Health inspection·July 7, 2023

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for four of five residents reviewed for hospitalizations (Residents R15, R16, R6, and R20). Findings include: Review of facility policy entitled Bed-Hold and Returns dated 5/4/23, revealed that All residents / representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at the time of transfer (or, if the transfer was an emergency, within 24-hours). Review of Resident R15's clinical record revealed an admission date of 7/25/22, with diagnoses that included high blood pressure, dementia (disease that affects the brains ability to think, remember, and function normally), and prostate cancer. Departmental notes indicated that Resident R15 was transferred to the hospital on 6/14/23, and returned to the facility on 6/20/23. The clinical record lacked evidence indicating that Resident R15 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R16's clinical record revealed an admission date of 4/25/23, with diagnoses that included high blood pressure, diabetes, and bilateral above the knee amputations (removal of both legs to above the knee). Departmental notes indicated that Resident R16 was transferred to the hospital on 6/2/23, and returned to the facility on 6/5/23. The clinical record lacked evidence indicating that Resident R16 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R6's clinical record revealed an admission date of 9/17/22, with diagnoses including dementia, heart failure, irregular heartbeat, and long-term kidney disease. Departmental notes indicated that Resident R6 was transferred to the hospital on 5/05/23, and returned to the facility on 4/12/23. The clinical record lacked evidence indicating that Resident R6 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R20's clinical record revealed an admission date of 12/18/20, with diagnoses includng long-term respirtory failure, Type 2 Diabetes (condition that affects how the body uses sugar), heart failure, and chronic obstructive pulmonary disease (COPD-a group of diseases that cause Page 1 of 9 395867 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few airflow blockage and breathing-related problems). Departmental notes indicated that Resident R20 was transferred to the hospital on 5/28/23, and returned on 5/31/23. The clinical record lacked evidence indicating that Resident R20 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 7/6/23, at 10:30 a.m. Business Office Manager, revealed the facility bed-hold policy is provided upon admission to the facility and for Medicare and private pay residents it is provided at the time of transfer. The Business Office Manager also stated that the bed-hold policy is not provided to Medicaid residents. During an interview on 7/6/23, at 10:55 a.m. Registered Nurse (RN) Employee E2 confirmed that there was no evidence that Residents R15, R16, R6, or R20 and/or their representatives received written notice of the facility bed-hold policy upon or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management 395867 Page 2 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 15 residents reviewed (Resident R26). Residents Affected - Few Findings include: Review of facility policy entitled Care Plans, Comprehensive Person-Centered dated 5/4/23, stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident R26's clinical record revealed an admission date of 5/22/23, with diagnoses that included Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior), anemia, and atrial fibrillation (a heart condition that makes your heart beat irregular and fast). Resident R26's clinical record revealed a physician's order dated 5/23/23, for an alarming security bracelet wanderguard every shift. Review of Resident R26's comprehensive care plan lacked reference to Resident R26's wandering behavior or usage of the alarming security bracelet wanderguard. During an interview on 7/6/23, at 2:22 p.m. Registered Nurse Assessment Coordinator confirmed that a care plan had not been developed to address Resident R26's wandering behavior or use of the alarming security bracelet wanderguard. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services 395867 Page 3 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

