Health inspection·January 11, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for three of three months (October, November, December 2023). Residents Affected - Some Findings include: Review of a facility policy entitled, Resident Council indicated that a Resident Council Response Form will be utilized to track issues and their resolution; and the facility department related to any issues will be responsible for addressing the item(s) of concern. Review of a facility policy entitled, Grievance Policy indicated: that all concerns and questions may be presented to the facility administrator (NHA), director of nursing (DON), the registered nurse supervisor (RN Supervisor), or any department head, this may be done either orally or in writing; any new grievance shall be brought to the morning meeting to ensure that they have been entered into the grievance log and assigned for follow up; upon completion of the facility investigation, the NHA will ensure that the investigation results and resolution steps are communicated to the individual who originally submitted the grievance, complaint and/or suggestion; and resolution of the concern is desired within five working days from the date the concern was filed. Review of the October 2023 Resident Council Meeting Minutes revealed; lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included with staff being on their cell phones while giving care, call bell response times, staff leaving residents in the bathroom unattended. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of the November 2023 Resident Council Meeting Minutes revealed; lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included wraps not being done on a resident's legs on 11/11/23, and 11/12/23, staff turning off call bells and not returning to provide care, 3-11 shift staff on their cell phones while feeding residents, staff eating off resident meal trays, late smoke breaks, staff yelling at residents, a Nurse Aid being too big to toilet a resident in their room, supper being late, dietary running out of supplies, unit pantries not being stocked with snacks, and residents requesting meal of the month being implemented. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of the December 2023 Resident Council Meeting Minutes revealed; that follow-up discussion from the previous meeting included that the smoke break time was better, and lacked evidence that other concerns from the previous meeting were discussed with the Resident Council; new concerns included call bells not being answered timely, staff sitting in chairs on the halls, staff on cell phones Page 1 of 3 395775 395775 01/11/2024 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0565 Level of Harm - Minimal harm or potential for actual harm while providing care, combative residents, female resident requesting to have no male nurse aids, [NAME] pantry not stocked (out of tea bags and crackers), and meal of the month to return in January. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Concern Logs revealed: Residents Affected - Some Dated 10/02/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 10/09/23. Dated 11/13/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 11/20/23, regarding care/treatment and dietary concern types. Dated 12/05/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 12/05/23. Dated 12/13/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 12/20/23. Review of an investigation/staff education dated 10/02/23, revealed that the Assistant Director of Nursing (ADON) educated staff on call bell response, leaving residents alone in the bathroom, and re-educated staff on the facility cell phone policy. There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 11/13/23, revealed that the ADON educated staff on completing resident treatments, call bell response, leaving residents alone in the bathroom, and re-educated staff on the facility cell phone policy, staff eating off resident meal trays, smoke break, toileting residents, and staff yelling at residents There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 11/13/23, revealed the Dietary Department was working on training staff, education regarding time management and stocking, and discussing bringing back the meal of the month. There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 12/13/23, revealed staff was educated on donning (putting on)appropriate personal protective equipment in the isolation hall, relocation of residents was disorganized, call bell response, staff using vulgar language while feeding residents. Corrective actions were documented, and there was no evidence of the responsible staff member, resolution of the issues and confirmation of the Resident Council's satisfaction with the outcome. During interviews on 1/11/24, between 10:30 a.m. and 2:00 p.m. Resident Council members (Residents R1, R2, R3, R4, and R8) confirmed that previous concerns are not discussed at Resident Council Meetings and they confirmed that staff continue to turn off call bells, sit in resident rooms on their cell phones in the evening, and were told there are no snacks in the pantry. During an interview on 1/11/24, at 2:30 p.m. the ADON confirmed that staff has been re-educated repeatedly on certain reported issues. 395775 Page 2 of 3 395775 01/11/2024 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0565 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/11/24, at 2:30 p.m. the Director of Nursing and Nursing Home Administrator confirmed that there was lack of evidence that the repeated education was effective, there was a lack of developing an alternative method of resolution to the repeated concerns, and also there was a lack of evidence that the Resident Council was informed of the outcome and was satisfied with the outcomes by the facility. Residents Affected - Some 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1)(4) Management 395775 Page 3 of 3