Linwood Nursing And Rehabilitation Center

F-F600

28 Pa. Code 201.19 (6)(7) Personnel records

28 Pa. Code 201.18 (e)(2)(3) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 potential for actual harm Based on a review of clinical records and resident and staff interviews, it was determined that the facility Residents Affected - Few failed to timely provide dental services required by one Medicaid Payor source resident out of the 21 sampled residents (Resident 7).

Findings include:

A clinical record review revealed Resident 7 was admitted to the facility on [DATE REDACTED], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to

the rest of the body), and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2024 revealed that Resident 7 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

A review of Resident 7's care plan, initiated July 29, 2021, revealed she exhibits or is at risk for oral health or dental care problems with planned interventions to obtain dental consults as ordered.

A progress note dated May 8, 2023, indicated that Resident 7 was out of the facility to see a dentist and a follow-up appointment was scheduled for November 9, 2023, for the extraction of tooth #28.

A progress note dated November 14, 2023, at 11:39 AM indicated that the facility contacted the dentist to reschedule the resident's dentist appointment, a message was left, and that staff would call with a new appointment time and date.

A progress note dated November 15, 2023, at 2:26 PM indicated that a new appointment was scheduled for Resident 7 on March 6, 2024, at 9:00 AM.

A progress note dated March 3, 2024, at 1:19 PM indicated that the dentist was called and notified that Resident 7's appointment needed to be canceled, and an appointment would be rescheduled upon Resident 7's return to the facility.

Continued review of the resident's clinical record conducted during the survey ending June 28, 2024, revealed no further documentation regarding the resident's dental appointment and if the resident received

the necessary dental services following the appointment on May 8, 2023, during which toot extraction was planned.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0791 During an interview on June 25, 2024, at approximately 9:30 AM, Resident 7 stated that she had an appointment to remove one of her teeth, but it was cancelled over a month ago. She explained that she has Level of Harm - Minimal harm or been waiting for a new appointment but has not heard anything recently. She explained that the facility potential for actual harm schedules her appointments and provides transportation.

Residents Affected - Few In response to surveyor inquiry during the survey, the facility entered a progress note in Resident 7's clinical

record dated June 27, 2024, at 1:20 PM noting that Resident 7 was not on the schedule for dental services.

During an interview on June 27, 2024, at approximately 1:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) failed to provide evidence that the facility scheduled the required dental services for Resident 7.

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

28 Pa. Code 211.15 Dental services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43944

Residents Affected - Few Based on observations, a review of facility's planned meal tickets, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to accommodate resident's food allergies and provide weight loss interventions for one resident, Resident 53, out of 21 residents reviewed.

Findings include:

A review of a facility policy entitled Supplements that was last reviewed on May 10, 2024, revealed that if maintenance of acceptable nutritional status is difficult through delivery/intake of regular meals, the facility will consider and provide the resident with additional nourishment through between-meal or dietary supplements. A nutritional assessment will be completed to determine the need and appropriateness of dietary supplement use and a physicians' order for a dietary supplement will be obtained and maintained in

the medical record. Dining services will provide supplements as ordered and nursing will document the acceptance of supplements in the electronic ADL (activities of daily living) flow records.

A review of Resident 53's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included subarachnoid hemorrhage (is a type of bleeding stroke that happens between your brain and the membrane that surrounds it), cerebral aneurysm (bulging or ballooning of the artery due to weakness in the wall of the vessel that supplies blood to the brain), and seizure disorder. The resident had severe cognitive impairment. Additionally, the resident's profile indicated an allergy to lactose.

A review of the resident's person-centered plan of care initiated on March 14, 2023, identified that Resident 53 was nutritionally at risk due to gradual weight loss, required a mechanically altered diet, and variable intakes with noted goals to prevent weight loss and for the resident to consume 50 - 75% of meals. Planned nutrition weight management interventions included to honor food preferences within meal plan, monitor intakes at all meals, and offer alternate choices as needed, alert dietitian and physician to any decline in intakes.

A review of a nutrition evaluation completed by the facility's Registered Dietitian on May 15, 2024, at 2:50 p. m., revealed that the resident was readmitted from the hospital on May 11, 2024, due to facial drooping, rule out stroke. Working with SLP (speech therapy) for swallowing, diet currently regular with dental soft textures and thin liquids per SLP. Consuming 75-100% of meals with supervision and assistance. Fluid intakes approximately 260-480 milliliters (ml) per meal. No ordered nutritional supplements. Skin is without pressure related breakdown. Current weight: 141.8-lbs., obtained 5/11 and weight history 1 month ago 4/10/24 - 143. 7-lbs., 3 months ago 2/16/24 - 147.4-lbs., 6 months ago 11/21/23 - 148.2-lbs. Weight does not trigger for a significant change however notably down 6.4-lbs. over 6 months. Gradual decline noted and was previously

on Magic Cup (high calorie/high protein supplement) with meals and will request to reorder same to encourage good oral fluids. Will monitor weekly weight trend. Med review completed with no diuretic therapy noted. Will continue to follow weights, skin, and oral intakes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0806 A review of physician's orders dated May 15, 2024, at 5:00 p.m., revealed an order for Magic Cup supplement with breakfast, lunch, and dinner. Level of Harm - Minimal harm or potential for actual harm During a meal observation on June 25, 2024, at 12:48 p.m., revealed that Resident 53's meal ticket noted that the resident had an allergy to lactose and indicated that the resident was to receive a Magic Cup. Residents Affected - Few Subsequently, the resident's tray had vanilla pudding present on the tray and the resident has an allergy to lactose and the tray failed to include the physician ordered supplement, Magic Cup, used to enhance nutrition support due to gradual weight declines and variable intakes.