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 on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for two of five residents reviewed for unnecessary medications (Residents R15 and R26). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 5/4/23, stated PRN orders for psychotropic medications are limited to 14-days. If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14-days, he or she will document the rationale for extending the use and include the duration for the PRN order and Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of medications when possible. Review of Resident R15's clinical record revealed an admission date of 7/25/22, with diagnoses that included high blood pressure, dementia (disease that affects the brains ability to think, remember, and function normally), and prostate cancer. A physician's order dated 4/7/23, identified to administer Ativan 1 milligram (mg) by mouth every 6 hours PRN for agitation. Another physician's order dated 6/29/23, identified to administer Ativan Injection Solution 2 mg per milliliter (ml) - Inject 1mg intramuscularly every 6 hours as needed for anxiety / agitation. Another physician's order dated 6/30/23, identified to administer Ativan Injection Solution 2 mg/ml - Inject 1mg intramuscular every 6 hours PRN for anxiety / agitation for 14-days and Ativan 0.5 mg by mouth every 6 hours PRN for agitation / anxiety for 14 days. Review of Resident R15's medication administration record (MAR) for June 2023 revealed that the PRN Ativan was used four times between 6/1/23, and 6/30/23. Review of June 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan two of the four times the Ativan was utilized in June 2023. Review of Resident R15's MAR for July 2023 revealed the PRN Ativan was used eight times between 7/1/23, and 7/6/23. Review of the July 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan four of the eight times the Ativan was utilized in July 2023. During an interview on 7/6/23, at 1:50 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan six of the 12 times it was administered to Resident R15 between 6/1/23, and 7/6/23. Review of Resident R26's clinical record revealed an admission date of 5/22/23, with diagnoses that included Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior), anemia, and atrial fibrillation (a heart condition that makes your heart beat irregular and fast). A physician's order dated 6/5/23, identified to administer Ativan 0.5 mg by mouth every 6 hours PRN for 395867 Page 4 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yelling, restless, hitting, pushing, anxious, and lacked the required stop date within 14-days or a clinical rationale for continued use beyond 14-days. Review of Resident R26's June and July 2023 MAR revealed he/she received the Ativan past the 14-days on 6/24/23, 6/25/23, 6/26/23, and 7/2/23. Review of Resident R26's MAR for June 2023 revealed the PRN Ativan was used eight times between 6/5/23, and 6/30/23. Review of June 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan four of the seven times the Ativan was utilized in June 2023. Review of Resident R26's MAR for July 2023 revealed the PRN Ativan was used one time between 7/1/23, and 7/6/23. Review of July 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan one of the one times the Ativan was utilized in July 2023. During an interview on 7/6/23, at 1:50 p.m. the Director of Nursing confirmed that Resident R26's Ativan order lacked the required stop date within 14-days or a clinical rationale for continued use beyond 14-days and that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan five of the eight times it was administered to Resident R26 between 6/5/23, and 7/6/23. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3) Management 395867 Page 5 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and manufacturer's instructions, observations, and staff interviews, it was determined that the facility failed to label multi-dose insulin bottle with the date it was opened, discard a pre-filled insulin pen within the use by timeframe, appropriately label over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on one of two carts (Cart 1) and the facility failed to discard an expired Tuberculin Purified Protein Derivative (TB) solution for one of one medication rooms observed. Findings include: Review of facility policy entitled Administering Medications dated [DATE], revealed When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy entitled Medication Labeling and Storage dated [DATE], revealed Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28-days unless the manufacturer specifies a shorter or longer date for the open vial. Review manufacturer's instructions for Lantus (type of insulin) multi-dose vial and pre-filled pen directed Do not use Lantus after the expiration date stamped on the label or 28-days after first use. Review of manufacturer's instructions on the box of TB solution indicated to Discard 30 days after opening. Observation of medication cart one on [DATE], at 4:15 p.m. revealed that Resident R20's Lantus multi-dose vial was currently in use, but not labeled with an open date. Further observation revealed Resident R17's Lantus Kwik Pen was open, dated for [DATE], and was currently in use, or 53-days past the open date. Observation of medication cart one on [DATE], at 4:15 p.m. revealed that the cart contained open stock medication bottles and/or boxes of Bisacodyl Suppositories, Omeprazole (one bottle and one box), Loperamide (2 boxes), Famotidine, Polyethylene Glycol, Geri-Lanta, Magnesium Citrate, and