Health inspection·May 18, 2023

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for one of 27 residents reviewed (Residents 7, 35). Residents Affected - Few Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 7, with an ARD of March 24, 2023, was due to be completed by April 7, 2023, but was not signed as completed until April 18, 2023, which was 25 days from the ARD until completion. A quarterly MDS assessment for Resident 35, with an ARD of February 21, 2023, was due to be completed by March 7, 2023, but was not signed as completed until May 1, 2023, which was 79 days from the ARD until completion. An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on May 17, 2023, at 1:08 p.m. confirmed that Resident 7 and 35's quarterly MDS assessments were completed late. 28 Pa. Code 211.5(f) Clinical records. Page 1 of 12 396132 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop individualized care plans that included resident-centered interventions for one of 27 residents reviewed (Resident 35). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated May 4, 2023, revealed that the resident was cognitively impaired, had diagnoses that included depression, and used anti-depressant medications. Physician's orders for Resident 35, dated January 15 and 18, 2023, included an order for the resident to receive 20 milligrams (mg) of Lexapro (used to treat depression) daily in the morning and 300 mg of Bupropion HCl extended release one time a day for depression. A physician's order, dated May 10, 2023, included an order for the resident to receive 10 mg of Lexapro in the morning for depression. Resident 35's Medication Administration Record (MAR) for April and May 2023 revealed that the resident received Bupropion and Lexapro as ordered. However, the resident's clinical record did not include a care plan regarding Resident 35's diagnosis of depression and use of anti-depressant medications. Interview with the Nursing Home Administrator on May 17, 2023, at 8:26 a.m. confirmed that Resident 35 did not have a care plan in place regarding the diagnosis of depression and use of Bupropion and Lexapro. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. 396132 Page 2 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident had effective interventions in place for fall prevention for two of 27 residents reviewed (Residents 5, 26), and failed to complete safety assessments for one of 27 residents reviewed (Residents 5) who used an air mattress. Findings include: The facility's policy regarding fall risk reduction, dated March 2, 2023, indicated that a complete fall risk assessment would be completed anytime a resident experiences a fall, develop an individualized plan of care considering environmental modifications, and review and revise the care plan regularly. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 11, 2023, revealed that the resident was severly cognitively impaired, was understood, could understand, and had a history of falls. Resident 5 required extensive assistance of one staff with bed mobility and required extensive assistance of two staff with transfers. A care plan for Resident 5, dated July 12, 2022, indicated that the bed was to be in the low position with bilateral fall mats on the floor when the resident was in bed. Physician's orders for Resident 5, dated July 13, 2022, included an order for the bed to be in low position with bilateral fall mats on the floor while in bed. Fall investigation documents for Resident 5, dated August 16, 2022, revealed that the resident slid off the side of the bed. Physician's orders for Resident 5, dated August 17, 2022, included an order for a low air loss mattress with bolsters. There was no documented evidence that a safety assessment was completed regarding the use of an air mattress. Fall investigation documents for Resident 5, dated October 21, 2022, revealed that the resident was found on the floor by her bed lying supine. There was no documented evidence that a safety assessment regarding the use of an air mattress was completed until January 22, 2023. Observations on May 17, 2023 at 2:43 p.m. revealed that Resident 5 was alone in her room lying in her bed. The bed was not at the correct height and there was only one fall mat down on the window side of the bed. Interview with Nurse Aide 1 on May 17, 2023, at 2:43 p.m. confirmed that Resident 5's bed was not in the lowest position and should have been. Interview with the Clinical Service Specialist on May 18, 2023, at 10:56 a.m. revealed that Resident 5's safety assessment was missed following her fall out of bed on October 21, 2022. Interview with the Clinical Service Specialist on May 18, 2023, at 12:59 p.m. also confirmed that Resident 5's bed should have been maintained in the lowest position with bilateral fall mats in place while she was in bed. Interview with the Nursing Home Administrator on May 18, 2023, at 12:31 p.m. confirmed that air mattress assessments should always be evaluated with changes. 