Every finding on record at Kadima Rehabilitation & Nursing at Pottstown

Based on observations and staff interviews, it was determined that the facility failed to properly label, date, and monitor food products in the Main Kitchen.Findings include:During an observation on November 18, 2025, at 9:45 a.m. in the dry storage room, the following items were observed without labels or dates:Six plastic bags of dried pastaOne bag of brown powderOne bag of toasted oatsDuring an observation on November 18, 2025, at 9:45 a.m. in the freezer located in dry storage, the following item was observed without a label or date:One bag of frozen English muffinsDuring an observation on November 18, 2025, at 9:45 a.m. in the freezer located in the Main Kitchen, the following item was observed without a label or date:One bag of frozen fishDuring an observation on November 18, 2025, at 9:45 a.m. in the refrigerator located in the Main Kitchen, the following item was observed to be expired:One container of sweet tea with a use by date of November 17, 2025An interview conducted on November 20, 2025, at 1:52 p.m. with the Dietary Manager confirmed that the facility failed to ensure food items were properly labeled, dated, and used within their designated timeframes. Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management.

Based upon observation, it was determined that the facility failed to ensure infection control practices were monitored on two of two nursing units and two of two medication carts.Findings include:Observation of the hand sanitizer units on November 19, 2025 at 9:15 a.m. revealed the following - hand sanitizer unit near the nurses' station had an expiration date of January, 2024; hand sanitizer unit in the short hallway near the nurses' station had an expiration date of January 2024; hand sanitizer unit outside the dining room had an expiration date of February 2023; hand sanitizer unit In the dining room had an expiration date of January 2024; hand sanitizer unit located inside the front door had an expiration date of January 2024; hand sanitizer unit in the activity room had an expiration date of December 2023 and the hand sanitizer unit outside the Nursing Home Administrator's office had an expiration date of January 2024.Observation on November 19, 2025, of two medication carts revealed pudding used for medication administration with a date of November 14, 2025, located on the top of the container. The above information was conveyed to administration on November 20, 2025, at 11:00 a.m. 28 Pa. Code 201.18(a) ManagementPreviously cited 11/27/2024, 2/27/2025

Based upon clinical record review, it was determined that the facility failed to obtain a physician's discharge summary for a resident discharged home (Resident 41)Findings include:Review of Resident 41's Closed Record revealed Resident 41 was discharged to home from the facility.Further clinical record review failed to reveal evidence that a Physician's Discharge Summary was completed prior to Resident 41's discharge.Interview with Director of Nursing on November 20, 2025, at 10:39 a.m. confirmed that no Physician's Discharge Summary was completed prior to Resident 41's discharge home. 28 Pa. Code 211.5(d)(f) Clinical Records Previously cited 2/27/2025

Based on clinical record review and staff interviews, it was determined that the facility failed to follow physician-ordered parameters for pain medication administration for one of 16 residents reviewed (Resident R24).Findings include:Review of Resident R24's clinical record revealed an active order for oxycodone-acetaminophen 5-325 mg, administer one tablet by mouth every eight hours as needed for moderate to severe pain. With a start date of August 28, 2025.Review of the facility's Pain Assessment, Step Five, indicated: Determine the appropriate type of pain medication as ordered by the physician using the following pain scale (may be individualized per physician order): 1-3 = mild pain; 4-7 = moderate pain; 8-10 = severe pain.Review of Resident R24's Medication Administration Records (MARs) for August, September, October, and November 2025 revealed the resident received the medication outside of the prescribed parameters on six occasions.An interview conducted on November 20, 2025, at 1:10 p.m. with the Regional Clinical Director confirmed that staff administered Resident R24's pain medication outside the physician-ordered parameters. Pa Code 211.12(d)(5) Nursing Services Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management.

Based upon observation, it was determined that the facility failed to ensure residents were free from accidents and hazards for one of two medication carts (Cart 1).Findings include:Observation of Medication Cart 1 on November 18, 2025, at 9:10 a.m. revealed the medication cart to be unlocked and unattended. Further observation of the medication cart revealed medications in a medication cup on the top of the cart with multiple residents in the hallway and room doorways. Further observation failed to reveal evidence of any nursing staff member in the vicinity of the medication cart at the time of the observation.Interview with the Director of Nursing on November 20, 2025, at 10:00 a.m. confirmed that nursing staff should not have left medications on the top of the cart unattended. 28 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 11/27/2024, 12/30/2024

Based on clinical record review, staff interviews, and policy review, it was determined that the facility failed to implement non-pharmacological interventions prior to administering PRN pain medication for one of 16 residents reviewed (Resident R24).Findings include:Review of Resident R24's clinical record revealed an active order for oxycodone-acetaminophen 5-325 mg, administer one tablet by mouth every eight hours as needed for moderate to severe pain. With a start date of August 28, 2025.Review of the facility's Pain Assessment documentation indicated: Record all assessment data obtained during the procedure, including location of pain, level of pain using the pain scale, type of pain relief used, and any non-pharmacological interventions applied prior to the administration of PRN pain medication.Review of Resident R24's clinical record failed to reveal documentation of any non-pharmacological interventions attempted prior to administering PRN pain medication.An interview conducted on November 20, 2025, at 1:10 p.m. with the Regional Clinical Director confirmed that staff were not implementing non-pharmacological interventions prior to administering PRN pain medication. Pa Code 211.12(d)(5) Nursing Services Pa Code 201.14(a) Responsibility of licensee.Pa Code 201.18(b)(3) Management.

Based on staff and resident interviews, it was determined that the facility failed to have petty cash available in the facility for any resident who may request funds from their accounts. Findings include: Interviews with Resident's 4, 5, 6,and 7 on Mach 28, 2025 from 11:15 to 11:40 a.m. revealed residents never request funds from their accounts and residents had no knowledge of how much money, if any, was available in their accounts. Interview conducted with Nursing Home Administrator (NHA) on March 28, 2025, at 2:00 p.m. when the above information was presented the NHA stated when residents request funds a check is written from the resident's account. The NHA will then take the check to the bank and cash it on behalf of the resident. The NHA confirmed that no petty cash was available in the facility for resident use. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a)(d)(e) Resident Rights

Based on clinical record review, staff and resident interviews it was determined that the facility failed to provide appropriate preparation of the resident prior to transfer and discharge for one of three residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed resident was admitted on [DATE], with medical diagnosis that include Chronic Obstructive Pulmonary Disease with Acute Exacerbation (lung and airway disease that restricts breathing with sudden or severe worsening), Pain, and Bronchitis (inflammation of airway to lungs). Review of Resident R1's clinical records revealed a nursing progress note dated February 20, 2025, documenting the resident was discharged and left at 1:25 p.m., with family to home in [NAME], PA, scheduled medications and prescriptions were made available. Discharge instruction was provided. Further review of Resident R1's clinical records revealed a discharge note dated February 24, 2025, documenting the resident was sent home with family. Discharge instructions were given to resident. Resident had order for Continuous Positive Airway Pressure (CPAP) machine, (a machine that keeps airways open while you sleep) and an oxygen concentrator (a medical device that supplies extra air) to be delivered to home. Home supplies were not delivered, and resident went to [NAME] hospital according to family. Review of Resident R1's clinical record revealed a discharge planning summary assessment dated [DATE]. Further review of the discharge summary failed to reveal any home supplies were ordered for the resident. Further review of resident's clinical records revealed no documentation a CPAP machine or oxygen concentrator was ordered for the resident. Interview conducted with Nursing Home Administrator (NHA) on March 28, 2025, at 2:00 p.m. when the above information was presented the NHA confirmed the facility had no documentation to confirm the resident's CPAP machine and oxygen concentrator were ordered. 28 Pa Code 211.16(a) Social Services

