Health inspection·June 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for two of three resident units (2 [NAME] and East). Findings include: Observations on 6/27/23, at 3:53 p.m., 6/28/23, at 2:28 p.m. and 6/29/23, at 11:30 a.m. revealed room [ROOM NUMBER] had a box fan sitting on the corner of the bedside stand with a black fuzzy substance on the fan blades and the front grill of the fan. During interview on 6/27/23, at 3:53 p.m. Resident R103 stated the fan was not theirs and was sitting there when they were admitted to the facility on [DATE]. During an interview on 6/29/23, at 11:30 a.m. Housekeeping Employee E1 confirmed he/she had just finished cleaning room [ROOM NUMBER]. Employee E1 confirmed housekeeping is responsible for cleaning the fans and that the box fan on the bedside table of room [ROOM NUMBER] was dirty and should have been cleaned by housekeeping. During an interview on 6/29/23, at 11:34 a.m. the Environmental Services Manager confirmed the box fan was dirty and should have been cleaned. Observations on 6/27/23, at approximately 2:00 p.m., on 6/28/23, at 9:15 a.m. and on 6/29/23, at 1:30 p.m. revealed room [ROOM NUMBER] had a pull cord string to the overhead bed light that was tied up and out of resident reach. During interview on 6/27/23, at 2:00 p.m. with Resident R10, he/she stated, It would be nice if I could have my light turned on, could you please turn it on for me? Resident R10 could not reach the light pull cord to turn her light on. During an interview and observation on 6/29/23, at approximately 2:00 p.m. with the Nursing Home Administrator it was confirmed that the pull cords in room [ROOM NUMBER] were rolled up and out of reach for the residents and the only way to turn the lights on and off was at the entrance door by a switch. It was also confirmed upon observation that Rooms 102, 103, 106, and 110 also did not have pull cords maintained in a homelike environment that residents could access and use independently. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Page 1 of 2 395003 395003 06/30/2023 Quality Life Services - New Castle 520 Friendship Street New Castle, PA 16101

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interviews, it was determined that the facility failed to ensure a copy of the notice of transfer or discharge of residents was provided to a representative of the Office of the State Long-Term Care (LTC) Ombudsman for each resident upon transfer or discharge from the facility for two of 22 residents reviewed (Residents R65 and R79). Findings include: Review of Resident R65s clinical record revealed an initial admission date of October 18, 2017, with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure, and chronic kidney disease. Further review of Resident R65's clinical record revealed that Resident R65 was transferred to a hospital on May 17, 2023, and returned on May 19, 2023. Review of Resident R79's clinical record revealed an initial admission date of November 20, 2020, with diagnoses that included left leg above knee amputation (surgical removal of the leg), chronic respiratory failure, pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Further review of Resident R79's clinical record revealed that Resident R79 was transferred to a hospital on April 27, 2023, and returned on May 1, 2023. Review of Resident R65 and Resident R79's clinical records lacked evidence that the Office of the State LTC Ombudsman was notified of their transfers out of the facility to the hospital. During an interview on June 29, 2023, at approximately 1:30 p.m. the Social Worker, confirmed that there was no written documentation the Office of the State LTC Ombudsman Office was notified of the transfers out of the facility for Residents R65 and R79. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3) Management 395003 Page 2 of 2