396132 Page 3 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A quarterly MDS assessment for Resident 26, dated April 3, 2023, revealed that the resident was cognitively impaired, was understood, and could understand. Resident 26 required extensive assistance of one staff with bed mobility and required extensive assistance of two staff with transfers. Observations of Resident 26 on May 17, 2023 at 3:14 p.m. revealed that she was alone and attempting to get out of bed. Her legs and feet were on the floor and she was using her arms to push herself. Resident 26 asked for assistance to get out of bed and appeared to be struggling to stand. Resident 26's call bell was hanging over the headboard and was not within reach of the resident. Registered Nurse 2 was notified and immediately assisted the resident back into bed. Interview with Registered Nurse 2 at that time confirmed that Resident 26's call bell was not within her reach, and that the resident was capable of using it. She handed the resident her call bell. Interview with Licenced Practical Nurse 3 on May 18, 2023, at 8:59 a.m. revealed that Resident 26 was sometimes able to use the call bell and was alert and able to make her needs known. Interview with Nurse Aide 4 on May 18, 2023, at 12:54 p.m. indicated that Resident 26 has used her call bell before and will sometimes use it. Interview with the Clinical Service Specialist on May 18, 2023, at 12:59 p.m. confirmed that the call bell should have been in reach of the resident as care planned. 28 Pa. Code 211.12(d)(5) Nursing services. 396132 Page 4 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral flushes (fluids through a tube inserted directly into the stomach) were followed for one of 27 residents reviewed (Resident 23). Findings include: The facility's policy regarding care of enteral tubes, dated March 2, 2023, indicated that staff were to flush the tube per physician's orders and before and after medication administration via tube. A care plan for Resident 23, dated May 3, 2023, revealed that the resident required an enteral tube related to an alteration in gastrointestinal status with disease process. Staff were to administer medication as ordered. A care plan for Resident 23, dated May 16, 2023, revealed that the resident required an enteral tube feeding related to being NPO (nothing by mouth) from acute respiratory distress and throat cancer. Resident 23 was dependent on staff for tube feedings and water flushes. Physician's orders for Resident 23, dated May 1, 2023, included orders for the resident to receive 30 milliliters (mL) of water before and after medication administration for hydration and for the resident to receive 50 milligrams (mg) of Tramadol (pain medication) via tube every 12 hours as needed for prostate cancer. Observations of Resident 23's medication administration on May 17, 2023, at 8:14 a.m. revealed that Licenced Practical Nurse 5 crushed the 50 mg Tramadol medication and prepared 30 mL of water. At the bedside, Licenced Practical Nurse 5 flushed Resident 23's tube with less than 5 mLs of water, mixed the crushed medication with approximately 10-13 mLs water, administered the medication via tube, and then flushed with the remaining water (approximately 10-13 mLs) . Interview with Licenced Practical Nurse 5 on May 17, 2023, at 8:34 a.m. revealed that she did not want to flush Resident 23 with 30 mLs before and after the medication because the resident just had a flush prior to the end of his enteral feeding at 8:00 a.m., so she split up the 30 mLs of water. Interview with the Clinical Service Specialist on May 18, 2023, at 9:15 a.m. confirmed that Resident 23 should have received 30 mls of water for medication administration. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 396132 Page 5 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physician for one of 27 residents reviewed (Resident 4) and it was determined that the facility failed to ensure that physician's orders were obtained to provide tracheostomy care (care of a surgical incision in the neck that creates an opening into the windpipe), suctioning, or that tracheostomy care was provided for one of 27 residents reviewed (Resident 23). Residents Affected - Few Findings include: The facility's policy regarding oxygen administration, dated March 2, 2023, indicated that the physician's order should be verified and the flow meter control knob was to be adjusted to the prescribed setting. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 28, 2023, revealed that the resident used oxygen and had diagnoses that included heart failure. Physician's orders for Resident 4, dated January 9, 2023, included an order for the resident to receive continuous oxygen at 5 liters per minute (flow rate) via nasal cannula (tubes that deliver oxygen into the nostrils). Observations of Resident 4 on May 18, 2023, at 9:13 a.m. revealed that the resident had oxygen in use via a concentrator (electrical machine that concentrates the oxygen from the air) at a flow rate of 3 liters per minute. Interview with Licensed Practical Nurse 3 on May 18, 2023, at 9:17 a.m. confirmed that Resident 4's oxygen flow rate was not set at 5 liters per minute and should have been. The facility's policy for tracheostomy care, dated March 2, 2023, indicated that tracheostomy care should be provided at least one time per shift using aseptic technique to maintain patency of the airway, staff were to verify the physician's order, provide suction, keep the trach tube and surrounding area clean, and prevent excoriation of the area around the tube. Staff should cleanse the face plate with a sterile swab dipped in peroxide, then use a saturated second swab or 4 inch by 4 inch (4 x 4) gauze with peroxide and clean areas around stoma and outer cannula. Then, using a saturated 4 x 4 gauze with sterile water, clean from the stoma site outward, and finally pat dry. A nursing note for Resident 23, dated May 2, 2023, indicated that the resident was a new admission, had been hospitalized for a closed airway related to cancer, and that he had a tracheostomy tube in place. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated May 8, 2023, revealed that the resident was cognitively intact, required limited assistance to total dependance on staff with daily care needs, and had diagnoses that included chronic respiratory failure and tracheostomy. A tracheostomy care plan for Resident 23, dated May 2, 2023, included that he had a tracheostomy related to throat cancer and that caregivers should be educated about caring for the tracheostomy. An oxygen therapy care plan for Resident 23, dated May 3, 2023, indicated that he should be provided suctioning as needed to maintain an open airway. 396132 Page 6 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician's orders for Resident 23, dated May 1, 2023, included orders to change the inner trach cannula (an inner tube that is inserted within the main tracheostomy tube) daily in the morning; however, a review of physician's orders for May 2023 revealed no orders for Resident 23 to receive tracheostomy care or suctioning from his admission date on May 2, 2023, until May 17, 2023. A review of medication administration records (MAR), and treatment administration records (TAR) for May 2023 revealed that there was no documented evidence that tracheostomy care or suctioning was provided to Resident 23 between May 2, 2023, and May 17, 2023. Observation of the cannula change and suctioning on May 17, 2023, at 8:15 a.m. revealed that Licenced Practical Nurse 5 used aseptic technique to provide suctioning and changed the disposable cannula. An interview with the Nursing Home Administrator on May 17, 2023, at 4:15 p.m. confirmed that there was no order for suctioning and there should have been. An interview with the Clinical Service Specialist on May 18, 2023, at 9:01 a.m. and 10:09 a.m. confirmed that there should be an order for tracheostomy care, but it does not necessarily need to have one because it is a nursing task and the task would be included in the daily cannula change. Interview with Licenced Practical Nurse 5 on May 18, 2023, at 11:42 a.m. revealed that she followed the orders on the MAR/TAR to change the cannula, but there was nothing to indicate any further care was to be provided so nothing further was done. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 211.12(d)(1)(5)Nursing services. 396132 Page 7 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 27 residents reviewed (Resident 20). Findings include: The facility's policy regarding controlled substance disposal, dated March 2, 2023, indicated that the destroying/disposal of controlled drugs should be according to federal and state regulations. Destruction was to be done by the Director of Nursing or designee (must be a Registered Nurse) and another licensed nurse. At the time of destruction, inventory sheets must be reconciled with the drugs in the medication cart and the final disposition of destroyed was to be documented and signed by both persons participating in the destruction. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated February 2, 2023, revealed that the resident was alert and oriented, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated September 12, 2022, included an order for the resident to receive a 50 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain control related to a pressure ulcer on the sacrum (lower part of the spine). The resident's Medication Administration Record (MAR) for March and April 2023 revealed that a Fentanyl patch was applied to the resident on March 21 and April 29, upon awakening. A controlled drug count record (tracks each dose of a controlled medication) for Resident 20's Fentanyl patches revealed that one patch was signed out on the controlled drug log on March 21 and April 29, 2023. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates. Interview with the Nursing Home Administrator on May 18, 2023, at 11:42 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches on March 21 and April 29, 2023. 