Health inspection·September 22, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that a resident was free from an accident by not providing the appropriate amount of supervison needed for toileting, for one of three residents reviewed (Resident R75). Findings include: Review of the facility policy fall prevention plan last review on 9/18/23, with a previous review date of 3/2/22, indicated that post fall the resident is assessed by a licensed nurse, once the resident is safely transferred a fall investigation begins, any witnesses to the fall should provide a written statement and interventions should be put into place to prevent further falls. Review of the facility policy Occurrence Incident Reporting policy last reviewed on 9/18/23, with a previous review date of 3/2/22, indicated incidents will be investigated, reported and tracked. documentation will be placed in progress notes and reviewed for potential harm. An event report will be submitted to the state if identified to be appropriate. Review of the clinical record indicated that Resident R75 was admitted to the facility on [DATE], with diagnoses which included indicated diagnoses of Parkinson's disease( a disorder of the central nervous system which affects movement and often causes tremors, other symptoms include unsteadiness and stiffness) and a history of falls. A Minimum Data Set (MDS- a periodic review of resident care needs) dated 7/19/23, indicated the diagnoses remained current and Section G0110 indicated that Resident R75 required assistnace of two for transfers and toilet use. Section G 0300 indicated unsteadiness for stabilization with toileting. A current physician order dated 7/14/23, indicated Resident R75 was a two person transfer. Review of a progress note dated 8/20/23, at 18:24 indicated that Resident R75 was found on the floor in the bathroom by the Nurse Aide. The note indicated that the resident stated he was on the toilet, went to stand up and lost balance and fell. The note further indicated that the Nurse Aide stated she took the resident to the bathroom, assisted him to the toilet and instructed him to ring when he was done. During an interview on 9/19/23, at 1:46 p.m., the Director of Nursing stated that the facility failed to ensure that a resident was free from an accident by not providing the appropriate amount of supervison needed for toileting. Page 1 of 6 395977 395977 09/22/2023 Terrace Health & Rehab Center 410 Terrace Drive Uniontown, PA 15401

F 0689 28 Pa. Code: 201.14(a) Responsibility of licensee. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. Residents Affected - Few 28 Pa. Code: 211.10(d) Resident care policies. 395977 Page 2 of 6 395977 09/22/2023 Terrace Health & Rehab Center 410 Terrace Drive Uniontown, PA 15401

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for three of seven residents (Residents R70, R77, and R82). Residents Affected - Few Findings include: A review of the facility policy Medication Administration dated 9/18/23, indicated to administer medications as prescribed by the provider. A review of the clinical record indicated that Resident R70 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder and insomnia. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/2/23, indicated the diagnoses remain current and the resident is alert and oriented and able to make needs known. A review of a physician order dated 9/18/23, indicated to give Lyrica oral capsule (pregabalin a controlled medication to treat nerve pain) 200 mg (milligrams) one capsule by mouth every morning and at bedtime for pain management at 07:00 and 21:00. A review of the Controlled Medication Administration log dated 9/19/23, indicated the Lyrica was not given to resident R70 at 21:00. A review of a progress note date 9/19/23, indicated Resident R70 had missed medication today to include Lyrica. During an interview on 9/21/23 at 10:30 a.m., Resident R70 confirmed they did not receive Lyrica on 9/19/23 as ordered. A review of the clinical record indicated that Resident R77 was admitted to the facility on [DATE], with diagnoses that included dementia, depression, and anxiety disorder. A review of the MDS dated [DATE], indicated the diagnoses remained current and the resident is cognitively impaired. A review of a physician order dated 8/8/23, indicated to give Alprazolam oral tablet 1.0 mg (a controlled medication to treat anxiety) one tablet by mouth at bedtime for anxiety and one tablet in the evening for anxiety at 17:00 and 20:00. A review of the MAR (medication administration record) dated 09/23, indicated Resident R77 did not receive the Alprazolam at 17:00 on 9/19/23. A review of the Controlled Medication Administration log dated 9/19/23, indicated the Alprazolam was not given at 17:00 on 9/19/23. A review of a progress note dated 9/19/23, indicated that Resident R77 missed medication. 395977 Page 3 of 6 395977 09/22/2023 Terrace Health & Rehab Center 410 Terrace Drive Uniontown, PA 15401

