Health inspection·February 5, 2025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and results of a test tray audit, it was determined that the facility failed to ensure that residents were served food that was palatable and at acceptable temperatures on one of three nursing units (First Floor) for five of six sampled residents. (Residents 1, 2, 4, 5, 6) Residents Affected - Few Findings include:. Observation on February 5, 2025, at 11:46 a.m., revealed that the food cart for the First Floor nursing unit left the kitchen at 11:46 a.m. and arrived on the nursing unit at 11:47 a.m. The cart sat in the dining room until 11:59 a.m., when staff began to distribute the food trays to residents. The last tray was served at 12:05 p.m., 18 minutes after the food cart had arrived on the nursing unit. At that time, the temperatures of the food on the tray were as follow: The main entree of penne pasta and [NAME] sauce was 122 degrees Fahrenheit. The chef's blend vegetables that included broccoli and carrots was 100 degrees Fahrenheit. The main entree and the vegetables were cool to taste and were not palatable. In an interview, on February 5, 2025, at 11:35 a.m., the Director of Dietary stated that hot food was to be served at 130 degrees Fahrenheit at the point of service to residents and that trays were to be distributed to residents from the food cart within 10 minutes of arrival to the nursing unit. Clinical record review revealed that Residents 1, 2, 4, 5, and 6 were alert and oriented and able to make their needs known to staff. In an inteview on February 5, 2025, at 12:05 p.m., Residents 4 and 6 stated that the lunch today was served cold and was not palatable. In an interview on February 5, 2025, at 12:10 p.m., Resident 5 stated that the food was not good and was often served cold. In an interview on February 5, 2025, at 12:15 p.m., Resident 1 stated that the food, including today, was often served cold and did not always taste good. Page 1 of 4 395277 395277 02/05/2025 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0804 Level of Harm - Minimal harm or potential for actual harm In an interview on February 5, 2025, at 12:20 p.m., Resident 2 stated that the food, including today, was often served cold and was not palatable. Observation revealed that Resident 2 did not eat much of her meal. 28 Pa. Code 201.14(a) Responsibility of licensee. Residents Affected - Few 28 Pa. Code 201.18(b)(3) Management. 395277 Page 2 of 4 395277 02/05/2025 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, it was determined that the facility failed to provide a working call bell for four of six residents (Residents 1, 2, 5, 6) on one of three nursing units. (First Floor) Residents Affected - Some Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart disease and diabetes. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. Observation on February 5, 2025, at 11:00 a.m. through 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no audible alert. In an interview at 11:00 a.m., Resident 1 stated that his call bell did not work and that staff did not respond to the light because there was no sound. Clinical record review revealed that Resident 5 had diagnoses that included adult failure to thrive and diabetes. Review of nursing documentation dated February 1, 2025, indicated that the resident was alert and oriented and able to make his needs known to staff. Observation on February 5, 2025, at 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no sound when activated. In an interview at 12:10 p.m., Resident 5 stated that his call bell did not work. Clinical record review revealed that Resident 6 had diagnoses that included major depressive disorder and anxiety. The MDS assessment dated [DATE], indicated that the resident was alert and oriented. Observation on February 5, 2025, at 11:10 a.m. through 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no call bell sounding from the room. In an interview at 11:10 a.m., Resident 6 stated that the call bell did not work, that the light stayed on all the time, and that it had not worked for a while. Clinical record review revealed that Resident 2 had diagnoses that included sepsis (infection). Review of nursing documentation dated January 30, 2025, indicated that the resident was alert and oriented and able to make her needs known to staff. Observation on February 5, 2025, at 11:20 p.m., revealed that in resident room [ROOM NUMBER], the call bell for the bed by the window was unplugged and laying on the floor near the heating vent. In an interview at that time, Resident 2 stated, that the call bell did not work even if it was plugged in to the wall. In an interview on February 5, 2025, at 10:35 a.m., the Director of Nursing stated that there had been an issue with the call bell system not working on a consistent basis on the First Floor nursing unit for a while. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. 395277 Page 3 of 4 395277 02/05/2025 Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a sanitary, functional, and comfortable environment for residents on one of three nursing units. (First Floor) Findings include: Observations on February 5, 2025, from 11:00 a.m through 12:20 p.m., on the First Floor nursing unit revealed the following environmental issues: In resident room [ROOM NUMBER], there was a large hole in the wall behind the toilet in the bathroom. There was a ceiling tile near the vent in the bathroom that was damaged. There were stained and missing floor tiles throughout the bathroom floor. The floor tiles around the bottom of the toilet and under the sink were stained. The toilet bowl was soiled. There was a bath tub in the bathroom of room [ROOM NUMBER] that had a basin on top of it. The basin was filled with a bag of soiled linen. There was no paper towel holder in the bathroom. In resident room [ROOM NUMBER], there were two boxes of wound dressing pads, two gallon jugs of sterile water, a box of gloves, a reacher, and other personal hygiene items stored on the window sill. In addition, the dresser near the window bed was overflowing with miscellaneous items on the top of the dresser and in the drawers. In an interview, the resident stated that he needed help to clean out the dresser and the window sill. The over-the-bed table for the first bed in room [ROOM NUMBER] was cracked and damaged. The bottom rungs of the table were soiled with a black substance. The sheets and comforter on the second bed in room [ROOM NUMBER] were stained. In the first floor dining room there were six stained ceiling tiles and one ceiling tile with a hole. There was also a large ceiling tile that was missing which exposed rusted pipes and wires. The tiles around the toilet in the bathroom of room [ROOM NUMBER] were stained. There were seven bathroom wall tiles that had fallen off the wall and were laying on the floor of the bathroom. The toilet bowl in this bathroom was soiled. The toilet seat was crooked and broken. The ceiling tile near the vent in the bathroom was damaged. The tiles on the bathroom floor of room [ROOM NUMBER] were damaged. The lower wall behind the toilet was damaged. The tiles in the bathroom of room [ROOM NUMBER] were stained and there was no paper towel holder in place. 28 Pa.Code 201.18(b)(1)(e)(2.1) Management. 395277 Page 4 of 4