Guardian Healthcare And Rehabilitation Center

F-F600

Level of Harm - Minimal harm or 28 Pa Code 201.14(a) Responsibility of Licensee potential for actual harm 28 Pa. Code 201.18(e)(1) Management Residents Affected - Some 28 Pa. Code 201.29(a) Resident Rights

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738

Residents Affected - Few Based on clinical record review and staff interview it was determined that the baseline care plan of one of 10. residents sampled (Resident B2) failed to fully address the resident's individual needs upon admission.

Findings:

A review of Resident B2's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included acute ischemic heart disease (disease or damage in the heart's major blood vessels).

An admission physician order dated July 5, 2024, was noted for the resident to wear a life vest (a wearable defibrillator that can stop an abnormal heart rhythm without anyone's help) for sudden cardiac arrest.

A review of the resident's baseline care plan failed to identify that the resident had a life vest and specific interventions to address the care of the resident while utilizing the life vest.

An interview with the director of nursing on July 21, 2024, at approximately 11:00 AM confirmed the facility to ensure that this resident's baseline care plan included the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and treatment needs.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738 potential for actual harm Based on a review of clinical records and resident and staff interview, it was determined that the facility failed Residents Affected - Some to provide person centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, Ace wraps (elastic bandage), and further failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for diabetes management for one resident (Resident B1) of out of 10 sampled.

Findings include:

Review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE REDACTED], with diagnoses which included diabetes and chronic peripheral venous insufficiency (leg veins do not allow blood to flow back up to the heart).

A review of Resident B1's clinical record revealed a physician's order dated June 10, 2024, to apply Ace wraps in the AM and remove at HS (at bedtime); may remove for care and hygiene; and to place back on until HS and remove every evening and night for edema.

Interview with Resident B1 on July 21, 2024, at 9:00 AM revealed that the resident was in bed and his Ace wraps were applied. The resident stated that the Ace wraps are to be applied in the morning but that staff inform the resident that they do not have time to apply the Ace wraps.

Review of Resident B1's Treatment Administration Record (TAR) dated June 10, 2024, through June 30, 2024, and July 1, 2024, through July 21, 2024, revealed that the TAR did no include the physician order to apply the Ace Wraps in the morning (AM). The TARs noted solely that the Ace wraps were off in the evening and on at night. On July 9, 2024, and July 16, 2024, nursing staff signed the TAR indicating that the Ace wraps were off in the evening but there was no documentation that the Ace wraps were applied on those dates.

During an interview on July 21, 2024, at approximately 1:30 PM, the Director of Nursing failed to provide documented evidence that Resident B1's Ace wraps were being consistently applied and removed as per physician orders.

Further review of Resident B1's clinical record revealed a physician order initially dated April 23, 2024, for

the administration of Novolog Flex Pen Subcutaneous Solution Pen Injector 100 units/milliliter (Insulin), with instructions for the dose to be based on a sliding scale, depending on the resident's blood sugar reading; inject as per the sliding scale: if the resident's blood sugar was between 0-150 0 units; if 151-200, administer 4 units; if 201-250, administer 6 units; if 251-300 administer 8 units; if 301-350 administer 10 units; if 351-400, administer 12 units; if [PHONE NUMBER], administer 14 units. If more than 401 call physician for further orders. Subcutaneously before meals and at bedtime.

During interview with Resident B1 on July 21, 2024, at 9:00 AM the resident stated that he was concerned because his blood sugars and insulin coverage were being completed after meals instead of before meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 Review of Resident B1's Medication Administration Record (MAR) dated July 1, 2024, through July 20, 2024, revealed that staff were to check the resident's blood sugars before meals at 8:00 AM, 11:30 AM, 4:30 PM, Level of Harm - Minimal harm or and bedtime at 9:00 PM. potential for actual harm

The July 2024 MAR indicated that on 13 occasions nursing staff checked the resident's blood sugars and Residents Affected - Some administered insulin after meals instead of before meals as ordered on the following dates and times:

July 1, 2024 - administration time was 9:05 AM (after breakfast)

July 1, 2024 - administration time was 1:18 PM (after lunch)

July 2, 2024 - administration time was 5:40 PM (after supper)

