Health inspection·May 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence and be treated with respect and dignity in death for one of four residents reviewed (Resident 4). Findings Include: Review of the facility's policy, titled Resident Rights revised [DATE], reads, in part, Employees shall treat all residents with kindness, respect and dignity. Review of Resident 4's interdisciplinary plan of care revealed diagnoses that included morbid obesity (Individuals are usually considered morbidly obese if their weight is more than 80 to 100 pounds above their ideal body weight) and chronic diastolic congestive heart failure (Diastolic heart failure occurs if the left ventricle muscle becomes stiff or thickened. The heart must increase pressure inside the ventricle to fill it. Over time, this causes blood to build-up inside the left atrium, and then in the lungs, leading to fluid congestion and symptoms of heart failure). Review of Resident 4's clinical record revealed an admission date to the facility on [DATE]. Review of Resident 4's interdisciplinary progress notes dated [DATE], at 12:04 AM, revealed documentation by Employee 5 (LPN- Licensed Practical Nurse) that reads Employee 6 (NA- Nurse Aide) provided care to resident [Resident 4 ] at 22:30 [10:30 PM]. At that time she was alert, oriented and offering no c/o [no complaints of] discomfort or pain. After providing care, the [nurse aide] exited the room and began charting. The progress notes continue Approximately 10 minutes later [nurse aide] heard the resident's roommate calling. He went into the room to offer assistance and observed the resident as nonresponsive. Employee 6 alerted the charge nurse [ Employee 5 ] who could not find a pulse, observed no breathing, could not detect a heartbeat using a stethoscope. According to documentation, Resident 4 was found to be without breath or respirations at approximately 10:40 PM on [DATE]. Documentation also revealed Resident 4's deceased body was not removed from the facility until approximately 3:00 PM on [DATE]. An interview with the Nursing Home Administrator on [DATE], at approximately 9:35 AM, revealed the Page 1 of 10 395844 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0550 Level of Harm - Minimal harm or potential for actual harm facility could not reach the family/responsible party during the night. The interview also revealed Resident 4 had no funeral arrangements in place in order to facilitate an expedited transfer to a funeral home of her or her family's choice. 28 Pa. Code 201.14 (a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.4 (b) Procedure in event of death 395844 Page 2 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, state regulations, facility policy review, and staff interview, it was determined that the facility failed to ensure services provided meet professional standards of quality for progress note documentation review of one resident (Resident 4) documented by one employee (Employee 4). Residents Affected - Few Findings Include: Review of the facility's policy, titled Discharging a Resident to the Mortuary revised [DATE], reads, in part, The resident must be declared legally dead in accordance with state law [either direct or indirect pronouncement by a Licensed Physician]. A Registered Nurse under the act of [DATE] (P.L. 317, No. 69), 1 known as The Professional Nursing Law, who are involved in direct care of a patient shall have the authority to pronounce death as determined under the act of [DATE] (P.L. 1401, No. 323) known as the Uniform Determination of Death Act, in the case of death from natural causes of a patient who is under the care of a physician or certified registered nurse practitioner when the physician or certified registered nurse practitioner is unable to be present within a reasonable period of time to certify the cause of death. Professional nurses shall have the authority to release the body of the deceased to a funeral director after notice has been given to the attending physician or certified registered nurse practitioner, when the deceased has an attending physician or certified registered nurse practitioner, and to a family member. Review of the facility's job description, titled Unit Manager describes the purpose of the Registered Nurse position is to assist the Director of Nursing Services in planning organizing, developing, and directing the day-to-day functions of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the Facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times. The job description continues Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided . An interview with the Employee 4 (RN - Registered Nurse) on [DATE], at 5:21 PM, revealed he received a call from the Nursing Home Administrator (NHA) a little after 6 AM, on [DATE], with a request to present to the facility as Employee 5 (LPN - Licensed Practical Nurse) could not get a hold of the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) in order to pronounce Resident 4 as deceased . The interview also revealed Employee 4 was not the on-call RN or scheduled to work at the facility during the night shift following Resident 4's passing on [DATE], at approximately 10:40 PM. Review of Resident 4's clinical record revealed documentation dated [DATE], and written by Employee 4, as a late entry and documented to have occurred at 2:00 AM, despite Employee 4 not arriving to the facility until a little after 6 AM. Review of the staff schedule and time punch report for [DATE], revealed that Employee 4 worked 7 AM - 11 PM. 395844 Page 3 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0658 During an interview with the NHA on [DATE], at 1:55 PM, she was asked if Employee 4 presented to work at the facility as the Registered Nurse on [DATE], from 7-11 AM and she stated, I believe so. