Health inspection·September 25, 2025

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 a review of clinical records, facility policy, observation, and staff interview it was determined the facility failed to ensure the resident environment was free from potential hazards for one of 14 sampled residents (Resident 56).Findings included: A facility policy titled ‘Self-Administration of Medications', last reviewed on November 1, 2024, revealed the organization promotes the right to self-administer drugs unless the team has determined that the practice would be unsafe. The policy indicated if it is deemed safe and appropriate for a resident to self-administer medications, self-administration of medication is documented in the medical record and the care plan. A facility policy titled ‘Procedure for Medication Administration', last reviewed on November 1, 2024, indicated the purpose of the procedure is to guide safe medication administration. The policy further stated the licensed nurse will remain with the resident while he/she swallows oral medication, follow with a drink to clear the oral cavity if appropriate. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included a displaced intertrochanteric fracture of the right femur (a type of broken hip). According to the Brief Interview for Mental Status (BIMS-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) dated September 18, 2025, Resident 56 had a BIMS score of 15. A score of 13-15 indicates intact cognition. During an observation on September 23, 2025, at 10:22 AM, in the resident room of Resident 56 (window side), two circular, white tablets were observed on Resident 56's bedside table. Resident 56 was observed sitting on the side of the bed, near the table. A clinical record review did not include documented evidence that Resident 56 was assessed or deemed safe to self-administer medication. During an interview on September 24, 2025, at 9:51 AM, the Director of Nursing (DON) confirmed there was no documented evidence that Residents 56 was assessed or deemed safe and/or appropriate to self-administer medication. The DON confirmed that Residents 56 medication should not have been left at the bedside table as licensed nurses were to administer medications and medication on the bedside table was an accident hazard. The DON also provided a documented entitled ‘Staffing Coaching Education' (Dated September 23, 2025, at 3:52 PM). In summary, the ‘Staffing and Coaching Education' document cited the reason for education as the observation described above and confirmed Resident 56 received Tylenol two tablets in the morning. The ‘Staffing Coaching/ Education' document also included employee comments from Employee 1 acknowledging Employee 1 RN (registered nurse) had thought the resident did take all the meds A clinical review of the electronic medication record revealed a physician order for Acetaminophen Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablets by mouth two times a day for pain (Start Date-September 17, 2025). The electronic medication administration record (MAR) revealed Resident 56 receives the medication at 08:00 AM and again at 05:00 PM daily. The DON confirmed that it is the facility's responsibility to ensure the environment is free from potential accident hazards. The facility Page 1 of 4 396109 396109 09/25/2025 Heinz Transitional Rehabilitation Unit 150 Mundy Street Wilkes-Barre, PA 18702

F 0689 Level of Harm - Minimal harm or potential for actual harm failed to maintain the residents' environment free of potential accident hazards by leaving medications accessible to anyone who enters the room and allows accidental consumption to those who the medication is not intended for. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. Residents Affected - Few 396109 Page 2 of 4 396109 09/25/2025 Heinz Transitional Rehabilitation Unit 150 Mundy Street Wilkes-Barre, PA 18702

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to fully implement enhanced barrier infection control procedures to prevent spread of infection for three of 14 sampled residents (Residents 13, 43, and 33). Findings include: According to the Centers for Disease Control (CDC) Enhanced Barrier Precautions (EBP) guidance focuses on gown and glove use and other important infection control measures for prevention of multi-drug-resistant organisms (MDRO type of bacteria or microorganism that has developed resistance to multiple classes of antibiotics, making infections harder to treat). EBP are recommended for residents with any of the following: infection or colonization with a MDRO, a wound, or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Review of the facility Enhanced Barrier Precautions Policy last reviewed/revised November 1, 2024, indicated it is the facility policy to implement the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices including central lines (device inserted into a central vein for administration of medication or withdrawing blood), urinary catheters (plastic tube inserted and retained in the bladder for continuous drainage of urine into a closed system), feeding tubes, and tracheostomies (surgical procedure where a surgeon creates a hole through the neck and into the windpipe in order to deliver oxygen to the lungs safely. A tracheostomy tube is placed into the windpipe), regardless of MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The facility uses EBP in conjunction with standard precautions (set of infection control practices that are used for all patients regardless of their suspected or confirmed infection status, and are based on the principle that all body fluids should be treated as if they are infectious) and expands use of PPE (personal protective equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The procedure to implement includes that each resident's status will be reviewed in accordance with the latest CDC guidance and for those residents for whom EBP are indicated orders will be obtained and signage posted. These precautions will be employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. EBP are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. PPE and alcohol-based hand rub will be readily accessible with placement near or outside the resident's room. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which include osteomyelitis (a bone infection) of lumbar vertebrae region (the five bones that make up the lower part of the spinal column located between the chest and pelvis) and diabetes (chronic condition where the body does not produce or use insulin properly). A physician order dated August 25, 2025, noted an order for Cefazolin Sodium (an antibiotic used to treat bacterial infection) 2 grams intravenously every 8 hours via PICC (peripherally inserted central catheter- a type of central line, a long catheter introduced through a vein in the arm and passed to the larger vein in the heart) for staphylococcal lugdunensis bacteremia (type of bacteria that can cause infection in the blood, skin, bone, and joints) Residents Affected - Some 396109 Page 3 of 4 396109 09/25/2025 Heinz Transitional Rehabilitation Unit 150 Mundy Street Wilkes-Barre, PA 18702

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some until September 29, 2025. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy. Observation on September 23, 2025, at 10:30 AM revealed no signage or evidence that EBP were implemented for Resident 13 based on the presence of a PICC line. A review of the clinical record revealed that Resident 43 was admitted on [DATE], with diagnoses which include atrial fibrillation (an irregular and often very rapid heart rhythm) and staph bacteremia (a bloodstream infection where Staphylococcus bacteria are present in the blood). A physician order dated September 23, 2025, noted an order for Vancomycin HCL (an antibiotic used to treat bacterial infection) 1250 mg intravenously once daily via PICC for bacteremia until October 3, 2025. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy. Observation on September 23, 2025, at 10:40 AM revealed no signage or evidence that EBP was implemented for Resident 43 based on the presence of a PICC line. A review of the clinical record revealed that Resident 33 was admitted on [DATE], with diagnoses which include congestive heart failure and benign prostatic hyperplasia (BPH- benign condition in which the gland surrounding the neck of the bladder in males is large than normal) with urinary obstruction (urine cannot drain through the urinary tract). A physician order dated August 27, 2025, noted an order for a Foley catheter (closed sterile system with a catheter and retention balloon that is inserted into the urethra to allow for bladder drainage) 18 Fr (French size, which is based upon measurement of the external diameter of the catheter tube) 10 cc (cubic centimeter, milliliter (ml) a measurement of volume in the metric system) balloon to straight bag gravity drainage for a diagnosis of urinary obstruction. Further review of the clinical record revealed no documented evidence of an order for EBP as per facility policy for Resident 33's use of a Foley catheter. Observation on September 23, 2025, at 10:50 AM revealed that PPE was available in an over-the-door caddy on the entry door to Resident 33's room. However, signage for EBP was not posted as required per facility policy based on the presence of the Foley catheter. Interview with the director of nursing on September 23, 2025, at 11:00 AM confirmed that the facility failed to implement EBP as required for residents at higher risk for the development of infections based on facility policy and CDC Enhanced Barrier Precautions guidance. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 396109 Page 4 of 4