Health inspection·September 26, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, review of facility's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for 1 of 35 residents reviewed (Resident R62) Findings include: Review of facility investigation report for Resident R65 from February 12, 2024, revealed that the previous administrartor was reported on February 10, 2024, that a licensed nurse Employee E20 called Resident R65 wicked b*!*h. Reviewed investigation for Resident R65 statement on February 10, 2024, revealed [licensed nurse Employee E20] came to my room and didn't knock I asked her to knock, and she pulled open the privacy curtain and didn't close it. She called me a wicked white b*!*h. I was in the hallway. This was Saturday morning. Between 6am-7am. Further reviewed investigation statement from licensed nurse Employee E20 stated did anything happen with [Resident R65] on Saturday morning? Yes, I am always having problem with [Resident R65]. Every night I have to put her on behavior monitoring when you care for B bed. I have to chairs and curtain to B bed. When I check on B bed, [Resident R65] always comes out of room and follows me out. [Resident R65] will yell and scream at me at the nurse station saying it her room, I need to knock louder. On Saturday morning staff was in the room and [Resident R65] was screaming at staff. [Resident R65] keeps saying she shouldn't be in there; I went into the room to calm down the situations and tell [Resident R65[ she's not allowed to move curtain back. [Resident R65] than followed me out of room. Said I shouldn't working here. You are b*!*h then [Resident R65], began to yell racial slurs your black, I'm white and I did say you wicked witch, go back to your room. Investigation completed on February 14, 2024, with concluded Licensed nurse, Employee E20 provided statement which said she called resident wicked witch and the Licensed nurse, Employee E20 was terminated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 211.12(d)(1) Nursing services Page 1 of 30 395258 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R135, with a documented history of substance abuse, to prevent relapse and access to illegal substances. This failure resulted in Resident R135, accessing and using illegal substance and experiencing four incidents (December 3, 2023; December 5, 2023; March 17, 2024 and July 23, 2024) of drug overdose which required immediate medical treatment/emergency medical intervention and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135). Findings include: Review of the facility's care plan policy titled Plan of Care Overview dated 2017, revealed it is the policy of this facility to provide each resident centered care that meets psychosocial physical and emotional needs and concerns of the resident's safety is the primary concern for all our residents staff and visitors. The primary purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the residents' goals choices and preferences. Review of facility policies and standard procedures on Individual Service Plan Overview with an effective date of May 1, 2022, revealed that under Definitions: For the purpose of this policy, that individual service plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. Under section Policy: It is the policy of this facility to provide resident centered care that meets the site, cause, social, physical, and emotional needs and concerns of the resident safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's choices and preferences including but not limited to goals related to their daily routines and goals to potentially return to a community setting. Under section Procedure #1,d. The facility will: i Provide an interdisciplinary assessment of the residents in 30 days of admission and then an ongoing periodic review that provides the foundation for resident focused care and the service planning process, ii provide access to the Service plan within 24 hours. iii review service plans quarterly and or with significant changes in care. Review of facility policy titled Resident Substance Abuse in the Facility revealed the facility is to provide each resident with care based on their individual medical and emotional needs and their physical ability to self-perform or have assistance to perform the operation. The policy includes the procedures, management of acute episodes, residents receiving Narcan protocols, observations of other residents, follow-up care for resident abusing substances, documentation and care plan and education. Review of Resident R135's clinical record reveled that Resident R135 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of S\Psychoactive Substance Use Unspecified, Major Depressive Disorder, Adjustment Disorder. 395258 Page 2 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Review of resident social history assessment dated [DATE], revealed that Resident R135 has history of alcohol use, age of first use: [AGE] year, last used: three weeks ago (three weeks before September 2, 2023), frequency and amount used: Daily. Further, Resident R135 had history of heroin and fentanyl abuse: Age of first use: [AGE] year, last used: three weeks ago (three weeks before September 2, 2023), frequency: daily. Further, resident was not aware of any triggers and resident was not able to identify any relapse prevention strategies. Residents Affected - Some Review of Resident R135's quarterly MDS (Minimum Data Set a federally required resident assessment completed at a specific interval) dated September 6, 2024, section C0500 BIMS (brief interview for mental status- a standardized assessment tool used to screen cognitive function)) revealed a score of 15 suggesting that resident was cognitively intact. Review of Resident R135's care plan revealed that there was no comprehensive person-centered care plan addressing Resident R135's, history of illicit drug and alcohol abuse, and potential for relapse. Review of Resident R135's progress note revealed that on December 3, 2023, time stamped 10:55 p.m. resident was observed by the nurse, unresponsive, gasping for air. 911 (Emergency Medical Services) called and resident taken to a local county hospital for evaluation. Review of hospital after visit summary dated December 3, 2023, revealed that, Resident R135 was seen at the hospital with respiratory distress and responsive. Symptoms are most likely secondary to opiates which was injected, given by the friend at the nursing home. Further review of the hospital after visit summary revealed the resident was given Naloxone hydrochloride on December 20, 2024. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing the resident's illicit drug use was not developed until after Resident R135 overdosed on December 3, 2023. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's receiving opiates by a friend at the nursing home as documented in the hospital after visit summary dated December 3, 2024. Nursing Home Administrator, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions to prevent the distribution of drugs to other residents in the facility. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse and there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Review of nurses note dated December 5, 2023, time stamped 8:11 p.m. revealed that writer was called by floor nurse at 7:15 p.m. to room [ROOM NUMBER], Upon writer arrived writer noticed resident in bed unresponsiveness, slowed breathing, snoring, skin cold, and pinpoint pupil. At 7:20 p.m. Narcan nasal spray 4 mg (milligrams) given. At 7:30 p.m. Resident respondent when name was called. 911 arrived at 7:32 p.m. Resident refused to go to the hospital. DON (director of nursing) notified order 1:1 observation, neuro check and vitals every four hours. 395258 Page 3 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of provider encounter (nurse practitioner) note dated December 11, 2024, time stamped 1:00 a.m. revealed that Resident R135 was seen for status post overdose. She had an unresponsive episode, requiring Narcan and visit to ER (emergency room). Resident overdosed on substance she reported buying from another resident. She refused to give the name of the resident but kept repeating that it's someone staff has been suspecting. Asked if it's a male or female, she said female. Asked the race of the resident, admitted resident is African American she said yes, and it is who you think it is. Drector of Nursing and Nursing Home Administrator made aware. Resident was placed on 1:1 supervision. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was developed after Resident R135 overdosed on December 5, 2024. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43a.m. revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Interview with ADON (Assistant Director of Nursing) conducted on September 24, 2024, at 12:34 p.m., revealed that he was not involved in the investigation with Resident R135's incident of overdose on December 5, 2023. Further ADON also revealed that he was not aware of any investigation conducted regarding Resident R135's allegations that she bought the drugs from a resident of the facility. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse, there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Review of Resident R135's progress notes dated January 24, 2024, revealed that IDT (interdisciplinary team) met and discussed resident's recent behaviors. It was determined, along with psych Certified Registered Nurse Practicioner, that 1:1 observation was no longer needed. Further review of Resident R135's clinical record revealed no plan of care on how to prevent relapse after 1:1 was discontinued. Further, there was no evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Review of nurses notes dated March 17, 2024, time stamped 3:44 p.m. revealed that Resident R135 went to use the general bathroom, when her mother came out to report that resident was unresponsive in the bathroom. A code was called and two doses of Narcan was administered before the resident regained consciousness. While resident was being revived 911 was called and the EMT (Emergency Medical Technician) met the resident conscious. Resident R135 refused to go to the hospital, resident admitted to the EMT in the presence of this writer that she had a little heroine but refused to state where and how she got it. Plan of care continues. DON Employee E2 and Administrator Employee E1 were notified about the situation, and they advised that the police be called, police was called, the officer said he cannot search Resident R135's room if the resident doesn't want him to do so. Administrator 395258 Page 4 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some made aware and she order every 15 minutes check on resident. Meanwhile, the physician ordered that all narcotics be put on hold until tomorrow. Review of Progress notes dated March 18, 2024, time stamped 1:00 a.m. revealed that Resident was seen today for S/P (status/post) heroin overdose yesterday. Per nurses' note, resident went to use the hall bathroom. Her mother, who was visiting, came out to notify nursing resident was unresponsive. She required two doses of Narcan before regaining consciousness. Resident refused to be transferred to ER. She refused to tell the police and EMT where she got the heroin. Today during this visit, she named the resident whom she purchased it from through bargaining, she gave the other resident her food stamps for the heroin, Resident was placed on 1-1 supervision and was moved to another floor. Review of psychotherapy progress note dated March 18, 2024, revealed the following: Goals Addressed: Anxiety, Depressive Symptoms, Acceptance of current setting, Use of Coping Strategies, Compliance with treatment regimen, Patient's Concerns/Focus: Resident seen on this date at the request of staff. Resident with overdose yesterday. Refused to go to outside hospital. Resident seen in private area immediately this morning. Currently being maintained on 1:1 observation. Resident is tearful. Discussing substance abuse and intent. Discussing feeling overwhelmed by both physical and emotional pain. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse, there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed after Resident R135 overdosed on March 17, 2024. Further interview with Nursing Home Administrator, Employee E1 revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated March 29, 2024, revealed that Resident R135 was released from 1:1 observation Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed. Review of progress note dated July 22, 2024, time stamped 3:14 p.m. revealed that Resident R135 was on LOA (leave of absence) to a local store. Resident R135 left at 1pm. The physician approved LOA. Review of progress note dated July 22, 2024, time stamped 10:00 p.m. revealed that Resident R135 came back to the facility with her friend from her outing. Review of progress note dated July 23, 2024, at 9:01 a.m. revealed that Resident R135 was found 395258 Page 5 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety unresponsive by nurse at approximately 8:20 a.m. Code blue called. Resident R135 received Narcan x 3, Resident R135 became responsive after receiving Narcan. 911 was called. Resident R135 refuse transfer to ER (Emergency room). Resident stated she took half bag of Fentanyl hours ago. Review of nurse's notes dated July 23, 2024; time stamped 4:00 p.m. revealed that Resident R135 was placed on a 1:1 because she had an OD (overdose) on the nightshift. Residents Affected - Some Review of psych note dated July 23, 2024, revealed that follow-up psychiatric evaluation requested by the facility staff. Patient and her boyfriend had a community outing to (major city) and patient returned very lethargic and they had to administer Narcan three times today. When patient was interrogated about using any other substances while they were out, patient admitted to, doing one bag of fentanyl in the community. When patient was evaluated to discontinue the 1:1 observation, patient was asked if there is any drugs hidden in her room or the boyfriend's room patient denied, but when one of the facility staff suggested we search the rooms. Patient was very anxious and not acceptable to the idea. This was a clear indication that there might be some drugs still hidden within the facility and it was communicated to the facility management to search the rooms before the patient is taken off 1:1. At this time we continue 1:1 observation and will reevaluate the next visit on Friday. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse and there was no person-centered care plan developed to address Resident R135's addiction, his recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Interview with facility Nursign Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed after Resident R135 overdosed on July 23, 2024. Further interview with Nursing Home Administrator Employee E1 conducted on September 24, 2024, at 11:43am revealed that there was no further investigation related to the indication that there might be some drugs still hidden within the facility as documented in the psych note dated July 23, 2024. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on September 25, 2024, at 9:55 a.m. for the facility's failure to develop and implement a comprehensive person-centered care plan for Resident R135 who had a documented history of drug abuse. This failure resulted in Resident R135 who had a documented history of substance abuse, accessing and using illegal substance which resulted in four incidents (December 3, 2023; December 5, 2023; March 17, 2024, and July 23, 2024) of drug overdose which required immediate medical treatment / emergency medical management. An Immediate Jeopardy Template was presented to the facility on September 25, 2024, 9:59 a.m. The facility submitted a written plan of action on September 25, 2024, at 4:10 p.m. and implemented the plan of action which included: 1. Resident named in deficient practice has been discharged from the facility on September 20, 2024. 395258 Page 6 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety 2. Assessment of all residents currently residing in the facility for history of substance abuse was completed in September 24, 2024. The Facility ensured that care plans were in place for each resident with history of substance abuse disorder on September 24th, 2024. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. On September 25, 2024. No residents were found to be suspicious for current use or found to have any materials. Residents Affected - Some 3. All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence. 4. All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility. On September 25, 2024. Ad Hoc QAPI held on September 25, 2024, to reviewed efficient practice. 5. Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration. o 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: o Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. o Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies o Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work. 6. 100% compliance in staff education by September 27, 2024. The action pan was accepted on September 25, 2024, at 4:09 p.m. The action plan was reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility documents and facility audits were reviewed to ensure care plans were developed. 395258 Page 7 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0656 Level of Harm - Immediate jeopardy to resident health or safety The Immediate Jeopardy was abated and NHA was notified on September 26, 2024, at 12:27 p.m. that the I.J. was lifted. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Some 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management 395258 Page 8 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to provide supervision for Resident R135 with documented history of substance abuse. This failure resulted in Resident R135 accessing and using illegal substance which resulted in four incidents (December 3, 2023; December 5, 2023; March 17, 2024 and July 23, 2024) of drug overdose which required immediate medical treatment / emergency medical management and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135) Findings include: Review of facility policies and standard procedures on Individual Service Plan Overview with an effective date of May 1, 2022, reveal that under Definitions: For the purpose of this policy, that individual service plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. Under section Policy: It is the policy of this facility to provide resident centered care that meets the site, cause, social, physical, and emotional needs and concerns of the resident safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's choices and preferences including but not limited to goals related to their daily routines and goals to potentially return to a community setting. Review of facility policy titled Resident Substance Abuse in the Facility revealed the facility is to provide each resident with care based on their individual medical and emotional needs and their physical ability to self-perform or have assistance to perform the operation. The policy includes the procedures, management of acute episodes, residents receiving Narcan protocols, observations of other residents, follow-up care for resident abusing substances, documentation and care plan and education. Review of Resident R135's clinical record reveled that Resident R135 was a [AGE] year-old female admitted to the facility on [DATE], with diagnosis of Psychoactive Substance Use Unspecified, Major Depressive Disorder, Adjustment Disorder. Review of resident social history assessment dated [DATE], revealed that Resident R135 has history of alcohol use, age of first use: [AGE] year, last used: three weeks ago (three weeks before September 2, 2023), frequency and amount used: Daily. Further, Resident R135 had history of heroin and fentanyl abuse: Age of first use: [AGE] year, last used: three weeks ago (three weeks before September 2, 2023), frequency: daily. Further, resident was not aware of any triggers and resident was not able to identify any relapse prevention strategies. Review of Resident R135's quarterly MDS (Minimum Data Set a federally required resident assessment completed at a specific interval) dated September 6, 2024, section C0500 BIMS (brief interview for mental status- a standardized assessment tool used to screen cognitive function)) revealed a score of 15 suggesting that resident was cognitively intact. Review of Resident R135's care plan revealed that there was no base line care plan for substance 395258 Page 9 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some abuse developed within 48 hours of Resident's admission to the facility. Further, there was no comprehensive person-centered care plan addressing Resident R135's, history of illicit drug and alcohol abuse, and potential for relapse. Review of Resident R135's progress note revealed that on December 3, 2023, time stamped 10:55 p.m. resident was observed by the nurse unresponsive, gasping for air. 911 (Emergency Medical Services) called and resident taken to a local county hospital for evaluation. Review of hospital after visit summary dated December 3, 2023, revealed that Resident R135 was seen at the hospital with respiratory distress and responsive. Symptoms are most likely secondary to opiates which was injected, given by the friend at the nursing home. Further review of the hospital after visit summary revealed the resident was given Naloxone hydrochloride on December 20, 2023. Further review of Resident R135's clinical record revealed no documented evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's receiving opiates by a friend at the nursing home as documented in the hospital after visit summary dated December 3, 2024. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated December 5, 2023, time stamped 8:11 p.m. revealed that writer was called by floor Nurse at 7:15 p.m. to room [ROOM NUMBER], upon writer arrived writer noticed resident in bed unresponsiveness, slowed breathing, snoring, skin cold, and pinpoint pupil. At 7:20 p.m. Narcan nasal spray 4 Milligrams (mg) given. At 7:30 p.m. Resident respondent when name was called. 911 arrived at 7:32 p.m. Resident refused to go to the hospital. DON (director of nursing) notified order 1:1 observation, neuro check and vitals every four hours. Review of provider encounter (nurse practitioner) note dated December 11, 2023, time stamped 1:00 a.m. revealed that Resident R135 was seen for status post overdose. She had an unresponsive episode, requiring Narcan and visit to ER (emergency room). Resident overdosed on substance she reported buying from another resident. She refused to give the name of the resident but kept repeating that it's someone staff has been suspecting. Asked if it's a male or female, she said female. Asked the race of the resident, admitted resident is African American she said yes, and it is who you think it is. DON and Administrator made aware. Resident was placed on 1:1 supervision. Interview with facility Nursing Home Administrator, Employee E1 conducted on September 24, 2024, at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Interview with ADON (Assistant Director of Nursing) conducted on September 24, 2024, at 12:34 pm, revealed that he was not involved in the investigation with Resident R135's incident of overdose on December 5, 2023. Further ADON also revealed that he was not aware of any investigation conducted regarding Resident R135's allegations that she bought the drugs from a resident of the facility. 