Health inspection·November 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report an injury of unknown origin, a fractured arm, and the results of the facility's completed investigation into possible resident abuse or neglect within 5 working days of the incident to the State Survey agency for one of four residents reviewed (Resident 2). Findings include: A review of facility policy titled, Abuse, neglect and misappropriation, reviewed by the facility August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment and exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable and local and state agencies in accordance with the procedures in this policy. The time frame for investigation is notes as, the investigation must be completed within 5 working days from the alleged occurrence. The administrator or designee will provide a written report for employees, using the PB-22, to the Department of Health within 5 calendar days of the incident. A review of a facility investigation dated September 22, 2023 at 4:10 P.M. revealed that when a nurse aide went into the Resident 2's room to provide care, and as she went to change her, the resident was complaining of pain in her left arm. As the nurse aide removed the resident's shirt, she noticed a dark purple bruise to the resident's left upper arm/axilla (underarm), extending into her left chest. The nurse aide called the nurse in to see the resident. Resident 2 was unable to say what happened to cause the bruising. She did say that her arm hurt. An x-ray completed that date revealed that the resident sustained a fractured humerus. The facility failed to investigate this resident's injury of unknown origin, and rule out neglect or mistreatment of the resident as the potential cause of the injury, until the day of the survey ending November 15, 2023. A review of the facility's investigation into this incident revealed no indication that the facility had notified the State Survey Agency, Pennsylvania Department of Health, Division of Regulatory Oversight & Nursing care Facilities of the resident's injury of unknown origin which may have been related to potential neglect due to the possible lack of proper assistance with the resident's care and transfers. The resident required assist of two staff for transfers and care and the facility failed to ascertain if the resident had consistently received the care and services as planned to prevent Page 1 of 9 395905 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0609 the injury, a fractured arm. Level of Harm - Minimal harm or potential for actual harm Following surveyor inquiry during the survey of November 14, 2023, the facility reported the potential neglect of Resident 1 with serious physical injury to the appropriate agencies as noted in their procedures and regulatory requirements. Residents Affected - Few The facility did not timely report and thoroughly investigate the resident's injury of unknown origin and potential neglect that was identified on September 22, 2023, until surveyor inquiry during the survey of November 14, 2023. Refer F610 28 Pa. Code 201.14 (c) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12 (c) Nursing Services 395905 Page 2 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse prohibition policy and procedures, facility provided documentation, and clinical records and interviews with staff it was determined that the facility failed to timely and thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment for one of the four residents sampled (Resident 2). Residents Affected - Few Findings include: A review of facility policy titled, Abuse, neglect and misappropriation, dated as reviewed August 30, 2023, revealed that the facility will not tolerate abuse, neglect, mistreatment and exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable and local and state agencies in accordance with the procedures in this policy. The time frame for investigation is notes as, the investigation must be completed within 5 working days from the alleged occurrence. The administrator or designee will provide a written report for employees, using the PB-22, to the Department of Health (State Survey Agency) within 5 calendar days of the incident. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning). A quarterly MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment, dated August 16, 2023, indicated that the resident was severely cognitively impaired with Brief Interview for Mental Status (BIMS) score was 5 and required extensive assistance with activities of daily living to include, bed mobility, transfers and toileting. The resident's care plan for activities of daily living (ADLs) initiated June 4, 2023, indicated that the resident required the assistance of two staff for all care. A review of a nurses note dated September 22, 2023, 7:38 P.M. revealed that Resident 2 had bruising to the left shoulder/axilla extending into left chest. Slight puffiness was noted to the resident's left shoulder. The resident had complaints of pain with movement. The immediate intervention was that the CRNP (Certified Registered Nurse Practitioner) was notified and an x-ray left of the resident's shoulder and humerus ordered. An x-ray of the left shoulder completed on September 22, 2023, 11:14 P.M. revealed, findings suspicious for acute proximal humeral neck and humeral head fracture. A nurses note dated September 23, 2023 12:13 AM revealed that the results of the X-ray report were called to CRNP reporting that the resident had sustained a fractured humerus. New orders were received for the resident to wear a sling to left upper extremity at all times. May remove for care. Tramadol (narcotic pain medication) 50 mg every 8 hrs as needed for pain, 4-10 (pain level, 1-10, one least pain, 10 greatest pain) was ordered. 