Health inspection·July 20, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review it was determined that the facility failed to notify the resident's representative in four of five residents sampled who were transferred to the hospital. (Residents 19, 56, 61, 112) Findings include: Clinical record review revealed that Resident 19 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 56 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident, the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 61 was transferred to the hospital on April 24 and June 1, 2023, after changes in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfers to the hospital. Clinical record review revealed that Resident 112 was transferred and admitted to the hospital on [DATE], after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital. 28 Pa. Code 201.29(c.3)(2) Resident rights. Page 1 of 3 395250 395250 07/20/2023 Holy Family Manor 1200 Spring Street Bethlehem, PA 18018

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 24 sampled residents. (Resident 20) Residents Affected - Few Findings include Clinical record review revealed that Resident 20 had diagnoses that included spina bifida, paraplegia, muscle weakness, and debility. A physician's order dated November 1, 2019, directed staff to apply a knee abduction cushion and check for alignment throughout the day. Review of the care plan revealed that the resident was at risk for skin breakdown. The intervention was for staff to apply a knee abduction cushion per the orders. Multiple observations on July 19, 2023, between 11:10 a.m., and 1:28 p.m., revealed Resident 20 sitting in a wheelchair, the knee abduction cushion was not in place. In an interview on July 20, 2023, at 8:20 a.m., the Director of Nursing confirmed that staff did not apply the knee abduction cushion and that it should have been applied per the care plan and physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395250 Page 2 of 3 395250 07/20/2023 Holy Family Manor 1200 Spring Street Bethlehem, PA 18018

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on facility policy review, clinical record review, and observation, it was determined that the facility failed to ensure that proper care was provided for one of two sampled residents who used a urinary catheter (a flexible tube that drains urine from the bladder). (Resident 20) Findings include: Review of facility policy entitled, Urinary Catheters, last reviewed January 2023, revealed that a catheter drainage bag was never to be elevated to or above bladder level. Clinical record review revealed that Resident 20 had diagnoses that included paraplegia, spina bifida, dementia, and dysfunction of the bladder. Review of the care plan revealed that the resident had an indwelling catheter. The intervention was for staff to position the catheter bag and tubing below the level of the bladder. Multiple observations on July 18, 2023, between 11:30 a.m. and 1:13 a.m., revealed Resident 20 was seated in a wheelchair. The tubing of the catheter was arranged such that it extended down the resident's pants leg and out the bottom to the drainage bag. The catheter bag was positioned inside the seat of the wheelchair, between the arm rest and the resident's hip. Neither the tubing nor the drainage bag were maintained below the level of the resident's bladder. Urine was observed in the tubing. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395250 Page 3 of 3