Health inspection·July 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable shower room environment on two of seven nursing units (Nursing Units 700 and 800). Findings include: Observation of the resident shower room located between the 700 and 800 nursing units on July 27, 2023, between 9:06 AM and 9:30 AM revealed the following: A hand-held shower wand in the shower stall was damaged. The stainless steel covering was starting to peel off the water hose near the base of the spray wand. The damaged area was jagged and sharp. A pink colored shower chair had several brown-colored stains on the cushioned seat. A window was partially open. There were small, dead flies accumulating on the screen. The windowsill was covered in these small, dead flies and a significant accumulation of dust. The base of the window has a significant accumulation of dust and small, dead flies. There was a shaving cream 1.5 oz dispenser with dust and a small, dead fly on the lid. The windowsill had a discarded glove and a balled-up used gauze bandage with a red blood-like stain visible. A fan forced heater in the wall has a significant accumulation of dust on the grates and the fan. The ceiling was cracking in a previously fixed area adjacent to a sprinkler head. The previously fixed area around the cracks had loose patching material. There were two large cracks that run the span of the ceiling at this area. Two operating ceiling vents that are both blowing air had a significant accumulation of dust on the vents. A used surgical mask was hanging on a hook in a shower stall along with a gait belt and a blue knitted scarf. There were two cracked and loose tiles on two of the interior wall corners. Small pieces of the tiles were missing, and the underlying wall was visible. There were two white foam positioning blocks noted on top of the spa tub. They were stuck together and the one foam block with multiple suction cups had debris, hair, and dust accumulated on it. Page 1 of 11 395895 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0584 A small four-inch drain in the floor near the spa tub had an accumulation of debris in the grates Level of Harm - Minimal harm or potential for actual harm A cream-colored bucket noted on top of a plastic shower chair had broken and cracked handles. A section of the top perimeter of the bucket was cracked. The bucket has a strong urine-like odor. Residents Affected - Few A sewer fly was noted on the mirror above the sink. The paper towel dispenser was empty with white and dried splash stains on it A large grey garbage can was empty and had no bag. There were multiple used gloves on the bottom of it. A [NAME] 3000 lift had a significant accumulation of unidentified debris on the blue colored foot area of the lift. A locked gray cabinet had a significant accumulation of dust on the top of it. The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 27, 2023, at 2:55 PM. 28 Pa. Code 201.18 (b)(1)(3) Management 395895 Page 2 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician orders for one of 27 residents reviewed (Resident 117). Residents Affected - Few Findings include: Review of the current physician orders for Resident 117 revealed an order dated April 20, 2023, that instructed staff to always utilize a heel protector to the resident's right heel except for transfers due to a deep tissue injury. Review of the current care plan for Resident 117 revealed the resident has actual impaired skin integrity related to a Stage II (a partial-thickness loss of skin with exposed dermis (layer of skin), presenting as a shallow open ulcer) pressure ulcer to the right heel. An intervention dated April 20, 2023, indicated a heel protector should be applied to the resident's right heel at all times except for transfers. A review of the [NAME] (includes pertinent resident information used for care) for Resident 117 revealed the resident should always have a heel protector to the right heel except for transfers. Clinical documentation for Resident 117 dated July 11, 2023, at 2:17 PM revealed a physician's assistant note that indicated the resident had a deep tissue injury and is to float heels in bed and always use a right heel protector aside from transfer and care. Observation of Resident 117 on July 25, 2023, at 12:57 PM revealed he was sitting in his wheelchair with his feet resting on the floor. The right heel protector was not on. Observation of Resident 117 on July 26 2023, at 9:47 AM revealed he was sitting in his wheelchair with his feet resting on the floor. The right heel protector was not on. Observation of Resident 117 on July 26, 2023, at 11:00 AM revealed an unidentified staff member transported the resident to lunch in the Bistro. There was no heel protector on, or footrests observed on the wheelchair. Observation