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14 (a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 211.5 (f) (h) Clinical records 395844 Page 4 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, state professional standards, clinical record review, document review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for each resident, resulting in the absence of a Registered Nurse in the facility to assess and pronounce a resident who was found with no pulse or respirations (Resident 4). This failure placed all residents who reside at the facility requiring services from a Registered Nurse in an Immediate Jeopardy situation (34 residents). Findings Include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing Chapter 21, Subchapter A, Section 21.11 states The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse Collects complete and ongoing data to determine nursing care needs. A Registered Nurse under the act of [DATE] (P.L. 317, No. 69), 1 known as The Professional Nursing Law, who are involved in direct care of a patient shall have the authority to pronounce death as determined under the act of [DATE] (P.L. 1401, No. 323) known as the Uniform Determination of Death Act, in the case of death from natural causes of a patient who is under the care of a physician or certified registered nurse practitioner when the physician or certified registered nurse practitioner is unable to be present within a reasonable period of time to certify the cause of death. Professional nurses shall have the authority to release the body of the deceased to a funeral director after notice has been given to the attending physician or certified registered nurse practitioner, when the deceased has an attending physician or certified registered nurse practitioner, and to a family member. Review of the facility's policy, titled Discharging a Resident to the Mortuary revised [DATE], reads, in part, The resident must be declared legally dead in accordance with state law [either direct or indirect pronouncement by a Licensed Physician]. Review of Resident 4's interdisciplinary plan of care revealed diagnoses that included morbid obesity and chronic diastolic congestive heart failure. Review of Resident 4's interdisciplinary progress notes dated [DATE], at 12:04 AM, revealed documentation by Employee 5 (LPN- Licensed Practical Nurse) that reads, Employee 6 (NA - Nurse Aid) provided care to resident [Resident 4] at 22:30 [10:30 PM]. At that time she was alert, oriented, and offering no c/o [no complaints of] discomfort or pain. After providing care, the [nurse aide] exited the 395844 Page 5 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 room and began charting. Level of Harm - Immediate jeopardy to resident health or safety The progress notes continue Approximately 10 minutes later [nurse aide] heard the resident's roommate calling. He went into the room to offer assistance and observed the resident as nonresponsive. The nurse aide alerted the charge nurse [ Employee 5 ] who could not find a pulse, observed no breathing, and could not detect a heartbeat using a stethoscope. Residents Affected - Many Employee 5 is an LPN and does not have the credentials to assess and pronounce a resident deceased . An interview with Employee 5 on [DATE], at 8:21 AM, revealed after Resident 4 was found with no pulse and no respirations, he placed calls to the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA). The interview revealed all calls went unanswered. Employee 5 stated he proceeded to place a call to the coroner's office as he was unable to contact facility administration. Employee 5 stated the coroner's office dispatched the local police and emergency services personnel to the facility for assistance. The interview also revealed that the facility had no Registered Nurse (RN) scheduled on the evening shift in order to assess and pronounce Resident 4 to be deceased . The facility designated the DON to be the on-call RN for the night shift. The on-call RN is expected to be able to come to the facility within 30 minutes if RN services are needed. The DON and ADON did not come to the facility throughout the night shift despite Employee 5's efforts to contact them for needed assistance. Employee 5 also stated the facility's NHA made contact with Employee 4 (RN) from the facility's sister facility, who presented to the facility around 7 AM to assess and pronounce Resident 4 to be deceased . Employee 5 stated Resident 4 remained in her room at the facility at the end of his shift, when he left the facility at approximately 7:30 AM. An interview with Employee 4 on [DATE], at 5:21 PM, revealed he received a call from the NHA a little after 6 AM on [DATE], with a request to present to the facility as Employee 5 could not get a hold of the DON or the ADON in order to pronounce Resident 4 as deceased . The interview also revealed Employee 4 was not the on-call RN or scheduled to work at the facility during the night shift following Resident 4's passing on [DATE], at approximately 10:40 PM. Review of employee files revealed that Employee 4 was not an employee of the facility on [DATE]. An interview with the NHA, on [DATE], at 9:35 AM, regarding the circumstances surrounding the death of Resident 4 and subsequent actions following her death, revealed Employee 4 to be on call and proceeded to the facility to assess and pronounce Resident as deceased . The interview revealed no information regarding Employee 5's difficulties in contacting the DON, ADON, or NHA. The interview did not reveal any information regarding Employee 5 contacting the 395844 Page 6 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many coroner, nor the local police and emergency personnel presenting to the facility for assistance as stated during the interview with Employee 5. An interview with the DON on [DATE], at approximately 4:00 PM, revealed she was not on duty on the evening of [DATE], as she was ill and would be unavailable for facility staff to reach her for assistance. The facility did not have a RN working the evening shift on [DATE]. The facility also did not have a RN available to present to the facility to assess a Resident who was found without a pulse or respirations. This failure resulted in Resident 4 laying in bed, deceased , from 10:30 PM until the following day, some time after 7:30 AM; when a RN came to the facility and received an order to pronounce the Resident and release the body to the funeral home. The Nursing Home Administrator (NHA 2) and the DON were notified of the concern regarding the lack of