Based on review of facility documentation, clinical records, and interviews with staff and residents it was determined the facility failed to ensure the transportation vehicle had a safety inspection from [DATE], until February 4, 2025, during which time the vehicle was used to transport seven residents on 11 separate occasions to medical appointments. Additionally, staff using the transport van had not been trained in safety procedures. This resulted in an Immediate Jeopardy which had the potential to cause residents discomfort or pain and to jeopardize the health and safety of residents. Findings include: Review of facility documentation revealed the facility's wheelchair accessible van had a state safety inspection completed on [DATE]. Further review of facility documentation revealed the next safety inspection was completed on February 4, 2025. Telephone interview conducted on February 26, 2025, at 11:03 a.m. with representative from the automotive establishment that completed the state safety inspection on [DATE], revealed the safety inspection sticker expired on [DATE]. Review of Resident 1's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated [DATE], revealed resident had a BIMS (brief interview for mental status) indicating resident was cognitively intact. The MDS also indicated the resident had a diagnosis of Hemiplegia (paralysis) following cerebral infarction (stroke) affecting the left non-dominate side. Resident 1 had a functional limitation in range of motion on one side for the upper and lower extremity and used a wheelchair for mobility. Review of facility documentation dated [DATE], revealed, resident was being transported to pain management this am 0820 [8:20 a.m.], (he/she) slid from (his/her) wheelchair to the floor of the van, the driver stopped (Employee E3) and repositioned back into the wheelchair, fastened the seat belts, and continued on to (his/her) appointment, after determining that there was not injury sustained during the fall. Review of Employee E3's written statement obtained [DATE], revealed at 8:20 a.m. in the transport van, Resident 1 fell out of (his/her) wheelchair onto the floor of the van. Employee E3 indicated that they had slowed down to allow a car (opposing traffic) to pass by on the road. As we slowed down (going down hill) a loud thud was heard. The resident reported (he/she) slid out of (his/her) wheelchair onto the floor of the van. Employee E3 indicated the wheelchair locks and brakes were placed on wheelchair prior to leaving facility. Van does not have seatbelt for resident. Inteview with Resident 1 on February 26, 2025, at 1:10 p.m. revealed that when being transported in the van there was a loud noise and abrupt braking. Resident R1 stated (he/she) was wearing a seatbelt, but (he/she) slid from the wheelchair onto the floor. Further review of Resident 1's clinical record revealed a progress note of [DATE], indicated the resident left for an urology appointment. Progress note of [DATE], revealed resident has gone for an urology appointment. Additional progress note of February 24, 2025, revealed pt [patient] went out for CT [imaging test] abdomen. Review of Resident 2's progress note of [DATE], revealed patient returned to facility around 1700 from appointment. Review of Resident 3's progress note of [DATE], revealed Pt [patient] returned from (his/her) appointment from the kidney specialist. Review of Resident 4's progress note of [DATE], revealed resident on LOA [leave of absence] at 1pm for a GI [gastrointestinal] appt [appointment]. Review of progress note of [DATE], revealed resident on LOA with PT (physical therapy) transport to appointment. Review of Resident 5's medication administration note of [DATE], revealed resident out for oncology follow up and progress note revealed resident returned to facility around 1900. Review of progress note of [DATE], revealed resident is out to (his/her) appointment with transportation services. Review of Resident 6's progress note of [DATE], revealed resident is out to (his/her) neuro [neurology]appointment with transport services. Review of Resident 7's progress note of [DATE], revealed resident was out for an orthopedic appointment. Interview with the Nursing Home Administrator (NHA) on February 26, 2025, at 1:05 p.m. revealed there was no documented evidence that Employee E3 had received any training in safety procedures. The NHA also confirmed the facility did not use an outside contractor for transportation during the time period of [DATE], to present, indicating the above residents were transported using the facility transportation vehicle. Interview with Employee E4 on February 26, 2025, at 12:30 p.m. revealed, Employee E4 drove Resident 3 to an appointment in [NAME] and the tire pressure light was on in the vehicle. An additional interview on the same date at 2:20 p.m confirmed that Employee E4 had not received any training in safety procedures related to the transportation vehicle. Observations and interview with Employee E5 on February 26, 2025, confirmed the transportation vehicle was inspected on February 4, 2025. Additional interview on the same date at 2:05 p.m confirmed Employee E5 had driven the transportation vehicle, but had not received any training in safety procedures. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and relayed to the Nursing Home Administrator on February 26, 2025, at 2:25 p.m. for failing to ensure that the transportation vehicle had a safety inspection while transporting residents to appointments and failing to provide training in safety procedures for transporting residents. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. The facility provided the following Action Plan on February 26, 2025 at 5:11 p.m.: 1. Facility vehicle will inspected by a mechanic at least annually. Regular maintenance (such as oil changes) will be maintained by the facility. Calendar for monthly checks was established to verify if preventative maintenance items are needed. 2. Corporate representative is now monitoring expiration dates of facility owned vehicles and will put vehicles out of service if they do not have a current vehicle inspection by a mechanic. A corporate contract with IMT (transportation company) was established for transportation services. 3. Facility designated drivers and back-up drivers will receive re-education and competency training on properly securing residents in wheelchairs to the vehicle. The facility will have at least three individuals designated as competent vehicle operators. 4. NHA or designee will complete an audit of staff competencies daily before appointments x 4 weeks. The audit will then transition to once weekly x 4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring. After review of facility education documentation and interviews with three staff members, the implementation of the above stated action plan was confirmed on February 27, 2025, at 3:30 p.m. and the NHA was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on February 27, 2025, at 3:30 p.m. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa Code 201.18(a) Management Previously cited [DATE] 28 Pa Code 201.18(b)(1) Management Previously cited [DATE] 28 Pa Code 201.18(b)(3) Management Previously cited [DATE]

Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed to ensure proper staffing to care for and protect residents from potentially unsafe condition in the facility. Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Director of Nursing revealed the purpose of the job position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administration and the Medical Director, to ensure that the highest degree of quality of care is maintained at all times. The findings in this report identified the facility failed to ensure the safety of the residents being transported to appointments through the use of a facility transportation vehicle. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/30/24, 11/27/24 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. Previously cited 11/27/24 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 11/27/24

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for one of eight residents reviewed (Resident 1). Findings include: Review of Resident 1's progress note of January 30, 2025, revealed resident returned to facility via transport van from pain management facility. Review of progress note of January 31, 2025, at 6:53 a.m. revealed resident is 2/9 (two of nine shifts) s/p (status post - condition or status after a specific event) fall. Further review of the clinical record revealed no documentation indicating that the resident had a fall. Review of facility documentation dated January 30, 2025, revealed that resident was being transported to pain management this am 0820 [8:20 a.m.], he slid from his wheelchair to the floor of the van, the driver stopped (COTA-L [certified occupational therapist - licensed] and repositioned back into the wheelchair, fastened the seat belts, and continued on to his appointment, after determining that there was not injury sustained during the fall. Interview with the Nursing Home Adminstrator on February 27, 2025, at 3:35 p.m confirmed that there was no documentation in the clinical record that the resident had sustained a fall. 28 Pa. Code 211.5(f) Clinical records Previously 10/25/24 28 Pa. Code: 211.12(d)(1) Nursing services

Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure correct installation, use, and maintenance of bed rails for one resident (Resident 1) Findings include: Review of Title 42 Code of Federal Regulations (CFR) S483.25(n) - Bed Rails states, If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements, Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails). Review of the facility policy Use of Side Rails dated August 28, 2018, indicated that the resident will be checked frequently for safety. Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with the following diagnoses: chronic respiratory failure with hypoxia (low oxygen levels in the blood), Hemiplegia, unspecified affecting left nondominant side (one-sided paralysis or weakness of the face, arm, or leg), Tracheostomy status (a surgical airway management procedure which consists of making an incision on the anterior front of the neck and opening a direct airway through an incision in the windpipe as a site for a tracheal tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth). Review of Resident 1's side rail/restrain enabler evaluation assessment dated [DATE], revealed at this time side rails are indicated to provide safety. Interview conducted on December 30, 2024, at 9:41 a.m. with Resident 1 revealed the side rail located next to Resident 1's left hand was not properly secured to the bed and was unusable for turning and repositioning. At 9:47 a.m. the Nursing Home Administrator (NHA) accompanied the surveyor to Resident 1's room. The NHA confirmed the bedrail/side rail was not properly secured to the bed and nursing staff should have regularly performed inspections on Resident 1's bedrails/ side rails. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of clinical records, facility documentation, observations, and interviews with staff, it was determined the facility failed to ensure residents were free from neglect by failing to provide sufficient nursing staff to ensure nursing care, safety, and related services for 39 residents on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. The facility failed to provide necessary nursing services to 39 out of 39 residents due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. (Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39) Findings Include: Observation upon arrival at the nursing home on November 22, 2024, at 3:53 p.m. revealed there was one Nursing Assistant (NA), one Licensed Practical Nurse (LPN) and one Registered Nurse (RN). Observations of the nursing unit upon entrance to the facility on [DATE] at 3:53 p.m. revealed all 39 residents, Resdients Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, were in bed and a strong odor of urine was noted throughout the facility and observed to be unkept with unwashed hair and soiled clothing. Observations of Resident R3's room on November 22, 2024 at 4:36 p.m. revealed the trashcan was overflowing with trash. Observation of Resident R6's room on November 22, 2024 at 4:39 p.m. revealed crumbs next to the bed. Obervations of Resident R4's room on November 22, 2024 at 4:45 p.m. revealed the trashcan was overflowing with trash and there were small pieces of paper on the floor. Observation of both the East and [NAME] hallways revealed the floors were dirty with food particles, dried liquids and trash. Interview with Licensed Nursing Employee E2 on November 22, 2024 at approximately 4:00 p.m. revealed the staff member's concern of lack of staff scheduled for the 3 p.m. to 11 p.m shift on November 22, 2024 or for the night shift 11 p.m to 7 a.m hours on November 22-23, 2024. Continued interview with Licensed nurse Employee E2, revealed the Nursing Home Administrator (NHA) was aware of the lack of staff scheduled for November 22, 2024 since the beginning of the 7 a.m. to 3 p.m. shift but nursing staff were only able to get in touch with the NHA via text messaging. Employee E2 revealed the staff did not have any communication with the Administrator throughout the day and were not aware if any staff were coming for the 3-11 shift. Continued Interview with Registered Nurse (RN) Employee E2 revealed, the facility did not have a Director of Nursing (DON) since the previous DON suddenly resigned on Wednesday November 20, 2024 and staff were instructed not to contact the corporate representative, Employee E4, who had removed all contact information from the building. Continued interview with Registered Nurse (RN), Employee E2 revealed that when no staff showed up for the shift starting at 3 p.m., the current staff remained in the facility. Employee E2 stated the facility had no current nursing contracts with staffing agencies due to outstanding bills. Further interview with RN, Employee E2 and Licensed Practical Nurse, Employee E3 revealed their belief the facility's failure to pay it's employees timely has led to multiple staff members resigning recently. Additional interview with Employee E2 and Employee E3 at 4:25 p.m. revealed the residents are receiving their medications, but the administration of the medications is longer than the two-hour window (hour before or hour after set administration time) due to the lack of staff and nurses needing to respond to the needs of the residents. Licensed Nursing Employees E2 and E3 revealed, they believed the residents at the facility were in an unsafe situation due to the lack of staff currently in the facility, and inability to determine when more staff were to arrive. Interview with Resident R3 on November 22, 2024 at 4:36 p.m. revealed concerns due to staffing shortages, and indicated staff were unable to provide showers or bed baths, assist with change of clothes, perform incontinence care timely or respond to call bells. Interview with Resident R4 on November 22, 2024 at 4:42 p.m. revealed Resident R4 had not received a shower or bed bath in serval days due to a lack of staff. Interview with the Nursing Home Administrator via telephone on November 22, 2024 at 5:10 p.m. revealed she had taken the day off and was working from home but was aware of a lack of staffing for the 3-11 shift. Administrator further indicated, the facility currently had no contacts with nursing staffing agencies to provide RNs (Registered Nurse) or LPNs (Licensed Practical Nurse) to the facility. Administrator indicated she called one sister facility, but they were unable to provide any staff. Administrator indicated there was a nurse on her way to the facility that was to relieve one of the nurses currently working and there were two nurse aides now, to care for 39 residents. Surveyors were unable to determine the time the second nurse aide arrived at the facility. Review of a list of residents who needed assistance during meals with feeding revealed eight residents needing assistance with eating. Observations of the dinner meal revealed the trays were delivered to the resident timely. Observations conducted on November 22, 2023 at 5:33 p.m. revealed Residents R1 and R2 receiving no assistance with the meal with the meal tray placed at residents' bedside but remained untouched. Review of the shower schedule revealed seven residents were scheduled to be showered on the 7-3 dayshift and seven residents on the evening 3-11 shift on November 22, 2024. Interview with Nursing Employees E2 and E3 on November 22, 2204 at 7:35 p.m. confirmed seven residents were scheduled to be showered but anticipating none of the residents would receive a shower today due to lack of sufficient staffing for each resident's care needs except one resident who was able to shower independently. Review of facility staffing schedule for November 22, 2024, on the 3 p.m. to 11 p. m. shift failed to reveal an RN and LPN scheduled with only an asterisk in each slot. Further review of the facility staffing schedule for November 22, 2024 revealed three nurse aides were scheduled from a nursing agency with their names yellowed on the schedule. Interview with Registered Nurse Employee E2 on November 22, 2024 at 11:25 p.m. revealed if a staff's name is yellowed on the schedule, it indicates a need, or the staff member had called off. Further review of the facility staffing schedule failed to reveal an RN or LPN scheduled for November 22 2024 on the 11 p.m. to 7 a.m shift. Interview with the Nursing Home Administrator on November 22, 2024 at 12:30 a.m. confirmed the facility schedules were accurate and open availability for staffing. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and presented to the Nursing Home Administrator on November 22, 2024 at 8:24 p.m. for neglect by failing to ensure sufficient nursing staff available to provide nursing care. This failure resulted in 39 residents not receiving medications timely and the required assistance during meals and adequate ADL (Activities of Daily living) care. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. The facility provided the following Action Plan on November 23, 2024 at 2:11 a.m.: 1. RN assessments were completed on residents to identify clinical needs. Corrections were made immediately. 2. The clinician completed clinical resident rounds to identify medical needs. Corrections were made immediately. 3. Facility staff were re-educated on what to do when staffing levels do not meet regulation requirements. A new Director of Nursing was hired and is working full time hours. 4. The DON or designee will complete clinical rounds weekly x 4 weeks then monthly x 2 months to ensure resident needs are being met. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring. After review of facility education documentation, observations of the facility and care provided to residents as well as interviews with six residents and 10 staff members, the implementation of the above stated action plan was confirmed on November 26, 2024, at 4:00 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on November 26, 2024 at 4:00 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, review of facility documentation, observations, and staff interviews, it was determined the facility failed to maintain sufficient nursing staff to provide nursing care and related services to assure resident safety on one of one nursing units on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. Residents did not receive care and services due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. (Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39) Findings Include: Review of facility policy and procedure titled Emergency Staffing Plan- Kadima at Pottstown, undated, revealed, in the event of a staffing emergency, the first step will be to call all staffing personnel that is not currently in the facility and eligible to work. Staffing bonuses will be offered to entice employees to pick up the open shifts. Sister facilities will be made aware of the staffing needs and bonuses and/or mileage will be offered to entice employees to pick up the open shifts. After Kadima staff have been offered the shifts, staffing agencies will be alerted of the ongoing need to attempt to fill the open shifts with contracted agency staff. In the event that shift coverage cannot be found, staff currently in the facility will be mandated to stay to cover the shift. The call-in off-duty policy will be followed to allow for additional staff. Department heads and those in ancillary departments may be asked to cover nonclinical resident care needs. Observation upon arrival at the nursing home on November 22, 2024, at 3:53 p.m. revealed there was one Nursing Assistant (NA), one Licensed Practical Nurse (LPN) and one Registered Nurse (RN). Continued observation of the skilled nursing facility failed to reveal any additional staff members including staff members from departments such as therapy, housekeeping, or social work. Observations of the nursing unit revealed all residents who were dependent on staff for care were in bed and the residents observed to be unkept with unwashed hair and soiled clothing. Continued observations of the skilled nursing facility revealed a strong odor of urine noted throughout the facility. Interview with Registered Nurse (RN) Employee E2 on November 22, 2024, at approximately 4:00 p.m. revealed no additional staff were scheduled for the evening 3 p.m. to 11 p.m. shift on November 22, 2024, or the night shift 11 p.m. to 7 a.m. November 22-23, 2024. The Nursing Home Administrator (NHA) had been aware of staffing concern since the beginning of the 7 a.m. to 3 p.m. shift. Continued interview with Employee E2 revealed, the nursing staff were only able to get in touch with the Nursing Home Administrator via text and had not talked to her through the day and were unaware if replacement staff were coming for the 3-11 shift or not. Continued interview with RN, Employee E2 revealed the lack of a Director of Nursing (DON) as the previous DON suddenly resigned without notice Wednesday November 20, 2024, and the staff were instructed not to contact the corporate representative, Employee E4, who removed all contact information from the building. Continued interview with Registered Nurse, Employee E2 revealed, when no additional staff came for the evening shift (3 p.m. to 11 p.m.); the current staff remained in the facility. Employee E2 further stated the facility had no current contracts with staffing agencies due to outstanding bills. Further interview with Registered nurse Employee E2 and Licensed nurse Employee E3 revealed their belief of facility's failure to pay its employees has led to multiple staff members resigning their positions recently. Additional interview with Registered Nurse Employee E2 and Licensed nurse Employee E3 at 4:25 p.m. revealed the residents are getting their medications, but the administration of the medications is longer than the two-hour window(hour before scheduled administration time and hour after scheduled administration time) due to the lack of staff and the nurses needing to respond to the needs of the residents. Continued interview with Registered nurse, Employee E2 and licensed nurse, Employee E3 revealed, they believed the residents at the facility were currently in an unsafe environment due to lack of staff currently in the facility and inability to determine when more staff were to arrive. Interview with Resident R3 on November 22, 2024, at 4:36 p.m. revealed concerns due to staffing shortages, and indicated staff were unable to provide showers or bed baths, assist with changing of clothes, perform incontinence care timely or respond to call bells. Interview with Resident R4 on November 22, 2024, at 4:42 p.m. revealed Resident R4 had not received a shower or bed bath in serval days due to a lack of staff. Interview with the Nursing Home Administrator via telephone on November 22, 2024, at 5:10 p.m. revealed she had taken the day off and was working from home but was aware of the lack of staffing for the 3-11 shift. Administrator indicated the facility currently had no contacts with nursing staffing agencies to provide RNs or LPNs to the facility. She reported she called one sister facility, but they were unable to provide any staff. There was a nurse on her way in that was to relieve one of the nurses that was currently there and there were two NAs in the building now. Surveyors were unable to confirm the time of the second nurse aide's arrival at the facility. Review of the shower schedule revealed seven residents were scheduled to be showered on the 7-3 dayshift and seven residents on the evening 3-11 shift on November 22, 2024. Interview with Nursing Employees E2 and E3 on November 22, 2024, at 7:35 p.m. confirmed there were seven residents scheduled to be showered but none of the residents would receive a shower today due to lack of sufficient staffing to safely conduct the activity except for one resident who was able to shower independently. Review of a list of residents who needed assistance during meals with feeding revealed eight residents needing assistance with eating. Observations of the evening meal on November 22, 2024, revealed meal trays were delivered to the residents timely. Further observation of the evening meal on November 22, 2024, approximately 5:33 p.m. revealed Residents R1 and R2 were observed receiving no assistance with meal items and meal tray was placed at residents' bedside but remained untouched. Review of facility staffing schedule for November 22, 2024, on the 3 p.m. to 11 p. m. shift failed to reveal an RN and LPN scheduled with only an asterisk in each slot. Further review of the facility staffing schedule for November 22, 2024 revealed three nurse aides were scheduled from a nursing agency with their names yellowed on the schedule. Interview with Registered Nurse Employee E2 on November 22, 2024 at 11:25 p.m. revealed if a staff's name is yellowed on the schedule, it indicates a need, or the staff member had called off. Further review of the facility staffing schedule failed to reveal an RN or LPN scheduled for November 22 2024 on the 11 p.m. to 7 a.m shift. Interview with the Nursing Home Administrator on November 22, 2024 at 12:30 a.m. confirmed the facility schedules were accurate and open availability for staffing. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and relayed to the NHA on November 22, 2024, at 8:24 p.m. for failing to ensure sufficient nursing staff were available to provide nursing care and services by ensuring during a staffing shortage emergency alternative resources could be utilized to ensure an adequate nurse staff level. This failure resulted in 39 residents not receiving medications timely and the required assistance during meals and adequate ADL (Activities of Daily living) care. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. The facility provided the following Action Plan on November 23, 2024, at 2:11 a.m.: 1. Agency contracts have been established with Eshyft, Revv, [NAME] and Ready shift. Sister facilities are available to be contacted for staffing support. There is a policy for calling in staff that are not currently in the facility and mandating staff to ensure resident care is completed. 2. Newly approved agency contracts were signed with [NAME] and Ready Shift staffing agency. Emergency protocols will be implemented when staffing drops below acceptable levels. 3. Nursing staff were re-educated on policy and procedure for when staffing levels are below adequate levels. Daily staffing meetings will be held to address needs. 4. The DON or designee will conduct an audit of staff PPD and ratios once/shift daily x7 days, then weekly x4 weeks, then monthly x2 months to ensure adequate staffing levels exist. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring. After review of facility education documentation, observations of the facility and care provided to residents and interviews with six residents and 10 staff members, the implementation of the above stated action plan was confirmed on November 26, 2024, at 4:00 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on November 26, 2024, at 4:00 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services

