Health inspection·September 26, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to conduct required criminal background checks in a timely manner prior to employment for three of five newly hired employees. (Employees 3, 4, 5) Residents Affected - Few Findings include: Review of the facility policy entitled, Abuse Neglect Exploitation Mistreatment, and Misappropriation of Property Prevention, last reviewed September 5, 2024, revealed that the facility was to screen and train employees on the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and chemical restraints. The procedure was for the faciltiy, prior to employment, to screen potential employees for a history of abuse, neglect, or mistreating residents. This included attempts to obtain information from previous employers and checking with the appropriate licensing boards and registries. Review of employee files revealed the following background checks that were not completed prior to employment: Employee 3 was hired on July 30, 2024. The facility failed to conduct a criminal background check until September 24, 2024. Employee 4 was hired on July 19, 2024. The facility failed to conduct a criminal background check until September 24, 2024. Employee 5 was hired on May 29, 2024. The facility failed to conduct a criminal background check until September 24, 2024. In an interview on September 26, 2024, at 12:10 p.m., the Administrator stated that the criminal background checks had not been completed prior to hire as per facility policy for the above listed newly hired employees. 28 Pa. Code 201.19 Personnel policies and procedures. Page 1 of 4 395277 395277 09/26/2024 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the current status of one of 22 sampled residents. (Resident 7) Residents Affected - Few Findings include: Clinical record review revealed that Resident 7 had an indwelling urinary catheter that was discontinued on July 29, 2024. The MDS assessment, dated August 27, 2024, incorrectly indicated in Section H that the resident still had the indwelling urinary catheter during the previous seven days. In an interview on September 26, 2024, at 10:30 a.m., the Director of Nursing confirmed that Resident 7's MDS assessment was inaccurate. 395277 Page 2 of 4 395277 09/26/2024 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 22 sampled residents. (Resident's 7, 59) Findings include: Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, kidney disease, and Crohn's disease (inflammatory bowel disease). The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 28, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 7 urinary incontinence was included in the current care plan. Clinical record review revealed that Resident 59 was admitted to the facility on [DATE], and had diagnoses that included heart failure and renal insufficiency (kidney disease). The MDS CAA summary dated August 5, 2024, noted that the resident's visual function, communication needs, and urinary incontinence were to be addressed in the care plan. There was no evidence that interventions to address Resident 59's visual status, communication needs, and urinary incontinence were included in the current care plan. In an interview on September 26, 2024, at 10:20 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395277 Page 3 of 4 395277 09/26/2024 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions and functional equipment in the dietary department. Residents Affected - Many Findings include: Observation of the dietary department on September 24, 2024, at 9:40 a.m., revealed the following: There were two sets of convection ovens. The first set of convection ovens was soiled on the inside of the doors and on the bottoms of the ovens. There was splattered, dark grease on the racks and on the inside of the doors of the ovens. In addition, the oven doors were rusted in the middle which made the doors difficult to close all the way. The second set of convection ovens was not operational. Observation of the range top stove revealed that there were only three of six burners on top of the stove that were functional. There was a black substance splattered and stained on the backsplash behind the range. In addition, both bottom ovens were not operational. In an interview at this time, the Director of Dietary stated that the second set of convection ovens did not work and that both of the bottom ovens of the range top stove were not operational. 28 Pa. Code 201.14(a) Responsibility of licensee 395277 Page 4 of 4