395258 Page 10 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident R135's progress notes dated January 24, 2024, revealed that IDT (interdisciplinary team) met and discussed resident's recent behaviors. It was determined, along with psych Certified Registered Nurse Practicioner, that 1:1 observation was no longer needed. Further review of Resident R135's clinical record revealed no plan of care on how to prevent relapse after 1:1 was discontinued. Further, there was no evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Review of nurses notes dated March 17, 2024, time stamped 3:44 p.m. revealed that Resident R135 went to use the general bathroom, when her mother came out to report that resident was unresponsive in the bathroom. A code was called and two doses of Narcan was administered before the resident regained consciousness. While resident was being revived 911 was called and the EMT (Emergency Medical Technician) met the resident conscious. Resident R135 refused to go to the hospital, resident admitted to the EMT in the presence of this writer that she had a little heroine but refused to state where and how she got it. Plan of care continues. Director of Nursing, Employee E2 and Nursing Home Administrator, Employee E1 were notified about the situation, and they advised that the police be called, police was called, the officer said he cannot search Resident R135's room if the resident doesn't want him to do so. Nursing Home Administrator made aware and she order every 15 minutes check on resident. Meanwhile, the MD ordered that all Narcotics be put on hold until tomorrow. Review of progress notes dated March 18, 2024, time stamped 1:00 a.m. revealed that Resident was seen today for S/P heroin overdose yesterday. Per nurses' note, resident went to use the hall bathroom. Her mother, who was visiting, came out to notify nursing resident was unresponsive. She required two doses of Narcan before regaining consciousness. Resident refused to be transferred to ER (Emergency Room). She refused to tell the police and EMT where she got the heroin. Today during this visit, she named the resident whom she purchased it from through bargaining, she gave the other resident her food stamps for the heroin, Resident was placed on 1-1 supervision and was moved to another floor. Review of psychotherapy progress note dated March 18, 2024, revealed the following: Goals Addressed: Anxiety, Depressive Symptoms, Acceptance of current setting, Use of Coping Strategies, Compliance with treatment regimen, Patient's Concerns/Focus: Resident seen on this date at the request of staff. Resident with overdose yesterday. Refused to go to outside hospital. Resident seen in private area immediately this morning. Currently being maintained on 1:1 observation. Resident is tearful. Discussing substance abuse and intent. Discussing feeling overwhelmed by both physical and emotional pain. Interview with Nursing Home Administrator revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated March 29, 2024, revealed that Resident was released from 1:1 observation Further, there were no evidence of environmental monitoring and supervision to identify potential sources of illegal substance. Review of progress note dated July 22, 2024, time stamped 3:14 p.m. revealed that Resident R135 was on LOA (leave of absence) to a local store. Resident R135 left at 1p.m. Physician approved LOA. 395258 Page 11 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of progress note dated July 22, 2024, time stamped 10:00 p.m. revealed that Resident R135 came back to the facility with her friend from her outing. Review of progress note dated July 23, 2024, at 9:01 a.m., revealed that Resident R135 was found unresponsive by nurse at approximately 8:20 a.m. Code blue called. Resident R135 received Narcan x 3, Resident R135 became responsive after receiving Narcan. 911 was called. Resident R135 refuse transfer to ER. Resident stated she took half bag of Fentanyl hours ago. Review of nurse's notes dated July 23, 2024; time stamped 4:00 p.m. revealed that Resident R135 was placed on a 1:1 because she had an OD (overdose) on the nightshift. Review of psych note dated July 23, 2024, revealed that follow-up psychiatric evaluation requested by the facility staff. Patient and her boyfriend had a community outing to (major city) and patient returned very lethargic and they had to administer Narcan three times today. When patient was interrogated about using any other substances while they were out, patient admitted to, doing one bag of fentanyl in the community. When patient was evaluated to discontinue the 1:1 observation, patient was asked if there is any drugs hidden in her room or the boyfriend's room patient denied, but when one of the facility staff suggested we search the rooms. Patient was very anxious and not acceptable to the idea. This was a clear indication that there might be some drugs still hidden within the facility and it was communicated to the facility management to search the rooms before the patient is taken off 1:1. At this time we continue 1:1 observation and will reevaluate the next visit on Friday. Further interview with Nursing Home Administrator conducted on September 24, 2024, at 11:43 a.m. revealed that there was no further investigation related to the indication that there might be some drugs still hidden within the facility as documented in the psych note dated July 23, 2024. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on September 25, 2024 at 9:55 a.m. for the facility's failure to supervise Resident R135 who had a documented history of drug abuse. This failure resulted in Resident R135, accessing and using illegal substance which resulted in four incidents (December 3, 2023; December 5, 2023; March 17, 2024, and July 23, 2024) of drug overdose which required immediate medical treatment / emergency medical management. An Immediate Jeopardy Template was presented to the facility on September 25, 2024, 9:59 a.m. The facility submitted a written plan of action on September 25, 2024, at 4:10 p.m. and implemented the plan of action which included: 1. Resident named in deficient practice has been discharged from the facility on September 20, 2024. 2. Assessment of all residents currently residing in the facility for history of substance abuse was completed in September 24, 2024. The Facility. Ensured that care plans were in place for each resident with history of substance abuse disorder on September 24th, 2024. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. On September 25, 2024. No residents were found to be suspicious for current use or found to have any materials. 3. All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence. 395258 Page 12 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 4. All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility. On September 25, 2024. Ad Hoc QAPI held on September 25, 2024, to reviewed efficient practice. 5. Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration. o 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: o Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. o Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies o Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work. 6. 100% compliance in staff education by September 27, 2024. The action plan was accepted on September 25, 2024, at 4:09 p.m. The action plan was reviewed, interviews were conducted with staff to confirm that the in-service education was completed. The Immediate Jeopardy was abated and NHA was notified on September 26, 2024, at 12:27 pm. that the I.J. was lifted. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 395258 Page 13 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0689 28 Pa. Code 211.12(d)(1) Nursing services Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 211.12(d)(3) Nursing services Residents Affected - Some 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services 395258 Page 14 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 35 residents reviewed (Residents R 141). Residents Affected - Few Findings Include: Review of the admission sheet of Resident 141, revealed that Resident R141 was admitted to the facility on [DATE]. Review of Minimum Data Set assessment (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated August 20, 2024, revealed that Resident R 141 had active diagnoses of Non Alzheimer's Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities, it is a progressive disease that destroys memory and other important mental functions). Review of MDS revealed that Resident R 141 received Antipsychotic (Antipsychotic medications have the effect of changing a person's behavior, mood, and emotions), and Anti-Depressant Medications (Antidepressant medications help relieve symptoms of depression, and anxiety disorders). On September 5, 2024, at 12:59 p.m., review of Resident 141's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R141. During an interview on September 5, 2024, at 1:19 p.m., the Director of Nursing (DON), confirmed the finding, and the DON stated that the facility tried to make the care plans as specific as possible. No additional information was received. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395258 Page 15 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of six residents observed during medication administration (Resident R33, and R89). Residents Affected - Few Findings include: On September 4, 2024, at 9:33 a.m., observed that Employee E21, a Licensed Nurse, administered to Resident R89, the medicine, Artificial Tears one drop in each eye. Review of physician order for Resident R89, dated March 26, 2024, revealed an order to administer Pataday Ophthalmic Solution 0.1 % (Olopatadine HCl), instill 1 drop in both eyes, two times a day for Allergic Conjunctivitis. At the time of the observation, interview with Licensed nurse Employee E21, confirmed the above findings. On September 4, 2024, at 10:20 a.m., observed that Employee E22, a Registered Nurse, did not administer to Resident R33, the medicine busPIRone HCl Oral Tablet 5 MG (Buspirone HCl), one tablet by mouth for Anxiety and Depression, even though Employee E22 searched for the medicine busPIRone HCl Oral Tablet 5 MG in the medication cart and in other medication storage areas. The Registered Nurse, Employee E22 stated that the medicine, busPIRone HCl Oral Tablet 5 MG was not available, and the nurses were going to reorder it. Review of physician order for Resident R33, dated August 13, 2024, revealed an order to administer busPIRone HCl Oral Tablet 5 MG (Buspirone HCl), give one tablet by mouth two times a day for Anxiety; Depression. At the time of the observation, interview with Registered Nurse, E22, confirmed the above findings. The facility incurred a medication error rate of 7.69%. Pa Code:211.12(d)(1)(2)(5) Nursing Services. 395258 Page 16 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and clinical record reviews, it was determined that the facility failed to correctly administer medications in accordance with physician orders, for one of six residents' medication administration observed, and one of 32 resident records reviewed resulting in significant medication error ( Resident R159). Residents Affected - Few Findings include: Review of clinical records revealed that Resident R159, was admitted in the facility on July 15, 2024, with diagnoses including Acute Osteomyelitis, Right Ankle and Foot (Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue). Review of Resident R159's nurses note dated August 8, 2024, indicated that on August 7, 2024, during the night shift, instead of the physician ordered medicine, (order dated July 15, 2024), namely Cefepime HCl Solution 1 GM/50ML 1 gram for Diabetic Foot Ulcer, a Licensed Nurse Employee E24, administered the medicine namely, DAPTOmycin Solution Reconstituted 500 MG, intravenously. (Cefepime injection is used to treat bacterial infections in many different parts of the body. It belongs to the class of medicines known as cephalosporin antibiotics. It works by killing bacteria or preventing their growth. Daptomycin injection is used to treat certain blood infections or serious skin infections caused by bacteria in adults and children 1 year of age and older). Review of the documentation the facility submitted to the State Survey Agency indicated that Employee E24, confirmed that on August 7, 2024, the employeee administered DAPTOmycin Solution to Resident R159 during the night shift, instead of administering Cefepime HCl Solution 1 GM/50ML 1 gram. On September 4, 2024, at 1: 54 p.m., the findings were confirmed with the Director of Nursing; and E24 was not available for interview. The DON also stated that there were no adverse reactions or consequences observed, and the physician was notified. It was determined that the facility failed to correctly administer medications in accordance with physician orders. Pa Code:211.12(d)(1)(2)(5) Nursing Services. 395258 Page 17 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on review of facility documentation, observations and resident and staff interviews it was determined that the facility failed to ensure residents were provided meals that honor food preferences for one of three nursing units. First floor). Findings include: Review of facility policy titled Dining Services Department policy and procedure Manual revealed the individual tray assembly tickets will identify all food items appropriate for the resident based on diet order allergies and intolerances and preferences. During meal service, any resident with expressed or observed refusal food will be offered an alternative selection of comparable nutritional value the alternate meal selection will be provided in a timely manner. Review of facility provided menu for September 3, 2024, revealed the lunch menu planned was to be tuna melt sandwich with buttered green peas and tater tots with alternative selection was honey Dijon chicken breast, green beans and parsley rice, both options served with tropical fruit salad. Observation of dining room lunch being served on September 3rd, 2023, revealed residents being served tuna salad sandwiches peas and tater tots, the menu that was provided by the facility revealed the lunch was planned to be tuna melt sandwich green peas and tater tots. Observation in first floor dining room during lunch on September 4, 2024, revealed a resident sending back their entrée asking for something else and told by the kitchen staff it's too late, the menu is on the wall. Interview with Resident R15 September 3, 2024, at 12:59 p.m. in the main dining room first floor admitted not knowing what was for lunch and not knowing how to change her order for something else. Interview with Resident R121 September 3, 2024, at 12:59 pm in the main dining room first floor revealed that she did not ask for a tuna melt or a tuna salad, she would like something else. Resident R121 stated We never get what we want to eat. Observation in first floor dining room during lunch on September 4, 2024, revealed a resident sending back their entrée asking for something else and told by the kitchen staff it's too late, the menu is on the wall. Interview with licensed nurse Employee E19, revealed they used to have a menu for the residence to choose from now the residents do not know what is being brought to them. This employee confirmed the menu on the wall was not the correct dates. A group meeting held at 11 a.m., on September 4, 2024, on the first floor in therapy gym with 9 alert and oriented residents (Residents R5, R130, R71, R76, R102, R77, R57, R136, and R112) revealed that facility did not offer food choices per resident's preferences. Menu was not posted or hand out ahead time to residents and residents meal tickets are not being followed. 28 Pa. Code 201.18(b)Management 395258 Page 18 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0806 28 Pa. Code 201.29 Resident Rights Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.6 Dietary Services Residents Affected - Few 395258 Page 19 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that meals were served timely on two of three nursing units observed (First floor and Second floor nursing units). Findings include: Review of the facilities policy titled Dining Services Department policy and procedure Manual revealed adequate staffing will be provided to prepare and serve palatable attractive nutritiously meals at proper temperatures and at appropriate times and to support proper sanitary techniques being utilized. At least three daily meals will be provided at regular times comparable to normal mealtimes in the community and the time between a substantial evening meal and breakfast following will not exceed 14 hours. Review of facility documentation titled Mealtimes, revealed that facility mealtimes are as follow: Breakfast at 7:00 A.M., lunch starts at 12:00 P.M. and dinner starts at 5:00 P.M. Observation of first floor dining room wall posting of mealtimes revealed breakfast is served at 8:00 a.m. lunch is served at 11:30 a.m., and dinner is served at 5:00 p.m. Observation of residents dining at lunchtime in the first-floor main dining room on September 3, 2024, revealed the first tray was