Health inspection·October 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 make certain that residents were provided appropriate treatment and care to possibly prevent hospitalization for one of five residents (Resident R18). Findings include: Review of the facility policy, Change in Status/Resident Condition dated 7/17/23, indicated the facility will notify the physician and representative of changes in the resident ' s condition. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R18 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 9/21/23, included diagnoses of pyogenic arthritis (painful injection in a joint), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and anemia (too little iron in the body causing fatigue). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R18's score to be 12. Review of the facility diagnosis list included gastro-esophageal reflux disease (GERD, when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) present upon admission, with a beginning date of 6/17/19. Review of Resident R18's care plan for GERD initiated 5/25/23, included the intervention Monitor/document/ report as need signs and symptoms of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, nausea/vomiting, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia (difficulty swallowing), substernal chest pain, increased gag response. Page 1 of 5 395873 395873 10/26/2023 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of multiple physician's orders for Zofran (Ondansetron, medication used to prevent nausea and vomiting) dated 5/17/23 (reordered 7/28/23, 8/30/23, and 9/15/23) indicated Resident R18 is to receive one 4mg tablet, every eight hours for nausea and vomiting, as needed. Review of Resident R18 Medication Administration Record (MAR) for June, July, and August 2023, through hospitalization on 8/26/23, revealed the following: June: Zofran administered two times (23, 28). July: Zofran administered three times (13, 15, 19). August: Zofran administered 16 times (2, 9, 11, 13, 14, 16, 18, 19, 20, 21, 22 twice, 23, 24 twice, and 25). Review of a progress note dated 8/9/23, at 9:39 a.m. indicated Medicated with Zofran this am per her request for nausea. Review of a progress note dated 8/19/23, at 4:52 a.m. indicated Was medicated with Tums and Zofran at 01:10 and 02:01 respectively related to epigastric discomfort and nausea. Review of a progress note dated 8/19/23, at 9:06 a.m. indicated Resident was vomiting when I came on duty this AM. Per 11-7 (11:00 p.m. - 7:00 a.m.) nurse she had been medicated for c/o (complaints of) n/v (nausea and vomiting). Review of a progress note dated 8/20/23, at 9:37 a.m. indicated Resident R18 Requested Zofran this AM (morning) for c/o nausea. Review of a progress note dated 8/21/23, at 9:34 a.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/22/23, at 1:00 p.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/22/23, at 9:29 p.m. indicated Resident R18 C/O nausea , medicated with Zofran. Review of a progress note dated 8/23/23, at 9:29 p.m. indicated Resident R18 C/O nausea , medicated with Zofran. Review of a progress note dated 8/24/23, at 9:39 p.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/25/23, at 6:24 a.m. indicated Answered call light Resident (R18) said she had vomited, I turned her bedside lamp on and noticed large. thick coffee ground emesis, denies pain or discomfort, was medicated earlier at 03:29 for c/o nausea Zofran given. Review of a progress note dated 8/25/23, at 7:19 a.m. indicated Resident R18 was transferred to the hospital. 395873 Page 2 of 5 395873 10/26/2023 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress note dated 8/30/23, at 4:30 p.m. indicated Resident R18 returned to the facility from the hospital. Review of hospital paperwork dated 8/29/23, indicated Resident had been admitted to the hospital with an acute gastric ulcer with bleeding (a new onset stomach ulcer, with bleeding present). The presenting problems noted during the hospital stay were hematemesis (vomiting of blood), GI bleed (bleeding in the digestive tract), acute gastric ulcer with bleeding, and vomiting. Review of the clinical record failed to reveal a notification to the provider of the increased nausea and use of Zofran. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that residents were provided appropriate treatment and care to possibly prevent hospitalization for 1 of 4 residents. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395873 Page 3 of 5 395873 10/26/2023 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for two out of five nurse aide personnel records (NA Employee E2 and E3). Residents Affected - Some Findings include: Review of the facility provided staff listing indicated that Nurse Aide (NA) Employee E2 was hired on 10/18/07. Review of NA Employee E2's most recent performance review revealed it was completed on 11/9/21. Review of the facility provided staff listing indicated that NA Employee E3 was hired on 5/8/09. Review of NA Employee E3's most recent performance review revealed it was completed on 4/23/20. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to complete annual performance evaluations for two of five nurse aides as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee. 395873 Page 4 of 5 395873 10/26/2023 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to make certain that medications, biologicals and medical supplies were properly stored or disposed of in one of one medication rooms. Findings include: Review of the facility pharmacy policy Storage of Medications dated 3/16/23, indicated medications are stored properly, following manufacturer's or provider recommendations, to maintain their integrity and to support safe effective drug administration. Outdated, contaminated, discontinued, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During an observation on the facility medication room on 10/25/23, at 1:17 p.m. the following was observed: -(4) One-liter bags of intravenous (IV) fluid, with the overwrap removed stored above the medication room sink -Under the sink, six bottles of drug disposal liquid, one lunch bag with food within it, a bottle of water, a bottle of nail polish remover, and four boxes of isolation masks. During an interview on 10/25/23, at 1:22 p.m. the Registered Nurse Employee E1 confirmed the above observation, and further confirmed that without the overwrap on the IV fluid, the injection port was accessible to inject a substance into the fluid. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain improperly stored medications, biologicals and medical supplies were properly stored or disposed of in one of one medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. 395873 Page 5 of 5