly MDS with an Assessment Reference Date (ARD) of 5/23/23, did not indicate the use of oxygen while a resident in the facility. Resident R84's clinical record revealed an admission date of 12/12/22, with diagnoses that included end stage renal disease (loss of kidney function), pneumonia, diabetes, and anxiety. Resident R84's clinical record revealed a physician's order dated 12/12/22, for the resident to attend dialysis (mechanical treatment to remove toxins from the body) three times a week. Review of progress notes documented in the clinical record that Resident R84 had been taken to dialysis during the fourteen-day look-back period. Page 1 of 5 395775 395775 07/28/2023 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R84's quarterly MDS with an ARD of 6/21/23, did not identify dialysis while a resident in the facility. During an interview on 7/27/23, at 4:45 p.m. Registered Nurse Assessment Coordinator confirmed that the 5/23/23, MDS for Resident R46 was coded incorrectly regarding oxygen and the 6/21/23, MDS for Resident R84 was coded incorrectly regarding dialysis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records 395775 Page 2 of 5 395775 07/28/2023 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R46). Residents Affected - Few Findings include: Review of facility policy dated 1/2023, entitled Care plan, Comprehensive Person-Centered revealed that A Comprehensive, person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident R46's clinical record revealed an admission date of 8/15/22, with diagnoses that included chronic obstructive pulmonary disease (a lung disease that obstructs airflow to the lungs resulting in difficulty breathing), high blood pressure, and anxiety. Observation on 7/26/23, at 2:00 p.m. revealed Resident R46 was utilizing oxygen at two liters per minute via nasal cannula (a tube that delivers oxygen to your nose through soft prongs). Resident R46's clinical record revealed a physician's order dated 8/15/22, for oxygen therapy at four liters per minute via nasal cannula continuously for difficulty breathing. A second physician's order dated 6/7/23, revealed Resident R46's oxygen was changed to two liters per minute via nasal cannula as needed for difficulty breathing and to maintain oxygen saturation levels between 88 percent and 92 percent. Review of Resident R46's comprehensive care plan on 7/27/23, lacked identification of Resident R46's usage of oxygen. During an interview on 7/27/23, at 4:45 p.m. Registered Nurse Assessment Coordinator confirmed that a care plan had not been developed to address Resident R46's usage of oxygen. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services 395775 Page 3 of 5 395775 07/28/2023 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on review of clinical records, family/resident interview, and staff interview, it was determined that the facility failed to ensure essential urostomy (a surgical opening into the abdomen directing urine away from the bladder) supplies were available for one of 24 residents reviewed (Resident R312). Findings include: Resident R312's clinical record revealed an admission date of 7/13/2023, with diagnoses that included bladder cancer, diabetes mellitus, and muscle weakness. Review of Resident R312's current physician's orders included an order to change urostomy pouch as needed for dislodgement with a start date of 7/13/2023 and an order to change urostomy pouch every day shift every five days with a start date of 7/18/2023. Review of progress notes dated 7/22/2023, revealed that Resident R312's spouse was in the facility with urostomy supplies and the urostomy was changed. On 7/23/2023, the urostomy was pulling away from skin and was changed. Treatment Administration Records (TAR) revealed that Resident R312's urostomy was changed on 7/18/2023 and 7/23/2023. During an interview on 7/26/2023, at 1:45 p.m. Resident R312 and his/her spouse revealed that Resident R312 had to contact his/her spouse to bring in urostomy supplies on 7/22/2023 because the urostomy had detached. Resident R312 and his/her spouse indicated that the facility did not have urostomy supplies available. During an interview with the Director of Nursing (DON) on 7/26/2023 at 2:15 p.m. it was confirmed that the facility failed to order and supply urostomy supplies in a timely manner. The DON confirmed the urostomy supplies were not ordered until 7/24/2023 and that Resident R312's spouse had to bring urostomy supplies from home. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395775 Page 4 of 5 395775 07/28/2023 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide oxygen for one of four residents reviewed for respiratory services according to a physician's orders (Resident R84). Residents Affected - Few Findings include: Review of facility policy dated 1/2023, entitled Medication Orders indicated When recording orders for oxygen, specify the rate of flow, route, and rationale. Review of Resident R84's clinical record revealed an admission date of 12/12/22, with diagnoses that included end stage renal disease (loss of kidney function), pneumonia, diabetes, and anxiety. Observation of Resident R84's oxygen flow meter (a medical device used for oxygen flow measurement) on 7/25/23, at 1:50 p.m. revealed the oxygen flow measurement was at two liters per minutes through a nasal cannula (a tube that delivers oxygen to your nose through soft prongs). Review of clinical record oxygen saturation summary revealed that staff documented that Resident R84 utilized oxygen via nasal cannula thirteen times during the month of July 2023. Clinical record progress notes revealed that staff documented that Resident R84 utilized oxygen via nasal cannula six times during the month of July 2023. Review of Resident R84's clinical record revealed that there was not a physician's order for oxygen usage. During an interview on 7/28/23, at 9:51 a.m. Registered Nurse (RN) Employee E1 stated that Resident R84 has oxygen in his/her room and does use it most of the time, but that he/she often times will remove it and staff have to reapply it. RN Employee E1 confirmed that the clinical record lacked a physician's order for oxygen therapy for Resident R84. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records 395775 Page 5 of 5