Susque View Home, Inc

F-F578

483.25 Quality of Care

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Previously cited deficiency [DATE REDACTED]

Level of Harm - Actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 38839

Residents Affected - Few Based on staff interview and clinical record review, it was determined that the facility failed to ensure that a medication was available in a timely manner for two of four residents reviewed for medication availability concerns (Residents CR1 and 2).

Findings include:

Closed clinical record review for Resident CR1 revealed a physician's order dated August 7, 2024, for the resident to be administered insulin glargine (a long-acting insulin medication used to control blood sugar levels) to be administered/injected via an insulin pen 30 units two times a day for a diagnosis of diabetes (a disease effecting the body's ability to control blood sugar levels).

Resident CR1 was also ordered blood sugar checks before meals and at bedtime for use of sliding scale insulin.

Review of Resident CR1's medication administration record for January 2024, revealed Resident CR1's evening dose of routine insulin glargine noted above for January 3, 2025, was identified as not administered.

A corresponding medication administration record note dated January 3, 2025, at 8:26 PM noted the insulin was not administered as it was unavailable.

Review of Resident CR1's vital sign blood sugar check on January 3, 2025, at 8:23 PM revealed the resident's blood sugar was documented as 227 milligrams (mg)/deciliter (dL), which was flagged as a high level as it exceeded 99 mg/dL in the vital check system.

In an interview with the Director of Nursing on January 9, 2025, at 1:22 PM it was revealed the insulin glargine was marked unavailable due to not arriving from the pharmacy in time for administration.

There was no evidence any facility staff contacted Resident CR1's physician regarding not being able to administer the resident's evening dose of insulin due to unavailability on January 3, 2025, and the resident's blood sugar level was high at 227 mg/dL. There was no evidence the resident received any alternative to the missed dose of the insulin glargine.

A nursing note dated January 4, 2025, at 4:59 AM (the next morning) noted the resident's blood sugar level had significantly increased and was 449 mg/dL and the on-call physician was notified and ordered a one-time dose of rapid/fast acting insulin to be administered to the resident. A recheck of the resident's blood sugar level at 7:46 AM was decreased to 95 mg/dL.

Clinical record review for Resident 2 revealed a physician's order dated September 11, 2024, for the resident to have a lidocaine external patch (pain reliever) applied to the right hip topically daily in the morning for pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Review of Resident 2's medication administration record for January 2025, revealed the resident was marked as not having the lidocaine patch administered on the morning of January 7, 2025. Level of Harm - Minimal harm or potential for actual harm A corresponding administration note for Resident 2, dated January 7, 2025, at 8:20 AM noted the lidocaine patch was on order. Residents Affected - Few

Interview with the Director of Nursing on January 9, 2025, at 3:45 PM revealed the patch was not available to be administered to the resident.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on January 9, 2025, at 3:45 PM.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12 (d)(1)(3) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 395616

F-F684

483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Trmnt; Formulate Adv Dir

Previously cited deficiency [DATE REDACTED]

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38839

Residents Affected - Few Based on closed clinical record review and staff interview, it was determined that the facility failed to provide

the highest practicable care for a resident's change in condition that resulted in death for one of six residents reviewed causing actual harm (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed that the resident had been a long-term resident of

the facility with an admitted [DATE REDACTED].

Review of Resident CR1's closed clinical record revealed a nursing note dated [DATE REDACTED], at 8:25 PM noting

the resident had complaints of nausea and not feeling well. A nursing note followed dated [DATE REDACTED], at 2:38 AM noting no further emesis, and a clear liquid tray was ordered for breakfast.

There was no further documentation identified between the notes identified above between the evening of [DATE REDACTED], through the night to [DATE REDACTED], regarding the number of times emesis occurred or any other details.

A review of meal intakes for Resident CR1 for [DATE REDACTED], revealed the resident was documented as only consuming ,d+[DATE REDACTED] percent of breakfast and lunch and had refused dinner on that day. Review of meal intakes for the resident prior to [DATE REDACTED], back to [DATE REDACTED], revealed the resident had normally consumed at least 51% of meals and mostly ,d+[DATE REDACTED] percent of meals. Resident CR1's meal intakes for [DATE REDACTED], breakfast continued to be low for the resident at ,d+[DATE REDACTED] percent, with lunch slightly better at ,d+[DATE REDACTED] percent and dinner ,d+[DATE REDACTED] percent.

Resident CR1 was also documented on his bowel record of having a loose/diarrhea bowel movement on the evening of [DATE REDACTED]. The resident was documented as having normal stools almost daily for several days leading up to [DATE REDACTED].

There were no further nursing notes for Resident CR1 for [DATE REDACTED], reflecting the decrease in meal intakes, whether his nausea had subsided, if there was any further emesis during the day of [DATE REDACTED], or that the resident had a loose/diarrhea bowel movement since nausea and vomiting has been recently documented.