July 3, 2024 - administration time was 5:36 PM (after supper)

July 5, 2024 - administration time was 9:55 AM (after breakfast)

July 6, 2024 - administration time was 9:34 Am (after breakfast)

July 6, 2024 - administration time was 1:05 PM (after lunch)

July 7, 2024 - administration time was 1:00 PM (after lunch)

July 8, 2024 - administration time was 12:56 PM (after lunch)

July 10, 2024 - administration time was 2:51 PM (after lunch)

July 16, 2024 - administration time was 1:25 PM (after lunch)

July 17, 2024 - administration time was 9:01 AM (after breakfast)

July 20, 2024 - administration time was 1:17 PM (after lunch)

During an interview on July 21, 2024, at approximately 1:30 PM the Director of Nursing confirmed that licensed and professional nursing staff failed to follow physican orders for diabetes management to include blood sugar monitoring and physician orders.

28 Pa. Code 211.5(f) Medical records

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0687 Provide appropriate foot care.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738 potential for actual harm Based on observation, review of clinical records, and staff and resident interview, it was determined the Residents Affected - Few facility failed to consistently provide timely and necessary foot care for one of 10 residents sampled (Residents B1).

Findings include:

Review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses, which included diabetes and chronic peripheral venous insufficiency (leg veins do not allow blood to flow back up to the heart).

Observation on July 21, 2024, at 9:00 AM revealed that Resident B1's toenails, on both feet, were thickened, yellowed, and extended past the tips of his toes. Resident B1 stated during interview at that time, that he had diabetes and was concerned that he was not routinely being seen by a podiatrist for foot care.

Further review of the clinical record revealed that Resident B1's last podiatry visit was on January 8, 2024.

Interview with the Director of Nursing on July 21, 2024, at approximately 1:00 PM, confirmed that Resident B1 was not provided routine podiatry and timely foot care.

28 Pa. Code 211.12 (d)(3)(5) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142 potential for actual harm Based on clinical record review and staff interview it was determined that the facility failed to timely obtain Residents Affected - Few and provide necessary respiratory care supplies and equipment required by one one of 10 sampled residents (Resident A3).

Findings include:

Clinical record review revealed that Resident A3 was admitted to the facility on [DATE REDACTED] with diagnoses of acute respiratory failure with hypoxia, dyspnea, sleep apnea and anxiety. The resident had a tracheostomy surgically placed during her recent hospital stay prior to admission to the facility.

A review of a 5-day admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 21, 2024, revealed that Resident A3 was cognitively intact and required staff assistance for activities of daily living.

The resident had a physician order, dated June 21, 2024, to change disposable inner cannula, (4DIC) two times a day.

When reviewed during the survey ending July 21, 2024, the resident's current care plan that was initiated June 21, 2024, did not include the type of tracheostomy the resident had in place, inner cannula or any care, and emergency care for this tracheostomy.

A nurses note dated June 22, 2024 at 3:03 P.M. revealed that Resident A3 complained of shortness of breath. The resident's oxygen saturation level was 88 via trach collar. Staff suctioned thick, blood tinged mucus. Breathing treatment was given. Nursing noted that the resident was declining and 911 was called. Nursing noted that the resident was sent out to the hospital via ambulance due to respiratory distress and admitted to ICU (intensive care unit) for Hypoxia (lack of oxygen) and Acute Respiratory Distress Syndrome.

A nursing note dated July 8, 2024, at 5 PM revealed that the facility employed respiratory therapist, upon the resident's readmission to the facility following the resident's hospital stay, the facility did not have the correct supplies for the resident's trach. It was noted that the hospital was supposed to send the correct supplies to

the facility and did not. The attending physician was made aware and a new order written to send the resident back to the hospital for eval and tx. Nursing noted that the resident was not currently in any respiratory distress. Emergency medical services (EMS) then called to see if the hospital staff could bring supplies to facility, but they stated they didn't have them. The hospital also stated they would refuse the resident if brought to emergency department (ED) as they do not have an obese bed in ED available at this time. The physician made aware and indicated that it was OK to send the resident to a different hospital for evaluation and treatment.