An interview with the Director of Nursing on June 25, 2024, at 1:00 p.m., confirmed that the facility failed to adhere to a resident's food allergy and failed to provide a planned nutrition intervention and physician ordered supplement on Resident 53's lunch tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 43944

Residents Affected - Some Based on a review of the facility's assessment, select facility policies and procedures, and resident clinical records, staff and resident interviews, the facility failed to document a facility-wide assessment to identify the resources needed to meet the residents, including sufficient staff with the necessary skills and competencies to provide the needed care and services for residents with behavioral health care and dementia care needs.

Findings include:

The facility assessment, dated Quarter 1 2024, and reviewed during the survey ending June 28, 2024, revealed the facility's census and acuity and general information regarding the facility's religious denominations, recreation, social services and physical, occupational and speech therapy services.

The facility assessment did not include evidence of an evaluation of diseases, conditions, physical, functional or cognitive status, of the residents that may affect and plan for the services the facility must provide for residents with behavioral health care and dementia care needs. The facility assessment failed to include the resources needed, including sufficient nurse staffing, and provision of necessary education and training, and competency evaluation for staff providing direct care and assessment of residents with behavioral symptoms to maintain the safety of residents residing in the facility.

Interview on June 28, 2024, at 11:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility assessment did not address staffing requirements, training and competencies. The NHA confirmed that the facility's population included multiple residents requiring increased supervision, including one to one supervision, to meet the needs of residents diagnosed with dementia and exhibiting behaviors. The NHA confirmed that facility staff would benefit from enhanced dementia care, behavioral health and abuse training to better meet the needs of the resident population.

Refer

F-F610, 697

28 Pa. Code 201.18 (e)(1)(3) Management

28 Pa. Code 211.2 (d)(3) Medical Director

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460

Residents Affected - Some Based on a review of clinical records and select facility policies and interviews with staff and residents it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality care to each resident including three residents out of 21 sampled (Resident 7, 21, 80).

Findings included:

A review of facility policy titled General Dose Preparation and Medication Administration, reviewed last by the facility on May 10, 2024, revealed that during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to, the following: administer medications within timeframes specified by facility policy or manufacturer's information.

A clinical record review revealed Resident 7 was admitted to the facility on [DATE REDACTED], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to

the rest of the body), and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2024 revealed that Resident 7 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

The resident had a physician order for Metoprolol Succinate extended-release oral tablet 24 hour 50 mg (a beta blocker medication that relaxes the blood vessels and slows heart rate to improve blood flow and decrease blood pressure) by mouth two times a day related to hypertension (high blood pressure) initiated May 19, 2024; Tramadol HCL oral tablet 50 mg (an opioid medication that changes how the body feels and responds to pain) by mouth two times a day for pain management initiated on May 19, 2024; Eliquis oral tablet 5.0 mg (apixaban- an anticoagulant medication that helps to prevent the body from forming blood clots) by mouth two times a day related to atrial fibrillation dated May 19, 2024; and Cefdinir Oral Capsule 300 MG (an antibiotic medication) 300 mg by mouth two times a day for a urinary tract infection for 7 days initiated on June 20, 2024.

A review of Resident 7's Medication Administration Record for June 2024 revealed that nursing staff failed to timely administer Metoprolol Succinate extended release oral tablet 24 hour 50 mg to Resident 7 on the following dates:

June 1, 2024, at 9:15 AM (one hour and 15 minutes late)

June 2, 2024, at 9:23 AM (one hour and 23 minutes late)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 June 4, 2024, at 9:30 AM (one hour and 30 minutes late)

Level of Harm - Minimal harm or June 4, 2024, at 9:51 PM (one hour and 51 minutes late) potential for actual harm June 6, 2024, at 9:38 AM (one hour and 38 minutes late) Residents Affected - Some June 7, 2024, at 9:12 AM (one hour and 12 minutes late)

June 8, 2024, at 9:18 AM (one hour and 18 minutes late)

June 9, 2024, at 9:35 AM (one hour and 35 minutes late)

June 11, 2024, at 9:18 AM (one hour and 18 minutes late)

June 14, 2024, at 9:10 AM (one hour and 10 minutes late)

June 16, 2024, at 9:41 AM (one hour and 41 minutes late)

June 17, 2024, at 9:25 AM (one hour and 25 minutes late)

June 22, 2024, at 9:57 AM (one hour and 57 minutes late)

June 23, 2024, at 9:46 AM (one hour and 46 minutes late)