395905 Page 3 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A nurses note dated September 23, 2023, at 10:03 AM revealed that Resident 2's sling to the left arm remained in place as ordered, bruising was observed to be dark purple/blue in color. A review of a CRNP progress note (documented at a late entry) dated September 25, 2023, at 10:05 AM revealed that Resident 2 was seen for an acute visit for reports of a fractured humerus. The resident was noted with some left upper extremity ecchymosis (black and blue bruising) and discomfort on September 22, 2023. X-ray was ordered and it was noted that she had acute proximal humeral neck and humeral head fracture. Patient denies any recent injury or fall. Resident is DNR (do not resuscitate) comfort per power of attorney. Family would like patient kept comfortable in the facility and do not want her sent to orthopedics for a consult given her advanced age. Impression and Plan noted as follows: 1. fx Left humerus - POA declined ortho consult 2. Pain - Tramadol 25 mg q 6 hours x 3 days 3. ambulatory dysfunction - receives assistance with ADLS. During the survey ending November 14, 2023, the surveyor requested the facility's investigation into the resident's injury of unknown origin, fractured humerus, as to date, none had been submitted to the State Survey Agency since the finding of the injury on September 22, 2023. The facility provided documentation dated September 22, 2023 at 4:10 P.M. that revealed that when a nurse aide went into the Resident 2's room to provide the resident care, and as she went to change the resident, the resident complained of pain in her left arm. As the nurse aide removed the resident's shirt, she noticed a dark purple bruise to the resident's left upper arm/axilla (underarm), extending into the resident's left chest. The nurse aide called the nurse in to see the resident. Resident 2 was unable to say what happened to cause the bruising, but stated that her arm hurt. The following witness statements were provided during the survey of November 14, 2023, but not submitted with a completed investigation into the resident's fracture of unknown origin, to the State Survey Agency within 5 working days of the incident. A witness statement dated September 25, 2023, from Employee 5, a nurse aide, indicated that on (on September 21, 2023, during the 7 PM to 7 AM shift) I took over [NAME] (hallway) assignment which included room [ROOM NUMBER] D (Resident 2' s room) at 3 P.M. I went to check on {Resident 2}, she was still in bed. So when I took her shirt off to put a hospital gown on her, I put my hand on her back to raise her up to lift her shirt the rest of the way off. Her dermasavers ( fabric sleeves used to protect a residents skin) were still in position. I didn't see any bruises at that time. I continued with her care. I went from side to side to change her, using the chux to bring her to me. The other nurse aide took over the assignment around 5 PM. A witness statement dated September 22, 2023, from Employee 4, a nurse aide, indicated that I was taking care of {Resident 2} the day before (September 21, 2023). I came on the shift around 4:30 PM and {Resident 2} was already in bed and changed. I helped with her dinner then changed her around 7:30 PM., then changed her again around 10 PM Then this morning (September 22, 2023) I gave her her breakfast tray, but she was dressed already. I didn't see any bruising on September 21 or 22, 2023. 395905 Page 4 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A witness statement dated September 22, 2023, from Employee 2, a nurse aide, indicated that (In the) early morning (September 22, 2023), I gave {Resident 2 care}. I took her night gown off. I did notice a bruise on her left arm, but thought it was old. I didn't report it because I thought it was reported already. A verbal statement obtained by the former Director of Nursing (DON) dated September 23, 2023, indicated that Employee 2, a nurse aide, also stated that Resident 2's bruise was observed during 5 AM rounds that morning, but she didn't visualize it (the bruise) on first rounds (at 1 A.M.) and didn't remove her gown (at that time). Resident 2 didn't complain of or display pain during this 1 A.M. round. A witness statement dated September 22, 2023, from Employee 3, a nurse aide, indicated that I had Resident 2 today (September 22, 2023, 7 AM to 3 PM. shift). She was already dressed by (the staff on the ) 11 P.M. to 7 A.M. shift. I repositioned her in bed. I helped her with her meals and I changed her. At no time did she complain of pain. She did nothing to indicate that she was in pain. I changed her around 2:10 PM and positioned her on her left side. She didn't complain when I was positioning her. She was not out of bed. I had her yesterday (Thursday September 21, 2023 morning) and she was not dressed. She did not have any complaints. I washed and dressed her. She did not have any bruising to her left shoulder. I did not get her out of bed that day. Nothing unusual. A witness statement dated September 22, 2023, from Employee 6, a nurse aide, stated I had Resident 2 on