of Resident 117 on July 26, 2023, at 12:18 PM revealed the resident did not have the heel protector on. Interview with Employee 3, nurse aide, revealed the resident sometimes refuses, but should have the heel protector on. The heel protector was found on the resident's bedside chair in his room. Employee 3 proceeded to place the heel protector on the resident with no noted refusals from the resident. Observation of Resident 117 on July 27, 2023, at 9:38 AM revealed the resident was sitting in his wheelchair. The heel protector was on; however, it was on the resident's left heel. Employee 4, licensed practical nurse, confirmed the heel protector is supposed to be on the resident's right heel. A review of the clinical documentation for Resident 117 revealed no evidence of refusal of the heel protector or evidence that the resident removed the heel protector. The above findings were discussed in an interview with the Nursing Home Administrator and Director 395895 Page 3 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0684 of Nursing on July 26, 2023, at 3:00 PM and July 27, 2023, at 2:45 PM. Level of Harm - Minimal harm or potential for actual harm 483.25 Quality of Care Previously cited 6/3/22 Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies 395895 Page 4 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of six residents reviewed, which resulted in actual harm (Resident 38). Residents Affected - Few Findings include: Resident 38's clinical record revealed the resident had a diagnosis of Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) and unspecified dementia (a condition with memory loss, poor judgment, and confusion) and vascular dementia (dementia caused by impaired blood loss to the brain). Review of Resident 38's care plan dated September 14, 2019, identified the resident as being at risk for pressure injuries/ulcers and impaired skin integrity due to facial cancer with an intervention added, for the RN (registered nurse) to assess the skin weekly. Resident 38's care plan identified bowel incontinence (inability to control bowel movements resulting in soiling) as a problem on March 21, 2022. Resident 38's care plan identified a Stage IV pressure ulcer/injury (full thickness tissue with exposed bone, tendon, or muscle to the sacrum on December 27, 2022. Review of Resident 38's skin assessment dated [DATE], revealed that the resident had four surgical wounds on his abdomen. There was no documentation of a pressure ulcer/injury. Clinical record review for Resident 38 revealed an order dated September 23, 2022, for the staff to cleanse the sacrum (lower back) and buttocks with Remedy Wash (cleansing solution) then apply Calmoseptine ointment (a skin protectant containing zinc oxide that is used to treat diaper rash) every day and evening shift. Review of Resident 38's weekly Skin check completed by the LPN (licensed practical nurse) dated October 4, 2022, revealed the resident's bottom was red and remained so after 30 minutes of pressure reduction, and Calazime (another name for Calmoseptine ointment) was applied. Clinical record review for Resident 38 revealed that there was no corresponding RN assessment of the resident. Review of an RN progress note for Resident 38 dated October 7, 2022, at 1:24 PM revealed as per the LPN the resident was noted to have a sacral (bottom of the spine) slit (a long narrow open area) and a new physician's order was obtained to apply Optifoam (a foam dressing that is waterproof and has a high fluid-handling capacity) and change it on Tuesdays and Fridays and PRN (as needed) for dislodgement. The nurse was to check the placement of the dressing every shift. Clinical record review for Resident 38 revealed there was no documented assessment of the resident's sacral wound performed by an RN. The above progress note by the RN indicated that the information was relayed per LPN. Review of a Wound consultation (physician ordered wound care specialist that visits the facility to provide care and recommendations) for Resident 38 dated October 13, 2022, revealed the consultant assessed and provided treatment, and recommendations for the resident's surgical wound to his right abdomen. There was no mention of the provider evaluating or treating the sacral wound. 