Health inspection·October 12, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of policies, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out neglect and/or abuse for one of three residents reviewed (Resident 2). Residents Affected - Few Findings include: The facility's policy for protection from abuse, neglect or exploitation, dated March 2, 2023, indicated that all reports of injuries of unknown source will be investigated. All investigations will be conducted thoroughly and will attempt to gather as much factual information as possible. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated September 7, 2023, revealed that he was alert and able to make his needs known; required extensive assistance of one for hygiene, eating, and bed mobility; used oxygen; and had a tracheostomy (a tube that is placed into a surgical opening made in the neck and into the trachea to breathe through). The plan of care for Resident 2, dated May 3, 2023, indicated that he agreed on a method to call for assistance by use of the call bell. A nursing note for Resident 2, dated September 24, 2023, indicated that the resident rang his call bell and he was noted to be holding his inner cannula (a tube inserted into the tracheostomy tube to help keep airway open) in his hand, waving his hand that he could not breathe and wanted suctioned. A nursing note for Resident 2, dated September 29, 2023, indicated that the resident was found lying crooked in the bed with the tracheostomy tube lying on his chest, the inner cannula was up around resident's shoulder, and the trach collar was removed. The resident was without pulse or respirations. The facility's investigation report, dated September 28, 2023, included interviews with staff; however, there was no documented evidence that the investigation was thorough to ensure that interventions were in place to rule out neglect, such as his call bell being within reach. Interview with the Director of Nursing on October 12, 2023, at 1:00 p.m. confirmed that Resident 2 always used his call bell and he was to have it within reach. However, she indicated that the facility's investigation did not ensure that his call bell was in reach when he was last seen prior to the incident. 28 Pa. Code 201.18(e)(1) Management. Page 1 of 4 396132 396132 10/12/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0610 28 Pa. Code 211.10(d) Resident care policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing services. Residents Affected - Few 396132 Page 2 of 4 396132 10/12/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 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 care plans were updated to reflect changes in care needs for one of three residents reviewed (Resident 2). Findings include: The facility's policy for care plan and interdisciplinary care conferences, dated March 2, 2023, indicated that an individualized care plan is a working tool and that it was to be reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 2, dated September 7, 2023, revealed that he was alert, able to make his needs known; required extensive assistance of one for hygiene, eating, and bed mobility; used oxygen; and had a tracheostomy (a tube that is surgically placed in the neck and into the trachea that the resident breathes through). The resident's plan of care, dated May 11, 2023, indicated that staff were to monitor him for any risk for harm to himself. A nursing note for Resident 2, dated May 2, 2023, indicated that he was on antipsychotic medications and that he was known to have frequent delusions or hallucinations. A nursing note for Resident 2, dated June 26,2023, indicated that the resident was found with the inner cannula (tubing placed inside of the trach tube that helps to keep the airway open) out of the tracheostomy, and the resident at that time indicated that he removed the cannula. A nursing note for Resident 2, dated September 11, 2023, indicated that the resident was observed attempting to remove his inner cannula and he then asked to be suctioned. A nursing note for Resident 2, dated September 24, 2023, indicated that the resident rang his call bell, and he was noted to be holding his inner cannula in his hand, waving his hand that he could not breathe and wanted suctioned. A nursing note for Resident 2, dated September 28, 2023, indicated that the resident was noted to have removed his inner cannula and was attempting to clean it with a blue mouth swab. A nursing note for Resident 2, dated September 29, 2023, at 11:08 p.m., indicated that the resident was found lying crooked in bed, the inner cannula was around his shoulder area, the trachea collar (device to hold the main trachea in place) had been removed, the trachea tube was lying on his chest, and he had ceased to breathe. There was no documented evidence that his plan of care was updated and individualized to reflect his actual removals of the trachea's inner cannula. Interview with the Director of Nursing on October 12, 2023, at 12:37 p.m. confirmed that the care plan was not individualized regarding Resident 2's history of removing the inner cannula. 396132 Page 3 of 4 396132 10/12/2023 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0657 28 Pa. Code 211.11(d) Resident care plan. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing services. Residents Affected - Few 396132 Page 4 of 4