Health inspection·April 3, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on review of the clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a clean and homelike environment related to the cleanliness of wheelchairs for one of 26 residents reviewed (Resident 18). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated February 14, 2024, indicated that the resident was moderately cognitively impaired, required assistance from staff for his daily care needs, had impairment on one side of the upper and lower extremities, and used a wheelchair. Observations on April 1, 2024, at 3:32 p.m. and April 3, 2024, at 11:05 a.m. revealed that Resident 18's wheelchair had a dried, brown/tan, removable substance on the metal bars of the chair. Interview with Nurse Aides 1 and 2 on April 3, 2024, at 11:07 a.m. confirmed that the chair had a dried, brown/tan, removable substance on the wheelchair that needed cleaned. Housekeeping and nursing staff were responsible for cleaning wheelchairs as needed and were not aware of a routine cleaning schedule. Interview with the Director of Nursing on April 3, 2024, at 11:09 a.m. revealed that wheelchairs were power washed twice a year, and Resident 18's had a removable substance on the chair that should have been washed. Page 1 of 19 396132 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for one of four employees reviewed (Licensed Practical Nurse 3). Residents Affected - Few Findings include: The facility's abuse policy, dated October 12, 2023, indicated that the facility developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. The facility's screening procedures included conducting reference checks of previous and present employers, criminal background checks on potential employees as well as contracted personnel, verification of nursing licenses with the State Board of Nursing, and verification of nurse aide standing with the state Nurse Aide Registry. The personnel file for Licensed Practical Nurse 3 revealed that she was hired on January 4, 2024, and as of April 2, 2024, (four months after hire) a professional licensure verification with the Pennsylvania State Board of Nursing had not been completed. Interview with Director of Nursing on April 2, 2024, at 11:39 a.m. confirmed that there was no documented evidence to indicate that Licensed Practical Nurse 3's professional licensure was verified with the State Board of Nursing prior to the nurse's hire date. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 396132 Page 2 of 19 396132 04/03/2024 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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to develop individualized care plans that included resident-centered interventions for two of 26 residents reviewed (Residents 23, 30). Findings include: The facility's policy regarding care plan development, dated October 12, 2023, indicated that an individualized, interdisciplinary care plan is initiated within 24 hours of admission based on available resident-specific information related to resident assessments, interviews, previous medical records, identified goals, and physician's orders. The care plan is formally reviewed and completed within 21 days after admission. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated March 6, 2024, revealed that the resident was cognitively intact, required assistance from staff for his daily care needs, and was frequently incontinent of bowel and bladder. Interview with Resident 23's wife (the resident's representative) on April 2, 2024, at 4:03 p.m. indicated that the resident had been incontinent of bowel and bladder prior to his admission to the facility, and he wore incontinence briefs. A review of nurse aide charting for bladder continence from March 5, 2024, through April 3, 2024, revealed that Resident 23 was mostly incontinent of urine. There was no documented evidence that a care plan was developed to address Resident 23's care needs related to bladder incontinence. Interview with the Director of Nursing on April 3, 2024, at 1:04 p.m. confirmed that a care plan was not developed for Resident 23's care needs related to incontinence and should have been. An admission MDS assessment for Resident 30, dated February 27, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, used supplemental oxygen, and had diagnoses including pulmonary fibrosis (a lung disease that causing scarring and stiffening of lung tissue, making it harder to breathe), respiratory failure (blood does not have enough oxygen and causes difficulty breathing), and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). Discharge notes from the hospital, dated February 21, 2024, indicated that Resident 30 was placed on a long-term antibiotic for prevention of pneumonia (an infection in the lungs that can cause difficulty breathing). Physician's orders for Resident 30, dated February 21, 2024, included an order for the resident to receive sulfamethoxazole-trimethoprim (an antibiotic) daily in the morning every Monday, Wednesday and Friday. There was no documented evidence that a care plan was developed to address Resident 30's need for 396132 Page 3 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0656 long-term antibiotic therapy. Level of Harm - Minimal harm or potential for actual harm An interview with the Director of Nursing on April 1, 2024, at 3:20 p.m. confirmed that there was no care plan in place to address Resident 30's need for long-term antibiotic therapy, and there should have been. Residents Affected - Few 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services. 