delivered to a seated resident at 12:46 p.m. and the last tray was delivered to a resident at 1:14 p.m. In the dining room. Observation of first floor nursing unit on September 3, 2023, at 1:28 pm. Revealed Resident R130 waiting in the nursing unit corridor for the food truck delivery. Interview with Resident R130 at time of above observation revealed that he never knows what time the meals will be brought to the floor. All meals come at all different times. Resident 130 received his lunch tray at 1:39 p.m. Observation of lunch in the first-floor dining room September 4, 2023, revealed the first tray was delivered to a seated resident at 12:10 p.m. and the last tray was delivered on the floor at 12:44 p.m. Interview with Resident R136 on September 4, 2024 at 9:31 a.m. revealed this resident feels the food is always late, dinner is not served until 6:30 p.m. This resident tried to complain but stated the dietary door is always locked and no one ever answers. Interview with Dietary Director, Employee E8 on September 5, 2024, at approximately 2:00 p.m. revealed that this employee is aware and confirmed that the dining times have been inconsistent. Review of facility documentation, Meal Times undated, revealed that, Breakfast starts 7:00 a.m.; lunch starts 12:00 p.m.; dinner starts 5:00 p.m. Observation on the Second Floor Nursing Unit on September 3, 2024, revealed that the first lunch 395258 Page 20 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some truck arrived at 12:40 p.m. Continued observation revealed that the second lunch truck did not arrive until 1:37 p.m. which was almost an hour after the first lunch truck had arrived. Further observation revealed that afternoon snacks, including sandwiches, pudding, and applesauce were delivered to the unit a 1:41 p.m. A group meeting held at 11 a.m., on September 4, 2024, on the first floor in therapy gym with 9 alert and oriented residents (Residents R5, R130, R71, R76, R102, R77, R57, R136, and R112 ) revealed that these residents are getting breakfast, lunch and dinner late daily. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa.Code 201.18(b)(3) Management 395258 Page 21 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stores, prepared, distributed, and served in accordance with professional standards for food service safety related to labeling and dating of refrigerated food items and the use of hair nets. Findings include: Review of facility policy titled Dining Services Department policy and procedure Manual revealed adequate staffing will be provided to prepare and serve palatable attractive nutritiously meals at proper temperatures and at appropriate times and to support proper sanitary techniques being utilized. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point of service dining. All staff members will have their hair off the shoulders confined in a hair net or cap and facial hair properly restrained. Per standards of the United States Department of Agriculture, Food Safety and Inspection Services (last updated July 2020) regarding Left Overs and Food Safety revealed leftovers can be kept in the refrigerator for 3-4 days(https://www.fsis.usda.gov/food-safty/safe-food-handeling-and-preparation/food-safty-basics/leftovers-and-food -safety#-Store). An initial tour of the food service department conducted on September 3, 2024, at 9:20 a.m. with dietary director Employee E8 and Employee E13, revealed the following: Dietary staff, Employee E11 and E12 were observed preparing food in the tray line without using hair nets. Observation or walk in refrigerator revealed a container of pork not dated, vegetables not covered; barbque chicken dated August 2, 2024, container of tuna salad dated August 26, 2024, macaroni and cheese with ham dated August 26, 2024, a container of rice dated August 2, 2024, baked ziti dated August 31, 2024; a container of baked beans with no date, a container of egg salad dated August 29, 2024, a container of chicken salad dated August 1, 2024 and a large container of cole slaw with no date. Interview with dietary staff, Employee E13 on September 3, 2024 at 9:42 a.m. confirmed above observation and stated that there is no explanation why some of the items are misdated and others are expired. Continued observation of the food service department on September 4, 2024 at 11:22a.m. revealed employees observed without proper dress code regarding absence of hair nets. Follow up tour of the food service department on September 4, 2024 revealed employees E11 and E12 with no hair net. 28 Pa. Code 201.14 Responsibility of licensee 28 Pa. Code 201.18 (b) (3) Management 395258 Page 22 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the QAA (Quality Assessment and Assurance) committee meets at least quarterly to coordinate and evaluate activities under the QAPI (Quality Assurance and Performance Improvement) program as required. Residents Affected - Few Findings include: Review of facility policy, QAPI (Quality Assurance and Performance Improvement) Plan undated, revealed that, The facility will have a QAPI meeting every month and that, Quarterly data will be reviewed over a quarter time frame on monthly meetings following the end of a quarter. Review of facility documentation related to QAPI meetings revealed that meetings were conducted in January, July and August 2024. Documentation included attendance logs of the QAA committee, data analysis of quality measures, analysis of resident care and performance improvement projects. There was no documentation available for review at the time of the survey related to QAPI meetings for any other months in 2024. Interview on September 9, 2024, at 1:15 p.m. the Nursing Home Administrator confirmed that there was no other QAPI meeting documentation available for review and that meetings had not been conducted at least quarterly as required. The Nursing Home Administrator revealed that she had only been working at the facility for a few weeks and conducted the meeting in August to review the facility's QAPI program. 28 Pa Code 201.14(a) Responsibility of licensee 395258 Page 23 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for two of two residents reviewed with infections (Residents R154 and R33), infection data reporting, enhanced barrier precautions and infection committee meetings, and Enhanced Barrier Precaution for one of one resident reviewed (Resident R165). Residents Affected - Some Findings include: Review of facility policy, Infection Prevention Program dated last reviewed February 24, 2022, revealed that the facility uses a systematic and data-driven method to prevent, track and trend infections, surveil for outbreaks and monitor infection control practices for compliance. Continued review revealed that the Infection Preventionist is responsible for monitoring infections and completing monthly line listings and report forms. The infection prevention program includes staff and resident education on risk of infection and practices to decrease risk. Further review revealed that the infection prevention program includes a system for reporting to local, state and federal authorities as required for each disease or suspicion of disease. Act 52 of 2007 mandates that nursing homes develop and implement comprehensive infection control plans and reporting of healthcare-associated infections as serious events. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was created as a system for facilities to submit the required information. Review of the Facility Assessment, dated updated August 8, 2024, revealed, The Infection Prevention Nurse is required to provide surveillance, analysis, and plan to recognize and prevent the spread of infection. Review of facility policy, Enhanced Barrier Precautions dated effective April 1, 2024, revealed that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms. Communication of enhanced barrier precautions is via signage posted on resident doors. Continued review revealed that enhanced barrier precautions are indicated for any residents with infection or colonization of multi-drug resistant organisms, wounds and/or indwelling medical devices, such as intravenous lines, urinary catheters and feeding tubes. During Entrance Conference on September 3, 2024, at 9:31 a.m. the Director of Nursing revealed that the role of the infection preventionist was shared between herself and Employee E4, Assistant Director of Nursing. Observation on September 3, 2024, at 10:41 a.m. and on September 4, 2024 at 10:50 a.m. revealed Resident R154 was resting in bed. The resident had a feeding tube and urinary catheter. There was no posted signage to indicate that the resident required enhanced barrier precautions. Review of the facility's wound tracking logs, dated August 30, 2024 revealed that Resident R154 had a stage four pressure ulcer on her sacrum (deep wound that affects muscles and bone). Review of Resident R154's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 12, 2024, revealed that the resident was admitted to the facility on [DATE], 395258 Page 24 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0880 Level of Harm - Minimal harm or potential for actual harm and had diagnoses including multi-drug resistant organism (bacteria that is difficult to treat because it is resistant to commonly used antibiotics), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (a life-threatening infection that occurs when bacteria enter the bloodstream), and sacral pressure ulcer. Continued review revealed that the resident had a feeding tube and indwelling urinary catheter. Residents Affected - Some Review of hospital records for Resident R154, dated August 9, 2024, revealed that the resident was treated in the hospital for shortness of breath and was found to have pneumonia. Resident R154 had sputum cultures completed that were positive for Klebsiella and ESBL (multi-drug resistant organisms) and was treated with intravenous antibiotics. The hospital records recommended to continue treatment with the intravenous antibiotic aztreonam for seven days upon discharge. Review of progress notes for Resident R154 revealed a nurses note, dated August 9, 2024, which indicated that the resident was readmitted to the facility. Continued review revealed a note, dated August 12, 2024, which indicated that lab results were received that the resident was positive for CRE (multi-drug resistant organism) and to initiate the intravenous antibiotic ertapenem for seven days. Review of Resident R154's Medication Administration Records (MARs) for August 2024, revealed physician orders, dated August 13 and 14, 2024, for ertapenem one gram intravenously every 24 hours for seven days. The medication was administered August 13 through 19, 2024. Further review of MARs revealed that there was no indication that the intravenous antibiotic aztreonam was administered as recommended in the hospital records. Review of Resident R33's Quarterly MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including urinary tract infection. Continued review revealed that the resident was taking an antibiotic medication. Review of progress notes for Resident R33 revealed a note, dated August 8, 2024, at 3:31 p.m. which indicated that the resident had a fall and was transferred to the hospital for evaluation. Continued review revealed a practitioner note, dated August 14, 2024, at 3:01 p.m. which indicated that the resident was admitted to the hospital with a diagnosis of urinary tract infection and to administer cefdinir (antibiotic medication) August 13 through 18, 2024. Review of Resident R33's MARs for August 2024, revealed that the resident received cefdinir from August 14 through 18, 2024. Review of the Facility Matrix, dated September 3, 2024, at 10:13 a.m. revealed that thirteen residents had indwelling urinary catheters, one resident had a feeding tube and three residents had intravenous therapy. Review of the facility's wound tracking logs, dated August 30, 2024 revealed that 40 residents had wounds. A tour of the facility was conducted on September 5, 2024, between 11:38 am to 12:02 p.m. Observations revealed that enhanced barrier precautions signage had been posted on only two resident rooms for Residents R154 and R165. Interview on September 5, 2024, at 1:00 p.m. Employee E4, Assistant Director of Nursing, stated that he did not perform any of the functions of the facility's infection preventionist role. 395258 Page 25 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on September 5, 2024, at 1:12 p.m. the Director of Nursing presented an antibiotic order listing for August 2024, however, continued interview revealed that she was unable to provide any evidence at the time of the survey to indicate infection surveillance that included tracking of infectious symptoms, infectious organism or evaluation of whether the infection was acquired while the resident was in the facility. The Director of Nursing was unable to provide any infection surveillance data for any months prior to August 2024. Continued interview, the Director of Nursing confirmed that enhanced barrier precautions were not implemented for Residents R154 and R165 until September 5, 2024, and that they were not implemented for all residents with indwelling urinary catheters, intravenous lines and chronic wounds as required. In addition, the Director of Nursing was unable to provide any evidence at the time of the survey to indicate that any staff received training related to enhanced barrier precautions. Continued interview revealed that no one at the facility had access to the PA-PSRS system and that they were unable to provide any utilization or infection reporting data. Further interview revealed that the Director of Nursing was unable to provide any documentation at the time of the survey of infection committee meetings. Review of clinical records revealed that Resident R165 was admitted in the facility on August 9, 2024, with diagnoses including Osteomyelitis of Vertebra, Thoracic Region (Osteomyelitis is an infection in a bone). Review of physician order for Resident R165, dated August 19, 2024, indicated a physician order; Enhanced barrier precautions related to: PICC Line Placement, When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting, Every shift until September 23, 2024 . On September 4, 2024, at 11:17 a.m., observed that a Registered Nurse (RN), Employee E 23 administered to Resident R 165, Unasyn Injection Solution Reconstituted 3 (2-1) GM (Ampicillin & Sulbactam Sodium), use 3 grams intravenously 6 hours for infection. Employee E23 did not implement Enhanced Barrier Precautions while providing the medication to Resident R165 intravenously. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management 395258 Page 26 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for two of two of residents reviewed for antibiotics (Residents R154 and R33). Residents Affected - Few Findings include: Review of facility policy, Antibiotic Stewardship Overview dated revised March 11, 2022, revealed, The facility will provide surveillance, tracking, trending and reporting to the leadership team to optimize the use of antibiotics in this facility. Continued review revealed, Provide standardized practices for the care of a resident suspected of an infection and/or one in which antibiotics are initiated. Standardized practices are comprised of a group of broad interventions to improve antibiotic use including but not limited to: Evaluation and reporting clinical signs and symptoms improvement; optimizing the use of diagnostic testing; and implementing an antibiotic review process (antibiotic time-out) for antibiotics prescribed in the facility. Review of facility policy, Antibiotic Stewardship Plan dated effective May 1, 2017, revealed that the facility will, Standardize practices to address care for suspected infections and the use of standardized definitions and criteria; this facility will utilize McGeer's Criteria [tool used for assessing infections] for monitoring, and reporting infections for surveillance and treatment. Continued review revealed that when a new antibiotics starts, the infection prevention nurse will monitor for clinical assessments, prescriptions/physician orders are present, complete and implemented as prescribed and in accordance with facility antibiotic use policies and practices; and track the amounts of antibiotic