Tylenol Elixir that lacked any resident names for use. During an interview on [DATE], at 4:20 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R20's insulin was in use and not labeled with an open date, that Resident R17's insulin pen was being used past the 28-days, and that cart contained open stock medication bottles and/or boxes of Bisacodyl Suppositories, Omeprazole, Loperamide, Famotidine, Polyethylene Glycol, Geri-Lanta, Magnesium Citrate, and Tylenol Elixir that lacked any resident names for use. Observation of facility medication room on [DATE], at 10:56 a.m. revealed one vial of TB solution with an open date of [DATE], reflecting 38-days beyond the opened date. During an interview at the time of observation, Registered Nurse Employee E2 confirmed that the TB solution vial was opened on [DATE], and past the expired 30-days after opening. 395867 Page 6 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0761 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Residents Affected - Some 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395867 Page 7 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and documentation and staff interviews, it was determined that the facility failed to provide evidence of a Quality Assurance and Performance Improvement (QAPI) Committee meeting for one of four (fourth quarter of 2022) quarterly QAPI Committee meetings reviewed occurring between August 2022 and July 2023. Residents Affected - Few Findings include: Review of a facility policy entitled, Quality Assurance and Performance Improvement (QAPI) ProgramGovernance and Leadership dated 5/04/23, indicated that the committee would meet at least quarterly. Review of the QAPI Committee Attendance Records revealed QAPI attendance sign-in sheets for the third quarter 2022, first and second quarters of 2023, and there was no attendance sign-in sheet for the fourth quarter of 2022. During an interview on 7/07/23, at 12:12 p.m. the Nursing Home Administrator confirmed that the facility could not provide evidence that a QAPI Committee meeting was held during the fourth quarter of 2022. 28 Pa. Code 201.18(e)(1)(2)(3) Management 395867 Page 8 of 9 395867 07/07/2023 Lakeview Healthcare and Rehab 15 West Willow Street Smethport, PA 16749

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to vaccinate eligible residents with the influenza vaccine, unless the resident had previously received the vaccine, refused, or had a medical contraindication present, and provide and/or document the provision of pertinent information regarding the immunizations to the resident/resident's representative such as the benefits and potential side effects of the influenza vaccine for five of five residents reviewed (Residents R2, R14, R15, R19, and R23) Residents Affected - Some Findings include: Review of the facility policy entitled, Influenza Vaccine dated 5/04/23, indicated that between October 1st and March 31st each year all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually, and that prior to receiving the influenza vaccine the resident/representative receives pertinent information about the significant risks and benefits of the influenza vaccine. Review of Resident R2's clinical record revealed an admission date of 2/18/14, with diagnoses including Alzheimer's (a gradual decline in memory, thinking, behavior and social skills), seizures, heart failure, arthritis, and generalized muscle weakness. Review of Resident R14's clinical record revealed an admission date of 8/23/17, with diagnoses including dementia, heart failure, skin cancer, and muscle wasting. Review of Resident R15's clinical record revealed an admission date of 7/25/22, with diagnoses including dementia, muscle wasting, prostate cancer, and fractured left leg. Review of Resident R19's clinical record revealed an admission date of 11/10/22, with diagnoses including long-term kidney disease, broken vertebrae (mid-back), irregular heartbeat, and asthma. Review of Resident R23's clinical record revealed an admission date of 12/24/20, with diagnoses including Alzheimer's, high blood pressure, heart disease, and muscle wasting. Review of Residents R2, R14, R15, R19, and R23's immunization records lacked evidence that the influenza vaccine was provided between October 1, 2022, and March 31, 2023, and lacked evidence/documentation that pertinent information about the significant risks and benefits of the influenza vaccine was provided to Residents R2, R14, R15, R19, and R23 and/or their representatives. During an interview on 7/07/23, at 10:05 a.m. Infection Control Nurse confirmed that residents did not receive influenza vaccines between October 1, 2022, and March 31, 2023, and there was no evidence that residents/representatives received pertinent information about the significant risks and benefits of the influenza vaccine. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395867 Page 9 of 9