Health inspection·October 19, 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. Based on a review of clinical records, facility investigation reports, and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of 36 residents reviewed (Resident 16). Findings include: A facility policy for fall prevention, dated December 28, 2022, revealed that the facility will provide a safe environment for all residents through safety standards, including ensuring the residents wear proper shoes, have adequate supervision, and staff use assistive devices to prevent falls. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of resident's care needs and abilities) for Resident 16, dated July 26, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for daily care needs, including transfers. Resident 16's care plan, most recently updated July 26, 2023, revealed that the resident was at risk for falls and that she required two staff and a wheeled walker for transfers. A nursing note for Resident 16, dated August 4, 2023, revealed that the resident fell in the bathroom. A witness statement, dated August 4, 2023, revealed that Nurse Aide 1 attempted to transfer Resident 16 by herself instead of with two staff, without a gait belt, and the resident did not have proper footwear on, resulting in the resident falling. Interview with the Director of Nursing on October 19, 2023, at 1:11 p.m. confirmed that Resident 16 was not transferred properly and that Nurse Aide 1 was educated to follow the resident's care plan, as well as the facility's policy regarding transfers when transferring a resident. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.6(f) Dietary services. Page 1 of 4 396069 396069 10/19/2023 Arbutus Park Manor 207 Ottawa Street Johnstown, PA 15904

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 the review of facility policy, observations, and staff interviews, it was determined that facility failed to ensure the proper storage of food. Residents Affected - Some Findings include: The facility policy for food storage-perishable, dated December 28, 2022, indicated that food was to be stored under sanitary conditions to prevent injury from foodborne illness. All food stored in the refrigeration units will be in covered containers or otherwise suitably protected. Observation and interview with Food Service [NAME] 2 on October 16, 2023, at 9:44 a.m. revealed that in the three-door refrigerator there was a pan of red jello and a pan of yellow jello, which were partially used and uncovered. The trays were dated October 13-17, 2023. Interview with Food Service [NAME] 2 indicated that the trays should have been covered. Observation and interview with Food Service Aide 3 on October 18, 2023, at 8:36 a.m. revealed that in the refrigerator with three doors, there was a full pan of yellow jello and a full pan of diet green jello, which were uncovered. The trays were dated October 17-20, 2023. Interview with Food Service Aide 3 at that time confirmed that the trays should have been covered. Interview with the Food Service Director on October 18, 2023, at 8:38 a.m. confirmed that when they initially make the jello staff are to let it cool for approximately five minutes then they are to cover it. 28 Pa. Code 211.6(f) Dietary services. 396069 Page 2 of 4 396069 10/19/2023 Arbutus Park Manor 207 Ottawa Street Johnstown, PA 15904

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 36 residents reviewed (Residents 33, 87). Findings include: The facility's policy regarding hospice, dated December 28, 2022, indicated that all hospice medical records will be delivered to the facility in a timely manner. A comprehensive Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 33, dated August 3, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, and received hospice care. A physician's order for Resident 33, dated July 19, 2023, revealed that the resident was ordered hospice services to begin on July 21, 2023. The hospice agreement, dated December 11, 2006, and renewed annually, revealed that hospice documentation will be updated on a weekly basis and as needed. As of October 18, 2023, a review of Resident 33's hospice records revealed that the hospice records had not been updated regarding hospice staff visits with the resident at the facility since September 21, 2023. An interview with the Director of Nursing on October 18, 2023, at 2:54 p.m. confirmed that Resident 33's hospice record was not updated in a timely manner. A quarterly MDS assessment for Resident 87, dated September 27, 2023, revealed that the resident was usually understood and could usually understand others, required extensive assistance for personal care needs, had an indwelling catheter (a thin tube inserted into the bladder to drain urine), and had diagnosis that included Alzheimer's disease and urinary retention. Physician's orders for Resident 87 dated, May 5, 2023, included an order for the resident to have the drainage bag of his foley catheter (type of indwelling urinary catheter) that was attached to his leg emptied three times per shift and the amount of urine that was drained was to be recorded every three hours. Review of the Treatment Administration Record (TAR) for Resident 87, dated August and September 2023, revealed that there was no documented evidence that the leg bag was emptied, or the amount of urine drained was noted on August 5 at 6:00 p.m. and 9:00 p.m.; August 11 at 12:00 p.m.; August 20 at 6:00 a.m. and 12:00 p.m.; August 23 at 9:00 p.m.; August 24 at 3:00 a.m. and 6:00 a.m.; August 28 at 6:00 a.m. and 9:00 p.m.; August 30 at 3:00 a.m. and 6:00 a.m.; August 31 at 6:00 a.m.; September 6 at 6:00 a.m. and 3:00 p.m., 6:00 p.m., and 9:00 p.m.; September 7 at 6:00 a.m.; September 10 at 6:00 a.m., 6:00 p.m., and 9:00 p.m.; September 11 at 6:00 a.m. and 3:00 p.m.; September 13 at 6:00 a.m.; September 14 at 6:00 a.m.; September 15 at 3:00 p.m., 6:00 p.m. and 9:00 p.m.; September 16 at 3:00 p.m., 6:00 p.m. and 9:00 p.m.; and September 19 at 3:00 p.m., 6:00 p.m. and 9:00 p.m 396069 Page 3 of 4 396069 10/19/2023 Arbutus Park Manor 207 Ottawa Street Johnstown, PA 15904

F 0842 Level of Harm - Minimal harm or potential for actual harm An interview with the Assistant Director of Nursing on October 19, 2023, at 12:52 p.m. revealed that Resident 87's foley catheter was being emptied and measured every three hours, however, documentation on the TAR was incomplete. Documentation should be present on the above dates and times that the drainage bag was emptied, and the amount of urine drained should have been recorded. Residents Affected - Some 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services. 396069 Page 4 of 4