June 24, 2024, at 9:15 AM (one hour and 15 minutes late)

June 25, 2024, at 9:30 AM (one hour and 30 minutes late)

June 25, 2024, at 9:55 PM (one hour and 55 minutes late)

June 26, 2024, at 9:38 AM (one hour and 38 minutes late)

A review of Resident 7's Medication Administration Record for June 2024 revealed that nursing staff failed to timely administer Tramadol HCL oral tablet 50 mg on the following dates:

June 1, 2024, at 9:16 AM (one hour and 16 minutes late)

June 2, 2024, at 9:31 AM (one hour and 31 minutes late)

June 4, 2024, at 9:30 AM (one hour and 30 minutes late)

June 6, 2024, at 9:38 AM (one hour and 38 minutes late)

June 7, 2024, at 9:11 AM (one hour and 11 minutes late)

June 8, 2024, at 9:16 AM (one hour and 16 minutes late)

June 9, 2024, at 9:33 AM (one hour and 33 minutes late)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 June 11, 2024, at 9:18 AM (one hour and 18 minutes late)

Level of Harm - Minimal harm or June 17, 2024, at 9:25 AM (one hour and 25 minutes late) potential for actual harm June 23, 2024, at 9:47 AM (one hour and 47 minutes late) Residents Affected - Some June 24, 2024, at 9:16 AM (one hour and 16 minutes late)

June 25, 2024, at 9:30 AM (one hour and 30 minutes late)

June 26, 2024, at 9:34 AM (one hour and 34 minutes late)

A review of Resident 7's Medication Administration Record for June 2024 revealed that nursing staff failed to timely administer Eliquis oral tablet 5.0 mg on the following dates:

June 2, 2024, at 9:23 AM (one hour and 23 minutes late)

June 4, 2024, at 9:30 AM (one hour and 30 minutes late)

June 6, 2024, at 9:38 AM (one hour and 38 minutes late)

June 9, 2024, at 9:33 AM (one hour and 33 minutes late)

June 17, 2024, at 9:21 AM (one hour and 21 minutes late)

June 19, 2024, at 9:43 AM (one hour and 43 minutes late)

June 22, 2024, at 9:58 AM (one hour and 58 minutes late)

June 23, 2024, at 9:47 AM (one hour and 47 minutes late)

June 25, 2024, at 9:29 AM (one hour and 29 minutes late)

A review of Resident 7's Medication Administration Record for June 2024 revealed that nursing staff failed to timely administer Cefdinir Oral Capsule 300 mg on the following dates:

June 21, 2024, at 6:07 PM (one hour and 7 minutes late)

June 23, 2024, at 9:46 AM (one hour and 46 minutes late)

June 24, 2024, at 9:15 AM (one hour and 15 minutes late)

June 25, 2024, at 9:29 AM (one hour and 29 minutes late)

June 25, 2024, at 8:29 PM (three hours and 29 minutes late)

June 26, 2024, at 9:31 AM (one hour and 31 minutes late)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 During a resident group interview on June 25, 2024, at 11:00 AM, Resident 7 stated that nursing staff does not administer her medication timely. She explained that the nursing staff is often late administering her Level of Harm - Minimal harm or medications, and it happens frequently. potential for actual harm

During an interview on June 27, 2024, at approximately 1:30 PM, the Nursing Home Administrator (NHA) Residents Affected - Some and Director of Nursing (DON) confirmed that the facility failed to ensure that Resident 7 received medications timely as scheduled.

A clinical record review revealed that Resident 80 was admitted to the facility on [DATE REDACTED], with diagnoses that included a cerebral infarction (brain damage that results from a lack of blood).

A review of a comprehensive admission MDS assessment dated [DATE REDACTED] revealed that Resident 80 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact), dependent on staff for toileting hygiene (the ability to maintain perineal hygiene and adjust clothes before and after voiding having a bowel movement) and required substantial or maximal assistance from staff for lower body dressing, showering, bathing, and moving from a sitting position to a standing position or transferring to the toilet.

A facility investigation, dated June 6, 2024, revealed Employee 15, NA, explained that the resident was soiled through her clothes and had dried bowel movement on her at 5:20 PM. Employee 15, NA, indicated that Resident 80 was upset because she asked to be changed after lunch, but no one changed her.

A witness statement provided by Resident 80 dated June 6, 2024, revealed that on June 5, 2024, Resident 80 indicated she rang her call bell between 1:00 PM and 2:00 PM to be changed. Resident 80 explained that

the nurse aide told her she would change her, then told her the next shift staff would provide her care and left without providing her care.

A witness statement provided by Employee 11, Registered Nurse, dated June 6, 2024, revealed that she entered Resident 80's room {on June 5, 2024,} at 5:20 PM and saw urine dripping to the floor from the resident's lift pad. Employee 11, RN, explained that Resident 80 looked at her with tear-filled eyes and said

they said they would be back, but they didn't come.