28 Pa. Code 211.9(a)(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 396132 Page 8 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents did not receive unnecessary medications for one of 27 residents reviewed (Resident 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated March 21, 2023, indicated that the resident was cognitively impaired, had no behavior symptoms, took an anti-psychotic medication, and had diagnoses that included dementia. Physician's orders, dated December 10, 2022, included an order for the resident to receive 25 milligrams (mg) of quetiapine fumarate (Seroquel-an antipsychotic medication) twice a day for dementia. A pharmacy recommendation for Resident 7, dated February 27, 2023, revealed that the pharmacist recommended that Seroquel be decreased to 12.5 mg at bedtime for four weeks and then discontinued. The physician agreed and signed and dated the form on February 27, 2023. However, a review of the resident's Medication Administration Record for February and March 2023 revealed that the gradual dose reduction was not attempted and the resident was still receiving the 25 mg of Seroquel twice a day. Interview with the Nursing Home Administrator on May 18, 2023, at 11:42 a.m. confirmed that there was no documented evidence that the gradual dose reduction of Seroquel that was recommended by the pharmacist and physician was attempted, and the resident continued to receive 25 mg of Seroquel twice a day. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 396132 Page 9 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's instructions and physican's orders, as well as observations and staff interviews, it was determined that the facility failed to ensure that two multi-dose insulin vials were removed from the medication cart when expired and failed to ensure that the facility's emergency controlled medications (narcotics) were properly secured in one of one medication rooms reviewed. Findings include: The manufacturer's instructions for Humalog (rapid-acting insulin), dated [DATE], and Lantus (long-acting insulin), dated [DATE], revealed that opened vials of Humalog and Lantus were to be thrown away 28 days after opened, even if there was insulin left in the vial. Physician's orders for Resident 27, dated [DATE], included an order for the resident to receive 4 units of Humalog insulin subcutaneously (under the skin) with meals, and 15 units of Lantus subcutaneously every evening. Observations of the B Hall medication cart on [DATE], at 12:30 p.m. revealed one opened vial of Humalog insulin, dated April, 2, 2023, and one opened vial of Lantus insulin, dated [DATE]. Interview with Licensed Practical Nurse 5 at that time confirmed that the vials of Humalog and Lantus should have been thrown away after 28 days of use. Interview with the Nursing Home Administrator on [DATE], at 1:44 p.m. confirmed that medication vials of Humalog and Lantus were to be thrown away after 28 days of use. The facility's policy regarding the storage of medications, dated [DATE], indicated that narcotic medications were to be stored behind a double lock. Observations on [DATE], at 8:35 a.m. revealed that the facility's emergency narcotic medications were stored in the medication room inside an unsecured cupboard and could be easily removed from the medication room. Interview with Registered Nurse 2 on [DATE], at 8:44 a.m. confirmed that the cupboard containing the narcotic box was not locked and that the narcotic box contained removable numbered tags for monitoring but were not a locking mechanism. Interview with the Clinical Consultant on [DATE], at 12:53 p.m. confirmed that the emergency narcotic medications should have been secured with a double lock and were not. 28 Pa. Code 211.9(a)(1) Pharmacy services. 396132 Page 10 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety, by failing to ensure that food items stored in the kitchen were dated and secured. Findings include: The facility's current policy regarding food storage revealed that any food that was opened must be labeled, dated, and secured in such a way that the food item was air tight. Observations in the kitchen's dry storage area on May 15, 2023, at 8:50 a.m. revealed that there was one ten pound bag of dried spaghetti and one bag of graham cracker crumbs that were open to the air and not labeled with the date they were opened. Interview with Dietary Worker 6 on May 15, 2023, at 8:51 a.m. revealed that the dried spaghetti and the bag of graham cracker crumbs should have been sealed and dated when opened and they were not. Interview with the Dietary Manager on May 16, 2023, at 11:35 p.m. confirmed that all food items in the kitchen should be labeled, dated, and resealed properly, 28 Pa. Code 211.6(f) Dietary services. 396132 Page 11 of 12 396132 05/18/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the surveys ending June 3, 2022, and March 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 18, 2023, identified repeated deficiencies related to failures to ensure that the resident environment remained free from accident hazards and failure to ensure that residents feeding tubes were properly maintained. The facility's plans of correction for deficiencies regarding the resident environment remaining free from accident hazards, cited during the survey ending June 3, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plan of correction for a deficiency regarding feeding tubes, cited during the survey ending March 7, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F693, revealed that the facility's QAPI committee failed to maintain ongoing compliance with this regulation. Refer to F689, F693. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 396132 Page 12 of 12