Based on observation and staff interview it was determined the facility failed to ensure a Director of Nursing was employed full time at the facility. Findings Include: Interview with Licensed Nursing Employee E2 on November 22, 2024 at 3:30 p.m. revealed there was no Director of Nursing (DON) since the last DON resigned on November 20, 2024. Interview with the Nursing Home Administrator on November 22, 2024 at 6:30 p.m. confirmed there has not been a DON employed since November 20, 2024 and there was a new DON starting on November 25, 2024. Interview with Licensed Nursing Employee E19 on November 25, 2024 at 9:30 a.m. confirmed it was the first day as DON and they were completing their orientation. The facility failed to have a full time Director of Nursing from November 20, 2024 to November 25, 2024. 28 Pa Code 201.3 Definitions 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 211.12(b) Nursing Services

Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed to ensure proper staffing to care for and protect residents from potentially unsafe condition in the facility. Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Director of Nursing revealed the purpose of the job position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administration and the Medical Director, to ensure that the highest degree of quality of care is maintained at all times. The findings in this report identified the facility failed to ensure sufficient nursing staff were available to provide nursing care and services by ensuring that during an emergency staffing shortage alternative resources could be utilized to ensure an adequate nurse staff level, resulting in inadequate resident care. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F600 and F725 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing. Findings include: Review of facility policy, Low Temperature Dish Machine Temperatures and Sanitizer Testing indicated a minimum wash temperature of 120 degrees Fahrenheit and a minimum rinse temperature of 140 degrees Fahrenheit. Additionally, the policy revealed 'Complete a test run before putting any dishes into machine. If the minimum temperature is not reached complete another test cycle. If the dish machine still does not reach the minimum temperature required, notify the Dining Service Manager and /or Administrator. DO NOT run any dishes through a wash/rinse cycle until the temperature is rectified. Observation on October 22, 2024, at 9:40am. with the Facility Cook, revealed staff using the dish machine, but the gauge was reading 100 Fahrenheit and rose to 110 Fahrenheit on the dish machine. The staff did not run a test cycle and ran the dishes in the dish machine. The Facility [NAME] indicated that the gauge had been changed and the facility was waiting on a booster for the dish machine. Review of the Dish Machine Temperature Log for October 2024 revealed that the wash temperature did not reach 120 degrees Fahrenheit on 17 of 21 occasions. Additional interview with the Nursing Home Administrator (NHA) on October 22, 2024, 01:54 p.m. confirmed that the minimum wash temperatures had not been reached. NHA indicated that earlier in the month the temperature gauge had been replaced, the facility was waiting on the booster for the machine. NHA stated that they are waiting on the repair company. Interview with the Nursing Home Administrator on October 24, 2024, at 10:15 a.m. confirmed that the minimum dish machine temperatures had not been met. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, staff interviews, and observations it was determined the facility failed to implement enhanced barrier precautions for the entire facility. Findings Include: Review of a training being developed based on facility policy revealed recommendations now include use of Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug-resistant organism status, EBP include the use of gown and gloves when there is a potential for exposure to the affected area. Observations made during all days of the survey revealed none of the residents with chronic wounds or indwelling medical devices had any signs to indicate the implementation of EBP or PPE available for use. Observation of tracheostomy care on October 25, 2024 at 10:30 a.m. with Licensed Nursing Employee E4 revealed while performing the care the staff did not don a gown. Interview with Licensed Nursing Employee E4 at the time of the observation revealed they had never heard of Enhanced Barrier Precautions needing to be implemented and had received no training. Interview with the Director of Nursing on October 25, 2024 at 10:45 a.m. confirmed the facility does not implement Enhanced Barrier Precautions. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to complete clinal assessments completely and accurately for 8 of 16 residents reviewed. (Residents 4, 6, 13, 17, 21, 29, 34, and 38) Findings Include: Review of Resident 4's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated August 29, 2024, revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 6's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 13's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 17's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 21's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 29's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 34's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 38's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Interview with licensed staff, Employee E3, on October 23, 2024 at 1:56 p.m. confirmed that sections C and D for the above residents were not completed. 483.20 Resident Assessments Previously cited 11/6/23 28 Pa. Code 211.5(f) Clinical records Previously cited 11/6/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 11/6/23

Based on staff interviews and review of facility policy it was determined the facility had no grievance offer to monitor and system in place to ensure the prompt resolution of grievances. Findings include: Review of facility policy titled Grievances, revised February 28, 2018, revealed the facility has a system in place to ensure the prompt resolution of all grievances with regard to the resident's rights. The grievance official shall oversee the grievance process, receive and track grievances through to their conclusion. The evidence of the results of all grievance will be maintained for no less than 3 years from the date the grievance decision was issued. During entrance conference with the Nursing Home Administrator and the Director of Nursing on October 22, 2024 at 9:10 a.m. the facility was asked to provide a list of the last 6 months of grievances. Interview with the Nursing Home Administrator and the Director of Nursing on October 25, 2024 at 10:00 a.m. revealed there was no tracking system at the facility and there was no evidence to show that grievances had been investigated and responded to by the facility or their conclusion. Further interview revealed it is the Social Worker who is designated the grievance official, but that position is currently vacant, and no one is acting in the role of grievance officer currently. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.29(d) Resident rights