The resident was admitted to the second hospital emergency department and returned to the facility with trach supplies, which were received from the hospital and returned to the facility on [DATE REDACTED], at 3 AM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0695 During an interview July 21, 2024, at approximately 11 AM the respiratory therapist confirmed that the facility did not have the necessary respiratory care supplies that the resident required upon readmission to the Level of Harm - Minimal harm or facility on [DATE REDACTED]. She stated that the hospital was supposed to send the required supplies with the resident potential for actual harm upon discharge from the hospital. She stated that the facility attempted to get the hospital to deliver respiratory supplies to the facility. When the hospital refused the facility's request, the facility attempted to Residents Affected - Few send the resident back to the hospital. The hospital told the facility that they would refuse to see the resident

in the ED. The facility then sent the resident out to a different hospital for treatment and supplies. The respiratory therapist confirmed that the facility did not obtain the necessary supplies the resident required prior to the resident's readmission to the facility on [DATE REDACTED], to assure their availability and did not maintain those supplies in the facility to prevent the resident's unnecessary transfers to hospital emergency departments to secure the supplies needed for the resident's respiratory care in the long term care facility.

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

28 Pa. Code 211.10 (c) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142

Residents Affected - Few Based on clinical record review and staff interview, it was determined that the facility failed to provide pharmacy services to assure timely acquiring of physician ordered medications for one of 10 residents sampled. (Resident A3).

Findings include:

A review of the clinical record revealed that Resident A3 was admitted to the facility on [DATE REDACTED], with diagnosis to include narcolepsy (Narcolepsy is a chronic neurological disorder that impairs the ability to regulate sleep-wake cycles, and specifically impacts REM sleep).

A physician order dated July 10, 2024, was noted for Modafinil 200 mg, one tablet via the PEG tube (a plastic tube inserted into the stomach for liquid nutrition when a person can not eat by mouth) one time a day for anti-narcolepsy.

A review of the resident's July 2024 medication administration record (MAR) revealed that the resident did not receive the prescribed medication from July 10, 2024, 2024, through July 20, 2024. The MAR indicated that the resident received the first dose of the medication July 21, 2024.

An interview July 21, 2024 at approximately 2 P.M., the Director of Nursing confirmed that the medication was not available in the facility for administration to the resident, and its administration was delayed 11 days.

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

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F-F609

28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.12 (d)(5) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142

Residents Affected - Some Based on a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report multiple instances of verbal and mental abuse perpetrated by one resident out of 10 sampled (Resident A1) to the State Survey Agency and local Area Agency on Aging.

Findings include:

A review of the facility's abuse prohibition policy, dated as reviewed by the facility May 1, 2024 revealed revealed that residents residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance to describe residents, regardless of their age, ability to comprehend or disability.

According to long term care regulatory requirements under S483.12 Freedom from Abuse, Neglect, and Exploitation Mental and Verbal Abuse are defined as:

Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.

Examples of mental and verbal abuse include, but are not limited to:

o Harassing a resident;

o Mocking, insulting, ridiculing;

o Yelling or hovering over a resident, with the intent to intimidate;

o Threatening residents, including but limited to, depriving a resident of care or withholding a

resident from contact with family and friends; and

o Isolating a resident from social interaction or activities.

Review of Resident A1's clinical record revealed admission to the facility on [DATE REDACTED], with diagnoses, which included Alzheimer's disease, adjustment disorder with anxiety, and major depression. The resident was significantly cognitively impaired with a BIMS (Brief Interview for Mental Status a tool to assess cognitive function) score of 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0609 Resident A1's care plan, initiated May 27, 2024, identified that the resident had impaired cognitive function related to Alzheimer disease as evidenced by, confusion, long and short term memory problem and poor Level of Harm - Minimal harm or safety awareness. Planned interventions were to administer medication as per physician orders, allow time potential for actual harm for the resident to respond, approach in a calm manner, and to provide activities.

Residents Affected - Some The resident's care plan did not identify that Resident A1 displayed any physically or verbally abusive behaviors towards other residents and staff.

A review of clinical record documention dated June 8, 2024 at 10:38 AM, revealed that Resident A1 displayed behaviors during this shift of nursing duty. The resident was making sexually inappropriate comments to staff. A nurses note dated June 18, 2024 at 2:23 PM, revealed that the resident continue to make sexually inappropriate comments towards staff.

