Health inspection·August 18, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on a review of facility policy and resident and staff interviews, it was determined the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable mental and psychosocial well-being by not serving all meals in the dining room daily. Findings include: Review of a facility policy, Serving of Food, dated 1/24/23, stated All residents are encouraged to eat in the dining room/s. During resident interviews on 8/16/23, at approximately 9:00 a.m. and 10:00 a.m. Residents R6, R10, R22, R25, R29, R37, and R49 indicated they enjoy eating their meals in the dining room with other residents, however, the dining room was not open for dinner on the weekdays and all meals on the weekends. During an interview on 8/16/23, at approximately 2:45 p.m. Dietary Staff Employee E8 indicated the residents do not eat in the dining room for certain meals, such as dinner on the weekdays and all meals on the weekends, due to a lack of nursing staff. During an interview on 8/18/23, at approximately 9:50 a.m. the Director of Nursing confirmed that the residents were served meals in the dining room for breakfast and lunch on week days but not on weekends or for the evening meals due to staffing concerns. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 201.18(b)(3) Management Page 1 of 2 395158 395158 08/18/2023 Kadima Rehabilitation & Nursing at Greenville 110 Fredonia Road Greenville, PA 16125

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications and medication information on one of four medication carts observed (Unit 1). Findings include: Review of a facility policy entitled, Storage of Medications dated 1/24/2023, indicated that compartments containing medications are locked when not in use and carts used to transport such items are not left unattended. Observation on 8/15/23, at approximately 3:50 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 prepared medications for a resident from the Unit 1 medication cart parked in the hall in front of the resident room. LPN Employee E1 then proceeded into resident room to administer medications to a resident in the room behind a privacy curtain. LPN Employee E1 did not securely lock the Unit 1 medication cart or cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E1 was unable to view medication cart and drawers of the medication cart or the computer on top of the cart from behind the privacy curtain while unattended. During an interview on 8/15/2023, at the time of the observation, LPN Employee E1 confirmed that he/she left the medication cart unlocked and resident information in view while it was parked in the resident room doorway, which was out of view during administration of medications to a resident behind a privacy curtain. LPN Employee E1 also confirmed that the medication cart was to be locked and resident information covered when out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services 395158 Page 2 of 2