Based on observations and staff and resident interviews it was determined that the facility failed to maintain a temperature range between 71 to 81 degrees Fahrenheit in random selection of rooms and common areas occupied by residents resulting in immediate jeopardy to the residents. Findings include: Interview conducted with Resident 4 on November 1, 2023, at 12:30 p.m. and Resident 11 on November 2, 2023, at 9:30 a.m. revealed the residents were cold. Observations of residents residing in the facility revealed residents had multiple layers of clothing, including blankets and hats. Observation of resident rooms revealed multiple blankets on residents' beds. Observation of facility staff revealed staff wearing long sleeves under working attire (scrubs). Observations of the thermostats in the northwest hallway revealed temperatures of 69 and 67 degrees with additional observation of the front lobby with a temperature of 68 degrees. Interview with Maintenance Director revealed, the facility's boiler(heater) did not function properly, and a wire was recently fixed, but the boiler/heating unit malfunctioned again. The Maintenance Director only contacted a HVAC company after being informed by surveyors that temperatures on the thermostats were below required minimum standards of 71 degrees. Observation conducted with the Maintenance Director on November 2, 2023 at 9:45 a.m. revealed the following temperatures from the following locations using an infrared thermometer: Southwest hallway registered 68 degrees, room [ROOM NUMBER] registered 67.2 degrees, room [ROOM NUMBER] registered 64.5 degrees, room [ROOM NUMBER] registered 62.8 degrees, west hallway registered 58.1 degrees, room [ROOM NUMBER] registered 66.7 degrees, room [ROOM NUMBER] registered 66.2 degrees, and the activities room registered 68.1 degrees. Outside temperature at the time of the readings was 23 degrees Fahrenheit. Interview with Maintenance Director revealed the facility did not have temperatures logs documenting room or common area temperatures. Interview with the Nursing Home Administrator and the Director of Nursing on November 2, 2023 at 11: 45 a.m. revealed they were informed by Resident 4 on October 22, 2023 that the resident was cold. The Nursing Home Administrator went to the thermostat and raised the temperature. There was no communication of the resident being cold made to the Maintenance Director and there were no air temperatures conducted in the resident rooms to ensure a properly working HVAC (Heat Ventilation and Air Condition) system. The facility was asked to provide logs that air temperatures had been obtained to ensure safe temperature levels in the resident living areas. The Nursing Home Administrator and the Director of Nursing revealed that the current Maintenance Director was new and had not been routinely obtaining room temperatures and that they were unable to find logs from the previous Maintenance Director. An Immediate Jeopardy situation was identified by the facility having temperatures that were cold and unsafe, the facility had no process in place to monitor and ensure temperatures were at a safe level. The facility also had received complaints from residents of being cold and Administration failed to notify maintenance or put intervention's into place to ensure a properly working HVAC system. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator on November 2, 2023, at 12:50 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility. On November 2, 2023, at 4:15 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. The facility created a warm zone in the activities/dining room. Staff were instructed to provide residents with warm clothing and/or blankets. A warm drinking station was also set up in the activities/dining room. 2. A heating company was contacted to evaluate and correct the heating malfunction (boiler control switch). 3. The facility will conduct initial audit of all resident rooms and then monitor temperatures hourly. The facility will conduct audits every 2 hours for 24 hours to ensure temperatures are within specified range of 71-81 degrees. 4. Nursing Home Administrator/designee will educate staff on maintaining appropriate heating in facility of 71-81 degrees. 5. Nursing Home Administrator/Designee will conduct two temperature audits a day/each resident room for one week then conduct daily temperature audit for 30 days for each resident room. Facility will conduct a temperature audit once a month for two months to ensure ongoing compliance. After review of facility temperature logs, observations of all resident room ambient temperatures, three resident interviews and seven staff interviews, the implementation of the above stated action plan was confirmed on November 4, 2023, at 12:50 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management Previously cited on 12/9/21 28 Pa Code 201.18(e)(1) Management Previously cited on 12/9/21

Based on clinical record review, facility policy and staff interview it was determined that the facility failed to ensure that safety interventions were in place for Resident CL1 resulting in a fracture of the left rib, left femur, and three fractures in C1, 1 in the midline and 2 fractures in the posterior arch for one of two residents. Findings include: Review of facility policy titled Accidents and Incidents with a revision date of August 28, 2002 revealed under Guidelines Number 2 The occurrence of an incident will be recorded in the resident's clinical record. Further review of policy revealed Number 7 Staff will immediately notify family, attending physician, and other departments. Number 12 of the policy indicates, Care plan will be updated as appropriate. Review of Resident CL1's clinical record revealed diagnoses including but not limited to; Dementia (loss of cognitive functioning of thinking, remembering, and reasoning); [CONDITION(S)] (eye's optic nerve is damaged); difficulty walking; muscle weakness; and repeated falls. Review of Resident CL1's clinical record revealed, the most recent fall risk assessment dated [DATE] indicated resident was High Risk with a score of 13. Review of Resident CL1's clinical record revealed a quarterly MDS, dated [DATE] (periodic assessment of resident needs) revealed lower extremities had impairment on both sides. Review of Resident CL1's clinical record revealed a nursing assessment with an effective date of March 25, 2022; which indicated under Mobility the resident was rated very limited. Further review of the assessment revealed the resident was indicated as being chairbound in the ambulation/elimination status. Review of facility list of recent falls within the facility revealed the resident had falls on January 4, 2022 and April 17, 2022. Further review of Resident CL1's active care plans revealed, there was no active goal for falls as well as no documented fall prevention interventions. Review of care plans failed to reveal any interventions initiated after resident's falls on January 4, and April 17, 2022. Review of Resident CL1's clinical record including revised and resolved care plans revealed that a falls care plan and intervention of fall mat(s) were resolved in 2019. Review of Incident Audit Report indicated as in progress dated May 17, 2022, revealed a nursing description related to the fall of April 30, 2022 (3 a.m.) in which [LPN] was in another room caring for another resident. [LPN] heard screaming and approached client's room where [LPN] found [resident] on the floor halfway under roommate's bed screaming for help. No obvious new injuries. Assessed all vitals were stable/within normal limits. Assisted client from floor to bed. Client started to scream in pain again complaining of pain near hip joint. PRN [as needed] Tylenol given and client appears to be stable and in less pain. Neurochecks started per protocol. Additional review of document failed to reveal any evidence of neurochecks conducted. Review of Resident CL1's clinical record including nursing progress note dated April 30, 2022 (9:41 am) revealed, While providing care, CNA [certified nurse assistant] went to move the resident and she was in excruciating pain in her b/l [bilateral] legs from a s/p [status/post] fall; the resident screamed and can be heard over the entire building; spoke with administrator regarding the concern for the patient and requested an approval for an STAT [immediate] Xray. Review of Resident CL1's clinical record revealed a physician's verbal order dated April 30, 2022 at 9: 35 a.m. for Xray of the b/l (bilateral) hip s/p (status/post) fall STAT for s/p fall. Further review of CL1's clinical record including nursing progress note dated April 30, 2022 (14:44/2:44 p.m.) revealed, Reached out to [X ray Company] to follow up regarding a STAT Xray for the resident; representative stated that the technicians were very extremely busy and should be here within the hour. Additional review of clinical record revealed, nursing progress note dated April 30, 2022 (15:30/3:30 p.m.) revealed, [X ray company] arrived to perform that STAT Xray to the resident's hip. Review of Resident CL1's April 2022 MAR (Medication Administration Record) revealed resident was given Tylenol 650 mg (milligram) for pain at 15:31/3:31 p.m. Nursing Progress note dated April 30, 2022 (16:12/4:12 p.m.) revealed, Followed up with the administrator and stated to send the resident to the ED for further evaluation and assessment. Nursing Progress note dated April 30, 2022 (16:54/4:54 p.m.) 911 arrived to transport the resident to Pottstown Hospital for further assessment and evaluation for acute pain to the left hip. Additional review of CL1's clinical record revealed nursing progress note dated April 30, 2022, at 17:38/5:38 p.m. indicated, Received the results of the Xray from [x ray company]; the resident sustained an acute left intertrochanteric hip fracture and arthritic change of the right hip; administrator made aware. Review of hospital progress note dated May 2, 2022, revealed, presents to ED [Emergency Department] following a fall with c/b [complicated/by] multiple fractures, evaluated by Reading trauma surgery not candidate for acute intervention. Further review of hospital progress note including notation of a chest x-ray conducted at the hospital on April 30, 2022 revealed; suspected minimally displaced fracture of the lateral left rib. Communited intertrochanteric fracture of the left femur . Additional review of the hospital progress note revealed a CT [computerized tomography] scan of the brain was conducted on April 30, 2022. The scan indicated the following; there are three fractures in C1, 1 in the midline and 2 fractures in the posterior arch. Possible incomplete Type 2 fracture along the ventral margin of the base of the dens. Possible [MEDICATION(S)] hematoma C1-C2. Further review of the hospital progress note revealed that a bilateral x-ray of the hip and pelvis (5 views) completed on April 30, 2022 revealed, Acute appearing mildly displaced fracture through the left femur intertrochanteric region. Review of facility fall documentation failed to reveal witness statements or completed neuro checks of resident prior to being sent to hospital for evaluation and treatment. Interview on May 17, 2022 at approximately 8:06 p.m. with the Nursing Home Administrator revealed, the facility documentation relating to the fall including neuro check documentation and witness statements could not be located. The above information was presented to the Nursing Home Administrator on May 17, 2022 at 8:06 p.m. The facility failed to provide interventions to prevent Resident CL1 from falling and causing harm. 28 Pa Code 211.12(d)(5) Nursing services Previously cited 12/9/21 and 9/22/21