396132 Page 4 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 26 residents reviewed (Residents 1, 4, 12). Findings include: The facility's policy regarding care plan development and revision, dated October 12, 2023, indicated that resident care plans are reviewed and updated at least quarterly and as a resident's condition changes (such as when medications are added or discontinued, resident returns from the hospital, and with changes in mood, behaviors or care needs). A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. A care plan for Resident 1, dated March 22, 2023, revealed that the resident had oxygen related to respiratory illness. Observations of Resident 1 on April 1, 2024, at 10:00 a.m. revealed that the resident was sitting in her wheelchair beside her bed and did not have oxygen in her room. Physician's orders were reviewed, and the resident did not have orders for oxygen use. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that the Resident 1 was not on oxygen and the care plan should have been resolved. Physician orders for Resident 1, dated January 11, 2024, indicated that the resident was to have a fall mat to the left side of her bed. A fall care plan for Resident 1, dated January 19, 2024, indicated that the resident was to have a fall mat to the right side of her bed. Observation of Resident 1 on April 1, 2024, at 10:00 a.m. revealed that the resident was sitting in her wheelchair beside the bed and the fall mat was on the left side of her bed. An interview with the Director of Nursing on April 3, 2024, at 12:26 p.m. confirmed that Resident 1's fall mat should be on the left side of the bed and the care plan was inaccurate. An admission MDS assessment for Resident 4, dated February 15, 2024, indicated that the resident was cognitively intact, required partial to substantial assist with care needs, and had a Stage 2 pressure area (pressure wound with superficial skin loss) that was present on admission. Resident 4's care plan, dated February 14, 2024, included a focus for a Stage 2 pressure ulcer to the sacrum. A nurse's note for Resident 4, dated March 12, 2024, at 7:17 a.m. indicated that the Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved and the plan of care had been reviewed and updated. However, as of April 3, 2024, the care plan was not updated to reflect that the Stage 2 pressure area to the gluteal cleft/sacrum was resolved. 396132 Page 5 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with the Director of Nursing on April 3, 2024, at 2:34 p.m. confirmed that Resident 4's Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved and that the care plan should have been resolved and it was not. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A care plan for Resident 12, dated July 14, 2023, indicated that the resident was at risk for self-injury related to not keeping the head of the bed elevated due to having a PEG tube (tube inserted into the stomach for nutrition), refusing to accept bolus feeding. A nurse's note for Resident 12, dated September 25, 2023, revealed that the PEG tube was removed. An interview with the Director of Nursing on April 2, 2024, at 3:29 p.m. confirmed that Resident 12 does not have a PEG tube and that the care plan should have been resolved. 28 Pa. Code 201.24(e)(4) admission Policy. 396132 Page 6 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 26 residents reviewed (Resident 1, 4, 12). Residents Affected - Some Findings include: The facility's policy regarding physician's orders, dated October 12, 2023, revealed that physician's orders were to be followed in accordance with good nursing principles and practice and were to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated May 9, 2023, included an order for the resident to receive 60 milligrams (mg) of isosorbide mononitrate (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. Physician's orders, dated July 20, 2023, included an order for the resident to receive 2.5 mg of Lisinopril (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. Physician's orders, dated May 9, 2023, included an order for the resident to receive 50 mg of Metoprolol (a medication for high blood pressure) one time a day and to hold medication if systolic blood pressure was less than 100 mmHg and diastolic was less than 60 mmHg. A review of Resident's 1's Medication Administration Record for May 2023 through March 2024 revealed no documented evidence that the blood pressure was being monitored per physician order. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that there was no documented evidence that Resident 1's blood pressure was being monitored per physician order. An admission MDS assessment for Resident 4, dated February 15, 2024, indicated that the resident was cognitively intact, required partial to substantial assist with care needs, and had a Stage 2 pressure area (pressure wound with superficial skin loss) that was present on admission. Physician's order for Resident 4, dated February 16, 2024, included an order for Expedite (a nutritional supplement) to be given daily to aid in wound healing for 14 days or until the wound was healed. A nurse's note for Resident 4, dated March 12, 2024, indicated that the Stage 2 pressure ulcer to the gluteal cleft/sacrum was resolved. A dietary note for Resident 4, dated March 28, 2024, indicated that the resident's wound had been resolved and the Expedite had been discontinued. A review of Resident 4's clinical record revealed that he continued to receive Expedite through April 3, 2024 (22 days after the wound was resolved). 396132 Page 7 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Director of Nursing on April 3, 2024, at 2:34 p.m. confirmed that Resident 4's order for Expedite should have been discontinued and it was not. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). Physician's orders for Resident 12, dated September 20, 2023, included an order for the resident to receive 25 milligrams of Metoprolol (a medication for high blood pressure) one time a day and to hold the medication if systolic blood pressure was less than 100 mmHg and heart rate was less than 55 beats per minute. A review of Resident's 12's Medication Administration Record from September 2023 through March 2024 revealed no documented evidence that the blood pressure and heart rate were being monitored per physician's order. An interview with the Director of Nursing on April 2, 2024, at 12:26 p.m. confirmed that there was no documented evidence that Resident 12's blood pressure and heart rate were being monitored per physician's order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 396132 Page 8 of 19 396132 04/03/2024 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 review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of 26 residents reviewed (Resident 12) who was at risk for falls. Findings include: The facility's policy regarding managing falls and fall risks, dated December 21, 2022, indicated that in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A care plan for Resident 12, dated January 15, 2024, revealed that the resident had a fall when she tripped over oxygen tubing related to poor balance. Review of a facility fall investigation report for Resident 12, dated January 15, 2024, at 10:15 a.m., revealed that the resident was self-transferring to the restroom and tripped over her oxygen tubing. A fall intervention, dated January 15, 2023, indicated that the resident was to have a tether alarm (an alarm that attaches to the resident and alarms when disconnected). Observation of Resident 12 on April 3, 2024, at 10:35 a.m. revealed that the resident was lying in her bed on her right side facing the doorway and the alarm was on the resident's enabler bar and was not attached to the resident. Observation with Licensed Practical Nurse 4 on April 3, 2024, at 10:55 a.m. confirmed that the resident was lying in bed and the alarm was not attached to the resident and should have been. Interview with the Director of Nursing on April 3, 2024, at 11:41 a.m. confirmed that the alarm should have been attached to Resident 12. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 396132 Page 9 of 19 396132 04/03/2024 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 facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a physician's order was obtained to provide oxygen therapy for two of 26 residents reviewed (Residents 12, 30). Residents Affected - Few Findings include: The facility's policy for oxygen administration, dated October 12, 2023, revealed that oxygen therapy via nasal cannula will be administered as ordered by a physician and will include correct flow rate, concentration, mode of delivery, and frequency. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included heart failure, respiratory failure, and chronic obstructive pulmonary disease (lung disease). A review of physician's orders for Resident 12 revealed that there was no order for the resident to receive oxygen therapy. A care plan for Resident 12, dated June 19, 2023, indicated that she has oxygen related to chronic obstructive pulmonary disease. An observation of Resident 12 on April 1, 2024, at 10:03 a.m. revealed that she was in bed with a nasal cannula in place, providing her with oxygen at 3 liters per minute (L/min). An interview with the Director of Nursing on April 1, 2024, at 3:06 p.m. confirmed that Resident 12 did not have a physician's order for the oxygen she was receiving and that she should have. An admission MDS assessment for Resident 30, dated February 27, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, used supplemental oxygen, and had diagnoses including pulmonary fibrosis (a lung disease that causing scarring and stiffening of lung tissue, making it harder to breathe), respiratory failure (blood does not have enough oxygen and causes difficulty breathing), and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult). A review of physician's orders for Resident 30 revealed that there was no order for the resident to receive oxygen therapy. A care plan for Resident 30, dated February 21, 2024, indicated that she had oxygen related to pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease. An observation of Resident 30 on April 1, 2024, at 10:12 a.m. revealed that she was in bed with a nasal cannula in place, providing her with oxygen at 7 liters per minute (L/min). An interview with the Director of Nursing on April 1, 2024, at 2:58 p.m. confirmed that Resident 30 did not have a physician's order for the oxygen she was receiving and that she should have. 396132 Page 10 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0695 28 Pa. Code 211.12(d)(3)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 396132 Page 11 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility 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 three of 26 residents reviewed (Residents 1, 30, 31). Findings include: The facility's policy regarding medication administration, dated October 12, 2023, indicated that medications administered will be documented on the Medication Administration Record (MAR). For as needed medications, the nurse will document initials and time of administration on the MAR. A quarterly Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 1, dated February 2, 2024, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnosis that included heart failure, high blood pressure, and dementia. Physician's orders for Resident 1, dated December 28, 2023, included an order for the resident to receive 50 milligrams of Tramadol (a controlled medication used to treat pain) every six hours as needed. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 1 for January, 2024, indicated a dose of Tramadol was signed out on January 4, 2024, at 9:30 a.m.; January 5, 2024, at 11:43 a.m.; January 15, 2024, at 10:30 a.m.; January 28, 2024, at 11:30 p.m.; February 5, 2024, at 8:05 p.m.; February 14, 2024, at 7:00 p.m.; February 17, 2024, at 8:40 p.m.; February 21, 2024, at 6:59 p.m.; February 24, 2024, at 11:15 a.m.; March 17, 2024, at 9:04 a.m.; March 17, 2024, at 9:20 p.m.; and March 21, 2024, at 8:00 p.m. Review of Resident 1's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 2, 2024, at 3:28 p.m. confirmed that there was no documented evidence in Resident 1's clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 30, dated February 27, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, used supplemental oxygen, and had diagnoses including pulmonary fibrosis (a lung disease that causing scarring and stiffening of lung tissue, making it harder to breathe), respiratory failure (blood does not have enough oxygen and causes difficulty breathing), chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult), and anxiety disorder. Physician's order for Resident 30, dated February 21, 2024, included an order for the resident to receive 0.5 mg of Lorazepam (a controlled medication used to treat anxiety) every eight hours as needed for anxiety for three days. Physician's order for Resident 30, dated February 26, 2024, included an order for the resident to receive 0.5 mg of Lorazepam every four hours as needed for anxiety. 396132 Page 12 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the controlled drug record for Resident 30 for February and March 2024 indicated that a dose of Lorazepam was signed out on February 22, 2024, at 10:30 p.m.; February 23, 2024, at 1:40 p.m.; March 5, 2024, at 8:30 p.m.; March 15, 2024, at 12:30 p.m.; March 22, 2024, at 6:45 p.m.; March 23, 2024, at 12:00 p.m.; March 26, 2024, at 12:30 p.m.; and March 27, 2024, at 11:30 a.m. Review of Resident 30's MAR and nursing notes revealed no documented evidence that the signed-out doses of Lorazepam were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 2, 2024, at 12:27 p.m. confirmed that there was no documented evidence in Resident 30's clinical records to indicate that the signed-out doses of Lorazepam were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 31, dated March 8, 2024, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, and was taking opioid medication (controlled narcotic pain medication). A care plan for Resident 31, dated March 11, 2024, revealed the resident had pain related to spinal fusion surgery. Physician's orders for Resident 31, dated March 7, 2024, and March 21, 2024, included orders for the resident to receive 5 mg of Oxycodone (a controlled medication used to treat pain) every four hours as needed for pain for 14 days for spinal fusion. Review of the controlled drug record for Resident 31 for March 2024 indicated that a dose of Oxycodone was signed out on March 17, 2024 at 5:15 p.m. and 7:15 p.m.; March 18, 2024, at 7:00 a.m. and 3:00 p.m.; March 20, 2024, at 1:00 p.m.; March 27, 2024, at 2:30 a.m.; March 28, 2024, at 2:00 a.m. and 1:20 p.m.; and March 29, 2024, at 2:00 a.m. Review of Resident 31's MAR and nursing notes revealed no documented evidence that the signed-out doses of Oxycodone were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 3, 2024, at 3:30 p.m. confirmed that there was no documented evidence in Resident 31's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 396132 Page 13 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 26 residents reviewed (Resident 12). Residents Affected - Few Findings include: The facility's policy regarding physician's orders, dated October 12, 2023, revealed that physician's orders are to be followed in accordance with good nursing principles and practice and are to be transcribed and carried out by the persons legally authorized to do so. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 18, 2024, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, used supplemental oxygen, and had diagnoses that included diabetes mellitus. Physician's orders for Resident 12, dated May 1, 2023, included an order for the resident to receive 5 units of insulin Novolog (used to lower blood sugar levels) before meals and to hold if Accucheck is 150 milligram/deciliter (mg/dL) or less. Review of the March 2024 Medication Administration Record (MAR) for Resident 12 revealed that 5 units of Novolog insulin were administered to the resident at 8:00 a.m. on March 1 for a blood sugar of 129 mg/dL; March 2 for a blood sugar of 70 mg/dL; March 7 for a blood sugar of 70 mg/dL; March 13 for a blood sugar of 126 mg/dL; March 17 for a blood sugar of 123 mg/dL; March 18 for a blood sugar of 101 mg/dL; March 25 for a blood sugar of 116 mg/dL; and March 31 for a blood sugar of 146 mg/dL. Review of the March 2024 MAR for Resident 12 revealed that 5 units of Novolog insulin were administered at 11:00 a.m. on March 2 for a blood sugar of 142 mg/dL; March 13 for a blood sugar of 120 mg/dL; and March 31 for a blood sugar of 108 mg/dL. Review of the March 2024 MAR for Resident 12 revealed that 5 units of Novolog insulin were administered at 4:00 p.m. on March 7 for a blood sugar of 134 mg/dL; March 12 for a blood sugar of 147 mg/dL; and March 21 for a blood sugar of 122 mg/dL. Interview with the Director of Nursing on April 2, 2024, at 12:59 p.m. confirmed that on 14 occasions the parameters were not followed per physician's orders and the Novolog insulin was given to Resident 12. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 396132 Page 14 of 19 396132 04/03/2024 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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to discard two expired multi-dose insulin vials in one of one medication carts reviewed (B Hall), and failed to securely store medication in one of one medication carts reviewed (B Hall). Findings include: The facility's policy regarding administering medications, dated [DATE], indicated that during medication administration the medication cart will be locked if it is not clearly within view. No medications will be left unattended on top of the medication cart. Observations of a medication pass on [DATE], at 8:52 a.m. revealed that Licensed Practical Nurse 5 left a card of Januvia (a medication used to help lower blood sugar) 25 milligrams (mg) tablets on top of the medication cart unsupervised while she entered a resident's room to administer medication. Interview with Licensed Practical Nurse 5 at that time confirmed that she should not have left the medication on top of the cart unsupervised. Interview with the Director of Nursing on [DATE], at 9:03 a.m. confirmed that medication should not have been left unsupervised on top of the medication cart and should have been secured in the medication cart when the nurse walked away from the cart. Observations of the B medication cart outside of room [ROOM NUMBER] on [DATE], at 10:16 a.m. revealed that medication cart was left unlocked with no staff in view of the cart. Facility staff were sitting at the nurses' station and their view was blocked by the raised counter. Manufacturer's directions for Lantus insulin (injectable medication to lower blood sugar levels), dated [DATE], revealed that the vial of Lantus was to be thrown away after 28 days, even if there was insulin left in it. Observations of Medication Cart B on the 100 unit on [DATE], at 10:24 a.m. revealed that a multi-use vial of Lantus insulin for Resident 12 was opened and was not labeled with the date it was opened. A multi-use vial of Lantus insulin for Resident 23 was opened and was labeled February 29, 2024, the date it was opened. Interview with Licensed Practical Nurse 4 at that time confirmed that the Lantus for Resident 12 should have been labeled with the date it was opened, the Lantus for Resident 23 should have been discarded after the expiration, and the medication cart should be locked when not in view. Interview with the Director of Nursing on [DATE], at 11:41 a.m. confirmed that Lantus should have been labeled when the vial was opened, discarded when expired, and the medication cart should have been locked when not in use or view. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 396132 Page 15 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0761 28 Pa. Code 211.12(d)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 396132 Page 16 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by not discarding an opened, expired food item. Findings include: The facility's policy regarding food storage, dated October 12, 2023, revealed that all staff must provide the date a food or beverage item is opened with a date marked to indicate the date by which the food item should be consumed or discarded. Foods with a manufacturer use-by date must be used or discarded by the stamped date. Observations in the small kitchen refrigerator on April 1, 2024, at 8:43 a.m. revealed an opened container of Miracle Whip salad dressing with a resident's name on it and an opened date of September 2023. No use-by date was indicated on the jar and the container had a stamped expiration date of January 2024. Interview with the Dietary Manager, at the time of observation, confirmed that the opened container of Miracle Whip salad dressing was expired and should have been discarded and it was not. 28 Pa. Code 211.6(f) Dietary Services. 396132 Page 17 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 May 18, 2023; August 21, 2023; and October 12, 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 April 3, 2024, identified repeated deficiencies related to comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food procurement-storing/preparing/serving food under sanitary conditions. The facility's plans of correction for deficiencies regarding residents having comprehensive care plans, cited during the survey ending May 18, 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 F656, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding care plan timing and revision, cited during the survey ending October 12, 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 F657, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding quality of care, cited during the survey ending August 31, 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 F684, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding the resident environment remaining free from accident hazards/supervision, cited during the survey ending May 18, 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 F689, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding respiratory care, cited during the survey ending May 18, 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 F695, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. 396132 Page 18 of 19 396132 04/03/2024 Quality Life Services - Westmont 787 Goucher Street Johnstown, PA 15905

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's plans of correction for deficiencies regarding pharmacy services, cited during the survey ending May 18, 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 F755, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding labeling and storage of drugs/biologicals, cited during the survey ending May 18, 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 F761, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. The facility's plans of correction for deficiencies regarding food procurement-storing/preparing/serving food under sanitary conditions, cited during the survey ending May 18, 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 F812, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations. Refer to F656, F657, F684, F689, F695, F755, F761, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 396132 Page 19 of 19