A nursing note dated June 19, 2024 at 11:37 AM revealed that a nurse aide informed the nurse that the resident made inappropriate sexual comments, as well as derogatory comments regarding a nurse aide's ethnicity, while these nurse aides were showering the resident on June 18, 2024.

In response to these inappropriate behaviors, a psychiatric nurse practitioner ordered June 18, 2024, to start Buspirone 5 mg PO (anti-anxiety medication) as needed every 8 hours for anxiety x 14 days

Nursing documentation dated June 20, 2024 at 6:29 PM and June 21, 2024 at 2:58 PM revealed that the resident continued to make inappropriate sexual comments towards staff and had inappropriately touched a therapist and a nurse. Redirection was noted to be unsuccessful and the resident became agitated with redirecting. The resident's inappropriate sexual comments as well as derogatory comments, such as calling nursing staff a b*tch, continued to occur according to nursing documentation dated June 24, 20240 at 8:13 AM and June 24, 2024 at 2:26 PM. Staff reminded the resident that this inappropriate conversation cannot happen as other residents appear to be agitated by Resident A1's comments. Resident A1 was also interjecting himself into the conversation another resident was having, agitating that resident. Resident A1 asked another resident what the hell is wrong with your hands? (referencing the physical appearance of the resident's hands) Staff asked Resident A1 not bother this other resident, but he continued to do so. The nurse then removed the other resident from area due to Resident A1 continuing to ridicule the resident's physical condition.

A nursing note June 24, 2024 at 2:47 PM noted that Resident A1 was continuing to agitate another male resident, pulling the resident's chair alarm from his wheelchair causing it to sound the alarm. Upon staff arrival, Resident A1 accused the nurse of stealing my toy. Resident A1 refused to given alarm back to the nurse or any other staff stating I had two of them. The nurse also advised the resident to stop reaching for another female resident's arm, which agitated Resident A1. Resident A1 then pursued another female resident and reached out stroking her arm, and the female resident became agitated.

A nursing note June 28, 2024 at 1:37 PM, indicated that the psychiatric nurse practitioner wrote an order, in response to the resident's recent behavior, for depakote ( A seizure medication sometimes used for behavior control) 125 mg daily BID for dementia with behaviors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0609 Nursing noted on July 3, 2024 11:00 A.M that Resident A1 continued to make lewd sexual comments to a female resident and attempts to redirect Resident A1 were unsuccessful. Level of Harm - Minimal harm or potential for actual harm Nursing noted on July 3, 2024, at 1:40 PM that psych services saw the resident and increased the resident's buspirone to 10 mg TID (three times a day). Residents Affected - Some

A nursing note July 3,2024 11:24 P.M. revealed that Resident A1 threatened Resident A2, stating Wait till I get you alone later. The things I'm going to do to you. Resident A2 became fearful and started crying at which point the police were called to intervene due to Resident A1's physical aggression, assault and verbal/sexual remarks, comments and threats toward multiple staff at this time.

A nurse' note dated July 3, 2024, at 11:43 PM Resident A1 smiled, winked and then waved at Resident A2 who was seated in her wheelchair in front of nurses station. He then yelled out to her stating, I'm looking forward to seeing you later when no-one is around. Winking again.

Resident A2 began to cry, shake and tremble. She was immediately taken behind nurses station and other staff attempted to intervene while Resident A1 continued to advance down hallway in Resident A2's direction

after stopping to curse, yell out loud and threaten the supervisor and the nurse once again for asking him to please do not come down this hallway. You are making this resident (Resident A2) scared and very uncomfortable. Several staff members attempted to redirect him without success and began to yell, and threaten staff and the police and emergency services/transport were called.

A review of the clinical record revealed that Resident A2 was admitted to the facility on [DATE REDACTED], with diagnoses to include orthostatic hypotension. A quarterly MDS assessment dated [DATE REDACTED], indicated that she was moderately cognitively impaired with a BIMs score of 11 (a score of 8 to 12 indicated moderate, cognitive impairment).

