Health inspection·April 30, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on review of facility policies and documents, and clinical records, and resident and staff interviews, it was determined that the facility failed to provide written notification to the resident, family and/or the resident's representative, prior to a facility-initiated room change, including the reason for the change for one of 25 residents reviewed (Resident R53). Findings include: A facility policy entitled Bed Hold Notification dated 1/22/25, indicated that if the resident is covered by Medicaid and admitted to the hospital, the bed will be held automatically for 15 days by the Medicaid Provider regulations. A facility policy entitled Bed Holds and Returns dated 1/22/25, indicated that residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available. A facility policy entitled Room Assignment/Change Policy dated 1/22/25, indicated: when a room change is necessary, the resident and family will be consulted and reasons for the move will be explained by the Social Services Department/designee; each resident will be given reasonable, advance notice prior to transfer within the facility, notice will provided both verbally and in writing; Social Services will generate an in-house transfer notice to inform staff of the location and date of transfer within the facility, and that the transfer will also be documented on the resident's clinical record. Resident R53's clinical record revealed an admission date of 2/10/19, with diagnoses that included morbid obesity, lymphedema (chronic condition causing swelling, usually in an arm or leg, due to a buildup of lymph fluid), and ongoing blood clots in the right leg. Review of a resident census document indicated he/she was enrolled in Medicaid and was coded as a Paid Hospital Leave dated 4/22/25, and coded as Active on 4/25/25, to a different room. There was no evidence that the facility provided written notification with the reason for the change prior to the facility-initiated room change. Review of the facility Daily Census report provided by the facility on 4/30/25, revealed that Resident R53's previous room was not occupied by another resident during his/her hospital stay between 4/22/25, and 4/25/25, or since his/her return to the facility on 4/25/25. Review of a Bed Hold Policy notification provided to Resident R53 on 4/22/25, revealed that he/she Page 1 of 7 395775 395775 04/30/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0559 was notified that his/her bed will be held for 15 days while he/she is admitted to the hospital. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/28/25, at 2:02 p.m. Resident R53 confirmed that he/she was not permitted to return to his/her previous room upon return from the hospital, and that he/she wanted to return to their previous room and not stay in his/her current room. Residents Affected - Few During an interview on 4/29/25, at 1:24 p.m. the Nursing Home Administrator confirmed the facility failed to provide a written notice of facility-initiated room change to Resident R53. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 395775 Page 2 of 7 395775 04/30/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and resident's Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 25 residents reviewed (Resident R97). Findings include: The facility policy entitled Advance Directives dated [DATE], revealed The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive .the interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Resident R97's clinical record revealed an admission date of [DATE], with diagnoses that included dementia (thinking and social symptoms that interfere with daily living and functioning), hypertension (high blood pressure), and heart disease. Resident R97's physician's orders dated [DATE], revealed an order for Do Not Resuscitate-Allow Natural Death (DNR). Resident R97's clinical record revealed a POLST dated [DATE], for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). During an interview on [DATE], at approximately 9:51 a.m. Registered Nurse Supervisor Employee E3, confirmed Resident R97's physician's orders and POLST were not consistent with each other. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(iv) Medical records 28 Pa. Code 211.10(c) Resident care policies 395775 Page 3 of 7 395775 04/30/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to provide appropriate suprapubic urinary catheter (tubing inserted directly into the bladder through a small incision in the lower abdomen and above the pubic bone to drain urine into a bag) care for one of three residents reviewed for catheters (Resident R51). Findings include: Review of facility policy entitled Catheter Care, Urinary dated 1/22/25, revealed Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident R51's clinical record revealed an admission date of 7/23/24, with diagnoses that included cerebral infarction (stroke), neuromuscular dysfunction of the bladder (a communication breakdown in the body that controls bladder function), and muscle weakness. Review of Resident R51's clinical record revealed a physician's order dated 12/26/24, for a suprapubic catheter related to neuromuscular dysfunction of the bladder. Observations on 4/29/25, at approximately 9:25 a.m. revealed that the bottom of Resident R51's urinary drainage bag was on the floor and there was not a privacy cover on the urinary drainage bag. During an interview on 4/29/25, at approximately 9:27 a.m. the Assistant Director of Nursing confirmed that Resident R51's urinary catheter bag should not be on the floor and a privacy cover should in place. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395775 Page 4 of 7 395775 04/30/2025 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 clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for two of 25 residents reviewed (Residents R21 and R59). Residents Affected - Few Findings include: No facility policy was provided regarding management of oxygen therapy. Resident R21's clinical record revealed an admission date of 9/27/22, with diagnoses that included respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen throughout the body), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe) , diabetes mellitus (a group of diseases that result in too much sugar in the blood), and morbid obesity with alveolar hypoventilation (a breathing disorder that could affect a person who is overweight). Resident R21's clinical record revealed a physician's order dated 1/23/25, for O2 [oxygen]: therapy at 8 lpm (liters per minute) via nasal cannula [device that delivers extra oxygen through a tube and into your nose]. Pad tubing/humidify every shift for oxygen. Observations on 4/27/25, at 2:15 p.m. revealed Resident R21 sitting in his/her wheelchair with oxygen being delivered via nasal cannula at 8 lpm. The concentrator filter on the right side of the concentrator was observed covered with a dusty gray substance. During an interview with Resident R21 on 4/27/25, at 2:15 p.m. he/she indicated that the oxygen concentrator filter on the right side of the concentrator has never been cleaned and/or changed. During an interview on 4/27/25, at 2:20 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R21's concentrator filter was dirty and covered with a dusty gray substance and did not appear to be cleaned weekly. The Director of Nursing (DON) confirmed on 4/29/25, at 1:53 p.m. that Resident R21's oxygen concentrator's filters should be checked and cleaned weekly. Resident R59's clinical record revealed an admission date of 6/21/22, with diagnoses that included irregular heartbeat, chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), heart failure, and high blood pressure. Further review of Resident R59's clinical record revealed a physician's order dated 3/06/23, for O2 therapy at 2 lpm as needed (PRN) via nasal cannula. There was a lack of evidence for a physician's order for maintaining/cleaning the oxygen equipment and lack of evidence that staff documented/recorded Resident R59's use of oxygen therapy on his/her medication administration record (MAR)/treatment administration record(TAR), and lack of evidence that staff performed respiratory assessments related to the use of supplemental oxygen. Observation on 4/27/25, at 3:16 p.m. revealed Resident R59 sitting up in bed with supplemental O2 in place via nasal cannula, and the oxygen concentrator filter was covered with a thick layer of gray 395775 Page 5 of 7 395775 04/30/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0695 fluffy substance. Level of Harm - Minimal harm or potential for actual harm During an interview at that time, Resident R59 confirmed that he/she wears oxygen 24/7 (24 hours a day/seven days a week). Residents Affected - Few Continued observations on 4/28/25, and 4/29/25, between 8:00 a.m. and 3:00 p.m. revealed Resident R59 with his/her supplemental O2 in place. During an interview on 4/27/25, at 4:28 p.m. the DON confirmed that the oxygen concentrator filter was covered in thick layer of gray fluffy substance. During an interview on 4/28/25, at 10:28 a.m. the Assistant DON confirmed there was no order for cleaning the concentrator filter. During an interview on 4/29/25, at 12:05 p.m. LPN Employee E2 confirmed that Resident R59 had his/her O2 on for the last three days and that he/she has it on all the time; there was no evidence of documentation in MAR/TAR that he/she has been receiving the O2; and no documentation that staff completed respiratory assessments related to O2 use. During an interview on 4/29/25, at 12:23 p.m. the DON confirmed there was no evidence that staff monitored Resident R59's use of O2. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395775 Page 6 of 7 395775 04/30/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two unit refrigerators reviewed (West Unit and East Unit). Findings include: A facility policy entitled, Pantries and Pantry Refrigerators and Freezers dated 1/22/25, revealed, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation Observation on 4/30/25, at approximately 9:27 a.m. of the [NAME] Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to popsicles, candy bars, and several other food items. During an interview at the time of observation of the [NAME] Unit freezer with Social Services employee, he/she confirmed that ice packs that are used on resident's bodies should not be stored in the resident freezer with food. Observation on 4/30/25, at approximately 9:31 a.m. of the East Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to several food items. During an interview at the time of observation of the East Unit freezer with Social Services employee, he/she confirmed that the ice packs that are used on resident's bodies should not be stored in the resident freezer with food. 28 Pa. Code 201.18 (e)(2.1) Management 395775 Page 7 of 7