During an interview on June 27, 2024, at 10:30 AM, Resident 80 stated that she sometimes waits over 30 minutes or more for care when she needs to be changed. The resident stated that she needs staff assistance because she is not able to care for herself. Resident 80 recalled that on June 5, 2024, nursing staff came into her room and told her that they couldn't change her because they were assisting others and were too busy to provide her care. She explained that nursing staff told her the next shift would have to take care of her. She stated that she waited in a soiled brief for hours that day. Resident 80 indicated that she is upset, frustrated, and cries when she needs to wait for care after soiling her brief. Resident 80 indicated that staff continue to check on her, turn her call bell light off, but leave her without providing care.

A clinical record review revealed that Resident 21 was admitted to the facility on [DATE REDACTED], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood) and hemiplegia (paralysis on one side of the body).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 A review of a quarterly MDS assessment dated [DATE REDACTED] revealed that Resident 21 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). Level of Harm - Minimal harm or potential for actual harm A review of the MDS assessment Section GG Functional Abilities dated May 11, 2024 revealed that Resident 21 required substantial or maximal assistance for lower body dressing, showering, bathing, and moving from Residents Affected - Some a sitting position to a standing position or transferring to the toilet.

A facility investigation, dated May 23, 2024, revealed that Resident 21 reported that in the middle of the night last night {May 22, 2024}, she rang her call bell for assistance from nursing staff because she was wet. Resident 21 stated that staff came in and told her she wasn't wet and would be back later but did not return to provide her care for about two hours.

A facility investigation, dated May 24, 2024, at 11:00 AM, revealed that Employee 16, NA, indicated that {on May 22, 2024} she did not check to see if the resident was wet because she was trying to get caught up on documentation that night. Employee 16, NA, stated that she went back to the resident's room [ROOM NUMBER] to 25 minutes later.

During an interview on June 27, 2024, at 10:00 AM, Resident 21 stated that sometimes she waits a long time for care from nursing staff. She stated that she waits 20 minutes for nursing staff to provide her care and longer when the facility is short on staff. Resident 21 stated that a few weeks ago, there was an incident when she rang her call bell for staff assistance to be changed, but nursing staff told her she had to wait to be changed. Resident 21 stated that she felt disappointed because she was treated in that manner.

During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility investigation identified that Resident 21 rang her call bell because she soiled her brief but was not provided care because Employee 16, NA, was completing documentation.

A review of Resident 80's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures)and transient ischemic attack [(TIA) is a short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain].

Resident 80's clinical record revealed a nurse note dated June 7, 2024, at 7:27 a.m., indicating that the facility contacted the resident's (RP) and advised her that the resident's appointment with neurosurgery that was scheduled that day at 11:00 a.m. today had to be rescheduled because the facility did not have enough nursing staff to have a nurse aide available to accompany the resident to the appointment. The RP said that

she didn't have anyone to go to the appointment either and called the neurosurgery department to reschedule the resident's appointment.

During an interview with the Director of Nursing (DON) on June 28, 2024, at 11:00 a.m., confirmed that the facility didn't have enough nursing staff to accompany Resident 80 to her to her scheduled follow up appointment with neurosurgery and that the appointment had to be canceled and rescheduled delaying the resident's follow-up.

28 Pa. Code 211.12 (c)(d)(4)(5)(f.1)(2)(4) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0725 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0741 Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43944

Residents Affected - Some Based on a review of clinical records and select facility policy, and staff interview it was determined that the facility failed to provide sufficient staff, involved in the direct care of residents, who possess the appropriate skills and competencies to promptly identify and address an escalation in inappropriate sexual behaviors displayed by one resident (Resident 8) out of 21 sampled to maintain the safety and well-being of other residents.

Findings included:

A review of Resident 8's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included unspecified dementia and adjustment disorder (difficulty in managing stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning) with mixed disturbance of emotions and conduct. The resident had severe cognitive impairment.

A review of Resident 8's plan of care dated June 25, 2023, and revised on March 26, 2024, revealed that the resident had the potential to demonstrate verbally abusive and sexually inappropriate behaviors related to dementia and poor impulse control, with the noted goal that the resident would verbalize understanding of

the need to control verbally abusive behavior. Planned interventions included every fifteen-minute checks related to behaviors, analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, monitor and document observed behavior and attempted interventions in behavior log, and intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later.

Social Service progress notes dated October 16, 2023, at 5:13 p.m., indicated that it was called to the social worker's attention that Resident 8 may become a little too handsy with some female residents and likes to hold and sometimes kiss female residents hands and was known as a ladies' man. Employee 4, social services and the resident's daughter explained to him the best way possible. However, his BIMS (brief

interview for mental status - a tool to assess cognitive status) score was 9 (moderate cognitive impairment) with his short-term memory impaired and res needs reminders. Also, the Activity Department was also made aware and will intentionally seat Resident 8 closer to men and all staff will continue to provide reminders.