Based on a review of a clinical record, facility policy and interviews with staff, it was determined that the facility failed to ensure that one of 19 residents reviewed was provided cardiac [MEDICAL CONDITION] resuscitation (CPR) resulting in actual harm to Resident CL1 who was found unresponsive with a documented full code status (Resident CL1). Findings include: Review of the facility policy and procedure titled CPR Policy, undated, indicated the requirement for all Licensed nursing staff and facility van drivers to be CPR certified (CPR - Cardiopulmonary resuscitation - is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]). Additional review of the facility policy and procedure titled Emergency Response Policy, undated, indicated the following guidelines: 1. Determine unresponsiveness; 2. Notify or have another staff member immediately notify a licensed nurse; 3. Activate in-house emergency communication system; 4. Verify resident's response code status stated by resident or resident's responsible party; 5. Call 911; 6. If necessary, initiate CPR; a. open airway b. Breathing - determine breathlessness and begin rescue breathing; c. Circulation - determine absence of pulse and begin chest compressions; 7. Chart completely all events leading up to the situation, what transpired during situation and events that followed. All of this information along with the date, time and the nurse's signature should be documented in narrative nurse's notes. 8. If the resident is transported to the hospital, send completed transfer form. 9. Notification of events shall be communicated to the physician and the responsible party. Review of clinical record for Resident CL1 revealed an annual MDS assessment (MDS - periodic assessment of needs) dated (MONTH) 4, 2019, which indicated the following Diagnoses: [REDACTED]. Further review of Resident CL1's clinical record revealed (MONTH) 25, (YEAR), Resident CL1 signed and completed a Pennsylvania Orders for Life - Sustaining Treatment (POLST) which indicated wishes for CPR, full treatment such as intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated, use antibiotics if life can be prolonged and long-term artificial hydration and nutrition by tube. Continued review of the POLST form revealed Resident CL1's physician also signed the POLST, in agreement with CL1's wishes as indicated on the POLST. Review of Health Care Advanced Directives (Living Will) dated (MONTH) 24, 2010, signed by Resident CL1, and one designated responsible party (daughter), and witnessed by CL1's son, indicated that Resident CL1 expressed wishes for CPR, mechanical ventilator, [MEDICAL TREATMENT] and antibiotics. It was also indicated by Resident CL1 that the Health Care Agent must follow my living will instructions given above. Continued review of Resident CL1's clinical record revealed a physician's order dated (MONTH) 11, (YEAR), which indicated Resident CL1 was a full code, wanting CPR performed in the event her heart would stop. Review of physician progress notes [REDACTED]. A nursing progress note dated (MONTH) 9, 2019, written at 2:16 p.m. revealed, This writer went into resident's (CL1's) room, at 10:35 a.m. to see how resident was doing, resident was found unresponsive lying in bed. Resident (CL1), cool to touch, no respirations, no heart or breath sounds auscultated, (heard). Spoke with CL1's granddaughter, asked if she want CPR performed on resident and she indicated no. Death pronounced at 10:40 by this RN. An interview with Employee E3, Licensed Nurse, during the onsite visit on (MONTH) 15, 2019, at 4:05 p.m. confirmed that she was the assigned Licensed nurse to Resident CL1 on (MONTH) 9, 2019, starting at 7:00 a.m. Employee E3 further confirmed that she was the one that wrote the nursing progress dated (MONTH) 9, 2019, written at 2:16 p.m., indicating Resident CL1 was unresponsive, cool to touch and without heart and breathe sounds. Employee E3 also indicated during the interview that she did not perform CPR on Resident CL1, as Resident CL1 had indicated in her Advance Directive, completed POLST and physican's order for CPR to be performed. An interview with the Nursing Home Adminstrator and the Director of Nursing on (MONTH) 15, 2019, at 4:30 p.m. confirmed that the facility staff did not perform CPR on Resident CL1, as she had expressed in an Advance Directive, completed POLST and as indicated in the physician order. The facility failed to provide basic life support, CPR, to Resident R1 upon being found unresponsive which resulted in actual harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]

