Health inspection·July 8, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for two out of eleven residents reviewed (Resident R6 and R7). Findings Include: Review of the facility policy, Behavior Management Program Overview, Overview-The facility promotes the utilization of a behavior intervention and management program based on individual resident/patient needs. Review of Resident R6's clinical record revealed Resident R6 was admitted to the facility on [DATE] with a diagnosis of: Unspecified Dementia, Mood Disorder, and Anxiety Disorder. Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of Anxiety Disorder, Depression, Bipolar Disorder. Review of a social services note dated June 16, 2025, documented that the social worker spoke with the resident regarding Resident with BIMS (Brief Interview for Mental Status) score of 13 when tested this morning. She was offered support and validation in her friendship with fellow make resident. Resident made aware that they must meet in common areas and not in room as may be uncomfortable with a male visitor in room. Resident voiced understanding. She was also made aware that if she comfortable with a kiss but nothing further fellow male resident must respect her boundaries. Resident encouraged to update staff immediately if she is feeling uncomfortable or compromised in any way. She will continue to be followed by facility psych services. Staff to monitor and offer on going supports. Review of Resident R7's Minimum Data Set (MDS- assessment of resident's care needs) dated May 21, 2025, revealed that the resident's BIMS (Brief Interview for Mental Status) score of 10 . Review of Resident R6's progress notes from July 1, 2025 revealed social worker note from Employee E3 stating, Resident is slated to transfer to room (105-B) today in the morning for better monitor of relationship with fellow male resident and problematic behavioral patterns; drinking her hygiene products. Resident was updated. Family contacted via phone with message left via voicemail. Awaiting reply. Staff to monitor and offer ongoing supports. The male resident that had been involved with Resident R6 was Resident R7. Further review of the resident's clinical record revealed Resident R7 had a history of inappropriate sexual comments towards both other residents and staff. Page 1 of 2 395256 395256 07/08/2025 Harborview Rehabilitation and Care Center at Lansd 25 West Fifth Street Lansdale, PA 19446

F 0842 Level of Harm - Minimal harm or potential for actual harm Interview held with nurse aide, Employee E4 on July 8, 2025 revealed, I was working 7 a.m.-3p.m. shift on July 1st, and I thought it was okay for them to be in relationship as of then. I went to walk into Resident R6's room . and caught them kissing in the room so I told them break it up. I then told [the licensed nurse unit manager Employee E5]. A few days later after completing updated scores we was told they couldn't be alone together and then [Resident R6] was moved. Residents Affected - Few Interview with Resident R6 on July 8, 2025 at 1:38 p.m. revealed the resident did have a close relationship with Resident R7 when she was on the second floor. Resident R6 stated she just recently moved into her current room (first floor) but stated that she was moved down quickly. She stated staff was unsure if Resident R7 was good for her so they moved me down here. When asked if she felt safe around Resident R7, she stated yes. When asked if she had ever held hands or kissed Resident R7 she stated, oh yes, he loved to kiss me all the time, like couples do. Interview with Resident R7 on July 8, 2025 at 1:50 p.m. revealed the resident did state he had a close relationship with Resident R6. He stated that they kissed a few times, in a private room alone and in the library. Review of Resident R6 and Resident R7 progress notes from the last three months show no indication of kissing or touching at any time. 28 Pa Code 211.12(c) Nursing services 395256 Page 2 of 2