Employee 5, a licensed practical nurse (LPN), noted on January 7, 2024, at 12:09 p.m., that Resident 8 was observed multiple times this shift being sexually inappropriate with the female residents, rubbing their thighs up to their crotch. This was witnessed by this nurse {Employee 5} and by one of the CNAs. Resident 8 was placed in his room and told that he needs to be appropriate and to keep his hands to himself. This nurse {Employee 5} also called resident's daughter and explained the situation to her. Daughter seemed to be embarrassed and apologized. Daughter also stated that if it happened again, to give her a call and put him

on the phone with her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0741 A nurse progress note completed by Employee 6, RN Supervisor, dated January 7, 2024, at 12:31 p.m., revealed that related to inappropriate sexual behavior Resident 8 was redirected and placed on every Level of Harm - Minimal harm or 15-minute checks for behavioral observation. Resident made aware behaviors was inappropriate. Resident potential for actual harm stated, I don't remember doing it. Daughter was in to visit and made aware of behavior and behavioral monitoring checks and was okay with same. Residents Affected - Some Employee 7, RN/former DON, dated February 29, 2024, at 5:55 p.m., revealed that the resident's RP was made aware on February 28, 2024, that a female resident reported that on February 27, 2024, that Resident 8 approached her in the lobby and rubbed her leg over her clothes and stated oh you like this, and when she responded that she did not like this, he proceeded to grab her left breast over her clothes, female resident removed herself from the lobby. Resident's RP, daughter, very apologetic and has spoken with her father regarding these behaviors. RP reported that Resident 8 had no recollection of these behaviors when they happened, and he was remorseful and tearful when they discuss his actions.

A review of Resident 48's care plan, initiated on May 17, 2022, and revised on November 24, 2023, identified that the resident had impaired/declined in cognitive function or impaired thought processes related to diagnosis of Alzheimer's dementia without behavioral disturbance diagnosis. A review of the resident's annual Minimum Data Set assessment dated [DATE REDACTED], indicated that the resident had severe cognitive impairment with a BIMS of 3.

An incident report, completed by Employee 1, a Registered Nurse (RN), dated June 6, 2024, at approximately 5:30 p.m., revealed that Employee 2, a nurse aide (NA), reported that while by nurses' station talking with the scheduler, she looked down the hall (300's hallway) and saw another resident {Resident 8} close to Resident 48. Employee 2 went to Resident 48 and observed that her right breast was exposed and a male resident {Resident 8} had his hand on the resident's bare breast. Residents were separated immediately and taken to their rooms. Resident 48 was assessed by this writer {Employee 1} and no signs or symptoms of distress and offered no complaints and was acting per usual, pleasantly confused. Vital signs were obtained, and skin check completed with no abnormalities or injuries noted. Voice message left for Resident 48's attending physician and responsible party (RP), son, were informed of incident.

A review of a witness statement written by Employee 2, no date or time noted, described that at approximately 3:30 p.m., I was at the nurses' station talking to [scheduler] about staying tonight. I happened to look down the hall and saw Resident 8 feeling Resident 48's right exposed breast. I ran down the hall, separated them and I put her {Resident 48} in her room and Resident 8 in his room.

Further review of the incident report indicated that Resident 8's attending physician and RP were notified of

the incident and the facility immediately initiated one-to-one direct observation of Resident 8.

A review of a physician's order dated June 6, 2024, at 8:28 p.m., revealed an order for one-to-one direct

observation by staff at all times.

There was no documented evidence that the facility consistently provided sufficient supervision of Resident 8 and monitored the resident every fifteen-minute checks as care planned as of March 26, 2024, to ensure the safety of other residents due to Resident 8's sexual behaviors towards female residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0741 A review of Resident 8's clinical record revealed a nurses' progress note Health Status Note completed by Employee 3, a licensed practical nurse (LPN), dated June 6, 2024, at 10:26 p.m., revealed this writer last Level of Harm - Minimal harm or saw resident at approximately 5:00 p.m., seated in his wheelchair by nurses' station sleeping intermittently. potential for actual harm One-to-one supervision and one-to-one supervision followed post incident and continued with no further incident this shift. Residents Affected - Some

An interview with the Director of Nursing (DON) on June 26, 2024, at 2:05 p.m., revealed that that Resident 8 was known to have sexually inappropriate encounters/behaviors with female residents as noted in his clinical

record by staff. The DON confirmed that the facility could not provide documented evidence that every fifteen-minute checks were conducted to provide supervision of Resident 8 with known sexually inappropriate behaviors to prevent him from further sexually abusing other female residents.

During an interview with the facility's RN/Staff Development on June 28, 2024, at 10:30 p.m., revealed that

she educates all facility staff on abuse by means of an electronic educational platform and developed materials. However, the facility's actual abuse prohibition policy and procedures was not included in that online training.

At the time of the survey ending June 28, 2024, the facility failed to provide evidence that they had identified

the skills and competencies their staff required to work effectively with Resident 8 to manage his adjustment disorder, inappropriate sexual behaviors and meet his behavioral health needs. The facility failed to demonstrate the use of a competency-based approach to determine the knowledge and skills required among staff to ensure Resident 8 was able to maintain or attain their highest practicable psychosocial well-being and meet current safety needs of the female residents residing in the facility.