395895 Page 5 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0686 The only assessment of the sacral slit was provided 13 days later on October 20, 2022, and described below. Level of Harm - Actual harm Residents Affected - Few Review of a Wound consultation for Resident 38 dated October 20, 2022, revealed the consultant provided an initial evaluation of the resident's buttocks wounds. The staff reported the wound started as a coccyx (tailbone) slit. The wounds were assessed, and treatment recommendations were as follows: An unstageable (unable to identify staging or severity) pressure ulcer/injury of the right buttocks secondary to slough (dead tissue that needs to be removed for healing to occur) measured 3.0 cm (centimeters) length x 2.0 cm width x 0.2 cm depth. There was 20% granulation tissue (healing tissue) and 80% slough. The nurse was to cleanse the area with NSS (normal saline solution, similar to body fluid) or wound cleanser (special solution designated for wounds), apply Medihoney (a wound healing ointment that has antibacterial and anti-inflammatory properties that aides in removing dead tissue) to the wound base daily, cover with a bordered foam dressing, off-load pressure to affected areas, continue repositioning the resident, monitor for signs of infection such as bogginess, drainage, and erythema (redness). An unstageable pressure ulcer/injury due to a DTI (deep tissue injury, unable to see severity at this stage) of the left buttocks measured 1.5 cm x 1.5 cm x 0.0 cm. The nurse was to cleanse the affected area with NSS or wound cleanser, apply Skin prep (a protective barrier to help preserve the skin), cover with bordered foam dressing, off-load pressure, and continue to reposition the resident. Clinical record review of the TARs (forms for documenting treatments provided) dated October 2022 and November 2022, for Resident 38 revealed that the treatments to the buttocks recommended by the wound consultant was never implemented and the Optifoam dressing was applied though November 15, 2022. Review of a Wound consultation for Resident 38 dated November 10, 2022, revealed the right and left buttocks wounds merged and measured 3.0 cm x 2.5 cm x 0.2 cm, with 10% granulation and 90% slough. The wound was classified as unstageable. The treatment recommendations were changed to cleansing the affected area with NSS or wound cleanser, apply Medihoney to wound base daily, cover with bordered foam dressing, monitor for signs of infection, off-load pressure to affected areas, and continue to reposition in accordance to assessed needs. (The TAR dated November 2022 revealed this treatment was not applied.) Review of a Wound consultation for Resident 38 dated November 17, 2022, revealed the sacral wound measured 3.5 cm x 2.5 cm x 0.2 cm with 100% slough. The wound was classified as unstageable. The peri wound (the area surrounding the wound) was with erythema (redness). The consultant analysis was that the wound had larger measurements, the resident had poor mobility, and erythema to the peri wound. The Medihoney treatment was discontinued and Bactroban (antibiotic ointment) was ordered with a foam dressing daily. The consultant indicated that barriers to wound healing that can delay or impede wound healing were altered mobility, bowel and bladder incontinence, diabetes mellitus, and indicated the resident is at high risk for slow wound healing and secondary wound infection. (There was no documented evidence by the consultant that acknowledged that the previously ordered wound treatments were not provided as recommended for 26 days). Clinical record review of a TAR dated November 2022 for Resident 38 revealed that the Optifoam treatment was provided through November 15, 2022, and on November 16, 2022, the sacrum was cleansed with wound cleanser and Medihoney and a bordered dressing was applied. The sign-off area to complete 395895 Page 6 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0686 Level of Harm - Actual harm this treatment for November 16 and 17, 2022, was blank indicating no documented evidence that the treatment was provided before being discontinued on November 18, 2022. Review of the November 2022 TAR revealed Mupirocin (generic name for Bactroban) was administered from November 18, 2022, through December 1, 2022. Residents Affected - Few Clinical record review for Resident 38 revealed no weekly documented evidence of sacral wound assessments from November 17, 2022, until December 8, 2022 (two weeks without assessments). Review of a Wound consultation for Resident 38 dated December 8, 2022, revealed the sacral wound was larger in size, at 5.0 cm x 5.5 cm x 1.0 cm, with undermining (wound extends under the skin in all directions) from 8-12 o'clock, and 20% granulation tissue and 80% slough. The recommendation was to change the treatment to cleansing the area with NSS or wound cleanser, apply nickel thick size of Santyl (debriding agent to remove slough) to wound base, and gently packing the cavity with ¼ strength Dakin's (debriding agent) moistened gauze, and cover with bordered foam dressing. Review of the TARs indicated that this treatment was implemented through March 18, 2023. Review of a Wound consultation for Resident 38 dated December 15, 2022, revealed the sacral wound measured 7.0 cm x 6.0 cm x 3.0 cm, with