used in the facility, over time to review for patterns of use and adherence to determine if new stewardship interventions are effective. Review of the Facility Assessment, dated updated August 8, 2024, revealed that, The Infection Prevention Nurse is required to facilitate antibiotic stewardship in the facility. This is accomplished with collaboration of the clinical team, pharmacy consultant, and medical director or medical provider. Review of Resident R154's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 12, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multi-drug resistant organism (bacteria that is difficult to treat because it is resistant to commonly used antibiotics), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (a life-threatening infection that occurs when bacteria enter the bloodstream), and sacral pressure ulcer. Continued review revealed that the resident had a feeding tube and indwelling urinary catheter. Review of hospital records for Resident R154, dated August 9, 2024, revealed that the resident was treated in the hospital for shortness of breath and was found to have pneumonia. Resident R154 had sputum cultures completed that were positive for klebsiella and ESBL (multi-drug resistant organisms) and was treated with intravenous antibiotics. The hospital records recommended to continue treatment with the intravenous antibiotic aztreonam for seven days upon discharge. Review of progress notes for Resident R154 revealed a nurses note, dated August 9, 2024, which indicated that the resident was readmitted to the facility. Continued review revealed a note, dated 395258 Page 27 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few August 12, 2024, which indicated that lab results were received that the resident was positive for CRE (multi-drug resistant organism) and to initiate the intravenous antibiotic ertapenem for seven days. Review of Resident R154's Medication Administration Records (MARs) for August 2024, revealed physician orders, dated August 13 and 14, 2024, for ertapenem one gram intravenously every 24 hours for seven days. The medication was administered August 13 through 19, 2024. Review of Resident R33's Quarterly MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including urinary tract infection. Continued review revealed that the resident was taking an antibiotic medication. Review of progress notes for Resident R33 revealed a note, dated August 8, 2024, at 3:31 p.m. which indicated that the resident had a fall and was transferred to the hospital for evaluation. Continued review revealed a practitioner note, dated August 14, 2024, at 3:01 p.m. which indicated that the resident was admitted to the hospital with a diagnosis of urinary tract infection and to administer cefdinir (antibiotic medication) August 13 through 18, 2024. Review of Resident R33's MARs for August 2024, revealed that the resident received cefdinir 300 milligrams from August 14 through 18, 2024. Review of Resident R33's Antibiotic Time-Out tool, dated August 15, 2024, revealed that the resident was prescribed Keflex 500 milligrams (an antibiotic medication) for a urinary tract infection. Interview on September 5, 2024, at 1:12 p.m. the Director of Nursing revealed that the facility uses an Antibiotic Time-Out tool to assess prescribed antibiotics. Resident R33's Antibiotic Time-Out tool was reviewed; there was no indication of any infection surveillance data or criteria, nor any listed symptoms, clinical assessment or infectious organism. The Director of Nursing was unable to explain the discrepancy between Resident R33's prescribed antibiotic compared to the antibiotic listed on the Antibiotic Time-Out tool. Continued interview revealed that no Antibiotic Time-Out tool had been completed for Resident R154. The Director of Nursing presented an antibiotic order listing for August 2024, however, continued interview revealed that she was unable to provide any evidence at the time of the survey to indicate infection surveillance that included tracking of infectious symptoms, infectious organism or evaluation of whether the prescribed antibiotics were appropriate. The Director of Nursing was unable to provide any infection surveillance data for any months prior to August 2024. Further interview revealed that the Director of Nursing was unable to provide any documentation at the time of the survey of infection committee meetings or evidence of collaboration with the clinical team, prescribing physicians or medical director related to antibiotic use. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 395258 Page 28 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on review of facility policies and interviews with staff, it was determined that the facility failed to designate one or more individuals as the infection preventionist who work at least part time at the facility. Residents Affected - Few Findings include: Review of facility policy, Infection Prevention Program dated last reviewed February 24, 2022, revealed, that an Infection Preventionist is a nurse, epidemiologist, public health professional, microbiologist, physician, or other health professional who works to prevent germs from spreading within the healthcare facility and is qualified by training and experience to oversee the infection prevention program for the facility. Continued review revealed that the Infection Preventionist's responsibilities include infection surveillance including tracking, trending and identification of specific organisms; reporting of infectious outbreaks; compliance review, provides staff education and feedback; completes the line listing of infections; completes monthly report forms and reports findings to the QAPI (Quality Assurance Performance improvement) committee. Review of the Facility Assessment, dated updated August 8, 2024, revealed that, The facility shall have an Infection Prevention Nurse that has completed the required training. Continued review revealed, The Infection Prevention Nurse is required to provide surveillance, analysis, and plan to recognize and prevent the spread of infection. During Entrance Conference on September 3, 2024, at 9:31 a.m. the Director of Nursing revealed that the role of the infection preventionist was shared between herself and Employee E4, Assistant Director of Nursing. Interview on September 5, 2024, at 1:00 p.m. Employee E4, Assistant Director of Nursing, stated that he did not perform any of the functions of the facility's infection preventionist role. Interview on September 5, 2024, at 1:12 p.m. the Director of Nursing revealed that she was unable to provide any documentation at the time of the survey to indicate that either herself or any other staff at the facility had completed specialized training in infection prevention and control as required. Further interview revealed that the facility was in the process of hiring a nurse for the Infection Preventionist role. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1) Nursing Services 395258 Page 29 of 30 395258 09/26/2024 Bristol Health & Rehab Center 905 Tower Road Bristol, PA 19007

F 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for two of three nursing units observed (First and Second floor nursing units). Residents Affected - Few Findings include: Observation of the First Floor Nursing Unit on September 3, 2024, at 10:05 a.m. revealed the following: The handrail by room [ROOM NUMBER] was broken and top part coming off. The handrail by room [ROOM NUMBER] was broken. Observation of the Second Floor Nursing Unit on September 3, 2024, at 12:51 p.m. revealed the following: The handrail by room [ROOM NUMBER] was cracked with exposed sharp edges; The handrail by room [ROOM NUMBER] was broken and covered with tape; and The handrail between rooms [ROOM NUMBERS] was missing. Interview on September 3, 2024, at 2:00 p.m. the Nursing Home Administrator confirmed that handrails were broken or missing and that a full audit of all handrails would be conducted. Interview on September 4, 2024, at 2:37 p.m. the Nursing Home Administrator confirmed handrail parts order on September 3, 2024. 28 Pa Code 201.14(a) Responsibility of licensee 395258 Page 30 of 30