Health inspection·September 29, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of eighteen residents reviewed (Resident R49). Residents Affected - Few Findings include: Review of facility policy entitled Computer Terminals/Workstations dated 9/25/23, indicated computer terminals will be positioned so that screens are not visible to public or other unauthorized staff. During observation of medication administration for Resident R49 on 9/26/23, at approximately 3:45 p.m. Licensed Practical Nurse (LPN) Employee E2 prepared medication for a resident from Unit A second floor medication cart parked in the hall against the wall outside the resident room with the computer open sitting on top of medication cart facing into the hallway. LPN Employee E2 then proceeded into the resident room to administer medication. LPN Employee E2 did not cover resident/medication information that was on the computer on top of the medication cart with information visible to those walking in the hallway. LPN Employee E2 was unable to view the computer on top of the medication cart parked in the hall against the wall while in the resident's room. During an interview on 9/26/23, at the time of the observation, LPN Employee E2 confirmed that he/she left the medication cart with the computer open and did not cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E2 also confirmed that resident information was to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 8 395959 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for two of 19 residents reviewed (Residents R20 and R64). Residents Affected - Few Findings include: Review of Resident R20's clinical record revealed an admission date of 9/08/23, with diagnoses that included dementia (disorder of the mental processes caused by brain disease), depression, fractured left knee, diabetes and high blood pressure. Review of Resident R20's clinical record revealed that an antidepressant (medication to treat depression) medication Zoloft was ordered on admission 9/08/23. Review of the admission MDS dated [DATE], Medications Section N0410C indicated that Resident R20 did not receive an antdepressant medication during the seven-day look back period (from 9/07/23 to 9/14/23). During an interview on 9/28/23, at 12:05 p.m. the Director of Nursing (DON) confirmed that Section N0410C of the admission MDS dated [DATE], was incorrectly coded for Resident R20 regarding antidepressant medications. Review of Resident R64's admission record revealed an admission date of 1/25/23, with diagnoses that included hypothyroidism (below normal thyroid functioning), Chronic Obstructive Pulmonary Disease (condition where your lungs do not have adequate air flow), low potassium level, and high blood pressure. Observation of Resident R64's room revealed and enabler bar (a device attached to the bed to assist in turning and repositioning) attached to the top of the right side of her bed. Observation revealed no evidence of a restraint being used with Resident R64. Review of the MDS dated [DATE], Restraints and Alarms revealed section P0100 identified that a bed rail was used daily. Review of Resident R64's care plans revealed no care plan for the use of restraints, review of the resident physician orders revealed no order for restraints. During an interview on 9/28/23, at 1:35 p.m. the DON revealed that there were no residents in the facility utilizing restraints. The DON confirmed that Section P0100 of the MDS dated [DATE], was incorrectly coded for Resident R64 regarding restraints. 28 Pa. Code 211.5(f) Clinical records 395959 Page 2 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for four of 19 residents reviewed (Residents R20, R92, R73, and R196). Findings include: Review of a facility policy entitled, Baseline Care Plan Guidelines dated 9/25/2023, revealed that the facility will provide a written summary to the resident/resident representative of the baseline care plan and discharge plan. Review of Resident R20's clinical record revealed an admission date of 9/08/23, with diagnoses that included dementia (disorder of the mental processes caused by brain disease), depression, fractured left knee, diabetes and high blood pressure. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of Resident R92's clinical record revealed an admission date of 9/03/23, with diagnoses that included fractured lower leg, history of falling, difficulty in walking and depression. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of R73's clinical record revealed an admission date of 8/18/23, with diagnoses including acute and chronic respiratory failure, type II diabetes, difficulty in walking, cognitive communication deficit (difficulty communicating), and dysphagia following a cerebral infarction (difficulty swallowing following a stroke). The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of Resident R196's clinical record revealed an admission date of 9/18/23, with diagnoses including fracture of the left lower leg, muscle weakness, and history of falling. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. During an interview on 9/28/23, at 12:56 p.m. the Assistant Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan was provided to Residents R20, R92, R73, and R196 and/or the resident's representative. 28 Pa. Code 211.5(f) Clinical records 395959 Page 3 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of four closed records reviewed (Resident R94). Findings include: Review of a facility policy entitled, Disposition of Medication Policy dated 9/25/2023, indicated that disposition will be recorded in the electronic health record or paper form. Review of Resident R94's clinical record revealed an admission date of 7/6/23, with diagnoses that included, diabetes, low blood pressure, depression, and muscle weakness. Resident R 94's clinical record also revealed a discharge date of 8/5/23. Review of discharge summary lacked evidence of reconciliation of discharge medications on discharge. Review of nursing documentation lacked evidence of the type or number of medications sent home with resident on discharge. Review of Resident R94's physician orders indicated Resident R94 was receiving fourteen prescribed medications at time of discharge. During interview on 9/29/23, at 9:10 a.m. with the Nursing Home Administrator he/she confirmed that there was no documentation to account for Resident R94's s pre-discharge medications. During interview on 9/29/23, at 11:15 a.m. with the Assistant Director of Nursing he/she confirmed that there was no documentation of what medications or number of medications were sent home with Resident R94. He/She also confirmed that discharge medications should have a reconciliation of type of medication, amount of medication and signatures of nurse and resident/resident representative on discharge summary. 28 Pa. Code 211.5(d)(f) Clinical records 395959 Page 4 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