September 20, 2023. I assisted another nurse aide with the resident's shower, transfer and dressing the resident. Resident 2 had no marks. Her skin was also checked after the shower by the licensed nurse. On September 22, 2023, today, around 4:15 P.M. I went to change and dress down the resident. She complained that her arm hurt after getting her right arm out of the sleeve and neck of her shirt. Resident got rolled for a new brief and took her left arm out of the shirt. I seen {Resident 2's} arm was bruised. I went and notified the resident's nurse and the RN Supervisor. I did not work September 21, 2023. Another aide and myself continued changing and dressing the resident. An employee witness statement dated September 22, 2023, from Employee 7, RN Supervisor, indicated that I was called to {Resident 2's} room by {Employee 6}, nurse aide, reported bruising of the left shoulder/axilla area. {Resident 2} did complain of pain with movement of the left upper extremity. Bruising and puffiness to the left shoulder with bruising extending into the left axilla and left upper chest. {Resident 2} was not able to say how or what happened to cause the bruising due to her cognitive status. The physician was notified and ordered left shoulder/humerus x-ray. The family was notified. I (Employee 7 RN Supervisor) worked September 20, 2023, 7 P.M to 7 A.M Nothing was reported to me about bruising or pain in Resident 2's left shoulder. There was no documented evidence at the time of the survey ending November 14, 2023, that the facility had thoroughly investigated to determine if the resident's care plan for the assistance of two staff with all ADL care was consistently followed in the days prior to the resident's injury being identified. Resident 2's bruise and associated fracture were not timely reported by staff and timely and thoroughly investigated by the facility. The facility failed to fully investigate to determine if all direct care staff involved in the resident's care in days leading up to the resident's fracture had consistently provided the assistance of two staff members with all her care to rule out neglect the cause of the resident's fracture. During an interview on November 14, 2023, at approximately 2 p.m., the former Director of Nursing (DON) was unable to provide evidence that the facility fully investigated Resident 2's fracture of 395905 Page 5 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0610 unknown source to rule out neglect as the potential cause. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.14 (c) Responsibility of Licensee Residents Affected - Few 395905 Page 6 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility reports and employee personnel files, and resident and staff interviews it was determined that the facility failed to assure that licensed and professional nursing staff possessed the necessary skills and competencies to accurately perform medication administration as prescribed to one resident out of four sampled (Resident 1). Findings included: Review of Resident 1's clinical record revealed admission to the facility on September 24, 2022, with diagnoses, which included cerebral vascular disease ( a stroke) with left sided hemiparesis. A review of a facility investigation report dated September 9, 2023, at 6:30 P.M. revealed that a licensed nurse administered the wrong medications to Resident 1, which the resident identified prior to ingestion. Resident 1, who resided in room [ROOM NUMBER] W, notified staff of the error and pills were removed. Nursing staff then provided Resident 1 the correct medications. Resident 1 reported that I was given 8 pills instead of my prescribed 5. I looked them (the pills) up to make sure they were the wrong ones (pills). I informed the facility that I would be filing a report. A witness statement dated September 9 2023, from Employee 1, LPN, revealed that During the 3 PM. to 11 PM med pass I decided to get (the medications for the residents residing in) rooms 30 D and 30 W first due to timing of the medication to be given. I gathered (resident residing in room [ROOM NUMBER] Window) 29 W medications to be given but she is independent and was in the bathroom so I didn't want to leave them in the resident room, so I labeled the cup because I didn't want to get it mixed up and would return (to the resident's room) in a little bit. I then returned down the hall. I had went into room [ROOM NUMBER] D and 27 W first and the resident in 27 W was upset that I put her meds in applesauce, so I had to get them for her ( reported her medications). When I got to room [ROOM NUMBER] W, I got {Resident 1}'s meds together and just when I was going into {Resident 1's} room, I got called back into resident room [ROOM NUMBER] W because she had dropped her call bell. I went into that room to assist the resident. I came back out to go into {Resident 1's} room. I grabbed her (cup of prepared medications). When i got into her room, I placed the cup of medications on the side table with a cup of ice water. I asked {Resident 1} how she was doing today, she said not so good.'' I lifted her head of the bed up so she could take her meds. {Resident 1} picked up the cup and put it to her mouth as she usually does and said thank you. I said no problem and started out of the room where my medication cart was and said, let me know if you need a little more water. She replied, no, this is fine. The resident in room [ROOM NUMBER] D called me