The next nursing note for the resident was dated [DATE REDACTED], at 2:13 PM, which noted the resident had emesis twice during the shift with coffee ground appearance, very foul odor, and the resident complaining overall of not feeling well. It was noted the registered nurse supervisor was notified and observed the emesis, and the resident would be monitored for increased emesis and vital sign changes.

A late entry note documented by the registered nurse on [DATE REDACTED], at 9:54 AM for [DATE REDACTED], at 2:51 PM noted

the resident was having multiple emesis during the shift, it was liquid brown in color, there was no concern for gastrointestinal (GI) bleeding, and the emesis had no coffee brown texture noted upon assessment. The note indicated GI illness was circulating around the building and the resident's provider was aware with Zofran (an anti-nausea medication) ordered and fluids encouraged.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of Resident CR1's orders revealed Zofran was ordered on [DATE REDACTED], at 10:00 PM to be administered every eight hours for nausea/vomiting for three days. Level of Harm - Actual harm

An order for the resident to have vital sign checks each shift was also identified as ordered on [DATE REDACTED], at Residents Affected - Few 11:00 PM.

Further review of Resident CR1's bowel records for [DATE REDACTED], also revealed loose stools/diarrhea were documented for that day.

Nursing documentation dated [DATE REDACTED], at 8:05 PM noted the resident refused an evening snack due to nausea and vomiting.

A nursing note dated [DATE REDACTED], at 10:22 PM noted the resident had two extra-large emesis during the shift of dark brown liquid noting the resident consumes a chocolate nutritional supplement, and the Zofran was given.

Resident CR1's bowel records also indicated the resident had a loose/diarrhea stool documented the early morning hours of [DATE REDACTED].

A review of resident CR1's vital signs on [DATE REDACTED], revealed the resident's blood pressure obtained at 8:49 AM as ,d+[DATE REDACTED] mmHg (millimeters of mercury) with a warning indicating the Diastolic (bottom number) was low below 60, and the Systolic (top number) was low below 90.

Review of Resident CR1's [DATE REDACTED], medication administration record revealed a medication Lisinopril (medication used to treat high blood pressure) was ordered for the resident daily in the morning and is to be held for a Systolic blood pressure less than 110 mmHg. The Lisinopril was documented as not administered due to vitals outside parameters for administration. A correlated administration note for [DATE REDACTED], at 10:38 AM noted the medication order as it appears on the medication administration record to hold for a Systolic blood pressure of less than 110 mmHg.

An administration note also followed for Resident CR1 at 10:39 AM on [DATE REDACTED], noting the resident's sliding scale insulin was not administered as the resident is vomiting and refusing meals. The resident's routine insulin was also noted in an administration note that followed at 10:41 AM that it was not administered as the resident was refusing meals, and an administration note at 12:03 PM that the resident's nutritional supplement was refused as the resident was vomiting.

A nursing note dated [DATE REDACTED], at 12:58 PM indicated Resident CR1 was assessed by the provider on that day for nausea and vomiting and the resident continued to receive Zofran every eight hours for three days, labs were to be completed the next day, and clear liquids were to be given for 24 hours.

A review of Resident CR1's physician orders revealed the following orders on [DATE REDACTED]:

7:00 AM encourage 120 milliliters of fluid every shift

7:00 AM clear liquids for 24 hours

12:45 PM KUB (an Xray/scan of the urinary system)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 12:45 PM CBC, BMP, and LFT's (diagnostic testing of complete blood count, basic metabolic panel, and liver function testing) Level of Harm - Actual harm

A review of physician assistant (PA) documentation for [DATE REDACTED], for an encounter with Resident CR1 on Residents Affected - Few [DATE REDACTED], revealed the resident was noted as seen for evaluation of nausea and vomiting and the PA was asked to see the resident after having developed symptoms of nausea and vomiting yesterday, ([DATE REDACTED], even though the nausea and vomiting started on [DATE REDACTED]), and upon evaluation had vomited once on [DATE REDACTED], prior to the visit. The resident indicated to the PA that his bowels were moving normally, and he did not have

a fever. It was noted staff reported the resident had coffee ground emesis on [DATE REDACTED], however, the registered nurse reported it was slightly brown in color but did not feel it was coffee ground emesis. The PA noted the resident's blood sugar was over 200 for the day and his blood pressure from ,d+[DATE REDACTED] was , d+[DATE REDACTED] mmHg. The encounter note indicated the PA reviewed the most recent facility's vitals for the resident and due to the discrepancy reports on the coffee ground emesis would check the CBC, BMP, LFT's, continue the Zofran, clear liquid diet, check KUB given slightly hypoactive bowel sounds, and recheck on [DATE REDACTED], after KUB was reviewed.