Based on review of facility's policy, clinical record review, family and staff interviews, it was determined that the facility failed to properly monitor a resident's respiratory and neurological status prior to the time of transfer from the facility and at the time the resident was transferred out of the building into the care of the emergency personnel; failed to provided emergency medical personnel with complete medical information in regard to the resident not having a sternum for a resident in respiratory distress which resulted in to actual harm to Resident CL1; and failed to obtain a physician's orders [REDACTED]. Findings include: Review of the facility's policy titled, Oxygen Therapy' states, Oxygen therapy is administered to the resident only upon the written order of a licensed physician. Review of Resident CL1 ' s clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. the lung), [MEDICAL CONDITION] (the arteries of the heart are constricted), [MEDICAL CONDITION] (fluid accumulation around the heart causing breathing difficulties), and removal of the sternum bone of the chest due to infection. Review of Resident CL1's clinical medical record revealed a progress note dated [DATE] at 10:30 p.m. from licensed staff, Employee E4 and stated, Resident complaining of shortness of breath and asked for a breathing treatment. Resident oxygen level was 86% at the time. Resident was receiving a breathing treatment while this nurse was present and took off mask with visible agitation and respiratory distress. Resident had expiratory wheezes present. RN Supervisor was called back and I told resident he needed to go to the hospital as his oxygen level dropped to 82%. Resident was in agreement and told this nurse he wanted to go. RN supervisor arrived and I informed him to call 911 first then call MD. 911 was called and wife was notified. First responder arrived approximately 20 minutes after call was initiated. When first responders arrived resident was lethargic with eyes still open. First responders were made aware that the resident did not have a sternum. Resident was transported to ambulance at this time. First responder came back into facility and notified RN and this nurse that the resident had coded (stopped breathing and heart stopped beating and they were not familiar with CPR (cardiopulmonary resuscitation) on a resident without a sternum. this nurse was on the phone with Director of Nursing who was in contact with physician and stated to give chest compressions above heart on left chest. Review of the Medication Administration Record [REDACTED]. On the [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The last set of vital signs documented in the electronic medical record was at 5:30 p.m. which included the same blood pressure and pulse documented for the 5:00 p.m. medication and also included a respiratory rate of 22 per minute (breaths per minute). There was no documented evidence on the resident's clinical medical record of when the incident actually occurred, what the vital signs of the resident were at the time of the incident-including the respiratory rate of the resident, the resident's neurological status at the time of transfer or when the resident was transferred out of the building into the care of the emergency personnel. The resident's clinical medical record also did not reveal any information that the emergency medical personnel was notified at time of 911 call that the resident did not have a sternum to notify the emergency medical system to be able to alert them of this important medical factor in deciding who to send to the facility (first responders, EMT's or paramedics). Interview with Employee E4 on [DATE] at 10:30 a.m. revealed that he was the one who took care of the resident on the evening of [DATE] and he did not remember what time the incident occurred, stating he thinks somewhere between 7 and 8 pm, stated that he was not sure if the emergency 911 dispatch was told in regard to the resident not having a sternum and that the facility would not do chest compressions on the resident as per the physician's orders [REDACTED]. Interview (on the phone) with Resident CL1's family on [DATE] at 4:00 p.m. revealed that the family member was at the facility with the resident on [DATE] prior to the incident and left the facility around 7:00 p.m. and received a call from the facility before 8:00 p.m. that the resident was going to the hospital for breathing treatment. The family member stated that the facility never informed her that the resident's breathing and heart stopped and needed to have CPR performed on him until she went to the hospital to see the resident in the emergency room . the family member stated that there was nothing unusual with the Resident when she left the facility, but did admit that the resident seemed a bit more tired than usual. Interview with the Nursing Home Administrator, the Director of Nursing and Employee E3 on [DATE] at 3:00 p.m. confirmed that there was no documentation on the time of when the event occurred, no documentation that oxygen was administered and titrated as ordered, no documentation that vital signs were taken at the time of the event. The facility failed to monitor Resident CL1's neurological status prior to the time of transfer from the facility and/or at the time the resident was transferred out of the building into the care of the emergency personnel; failed to provided emergency medical personnel with complete medical information in regard to the resident not having a sternum in order to ensure that appropriate emergency services were send to the facility and failed to provide documented evidence of oxygen administration for Resident CL1 who was at respiratory distress, which resulted in to actual harm to Resident CL1. Review of Resident CL2 ' s clinical medical record revealed that the Resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. the brain (cancer of the brain). Review of Resident CL2's clinical medical record revealed in multiple entries that the resident was on oxygen on various liters per minute by nasal cannula ([DATE], and 27, 2015 3.5 liters per minute, [DATE] and [DATE] 2 liters per minute; [DATE] at 3 liters per minute; and [DATE], 9,10, 14, 2015 4 liters per minute). Review of the physician's orders [REDACTED]. Interview with the Nursing Home Administrator on [DATE] at 1:00 p.m. confirmed that all residents that utilize oxygen an order must be obtained from a prescribing physician. 28 Pa code 211.5(f) Clinical Records Previously cited: [DATE], [DATE] 28 Pa Code 211.10(c) Resident Care Policies Previously cited: [DATE] 28 Pa Code 211.11(d)(1)(5) Nursing Services Previously cited: [DATE], [DATE], [DATE]

Based on clinical record review, and facility policy and procedure review it was determined the facility failed to ensure that the physician was notified promptly of laboratory results and lab studies were done as ordered to effectively monitor the resident's care and treatment for one of 10 residents reviewed resulting in actual harm to the resident. (Resident B3). Based on review of facility policies, clinical record review, facility documentation and staff interview, the facility failed to ensure that neurological checks were completed for a resident who had an unwitnessed fall for one of 10 residents reviewed (Resident D7). ( Residents B3, D7). Findings Include: Review of facility policy titled Anticoagulant/Therapy Monitoring revealed that proper management included clear and current medication orders, routine monitoring of INR (a test to monitor anticoagulation therapy), timely communication of INR results to physician, complete and timely documentation, monitoring for signs and symptoms of adverse effects of medication, and care planning. The dose of [MEDICATION NAME] (an anticoagulant used in the prevention of the formation of blood clots in the blood vessels and their migration elsewhere in the body) is individualized for each resident based on the INR laboratory test. All residents receiving [MEDICATION NAME] will have a PT/INR (lab studies used to determine the clotting tendency of blood) drawn weekly unless ordered more frequently by a physician. Every INR less than 2 or greater than 3 will be called to the physician unless other parameters are ordered by the attending physician. Review of resident B3 [DIAGNOSES REDACTED]. Review of Resident B3 ' s physician orders [REDACTED]. Further review of Resident B3s physician orders [REDACTED]. Review of the orders dated January 26, 2015 included an order for [REDACTED]. Review of the laboratory report January 29, 2015 revealed the PT/INR was drawn as ordered on January 29, 2015; however, review of the entire clinical record revealed there was no evidence that the physician was notified of the high levels of PT (18.9 - reference range 9.6-11.5) and the high INR (1.7 - reference range 0.8-1.2). There was an undated note with a physician ' s signature written on the January 29, 2015, PT/INR lab report ordering [MEDICATION NAME] 4 mg. daily and to check Monday. The order on the lab report was not entered into the computer orders until January 30, 2015. Review of the Medication Administration Record [REDACTED]. Further review of Resident B3 ' s physician orders [REDACTED]. Review of the MAR for the month of February, 2015, revealed the resident received 3.5 mgs of [MEDICATION NAME] once a day from February 1, 2015 until February 13, 2015, not the 4 milligrams that were ordered only to be given until February 2, 2015, a total of 13 doses administered incorrectly. Review of the entire clinical record revealed there was no documentation that the physician was notified of the PT/INR laboratory study that was not drawn on February 2, 2015 and there was no further PT/INR drawn until the resident was hospitalized [DATE]. Nurses notes dated February 13, 2015 stated transported to ER for evaluation of GI/urinary bleed. Review of Resident B3s progress notes revealed an entry dated February 13, 2015 at 10:32 a.m. that resident B3 was being changed by a Certified Nursing Assistant and was discovered to have blood in his incontinence brief. This was reported to the physician and the resident was sent out to the hospital after a second episode of blood in his urine. Further review of Resident B3 ' s progress notes revealed an entry dated February 14, 2014 at 10:29 a.m. that the resident was admitted to the hospital for [MEDICATION NAME] Toxicity and had a PT of greater than 100 (reference range 9.6-11.5) and an INR of greater than 10 ( reference range 0.8-1.2). Resident B3s [MEDICATION NAME] therapy was not being monitored and communicated to the physician as indicated in the facilities ' policy from February 1, 2015 to February 13, 2015 resulting in the resident having internal bleeding and admission to the hospital causing actual harm to the resident. Review of facility policy and procedure titled Resident Incident Form and Review reviewed on September 6, 2014 revealed if a fall occurs that is unwitnessed, Neuro Checks will be initiated for a minimum of 24 hours after the incident and only discontinued if within normal parameters or with a physician order. Review of facility documentation revealed on September 24, 2014 at 12:25 p.m. Resident D7 was found sitting on the ground with her back against the bed in another resident ' s room. Review of the entire clinical record revealed there were no neurological checks done for this unwitnessed fall. Interview with the DON on February 25, 2015 at approximately 10:00 p.m. confirmed there were no neurological checks completed as indicated should have been by the facilities policy. 28 Pa Code: 201.14(a) Responsibility of licensee 28 Pa Code: 201.18(b)(1) Management 28 Pa Code: 211.10(c) Resident care policies 28 PA Code 211.5(f) Clinical records Previously Cited: 10/23/14, 1/31/14 28 PA Code 211.12(d)(1)(5) Nursing services Previously Cited: 10/23/14, 1/31/14