RN coverage on the 3 PM-11 PM evening shift on [DATE], and were provided the Immediate Jeopardy template at 5:06 PM on [DATE]. An immediate action plan was requested at that time. On [DATE], at 6:59 PM, the facility's immediate action plan was accepted, which included: - All licensed staff will be educated on requirement for On-Duty RN for 7 AM-3 PM and 3 PM-11 PM shifts, and on call RN for 11 PM-7 AM with the ability to be at the facility within 30 minutes. NHA or designee will in-service on each shift for licensed staff by [DATE]. - All licensed staff will be educated to proper procedure for handling call-offs and need to obtain RN coverage. NHA or designee will in-service on each shift for licensed staff by [DATE]. - Facility will immediately contract with staffing agency for RN use. COO signed a contract with a staffing agency on [DATE]. - NHA to audit schedule daily. NHA or designee will audit daily RN Coverage and RN On-Call Coverage. - On-call RN to be designated daily. There will be a calendar/schedule posted at the nurses' station. On [DATE], at 12:55 PM, the Immediate Jeopardy was lifted during an on-site survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12 (a)(c)(d)(1)(4)(5) Nursing Services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management 28 Pa. Code 201.14(a) Responsibility of licensee 395844 Page 7 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable mental and psycho-social well-being for one of five residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and suicidal ideations (a broad term used to describe a range of contemplation, wishes, and preoccupations with death and suicide). Review of the facility's interdisciplinary progress notes revealed documentation dated March 30, 2023, that read Resident 2 answered yes to having thoughts that she would be better off dead or of harming herself. The progress notes continued staff would refer Resident 2 for psychiatric follow-up. During an interview on May 3, 2023 at 5:45 PM Resident 2 voiced concern over the recent death of her roommate. Continued interview with Resident 2, concerning her current mental health, revealed she was just talking to her roommate and all of a sudden she just stopped answering me. The interview continued They left her in my room all night and took her out about 3:00 [PM] the next day. An interview with the Assistant Director of Nursing on April 24, 2023, at approximately 1:30 PM, revealed she was not aware of Resident 2 receiving psychiatric interventions or support post the passing of her roommate on April 14, 2023. The interview revealed the notion of support to be a good idea. Information provided by the facility on May 8, 2023, revealed Resident 2 was seen for a psychiatric evaluation on April 27, 2023. Review of the psychiatric evaluation revealed no documentation of discussion related to the circumstances surrounding the death of Resident 2's roommate and her voiced concerns with the Roommate's body remaining in their shared room from the documented time of passing at 10:40 PM on April 14, 2023, until the following day, April 15, 2023 at approximately 3:00 PM. An interview with the Nursing Home Administrator on May 8, 2023, at approximately 2:45 PM, revealed uncertainties regarding the date of referral for psychiatric services for Resident 2 and no additonal information regarding the circumstances of the referral. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 395844 Page 8 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0740 28 Pa. Code 211.12 (d) (5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.16 (a) Social services Residents Affected - Few 395844 Page 9 of 10 395844 05/08/2023 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on facility provided documentation and staff interview, it was determined that the facility failed to ensure its administration functions in a manner that enables it to use its resources effectively and efficiently by ensuring sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for each resident on two of three days reviewed (April 14, 2023 and April 15, 2023). Residents Affected - Few Findings Include: Review of the facility's punch detail report dated April 14, 2023, revealed one Registered Nurse (Employee 3) on the schedule performing duties during the hours of 3:00 PM- 11:00 PM. Review of the facility's staff schedule dated April 14, 2023, also revealed documentation of Employee 3 to have been scheduled and present performing duties during the hours of 3:00 PM-11:00 PM. An interview with Employee 3 on April 28, 2023, at 2:21 PM, revealed she absolutely did not work those hours documented by the facility on April 14, 2023. During an interview with Employee 5 on May 5, 2023, at 8:21 AM confirmed that he worked as scheduled from 7:00 PM - 11:00 PM on April 14 and confirmed that there was no RN working. An interview with the Nursing Home Administrator on May 3, 2023, at 1:41 PM, confirmed Employee 3 had not worked those hours as documented on the facility's punch detail and schedule reports submitted to the Department of Health, and stated the facility had no additonal information to provide. The facility designated the DON to be the on-call RN for the night shift. The on-call RN is expected to be able to come to the facility within 30 minutes if RN services are needed. Employee 5 (LPN) was scheduled to work from 7:00 PM on April 14th to 7:00 AM on April 15th. Employee 5 needed a RN to come to the facility and assist with assessment of a resident who was found without a pulse or respirations. An interview with Employee 5 on May 5, 2023, at 8:21 AM revealed he placed calls to the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA). The interview revealed all calls went unanswered. The DON and ADON did not come to the facility throughout the night shift despite Employee 5's efforts to contact them for needed assistance An interview with the DON on May 3, 2023, at approximately 4:00 PM, revealed she was not on duty on the evening of April 14, 2023, as she was ill and would be unavailable for facility staff to reach her for assistance. 28 Pa. Code 201.14 Responsibility of licensee 28 Pa. Code 201.18 (a) Management 395844 Page 10 of 10