The facility failed to demonstrate consistent monitoring of the effectiveness of the interventions planned to manage Resident 8's behaviors, including timely changing those approaches, if needed, in accordance with current standards of practice, and show evidence of ongoing assessment as to whether those care planned approaches were improving or stabilizing the resident's psychosocial status and de-escalating the resident's behaviors.

Refer

F-F713

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

28 Pa. Code 211.10 (c)(d) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0713 Provide or arrange emergency care by a doctor 24 hours a day.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460 potential for actual harm Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure Residents Affected - Some the provision of consistent and timely physician services for one of 21 sampled residents (Resident 48).

Findings include:

A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included rheumatoid arthritis (a chronic autoimmune disease that causes inflammation and damage to the body's joints and other tissues), Alzheimer's disease, age-related osteoporosis (a bone disease that causes bones to become fragile due to a decrease in bone mass and density).

A nurse's note dated February 17, 2024, at 2:07 PM indicated that the resident's family approached the nurse, concerned over swelling of the resident's left leg and requested results of the x-ray that was performed on February 5, 2024. According to the note, a call was placed to the physician, and message left.

Nurse's note dated February 18, 2024, at 1 PM indicated that a follow-up call placed to physician's answering service regarding swelling on resident's left ankle. Voicemail left with answering service requesting call back.

Nurse's note dated February 21, 2024, at 1:33 PM indicated that another follow-up call placed to physician regarding family concern over swelling noted on left ankle. Message left with answering service.

Review of nurse's note dated February 21, 2024, at 3:47 PM, revealed that orders were received from the physician, four days after initial concern identified. The physician ordered an x-ray of the left ankle.

On February 21, 2024, at 7:52 PM, documentation indicated that Resident 48 had fracture(s) of the left ankle and orders were obtained to apply an Ace wrap, to the left ankle, elevate, apply ice to the area, and for resident to see orthopedics on February 22, 2024.

There was no evidence that the facility attempted to reach an on-call physician or contact the facility's medical director in the absence of a timely response to Resident 48's change in condition.

Nursing noted that Resident 48 was transferred to the emergency roiagnom on [DATE REDACTED], from the orthopedics office and was admitted .

According to nurse's note dated February 25, 2024, at 10 AM, resident was readmitted to the facility after being hospitalized for a fractured leg, pain management, and exacerbation of cardiac condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0713 Interview with the Director of Nursing (DON) on June 28, 2024, at approximately 12:10 PM, confirmed that approximately 4 days (February 17, 2024, to February 21, 2024), had passed before a physician responded Level of Harm - Minimal harm or to the facility's repeated calls regarding an acute change in Resident 48's condition. potential for actual harm

Interview with the Director of Nursing on June 28, 2024, at approximately 1:30 AM, acknowledged that the Residents Affected - Some physician failed to respond timely.

Refer

F-F741

28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 43944 potential for actual harm Based on review of facility QAPI meeting attendance records and staff interviews, it was determined the Residents Affected - Some facility failed to ensure that the required committee members met at least quarterly for one quarter out of three reviewed.

Findings include:

An interview was conducted with the Nursing Home Administrator (NHA) on June 28, 2024, at approximately 12:30 p.m., revealed that facility's QA/QAPI committee members included the Administrator (NHA), Director of Nursing (DON), Medical Director, and department heads. The NHA reported that the committee should meet at least quarterly.

Review of the facility's QA/QAPI committee attendance sheets for the QA meetings held since the last annual survey ending July 23, 2023, through annual survey ending June 28, 2024, revealed that the QA/QAPI committee only held one quarterly meeting that was conducted on April 30, 2024.

Interview with the NHA, at approximately 12:33 p.m., reported that she was unable to locate the QA/QAPI signature sheets to show documented evidence that the facility's QA/QAPI committee met at least quarterly.

28 Pa. Code 201.18 (e)(2)(3)(4) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41460 potential for actual harm Based on observation and review of select facility policy and staff interview, it was determined that the facility Residents Affected - Few failed to maintain infection control practices during administration of resident medication by one nurse out of two observed administering medications (Employee 10).

Findings include:

Review of facility policy entitled General Dose Preparation and Medication Administration, last reviewed by

the facility on May 10, 2024, indicated that appropriate hand hygiene should be performed before and after direct resident contact. Medications should not come in contact with any surface except for the medication cup. Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package.

During an observation of medication administration on June 28, 2024, at approximately 8:15 AM., with Employee 10, licensed practical nurse, Employee 10 was observed preparing medications for administration to a resident.

Employee 10 was observed handling each medication, nine in total, with her bare hands prior to placing in

the plastic medication cup. Employee 10 was not observed to perform hand hygiene prior to handling the medications.

During verification of medications for accuracy with the surveyor, Employee 10 poured all the medications from the plastic medication cup into her bare hand, counted them, and placed them back into the plastic medication cup. One of the nine medications was very small, so Employee 10 picked it up from her bare hand with her long acrylic fingernails and placed into the cup. Employee 10 then administered the medications to the resident. The employee did not perform hand hygiene, prior to handling or administering

the medications.

Observation of the medication cart used by Employee 10, during this med pass revealed a [NAME] cup and personal cell phone on top of the medication cart.