The time of the PA's visit was not indicated on the encounter visit report although per interview with the Director of Nursing on [DATE REDACTED], at 3:45 PM indicated the PA reported she had visited the resident around 11:00 AM on [DATE REDACTED]. The note was electronically signed by the PA on [DATE REDACTED], at 2:49 PM.

A nursing note dated [DATE REDACTED], at 2:30 PM noted the nurse was called to Resident CR1's room as the resident was again vomiting and cool to tough. He was alert and speaking. The resident's blood sugar was noted as high at 476 mg/dL, and the provider was consulted, and the decision was made to send the resident to the emergency department for further evaluation. It was noted emergency medical services was called, and the resident expired at 2:20 PM, noting emergency medical services was updated upon arrival.

An additional note from the PA with an encounter date of [DATE REDACTED], electronically signed by the PA on [DATE REDACTED], at 12:41 PM, noted a few hours after the PA had seen Resident CR1, the registered nurse came to the PA's office indicating the resident had several more episodes of vomiting since she has seen him and seemed to be declining. The registered nurse reported the resident's color did not look good and the resident seemed diaphoretic, also reporting his blood pressure was low. The registered nurse reported that there were a few spots of bright red blood on the resident's sheet but on assessment concluded it to be from a sacral wound.

The PA advised to call emergency medical services and have the resident transferred to the emergency department. The PA noted the registered nurse then called her moments later and reported the resident was not responsive and had signs of respiratory distress, the nurse confirmed the resident did have a pulse and

the resident's code status was reviewed and confirmed the resident was a do not resuscitate/do not intubate.

The nurse was advised if the resident still had a pulse to call 911. It was noted the nurse called again a few moments later and reported 911 had been called; however, the resident was now pulseless and ceased to breathe. Emergency staff arrived just after they hung up the phone, and the nurse pronounced the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 395616 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395616 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lock Haven Rehabilitation and Senior Living 22 Cree Drive Lock Haven, PA 17745

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A physician's note dated [DATE REDACTED], at 12:11 PM as a death pronouncement noted the resident's date of expiration was [DATE REDACTED], with a cause of death as aspiration pneumonia, acute hypoxic respiratory failure, with Level of Harm - Actual harm secondary diagnosis listed of diabetes type 2, peripheral vascular disease, ventral hernia, neurogenic bladder, major depressive disorder, and intellectual disability. The note only referenced on [DATE REDACTED], the Residents Affected - Few resident was noted to have nausea and vomiting, and a GI virus had been affecting other residents in the facility. It noted symptoms continued [DATE REDACTED], and the resident was evaluated by the medical team and noted to be at baseline mental state, stating he was feeling nauseous and tired. It was noted there had been some concerns of coffee ground emesis but on further evaluation of emesis by nursing was not found to be the case, more consistent with bilious/stomach acid. It was noted later that afternoon the resident had a worsening of status, emergency services were called for transfer to the emergency department, and unfortunately while they were enroute the resident was noted to have agonal breathing, respiratory distress, became pulseless, and no code blue (emergency alert for a patient in cardiac arrest) was called as the patient was a known do not resuscitate/do not intubate.

There was no evidence the PA or the resident's physician was made aware Resident CR1's nausea and vomiting had actually started as documented late on [DATE REDACTED] into the early morning hours of [DATE REDACTED], as the PA referenced in the note as symptoms started on [DATE REDACTED], per staff, or that the either was aware the resident had loose stools identified in bowel records also beginning [DATE REDACTED], and significantly decreased intakes of meals due to nausea and vomiting beginning [DATE REDACTED], not one day before on [DATE REDACTED].

The PA's note did not reflect being made aware of the resident's significant decrease in blood pressure as it was obtained on [DATE REDACTED], in the morning at 8:49 AM as the PA's note reflected the resident's blood pressure from the day before ([DATE REDACTED]) in normal range in the visit on [DATE REDACTED]. The PA did not reference being made aware of any low blood pressure until the later encounter with the registered nurse on [DATE REDACTED], as noted above when the resident rapidly declined in the afternoon.

Facility staff were not able to provide any evidence to the surveyor to indicate Resident CR1's providers were made aware the resident's change in condition began late on [DATE REDACTED], greater than 24 hours prior, and not [DATE REDACTED], as indicated in provider reports. Additional diagnostics were not ordered until [DATE REDACTED], after the PA visited the resident.

There was no evidence of any follow up to the resident's condition on [DATE REDACTED], as emesis was noted in the very early morning hours, the resident had loose stools documented, and the resident's meal intakes reflected significant decline for the day with refusal of dinner, until emesis was documented on [DATE REDACTED].

Resident CR1 expired on [DATE REDACTED], at 2:20 PM prior to any of the ordered diagnostic testing being completed.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE REDACTED], at 3:45 PM.

Cross Refer