undermining from 8-12 o'clock from 0.5 cm, and 20% granulation tissue and 80% slough. A foley catheter (tubing inserted in the bladder that drains urine into a collection bag, keeping the skin dry) was implemented to aide in wound healing. Clinical record review for Resident 38 revealed weekly Wound consultations with assessments of the sacral wound, and on January 12, 2023, the sacral wound measured 6.0 cm x 5.0 cm x 2.5 cm with undermining from 8-12 o'clock for 2.5 cm. A sacral Xray was recommended to rule out osteomyelitis (bone infection). Review of a Sacrum/coccyx Xray completed for Resident 38 on January 15, 2023, revealed no acute abnormalities and no definite evidence of osteomyelitis (bone infection). Should a clinical concern persist then consider follow up with a more sensitive CT scan (computer tomography, uses computer and x-rays). Review of a CT pelvis with contrast for Resident 38 completed on March 8, 2023, revealed the resident had Sacrococcygeal (sacral and coccyx area) osteomyelitis with tiny fluid collection/abscess. Clinical record review for Resident 38 revealed weekly Wound consultations with assessments of the sacral wound with their last consultation on March 9, 2023. The wound measured 4.5 cm x 4.5 cm x 2.5 cm. During a meeting with the Director of Nursing on July 27, 2023, at 11:30 AM the surveyor requested additional documentation of Resident 38's sacral wound as there was no documented evidence of wound assessments after March 9, 2023, to current. The Director of Nursing indicated that the resident's responsible party wanted to change consultants. Resident 38 was seen in the new Wound consultation office, and she indicated the facility had problems obtaining the written consultations. The new Wound consultations were provided to the surveyor after requested. Review of these documents revealed they were faxed to the facility on July 27, 2023. The first consultation by the Wound Center for Resident 38 was on March 2, 2023, and revealed a Stage IV (full thickness tissue with exposed bone, tendon, or muscle) pressure ulcer that measured 4.5 cm x 3.5 cm x 2.8 cm with 4 cm of undermining from 11-3 o'clock. The consultant indicated that the bone was exposed, and chronic 395895 Page 7 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0686 osteomyelitis was suspected. A CT (computer tomography, uses computer and x-rays) scan was ordered. Level of Harm - Actual harm Review of a CT pelvis with contrast for Resident 38 completed on March 8, 2023, revealed the resident had Sacrococcygeal (sacral and coccyx area) osteomyelitis with tiny fluid collection/abscess. Residents Affected - Few Review of a deep wound culture of Resident 38's sacral wound dated March 16, 2023, revealed Pseudomonas aeruginosa and Escherichia coli (both bacteria found in stool). Review of a physician's order for Resident 38 dated March 21, 2023, revealed the nurse was to administer Cefepime Hcl (hydrochloride; an antibiotic) 2 gram/100 milliliters intravenously twice daily for six weeks for sacral osteomyelitis. Review of Wound Center consultations revealed that Resident 38 was provided additional consultations on March 16 and 23, April 11, May 2 and 23, June 6, 27, and July 18, 2023. Review of a physician's order for Resident 38 dated June 7, 2023, to current, revealed that Z-guard (zinc ointment, protective barrier) was to be applied to the sacral peri wound with each dressing change twice daily. Review of a physician's order for Resident 38 dated June 27, 2023, revealed the current treatment ordered for the sacral wound was to wash the area with soap and water, pat dry, apply moistened Puracol plus (a collagen healing solution), cover with gauze and ABD (large abdominal size dressing), use Hypafix tape to sacrum, change every other day and PRN for soiling/dislodgement for sacral ulcer. Review of Wound Center consultation for Resident 38 dated July 18, 2023, revealed the Stage IV sacral wound was stable and smaller. The wound was debrided and measured 3.5 cm x 1.5 cm x 1.5 cm with undermining of 2.5 cm. During an interview with the Director of Nursing on July 28, 2023, at 8:20 AM it was confirmed that there were no weekly assessments done on the sacral wound from March 3, 2023, to current other that the dates assessed by the Wound Center as above. Observation of a sacral dressing change by Employee 1, LPN, on July 26, 2023, at 2:00 PM revealed the resident's sacral wound had scant active bleeding after the old dressing with brown drainage was removed. Employee 1 indicated that she did not need as much gauze to pack it. Employee 1 administered the treatment containing Puracol plus as ordered but did not apply Z-guard to the peri wound. During an interview with the Director of Nursing on July 28, 2023, at 8:20 AM the surveyor