into her room for me to pull the side table closer to her. I went into room [ROOM NUMBER] then up towards the nursing station. I went back into the med cart for the resident in room [ROOM NUMBER] W's medications and thought I was going crazy because I only had 2 meds in the cup. So I thought I knocked them over (in the med cart) while coming up the hall. I rechecked The resident in room [ROOM NUMBER] W's meds and got them together and went to give them to her now that she was done in the bathroom. The supervisor then gave me the (cup of pills) meds and says that {Resident 1} said that these were not her pills. I went into the cart and the medication administration record and got the correct meds for her (Resident 1). I took them down to her immediately and told her I apologize. {Resident 1} stated, I get that you may have made a mistake, but I will be reporting you. I know that these were not my meds, so I looked them up (on 395905 Page 7 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0726 the internet). Level of Harm - Minimal harm or potential for actual harm A review of Employee 1 (LPN)'s employee file revealed that she was hired on April 3, 2023. A medication skills checklist, competencies for medication administration was signed as completed on April 5, 2023. Residents Affected - Few An interview conducted on November 14, 2023 at 11 AM with Resident 1 confirmed that on September 9, 2023, second shift, Employee 1 (LPN) gave her a cup of medications that was not hers. She stated that the LPN handed her the cup of pills then left the room. The resident then poured the meds out on her table. She stated that she did not recognize the meds. She then took out her phone and looked up the meds to identify them. She stated that she then took a photo of the medications and called the nursing supervisor to inform her of the situation. She stated that she did not take the wrong pills. Employee 1 (LPN) had prepared multiple residents' medications prior to administration resulting in Resident 1 being provided the the incorrect medications. Interview with the former Director of Nursing on November 14, 2023, at 1 p.m. confirmed that the facility failed to ensure that nursing staff had the demonstrated the competencies and skills sets to accurately administer resident medications. She confirmed that Employee 1 (LPN) did prepour medications resulting in the error. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 395905 Page 8 of 9 395905 11/14/2023 Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and select facility reports and staff interview it was determined that the facility failed to assure that one resident out of six sampled was free from a significant medication error. (Resident 2). Residents Affected - Some Findings include: A review of Resident 2's clinical record revealed that the resident had diagnoses that included dementia and hypertension. Further review of the resident's clinical record revealed that the resident required that her medications be crushed. A pharmacy consultant report dated October 24, 2023, identified that some of the resident's prescribed medications not recommended to be crushed per manufacturer guidelines. The pharmacist recommended changing Metoprolol succinate 25 mg (antihypertensive) to Metoprolol tartrate 12.5 mg two times a day (immediate release antihypertensive that may be crushed). The physician reviewed and accepted the pharmacist's recommendations on November 28, 2023. Review of a time sensitive pharmacy consultant report dated December 20, 2023, indicated that Resident 2 was receiving duplicate drug therapy. The resident was receiving both Metoprolol succinate 25 mg QD and Metoprolol tartrate 12.5 mg BID for hypertension. According to the report, the pharmacist called the facility on December 20, 2023, to alert them of the duplicate antihypertensive drug therapy and potential medication error. Review of a facility Medication investigation dated December 20, 2023, revealed that a new order had been received to change the antihypertensive medication from Metoprolol succinate to Metoprolol tartrate, but Resident 2 received both medications from November 28, 2023, through December 20, 2023. The Metoprolol Succinate 25 mg once daily was not discontinued as ordered by the physician on November 28, 2023, when metoprolol tartrate 12.5 mg BID was ordered. Further review of the facility's investigation revealed that the resident had no adverse effects as the result of receiving both antihypertensive medications for approximately three weeks. Review of witness statement dated December 20, 2023, completed by Employee 3, registered nurse, indicated that Employee 3 thought she had discontinued the order, but stated I did not review the orders portal before I got out of the resident's chart. Review of Resident 2's Medication Administration Records dated November 2023 and December 2023 revealed that Resident 2 received both antihypertensive medications for 18 days. Interview with the Director of Nursing on January 23, 2024, at approximately 1:00 PM confirmed that due to a nursing transcription error the antihypertensive medication was not discontinued as ordered by the physician. The director of nursing further confirmed that the facility had failed to timely identify the transcription error to prevent the significant medication error and potential adverse outcome to the resident. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 395905 Page 9 of 9