The observations were confirmed by the Director of Nursing on June 28, 2024, at 8:25 AM.

Interview with the Director of Nursing on June 28, 2024, at 8:45 AM confirmed that Employee 10 failed to adhere to infection control practices during medication administration to prevent the potential spread of infection.

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

28 Pa. Code 211.10 (a)(d) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43944 potential for actual harm Based on a review of clinical records, facility policy, and the facility's infection assessment tool, and staff Residents Affected - Few interview it was determined that the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use for two residents out of 21 sampled. (Resident 2 and Resident 188)

Findings included:

Review of a facility policy entitled Antibiotic Stewardship last reviewed May 10. 2024, indicated it was the policy of the facility to provide optimal use of antibiotics based on clinical guidelines and avoided unnecessary adverse events related to the use of medications. Goals of the program were to provide a clearly defined empiric therapy for treatment of suspected infections when appropriate, promote safe and effective use of antibiotics that will adequately treat the patient for susceptible bacterial infections, and to change broad spectrum antibiotics to promote narrowed therapy to minimize bacterial resistance in the facility and community. The facility will utilize an empiric treatment protocols in residents who present with signs and symptoms of an infection. Cultures are ordered when indicated and microbiology reports are received by the unit, the pharmacy and the infection control office directly from the contracted laboratory.

These are monitored for appropriate antibiotic selection. Minimum criteria for initiation of antibiotics based on

the McGeer criteria.

Review of McGeer Criteria for urinary tract infection ([UTI] an infection of the urinary system), surveillance indicates that UTI without indwelling catheter must fulfill both one and two under criteria which is listed as the following: One: at least one of the following sign or symptoms; acute dysuria (painful urination) or pain, swelling, or tenderness of testes, epididymis, or prostate. Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria (blood in urine), new or marked increased incontinence (involuntary urination), urgency, or frequency. If no fever or leukocytosis, then two or more of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency, or frequency. Two: at least one of the following microbiologic criteria; greater than or equal to 10^5 CFU (colony-forming-unit the estimated number of microbial cells)/milliliter (ml) of no more than two species of organisms in a voided urine sample or 10^2 CFU/ml of any organism(s) in a specimen collected by an in-and-out catheter. Urine specimens for culture should be processed as soon as possible preferably within one to two hours, if the specimen is not processed within 30 minutes of collection they should be refrigerated and used for culture within 24 hours.

A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included urinary retention (inability for the bladder to completely drain when urinating) and neurogenic bladder (is when a person lacks bladder control due to brain, spinal cord or nerve problems) with need for Foley catheter [is a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0881 Employee 8, a RN, noted on June 3, 2024, at 10:38 a.m., that the resident displayed increased behaviors.

The CRNP (certified registered nurse practitioner) was onsite and noted a new order for a urinalysis and Level of Harm - Minimal harm or culture & sensitivity lab studies [(C&S) is a lab test to check for bacteria or other germs in a urine sample and potential for actual harm allows practitioners to select a susceptible antibiotic treatment to best treat the bacteria]

Residents Affected - Few Lab study results dated June 3, 2024, at 12:36 p.m., revealed that the complete blood count was within normal limits. The urine culture results dated June 7, 2024, at 2:42 p.m., revealed E. coli (the E. coli bacteria from the intestines is present in fecal matter and trace amounts of fecal matter make their way into the urinary tract through the urethra opening and begin to multiply) > 100,000 colonies/ml present in her urine and > 10,000 colonies/ml mixed normal flora.

A facility communication tool, eINTERACT Change in Condition Evaluation - V4.2 documentation dated June 8, 2024, at 3:52 a.m., revealed that resident had a suspected infection of UTI, the date the symptoms were identified were June 7, 2024. The most recent vital signs documented included: blood pressure 138/74 on June 8, 2024, at 2:08 a.m., temperature 97.7 degrees on June 8, 2024, at 3:34 a.m., pulse 68 on June 8, 2024, at 3:39 a.m., respiration 18 on June 8, 2024, at 3:40 a.m., oxygen saturation 96 % on room air on June 8, 2024, at 3:41 a.m. Other relevant information noted was resident has indwelling catheter and history of recurrent UTIs. Protocol criteria not met resident does not need an immediate prescription for an antibiotic but may need additional observation. New orders received from the provider for urinalysis ([UA] is an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection), culture and sensitivity ([C & S] identifies the organisms create infections and illnesses. Sensitivity tests to identify the most effective medications to treat the illnesses or infections).

However, Employee 8 noted on June 7, 2024, at 1:18 p.m., that the resident was positive for UTI and that the attending physician ordered the antibiotic drug Macrobid 100 mg on orally twice per day for ten days, despite not meeting the McGeer Criteria.

An interview with the infection preventionist (IP) on June 28, 2024, at 10:05 a.m., revealed that Resident 2 did not meet McGeer's criteria for the attending to prescribe antibiotic therapy, Macrobid. Additionally, the IP confirmed that the facility failed to provide documented evidence that the facility's chosen McGeer Assessment Tool for a Urinary Tract Infection was used to ensure the administration of Macrobid was clinically indicated and the clinical necessity of initiating the antibiotic prior to and based on the urinalysis C&S results.