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 evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R30). Findings include: Review of facility policy entitled, Behavioral Management-General Policy, dated 9/25/23, stated management of aggression requires behavioral interventions through a behavior management program and interdisciplinary care planning, staff in-service education on behavior management and techniques, sequential use of psychotropic medications if necessary, and most aggressive behavior can be managed by a combination of behavioral interventions and psychopharmacology. Review of Resident R30's clinical record revealed an admission date of 7/25/23, with diagnoses that included fracture of the left ulna, muscle weakness, difficulty in walking, unspecified dementia (disorder of the mental processes caused by brain disease), and psychotic disorder with delusions (seeing and hearing things that are not there). The clinical record revealed that on 8/4/2023, Resident R30's physician ordered Haldol injection solution (medication used to treat psychosis) inject 1 milliliter (ml) intramuscularly every six hours PRN for psychosis and on 8/17/23, Resident R30's physician ordered Clonazepam (medication ordered to treat anxiety) 0.5 milligrams (mg) every six hours PRN for anxiety. Review of the August 2023 Medication Administration Record (MAR) for Resident R30 revealed that the PRN Haldol was used on 8/4/23, 8/10/23, 8/12/23, 8/15/23 and the PRN Clonazepam was used on 8/17/23, 8/19/23, 8/22/23, and 8/26/23. Review of August 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Haldol for the four administrations and Clonazepam for the four administrations in August 2023. During an interview on 9/28/23, at 12:56 p.m. the Assistant Director of Nursing confirmed that R30's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications and that non-pharmacological interventions should be attempted and documented in the clinical records when using PRN psychotropic medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395959 Page 5 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

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 and manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of four medication carts observed and failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of two medication rooms reviewed (Unit A second floor medication cart and first floor medication room). Findings include: Review of a facility policy entitled, Storage of Medications dated 9/25/23, indicated that compartments containing medications are locked when not in use and carts used to transport such items are not left unattended. Review of facility policy entitled Administering Medications dated 9/25/23, indicated that during administration of medications, the medication cart will be kept closed and lock when out of view and multi-dose containers will have date opened recorded on the container. Review of manufacturer's recommendations for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observation on 9/26/23, at approximately 3:40 p.m. revealed that Licensed Practical Nurse (LPN) Employee E2 prepared medication for a resident from Unit A second floor medication cart parked in the hall against the wall outside the resident room with the drawers of the medication cart facing into the hallway. LPN Employee E2 then proceeded into the resident room to administer medication. LPN Employee E2 did not securely lock Unit A second floor medication cart. Employee E2 was unable to view medication cart and drawers of the medication cart from inside the room while left unattended. During an interview on 9/26/23, at the time of the observation, LPN Employee E2 confirmed that he/she left the medication cart unlocked while it was parked in the hallway against the wall outside the resident room, which was out of view during medication administration. LPN Employee E2 confirmed that the medication cart should be locked when not within view. Observation of drug storage on 9/27/23, at approximately 9:30 a.m. in first floor medication storage room refrigerator revealed an opened vial of Tubersol without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, LPN Employee E1 confirmed that the opened Tubersol vial lacked an open date and staff were unable to determine the discard date. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services 395959 Page 6 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain accurate clinical records for one of 18 residents reviewed (Resident R79). Residents Affected - Few Findings include: Review of facility policy entitled Charting and Documentation dated 9/25/2023, indicated that documentation in the medical record will be complete and accurate. Review of Resident R79's clinical record revealed an admission date of 1/25/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), diabetes, dysphagia (difficulty swallowing) and dementia (a disease that affects short term memory and the ability to think logically). Review of Resident R79's clinical record nursing documentation revealed that on 8/6/23, at 10:29 a.m. Resident R79 was sent to the emergency room for evaluation, then on 8/6/23 at 12:03 p.m. nursing documentation revealed that Resident R79 was being admitted to the hospital. Further review of Resident R79's clinical record revealed skilled nursing documentation on 8/6/23, at 3:15 p.m. that Resident R79 had voiced no concerns and the nurse was going to continue to monitor. Review of Minimum Data Set (MDS-a period assessment of resident care needs) dated 8/6/23, section A2000 revealed a discharge date of 8/6/23, section A2100 revealed discharge status of 03 --acute hospital. During interview on 9/28/23, at 12:08 p.m. the Director of Nursing confirmed that Resident R79 was not in the facility on 8/6/23 at 3:15 p.m. and that the resident was admitted to the hospital. He/she also confirmed that skilled charting on residents should not be completed when residents are not physically in the facility. 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.5(f) Clinical records 395959 Page 7 of 8 395959 09/29/2023 Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program that contained a system of reports related to monitoring antibiotic usage and resistance data for 12 consecutive months reviewed (September 2022-September 2023). Residents Affected - Some Findings include: Review of a facility policy entitled Antibiotic Stewardship dated 9/25/23, indicated that administrative and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on how to access the current facility antibiogram (a collection of data usually in the form of a table summarizing the percent of individual bacterial pathogens [disease causing organisms susceptible to different antimicrobial agents]. Review of facility infection control reports/documentation revealed there was no evidence to support that the facility had an antibiogram for 12 consecutive months (September 2022-September 2023). During an interview on 9/28/23, at 1:00 p.m. the Infection Preventionist confirmed that the facility had not obtained antibiograms from the participating lab to monitor antibiotic usage and resistance data for 12 consecutive months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 395959 Page 8 of 8