Health inspection·December 24, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, review of information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 24 residents (Resident 9).Findings include: Review of Resident 9's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated October 22, 2025, section J1900 - Number of Falls since Admission/Entry or Reentry or Prior Assessment revealed that Resident 9 had one major injury. A major injury Includes, but is not limited to, traumatic bone fractures, joint dislocations/ subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries as per the Resident Assessment Instrument. Review of Resident 9's progress note of October 20, 2025, indicated resident was found on the floor in the bathroom. 911 was called to transport the resident to the hospital. Review of information submitted October 21, 2025, to the Department of Health revealed only observed injury was a 2.5 centimeter laceration to the occiput (back of the head or skull) region of the scalp. Laceration was stapled and resident returned to the facility. Interview with licensed staff E3 on December 22, 2025, at 1:30 p.m. revealed that the laceration was coded as a major injury because it involved the head. 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few Page 1 of 3 395806 395806 12/24/2025 St Anne's Retirement Community 3952 Columbia Avenue Columbia, PA 17512

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of one resident. (Resident 1)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included pneumonia due to pseudomonas (lung infection caused by bacteria), other chronic pain (persistent pain lasting or recurring for an indefinite period) and chronic respiratory failure with hypoxia (is a long-term condition where lungs cannot adequately exchange gases, leading to persistently low oxygen levels in the blood). Review of Resident 1 physician's orders dated December 15, 2025, revealed an order for ‘Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for severe pain'. Review of Resident 1's care plan revealed the resident has chronic pain with interventions for staff to ‘identify other factors that may enhance pain such as body position, tight clothing, anxiety or other emotional issues, etc. Provide relief as able'.Review of the Medication Administration Records for December 2025, revealed that the Resident 1 received the as needed narcotic (Oxycodone HCl) on December 5, 2025, to December 22, 2025, without documented evidence that non-pharmacological interventions were attempted prior to administration. During an interview on December 24, 2025, at 10:30am., the Assistant Director of Nursing confirmed that the Oxycodone HCl was administered to Resident 1 and failed to provide documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few 395806 Page 2 of 3 395806 12/24/2025 St Anne's Retirement Community 3952 Columbia Avenue Columbia, PA 17512

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure enhanced barrier precautions were in place for residents requiring enhanced barrier precautions for one of 12 residents reviewed (Resident 2).Findings include:Review of facility policy, Enhanced Barrier Precautions, reviewed February 27, 2025, indicated that the facility will have the appropriate signage on how to communicate to staff which residents require the use of enhanced barrier precautions (EBP). The following will list EBP criteria: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multidrug-resistant organism.Observation on December 23, 2025, at 9:00 a.m. revealed Resident 2 with tube feeding running. Observations of Resident 2's room on all days of the survey failed to reveal evidence of EBP signage or personal protective equipment. Review of Resident 2's physician's orders revealed that the resident was receiving an enteral feed (tube feeding - soft tube which delivers liquid nutrition directly into the gastrointestinal tract).Interview with licensed staff Employee E4 on December 24, 2025, at 10:05 a.m. confirmed that Resident 2 would meet the criteria for EBP due to the tube feeding and that EBP was not in place for Resident 2.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(1)(5) Nursing services Residents Affected - Few 395806 Page 3 of 3