Health inspection·December 5, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 24 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], and had diagnoses that included malnutrition, colitis (inflammation of the colon), and dysphagia (difficulty swallowing). The Minimum Data Set Care Area Assessment summary dated November 18, 2024, noted that the resident's dehydration and fluid maintenance and dental care were to be addressed in the care plan. There was no evidence that interventions to address Resident's 10's dehydration and fluid maintenance or dental care included in the current care plan. In an interview on December 5, 2024, at 11:32 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 4 395047 395047 12/05/2024 Heritage Pointe Rehabilitation and Healthcare Ctr 400 South Main Street Doylestown, PA 18901

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on policy review, staff interview, and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Residents Affected - Many Findings include: Review of the facility's policy entitled, Labeling and Dating, dated October 29, 2024, revealed that leftovers were to be labelled with the date that they were prepared and the use-by date. Prepared foods were to be discarded after seven days. Review of the facility's policy entitled, Staff Attire, dated October 29, 2024, revealed that all staff with facial hair were to have it properly restrained. Observations during the tour of the dietary department on December 3, 2024, at 10:12 a.m., revealed the following: In dry storage, there was food and paper debris on the floor under two sets of shelves storing food items. There was flour on the floor below the bulk container of flour. There were two bulk containers of cereal that had food debris and/or a dried liquid ring on the lids. In reach-in freezer #7, there was an accumulation of a frozen liquid on the bottom of the freezer. In reach-in freezer #6, there was an opened, uncovered box of green beans. There was a layer of food debris along the inside bottom of the freezer. In reach-in cooler #5, there was dried white liquid on the floor under the milk storage. In reach-in cooler #4, there were two opened containers with yogurt that had dripped onto the containers and the shelf below. In reach-in coolers #3 and #5, there was a layer of food debris along the bottom of the inside of the coolers. In reach-in cooler #2, there was an opened bag of shredded carrots that was not dated. There was a large bowl coleslaw labeled use-by November 30 and an opened container of bulk applesauce that was dated November 22, 2024. There was a container with leftover pancakes stored directly on top of bread that was not dated. There was a layer of food debris on the bottom of the cooler. In reach-in cooler #1, there was a large container of cooked green beans that was not dated. There were two containers and one metal lid on the floor under a storage rack of pans and containers. Inside the microwave, there were multiple areas of dried food debris. In an interview on December 3, 2024, at 11:10 a.m., the District Manager of the dietary department (DM 1) confirmed the previously mentioned foods should have been dated and expired items removed. Observation during of the lunch meal service tray line on December 4, 2024, from 12:25 p.m. to 12:43 p.m., revealed Dietary Employee 1 (DE 1) and Dietary Employee 2 (DE 2) were both observed to have facial hair of a full beard and mustache that were not covered. 395047 Page 2 of 4 395047 12/05/2024 Heritage Pointe Rehabilitation and Healthcare Ctr 400 South Main Street Doylestown, PA 18901

F 0812 Level of Harm - Minimal harm or potential for actual harm In an interview on December 4, 2024, at 12:50 p.m., the DM 1 confirmed that DE 1 and DE 2 should have been wearing beard guards during meal tray line. 28 Pa. Code 201.14(a) Responsibility of licensee. Residents Affected - Many 395047 Page 3 of 4 395047 12/05/2024 Heritage Pointe Rehabilitation and Healthcare Ctr 400 South Main Street Doylestown, PA 18901

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Residents Affected - Many Observation of the trash compactor area on December 3, 2024, at 10:30 a.m., revealed various items on the ground next to the trash compactor, including a full bag containing three used briefs, used gloves, used gauze, and several pieces of crushed plastic items. There was a plastic bag containing garbage items that was sticking out from below the trash compactor. 28 Pa Code 201.18(b)(3) Management. 395047 Page 4 of 4