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the clinical record indicated that Resident R82 was admitted to the facility on [DATE], with diagnoses that included low back pain, gout (a disease that causes episodes of acute pain in the smaller bones of the feet), and a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A review of the MDS dated [DATE], indicated diagnoses remain current and the resident is alert and oriented and able to make their needs known. A review of a physician order dated 9/19/23, indicated to give Lyrica oral capsule 50 mg one capsule by mouth two times a day for neuropathy (nerve pain) at 07:00 and 17:00. A review of the MAR dated 09/23, indicated the Lyrica was not given on 9/19/23 at 17:00. A review of the Controlled Medication Administration log dated 9/19/23, indicated Resident R82 did not receive the Lyrica as ordered at 17:00. During an interview on 9/21/23 at 11:00 AM, Resident R82 confirmed that he did not receive his Lyrica at 17:00 on 9/19/23. During an interview on 9/20/23, at 1:20 PM, the DON confirmed the above findings and the facility failed to make certain medications were administered as ordered by the physician for Residents R70, R77, and R82. 28 Pa. Code 211.12 (c)(1)(3) Nursing Services. 395977 Page 4 of 6 395977 09/22/2023 Terrace Health & Rehab Center 410 Terrace Drive Uniontown, PA 15401

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. Residents Affected - Many Findings include: Review of facility policy Food: Preparation last reviewed 9/18/23, with a previous review date of 3/2/22, indicated all facility dietary staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. involved in the preparation and service of food adheres to safe food handling techniques, and food is served with clean, sanitized utensils. During an observation on 9/21/23, from 11:40 a.m., through 11:53 a.m., the following was observed: -At 11:40 a.m. Dietary Manager Employee E1, while wearing plastic gloves, was placing biscuits onto each plated food, he left the tray service area obtained a set of tongs, opened the hot food cart, obtained a hamburger using the tongs, used gloved hand to place a bun then placed burger, placed tongs into pan with plastic covered cheese, opened the plastic covered cheese removed a piece with his gloved hand placed it on the burger closed the bun, then opened a bag of potato chips and closed the bag then scooped potatoes onto the plate. - Dietary Manager Employee E1 continued tray line service with no hand washing or glove change between tasks. He continued to plate foods picking up biscuits with gloved hand and placing them on each plate. -At 11:53 a.m., the Dietary Manager Employee E1 continued with the same gloves, opened the hot food cart, using tongs obtained a burger, opened a bun and placed burger, placed tongs in pan with cheese, opened plastic, obtained a piece of cheese with the gloved hand, opened the bag of potato chips, grabbed a handful of chips and plated them with he burger, no hand washing or glove change between tasks. During an interview on 9/21/23, at 11:56 a.m., confirmed with the Dietary Manager Employee E1 and the Nursing Home Administrator the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. 28 Pa. Code: 211.6 (c)(f) Dietary services. 395977 Page 5 of 6 395977 09/22/2023 Terrace Health & Rehab Center 410 Terrace Drive Uniontown, PA 15401

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of manufacturer directions, observation and staff interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination during blood sugar monitoring for one of two residents (Resident R4). Residents Affected - Few Findings include: The manufacturer directions for cleaning the Assure Platinum (brand of blood glucose meter utilized by the facility) was to wipe the exterior of the meter with an approved EPA approved wipe (Clorox, Micro-Kill Microdot, Super Sani cloth, all which contain a form of bleach) between each use. During an observation of a medication pass on 9/22/22, at 11:31 a.m., Licensed Practical Nurse (LPN) Employee E2 obtained a blood glucose reading from Resident R35, after cleaning the blood glucose monitor with a alcohol wipe and again after using the glucose meter on Resident R4. During an interview on 9/22/23, at 11:33 a.m., LPN Employee E2 confirmed not cleaning/sanitizing the blood glucose monitor prior to and after using it on Resident R4 had the potential for cross contamination as proper cleaning wipes had not been used. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395977 Page 6 of 6