A review of Resident A2's clinical record conducted during the survey ending July 21, 2024, revealed no reference to the above incident of verbal and mental abuse and the resident's emotional distress. There was no documented evidence that the facility had provided therapeutic psychosocial interventions to Resident A2 to address the psychosocial harm suffered by the resident as the result of being verbally and mentally abused by Resident A1.

During an interview conducted on July 21, 2024, at approximately 12 PM, Resident A2 stated that she did not want to discuss Resident A1 with this surveyor, only stating that she did not want him near her.

A nursing note dated July 3, 2024, at 11:48 PM revealed that local police and EMS (emergency medical services) arrived at the facility and removed Resident A1 from the facility. The resident returned to the facility July 4, 2024, at 4:31 AM

A nursing note dated July 7, 2024 at 10:18 AM revealed that Resident A1 continued to display inappropriate sexual behaviors, despite re-direction attempts. Resident A1 became agitated with re-direction. He sat across the hall from a female resident stating the things I would do to you. Staff again attempted to redirect Resident A1 with with no effect noted. Resident A1 then went and sat in the doorway of another resident's room, taunting the other resident by shouting at her causing her to become distressed and needing to be consoled. Resident A1 then began reaching towards a female resident's arm, and told staff You can't tell me not to touch her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0609 At the time of the survey ending July 21, 2024, the facility was unable to identify these female residents.

Level of Harm - Minimal harm or A nursing note dated July 7, 2024 at 6:42 PM revealed that due to the resident's behaviors, and the risk to potential for actual harm the safety of staff and other residents, he was sent to emergency room for evaluation and behaviors and will be placed on one on one upon return. The resident was transferred to the hospital at 7:52 PM and returned Residents Affected - Some to the facility on [DATE REDACTED], at 6:47 P.M.

A nursing note dated July 13, 2024 at 2:07 PM revealed that staff removed Resident A1 from the activity room because he initiated an argument with another resident, which was witnessed by several witnesses within the activity room.

A nursing note dated July 13,2024 3:00 PM revealed that Resident A1 was overheard asking another resident, the age of the female resident's daughter, stating well if she needs a man I can be your son-in-law. Staff asked Resident A 1 to please keep conversation appropriate as the female resident did not seem to welcome this conversation

A nursing note dated July 13, 2024, at 3:21 PM revealed that nursing responded to the sound of a female resident shouting. Nursing noted that the female resident shouted at Resident A1 You're a pain in the a*s you know that. You just won't shut up. Another female resident shouted to Resident A1 oh no buddy you, have the wrong one. Both (unidentified) female residents reported to nursing staff that Resident A1 will not leave them alone nor do they like his conversation. Resident A1 stated to one female resident I'm keeping my eye on you so you know. The female resident stated I really don't give a sh*t what you do. The RN and another nurse attempted to return Resident A1 to his room however he has refused. Nursing noted resident remains under close supervision by this nurse due to complaints of female residents near by and {Resident A1} refusing to leave area.

A nursing note dated July 13, 2024, at 3:43 P.M. revealed that Resident A1 was at the nurse's station and began to self-transfer. Another female resident in the area, who was ambulatory told Resident A1 to sit

before you fall. Resident A1 told the female resident well come fix my pants, baby, that's what you're supposed to do.

A nursing note dated July 15, 2024 at 1:59 PM revealed that Resident A1 was insulting other female residents this morning regarding their appearances, such as hairstyle. Resident A1 was attempting to enter other residents' rooms and when redirected jumps up defensively and becomes aggressive with staff.

A nursing note dated July 17, 2024, at 2:19 P.M. revealed that Resident A1 with was asking female resident to remove her panties and making derogatory racial comments to another resident.

A nursing note dated July 17, 2024, at 3:51 P.M. revealed that Resident A1 was placed on 1:1 supervision due to safety issues. There was no facility incident investigation for this event at the time of the survey.

During an interview July 21, 2024 at approximately 2 PM the Director of Nursing that the facility did not report

these instances of verbal and mental abuse to the State Survey Agency and local Area Agency on Aging.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 395298 Department of Health & Human Services Printed: 09/17/2025 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 395298 B. Wing 07/21/2024

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

Lakewood Rehabilitation & Healthcare Center 147 Old Newport Street Nanticoke, PA 18634

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 0609 Refer