A review of Resident 188's clinical record revealed that the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included urinary tract infection, muscle weakness, and difficulty walking.

Resident 188 was transferred to the hospital on February 18, 2024, at 10:01 a.m., for an evaluation due to positive urine culture and sensitivity results for Klebsiella present in the culture results and not too many antibiotic choices and many allergies.[is a Gram-negative bacterium that commonly causes urinary tract infections (UTIs) and is a part of the normal flora in the intestinal tract, but when it enters the urinary system,

it can lead to various complications] and ESBL [(Extended Spectrum Beta-Lactamase) is a type of enzyme that is produced by certain bacteria, making them resistant to certain antibiotics. When ESBL is found in urine, it can cause urinary tract infections (UTIs) that are difficult to treat]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0881 Resident 188 returned from the hospital later that evening, with diagnosis of UTI. Antibiotics were started in

the emergency room (ER) due to positive urine culture, which was sensitive to Macrobid (is an antibiotic that Level of Harm - Minimal harm or fights bacteria in the body and used to treat urinary tract infections). However, Resident 188's clinical record potential for actual harm failed to reveal that Macrobid was administered at the facility upon the resident's return as noted in the ER discharge instructions. Residents Affected - Few

A nurse's progress note completed by Employee 1, a Registered Nurse, dated February 20, at 9:21 p.m., revealed that Cefdinir (antibiotic that is used to treat many different types of infections caused by bacteria) 300 mg every 12-hours was initiated for UTI.

A review of Resident 188's Medication Administration Record [(MAR, or eMAR for electronic versions), dated February 2024, revealed that the resident received four doses of Cefdinir ATB.

On February 21, 2024, at 3:47 p.m., the attending physician was notified that the resident did not void during that shift and ordered to stop Cefdinir for UTI, and that he would be in tomorrow to see resident.

A review of nurse progress notes dated February 22, 2024, at 6:59 a.m., revealed that the resident voided a moderate amount of dark amber urine time one this AM with no complaints of urinary discomfort.

Employee 8, a RN, noted on February 22, 2024, at 1:52 p.m., that the resident's attending physician was in and assessed the resident and reviewed results of labs and U/A C & S results. Resident asymptomatic (producing or showing no symptoms) and afebrile (without fever). Physician ordered IV (intravenous) Zosyn [is used to treat many different infections caused by bacteria, such as stomach infections, skin infections, pneumonia, and severe uterine infections] for five days.

Resident 188's MAR for dated February 2024, revealed that the resident received only one dose of Zosyn and refused administration of other prescribed doses. Employee 8 noted that the attending physician was notified at that time and updated on the resident's status. Resident remained asymptomatic and afebrile 97.1

A new order was noted to discontinue Zosyn. The resident's urinalysis was within normal limits. Resident was comfortable, no signs or symptoms of distress.

The results of the the culture and sensitivity results dated March 3, 2024, at 9:22 a.m., revealed that less than 10,000 colonies/ml normal flora and greater than 100,000 colonies/ml Enterococcus species were present in urine and resistive to ampicillin. A new order was noted to start Macrobid 100 mg orally twice daily for seven days.

Interview with the facility's Infection Preventionist (IP) on June 28, 2024, at 10:10 a.m., revealed that Resident 188's received doses of unnecessary antibiotic due to the resident's attending physician not adhering to McGeer's criteria for infection surveillance and prescribing practices and that staff failed to complete the necessary steps of ATB Stewardship to deter unnecessary antibiotic use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0881 There was no evidence that the facility consistently followed McGeer Criteria prior to initiating antibiotic therapy for Resident 2 and Resident 188 by failing to follow its Antibiotic Stewardship policy to improve Level of Harm - Minimal harm or antibiotic prescribing, administration, and management practices to reduce inappropriate use to ensure that potential for actual harm residents receive the right antibiotic for the right indication, dose, and duration.

Residents Affected - Few 28 Pa. Code 211.10(a)(d) Resident care policies

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 50 of 51 395717 Department of Health & Human Services Printed: 09/22/2025 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 395717 B. Wing 06/28/2024

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

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 43944

Residents Affected - Many Based on staff interviews and a review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received training on the facility's abuse prohibition policy and facility specific-procedures.

Findings include:

During an interview with the Nurse Educator on June 28, 2024, at 10:00 a.m., revealed that the facility utilizes an on-line education platform for staff to complete mandatory education and additional education topics were provided as needed on paper and offered a variety of educational methods present topics.

The Nurse Educator provided the educational content on which staff received for their annual abuse prevention education program. The education failed to include the facility's specific procedures for identifying and reporting abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention.

During an interview on June 28, 2024, at 11:15 a.m., the Nursing Home Administrator (NHA) stated that prior to survey that it was identified that the mandatory annual abuse training and new hire abuse training failed to include the complete training on the facility's specific-abuse prohibition policy and procedures.

28 Pa. Code 201.20 (b) Staff development

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 51 395717