Siemons' Lakeview Manor Nursing And Rehab Ctr

F-F583, revealed that

the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding personal privacy and confidentiality of records.

The facility's plan of correction for a deficiency regarding a failure to provide implementation of abuse and neglect policies, cited during the surveys ending April 25, 2024, and January 22, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F607, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development and implementation of abuse and neglect policy.

The facility's plan of correction for a deficiency regarding a failure to provide accurate resident Minimum Data Set (MDS) assessments, cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting

the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of MDS assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 395398 Department of Health & Human Services Printed: 09/04/2025 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 395398 B. Wing 03/13/2025

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

Somerset Healthcare & Rehabilitation Center 228 Siemon Drive Somerset, PA 15501

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 0867 The facility's plan of correction for a deficiency regarding a failure to provide comprehensive resident care plans, cited during the surveys ending October 23, 2024, and March 13, 2025, revealed that the facility Level of Harm - Minimal harm or developed a plan of correction that included completing audits and reporting the results of the audits to the potential for actual harm QAPI committee for review. The results of the current survey, cited under

F-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations Residents Affected - Few regarding comprehensive resident care plans.

The facility's plan of correction for a deficiency regarding a failure to provide revisions to resident care plans, cited during the surveys ending April 25, 2024; November 20, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding revisions to resident care plans.

The facility's plan of correction for a deficiency regarding a failure to provide quality of care, cited during the surveys ending April 25, 2024; October 23, 2024; December 13, 2024; and March 13, 2025, revealed that

the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F684, revealed that

the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plan of correction for a deficiency regarding a failure to provide treatment and prevention of pressure ulcers, cited during the surveys ending November 20, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F686, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the treatment and prevention of pressure ulcers.

The facility's plan of correction for a deficiency regarding accident hazards, cited during the surveys ending July 10, 2024, and November 20, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accident hazards.

The facility's plan of correction for a deficiency regarding a failure to provide dialysis services, cited during

the surveys ending April 25, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F698, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 395398 Department of Health & Human Services Printed: 09/04/2025 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 395398 B. Wing 03/13/2025

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

Somerset Healthcare & Rehabilitation Center 228 Siemon Drive Somerset, PA 15501

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 0867 The facility's plan of correction for a deficiency regarding a failure to label and store drugs and biologicals, cited during the surveys ending December 30, 2024, and March 13, 2025, revealed that the facility Level of Harm - Minimal harm or developed a plan of correction that included completing audits and reporting the results of the audits to the potential for actual harm QAPI committee for review. The results of the current survey, cited under

F-F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations Residents Affected - Few regarding labeling and storage of drugs and biologicals.

The facility's plan of correction for a deficiency regarding a failure provide food of the nutritive value, appearance, preferred temperatures and palatability cited during the surveys ending April 25, 2024, and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the nutritive value, appearance, preferred temperature and palatability of foods.

The facility's plan of correction for a deficiency regarding a failure provide infection control and prevention practices cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 395398 Department of Health & Human Services Printed: 09/04/2025 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 395398 B. Wing 03/13/2025

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

Somerset Healthcare & Rehabilitation Center 228 Siemon Drive Somerset, PA 15501

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 42079 potential for actual harm Based on review of established infection control guidelines, facility policies, and clinical records, as well as Residents Affected - Few observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent

the development and transmission of communicable diseases and infections for one of 37 residents reviewed (Residents 56).

Findings include:

CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status,

in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.

The facility's policy regarding EBP, dated February 24, 2025, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs were necessary when performing high contact resident care. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room EBP's are indicated for residents with wound care. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech and was rarely or never understood, was dependent on staff for all care, had a diagnoses that included Alzheimer's disease, non-traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission. A care plan, dated December 9, 2024, revealed that Resident 56 had an unstageable pressure ulcer to his left heel related to immobility. A care plan, dated February 11, 2025, revealed that the resident was on EBP related to the area on the left heel.

Physician's orders for Resident 56, dated February 11, 2025, included an order for the resident to be on EBPs for the pressure area to the left heel.

Observations of Resident 56's wound care to his left heel and left great toe on March 11, 2025, at 10:49 a.m. revealed that Licensed Practical Nurse 6 washed her hands and donned clean gloves; however, she did not don a gown. She then performed the wound treatment to the resident's left heel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 395398 Department of Health & Human Services Printed: 09/04/2025 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 395398 B. Wing 03/13/2025

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

Somerset Healthcare & Rehabilitation Center 228 Siemon Drive Somerset, PA 15501

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 Interview with Licensed Practical Nurse 6 on March 11, 2025, at 10:59 a.m. confirmed that she did not don a gown prior to performing Resident 56's wound treatment. She indicated that she did not think that she need Level of Harm - Minimal harm or to wear any other PPE for the dressing change. potential for actual harm

Interview with the Infection Control Preventionist on March 11, 2025, at 3:14 p.m. confirmed that Licensed Residents Affected - Few Practical Nurse 6 should have donned a gown prior to performing Resident 56's wound treatment.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 395398