questioned how Z-guard could be applied to the sacral peri wound as the current dressing change was to be performed every other day and the dressing covers the peri wound and the Z-guard is ordered twice daily. The Director of Nursing indicated that she would clarify this order. Review of a nursing note dated July 28, 2023, at 12:15 PM revealed that the facility received a return call from the wound center and a new order was received to discontinue z-guard to peri wound BID with dressing change. The facility's failure to initially assess and treat Resident 38's buttocks wound resulted in harm. The facility failed to assess the reddened buttocks on October 4, 2022, which worsened to a sacral 395895 Page 8 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0686 Level of Harm - Actual harm Residents Affected - Few slit on October 7, 2022. The sacral slit was not assessed until 13 days later and then was classified as an unstageable pressure ulcer/injury. A new treatment recommendation was not provided for 26 days resulting in an infection requiring topical antibiotics. The pressure ulcer/injury enlarged to a Stage IV pressure ulcer/injury with undermining that resulted in osteomyelitis. The resident required intravenous antibiotics for six weeks and remains with a foley catheter to prevent urinary incontinence for optimal wound healing. Bone was observable in the sacral pressure ulcer/injury. These issues were discussed with the Director of Nursing on July 28, 2023, at 8:20 AM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services 395895 Page 9 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to regularly assess a resident's entrapment risk from the use of bed rails for three of nine residents reviewed for accident hazards (Residents 26, 29, and 96). Findings include: Observation of Resident 29 on July 25, 2023, at 10:35 AM revealed the resident sitting on the edge of the bed. An enabler bar was observed on the right side of the bed. Clinical record review for Resident 29 revealed a physician's order for the right enabler bar to promote independence dated July 10, 2021. Updated consent and therapy assessments for continued need for the right enabler bar were completed in March 2023. There was no evidence of an assessment of the entrapment risk for the right enabler bar. Observation of Resident 26 on July 26, 2023, at 9:12 AM revealed the resident lying in bed with bilateral enabler bars observed on the bed. Clinical record review for Resident 26 revealed a physician's order for bilateral enabler bars to maximize independence with bed positioning in bed dated December 24, 2021. Updated consent and therapy assessments for continued need for the enabler bars were completed in October 2022. There was no evidence of an assessment of the entrapment risk for the bilateral enabler bars. Observation of Resident 96 on July 25, 2023, at 10:17 AM revealed that she was sitting in a chair next to her bed. Concurrent observation of her bed revealed bilateral enabler bars observed on the bed. Clinical record review for Resident 96 revealed a physician's order for bilateral enabler bars on the bed dated July 29, 2021. Updated consent and therapy assessments for continued need for the enabler bars were completed in July 2022, and June 2023, respectively. There was no evidence of an assessment of the entrapment risk for the bilateral enabler bars. In an interview with the Director of Nursing on July 27, 2023, at 9:48 AM the above information was reviewed for Resident 29 and evidence of the entrapment zone assessment of Resident 29's right enabler bar was requested, and the same information was requested for Residents 26's and 96 's bilateral enabler bars. The Director of Nursing indicated in an interview on July 27, 2023, at 2:39 PM that original assessments of the entrapment zones for the rails on the beds for Residents 26, 29, and 96, could not be located and were completed after being brought to the attention of the facility during the survey process. In an interview with Employee 2, director of maintenance, on July 28, 2023, at 1:45 PM, Employee 2 indicated entrapment zones assessments are completed on residents when rails are initially installed, when they change beds, or mattress surfaces, and not regularly reassessed unless one of those events occur. Employee 2 stated the initial assessments for Residents 26, 29, or 96 could not be located. 395895 Page 10 of 11 395895 07/28/2023 Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754

F 0700 There was no evidence Resident 26, 29, or 96 were assessed for the risk of entrapment from bed rails prior to the observations noted above. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(d) Resident care policies Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395895 Page 11 of 11