Health inspection·November 3, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based upon clinical record review and interview it was determined the facility failed to notify resident's physician regarding the development of a pressure ulcer for one of two residents reviewed (Resident 40). Residents Affected - Few Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's clinical record revealed a Wound Healing Solutions report dated August 28, 2023, indicating resident was seen for evaluation and management for newly noted areas of skin breakdown along the left heel. Review of Wound Healing Solutions report dated August 28, 2023, revealed full-thickness wound of the left heel - 1.3 cm x 2.6 cm - wound base 100% stable eschar (dry scab, tan, brown or black in wound bed; dead tissue; black in color in wound bed), no fluctuance noted, edges adherent to the wound base, no drainage noted, periwound without erythema, induration or edema. Review of Resident 40's clinical record failed to reveal evidence Resident 40's physician was notified of the development of Resident 40's left heel pressure ulcer. Interview with the Director of Nursing on November 3, 2023, at 11:00 a.m. confirmed Resident 40's physician was not notified of Resident 40's change in condition. The facility failed to notify resident's physician of a change in condition. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022 Page 1 of 9 395857 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and interviews with staff, it was determined that the facility failed to complete a Quarterly MDS assessment at least every three months as required for one of eight residents reviewed (Resident 100). Residents Affected - Few Findings include: Review of Resident 100's MDS (Minimum Data Set - a mandatory periodic assessment) assessments revealed that the resident had an admission MDS assessment completed on May 29, 2023. Continued review revealed that no further MDS assessments had been completed for Resident 100 since May 29, 2023. Interview on November 3. 2023, at 10:20 a.m. with Employee E3, Registered Nurse Assessment Coordinator, confirmed that Resident 100 had not had an MDS assessment since her admission in May 2023. Employee E3 could not provide an explanation as to why no additional assessments were performed for Resident 100. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records 395857 Page 2 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based upon clinical record review and interview it was determined the facility failed to develop a comprehensive care plan for prevention and treatment of pressure ulcers for one of 22 residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of Resident 40's admission Braden Scale for Predicting Pressure Sore Risk dated June 16, 2023, revealed a score of 15. If the score is 18 or less resident is at risk for developing a pressure ulcer. Review of Resident 40's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated June 22, 2023, revealed Resident 40 required extensive assistance of two plus staff members for bed mobility (turning and repositioning while in bed). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's active care plan failed to reveal evidence that a skin care plan was implemented prior to August 15, 2023, the date upon which Resident 40's pressure ulcer was identified. Interview with the Director of Nursing on November 3, 2023, at 11:00 a.m. confirmed that no care plan was in place prior to the development of Resident 40's pressure ulcer. The facility failed to provide a care plan with interventions for the prevention and/or treatment of Resident 40's pressure ulcer. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022 395857 Page 3 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based upon review of facility policy and procedure, clinical record review and interview it was determined the facility failed to provide interventions to prevent pressure ulcers, failed to timely identify pressure ulcers and failed to provide treatment for pressure ulcers causing harm to one of two residents reviewed (Resident 40). Residents Affected - Few Findings include: Review of facility policy and procedure titled Skin Integrity Program - Pressure Ulcer Prevention/Treatment Program, revised April 27, 2023, revealed Pressure Ulcer Prevention: Every resident shall have a skin risk assessment (Braden Scale) upon admission, return from hospitalization, any significant change in condition and a routine quarterly screening to be completed by a licensed nurse. Further review of this policy revealed A routine skin inspection shall be performed daily as part of their personal hygiene. Further review of this policy revealed For residents determined to be 'at risk' a plan of care shall be implemented to maintain their skin integrity. Further review of this policy revealed Pressure Ulcer Assessment and Treatment: Upon completion of the assessment, the staff shall implement an interdisciplinary plan of care. The identification of risk factors and/or clinical conditions shall be incorporated in the plan of care' A plan to promote wound healing shall be implemented (e.g., films, hydrocolloids, foams, alginates, negative pressure wound therapy), including from excess moisture and incontinence. Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of Resident 40's admission Braden Scale for Predicting Pressure Sore Risk dated June 16, 2023, revealed a score of 15. If the score is 18 or less resident is at risk for developing a pressure ulcer. Review of Resident 40's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated June 22, 2023, revealed Resident 40 required extensive assistance of two plus staff members for bed mobility (turning and repositioning while in bed). Review of Resident 40's skin evaluation report dated August 14, 2023, revealed no new skin issues. Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's clinical record revealed a Wound Healing Solutions report dated August 28, 2023, indicating resident was seen for evaluation and management for newly noted areas of skin breakdown along the left heel. Review of Wound Healing Solutions report dated August 28, 2023, revealed full-thickness wound of the left heel - 1.3 cm x 2.6 cm - wound base 100% stable eschar (dry scab, tan, brown or black in 395857 Page 4 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0686 wound bed; dead tissue; black in color in wound bed), no fluctuance noted, edges adherent to the wound base, no drainage noted, periwound without erythema, induration or edema. Level of Harm - Actual harm Residents Affected - Few Further review of the Wound Healing Solutions report dated August 28, 2023, revealed a treatment order to cleanse the affected area with saline solution and apply skin prep daily and PRN (as needed). Review of Resident 40's Treatment Administration Record (TAR) dated August 2023, revealed treatments to the left heel began on August 29, 2023. Further review of Resident 40's TAR failed to reveal evidence that any treatments occurred to Resident 40's left heel from August 15, 2023, when the wound was discovered until August 29, 2023. Review of Resident 40's Skin Conditions care plan revealed that a Skin Conditions care plan was not developed until August 23, 2023. Further review of Resident 40's active care plan failed to reveal evidence that a Skin Condition care plan was initiated upon admission and no interventions were put into place upon admission or prior to the development of the left heel pressure ulcer. Interview with the Director of Nursing on November 3, 2023 at 11:00 a.m. confirmed the facility did not have interventions in place prior to the development of the pressure ulcer, confirmed that no treatments were in place from August 15, 2023 until August 29, 2023 and confirmed that skin evaluations were inaccurate prior to the identification of the wound. The facility failed to prevent the occurrence of a pressure ulcer, failed to timely identify a new pressure ulcer, and failed to treat a new pressure ulcer causing harm to Resident 40. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022 395857 Page 5 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for three of five staffing records reviewed. Residents Affected - Few Findings include: Review of staffing records and performance reviews revealed three staff members did not have annual performance reviews performed within the appropriate timeframe. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 3, 2023, at 11:27 a.m. confirmed staff performance reviews were not completed timely. Per the DON a performance plan has been made to catch up on past due staff performance reviews. 28 Pa. Code 201.20(a)(c) Staff Development FACILITY 395857 Page 6 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based upon clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale was provided by residents' physician for not performing a Gradual Dose Reduction of an antipsychotic medication and failed to provide a clinical rationale for the continued use beyond 14 days of an as needed anti-anxiety medication for two of five residents reviewed (Resident 38 and Resident 79). Findings include: Review of Resident 38's physician's orders included an order dated December 27, 2022, for Lorazepam (anti-anxiety medication) 0.5 milligrams one tablet by mouth as needed every six hours for anxiety. Review of Resident 38's clinical record revealed a Note to Attending Physician/Prescriber from the consultant pharmacist dated August 11, 2023, with a recommendation to evaluate the use of prn (as needed) Lorazepam. The note indicated that prn psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the prn order. Review of the physician/prescriber response dated August 21, 2023, indicated to cont.[continue] as ordered. Further review of the clinical record failed to reveal evidence that a clinical rationale or duration was provided as recommended by the pharmacist for the PRN use of Lorazepam. Review of Resident 79's clinical record revealed notes to Attending Physician/Prescriber from the facility pharmacist. Further review of Resident 79's clinical record revealed the facility pharmacist was recommending a Gradual Dose Reduction (GDR) of Resident 79's Seroquel (antipsychotic medication). Review of the physician response to facility pharmacist revealed a note continue as ordered. Further review of the physician response to facility pharmacist failed to reveal a clinical rationale for not performing a GDR as requested by the pharmacist. Further review of Resident 79's clinical record revealed notes to Attending Physician/Prescriber from the facility pharmacist. Further review of Resident 79's clinical record revealed the facility pharmacist indicated that PRN psychotropic orders cannot exceed 14 days. The pharmacist was requesting a clinical rationale for the continued use of PRN Lorazepam beyond the 14 days. Review of the physician response to the PRN Lorazepam request was continue with PRN Ativan. Further review of the clinical record failed to reveal evidence that a clinical rationale was provided as requested by the pharmacist for the PRN use of Lorazepam. Interview with Director of Nursing on November 30, 2023, at 11:15 a.m. confirmed that the physician failed to provide clinical rationales as requested by the facility pharmacist for the continued use 395857 Page 7 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0758 of Seroquel and Lorazepam. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/2022 Residents Affected - Few 395857 Page 8 of 9 395857 11/03/2023 Ephrata Manor 99 Bethany Road Ephrata, PA 17522

F 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12-hour annual re-training for two of five records reviewed. Residents Affected - Few Findings Include: Review of five staffing records and inservice documentation revealed three nurse aides received the required 12-hour annual retraining. Further review of the staffing records and inservice documentation revealed two of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator and DON on November 3, 2023, at 11:27 a.m. confirmed that the nurse aides did not receive the required in-service retraining within the appropriate timeframe. 28 Pa. Code 201.20(a)(c) Staff Development 395857 Page 9 of 9