Health inspection·September 5, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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, clinical record review, observations, and staff interviews, it was determined the facility failed to identify a bed against the wall and an abdominal binder as a possible restraint and failed to assess the functional status of the resident to determine the use of the restraint for one of eight residents reviewed. (Resident R5) Residents Affected - Few Findings Include: Review of facility policy titled Restraints (Physical) with a revision date of May 5, 2023 states, Policy: The resident has a right to be treated with respect and dignity, including: The right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Further review of the policy revealed, Procedure: 1. Complete a physical restraint assessment if resident is utilizing a restraint or there is potential that device may be a restraint, i.e. Geri chair, rock n go chair. Identify alternatives used prior to the initiation of the restraint. The restraint assessment will be completed upon admission/readmission, quarterly, annually, with a significant change, and initiation of or discontinuance of a restraint. 2. Obtain informed consent for physical restraint use identifying risks and benefits of its use. 5. A physical restraint will be removed at least 10 minutes out of every 2 hours during the normal waking hours to allow the resident an opportunity to move and exercise. Except during the usual sleeping hours, the resident's position will be changed every 2 hours if a device is in place. During sleeping hours, the position will be changed as indicated by the resident's needs. 6. The facility will document the use of a physical restraint and the release of the restraint; documentation can occur at the end of the shift indicating the restraints were released for ten minutes every two hours, I.e. on the MAR/TAR. Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral infraction (stroke), anxiety, dementia (progressive degenerative disease of the brain), end stage renal disease, spondylosis (abnormal wear on the cartilage and bones of the neck) Review of Resident R5's clinical record revealed a physician order with a start date of July 18, 2024 for Abdominal Binder remove for care and skin checks every shift. Observation of Resident R5 on September 5, 2024 at 11:15 a.m. with the licensed nurse Employee E4 revealed the resident did not currently have the abdominal binder on. The licensed nurse stated the Page 1 of 7 395334 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few binder was in the laundry. The laundry room was checked at 12:11 p.m. and laundry staff were able to locate two abdominal binders for Resident R5 which were clean and ready to be sent back up to the unit for use. Observation of Resident R5's room at 1:01 p.m. revealed the resident's bed was placed with the left side up against the wall. There was one fall mat in the room which was leaning up against the wall due to the floor being wet from mopping. Review of Resident R5's current care plan revealed that there was no care plan developed for the resident's bed to be against the wall and for the abdominal binder. Further review of the resident's clinical record revealed there was no restraint assessment completed for the bed against the wall or the abdominal binder. Interview held with the Director of Nursing Employee E2 on September 5, 2024 at 1:10 p.m. confirmed the above findings that the resident had no been assessed for the physical restraints the facility has in place including the abdominal binder and the bed against the wall. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code:211.12(d)(1)(5) Nursing services. 395334 Page 2 of 7 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews with staff, and review of facility policy and procedures, it was determined that the facility failed to ensure that one out of eight residents reviewed were monitored for acceptable parameters of weight. (Resident R5) Residents Affected - Few Findings Include: Review of facility policy titled, Weight and Height Assessment and Interventions with a revision date on March 18, 2024 states, Policy: Purposes of this procedure are to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a height in order to determine the ideal weight of the resident. The Facility will ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance are maintained, unless the resident's clinical condition demonstrates that is not possible or resident preferences indicate otherwise; The nursing staff and the Dietician will coordinate care to prevent, monitor, and intervene for undesirable weight loss/gain for our residents. Further review of the facility policy states, 4. Any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with licensed nurse confirming reweigh. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. Attending physician, resident/resident representative will be notified of unplanned significant weight changes as described below. Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; cerebral infraction, sepsis, diverticulitis, elevated blood cell count, gastrostomy malfunction, dementia, end stage renal disease, adult failure to thrive, and depression. Review of Resident R5's physician orders revealed an order from June 13, 2024 stating, Record post-dialysis (dry) weight in chart upon return from dialysis. The order was to be started on June 14, 2024 and weights should have been recorded Monday, Wednesday, and Friday. Review of Resident R5's Medication Administration record for the month of August 2024 revealed no post-dialysis weight recorded for August 2, 2024 or August 21, 2024. Review of Resident R5's Medication Administration record for the month of September 2024 revealed only two weights recorded: September 3, 2024-129 pounds and September 4, 2024-129 pounds. Review of Resident R5's Weight Summary record on September 5, 2024 at 10:15 a.m. revealed the following weights; August 30, 2024- 129 pounds August 16, 2024- 132.7 pounds August 9, 2024- 136 pounds 395334 Page 3 of 7 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0692 August 4, 2024- 137 pounds Level of Harm - Minimal harm or potential for actual harm August 2, 2024- 137 pounds July 22, 2024- 137.5 pounds Residents Affected - Few July 18, 2024- 137.5 pounds July 7, 2024- 155 pounds July 6, 2024- 155.1 pounds July 5, 2024- 155.1 pounds July 3, 2024- 155.1 pounds July 1, 2024- 155.1 pounds June 28, 2024- 155.2 pounds June 26, 2024- 155.4 pounds June 21, 2024- 155.6 pounds June 19, 2024- 155.4 pounds June 17, 2024- 155.4 pounds June 13, 2024- 155.4 pounds Review of Nutrition/Dietary note on July 19, 2024 states, readmission: Returns s/p hospital stay, PMHx includes CVA, OA and HTN. Currently weighs 138# indicating -17# weight loss since returning, will continue to monitor admission weights. Body Mass Index indicating underweight, slow weight gain desirable. Enteral feeding ordered as Nepro 60ml x 20 hrs providing 1200ml TV, 2124kcal, 97g PRO and 872ml H2O. Flush ordered at 250ml q 4 hrs, providing an additional 1500ml H2O. Enteral orders meet estimated needs for weight gain. Receives mechanical soft, thin liquid trays in addition to enteral feed. No skin breakdown or edema noted upon return. Continue current POC, encourage meal acceptance, monitor for s/sx of aspiration, will follow prn. Plan to wean off enteral feed as intakes improve/stabilize. Further review of resident clinical record shows no indication of the resident having a mechanical soft, thin liquid tray in addition to enteral feed. Review also revealed there was no indication of discontinuation of mechanical soft, thin liquid trays. Resident R5's record only showed resident as NPO (Nothing by mouth) while at the facility. Interview with the facility dietician Employee E3 held on September 5, 2024 at 11:47 a.m. revealed the dietician stated that the resident arrived at the facility NPO (Nothing by mouth). When asked if the dietician had been monitoring Resident R5's weights he stated that he monitors all weights daily and for dialysis residents, the dialysis center keeps their own set of weights, and he is sent the 395334 Page 4 of 7 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weights weekly by e-mail from the dialysis dietician. Employee E3 stated that he had some confusion on if the licensed nurse at the facility should be completing a post-dialysis weight when the resident arrives back to the facility. When asked if he provided intervention for Resident R5's significant weight loss he stated, I would have to look, I'm not familiar, I would have to look to see if the first weight was a one-time weight or if he was re-weighed to establish a baseline weight. I usually wait to see the first few weights before getting a baseline weight. When asked about the facilities weight policy the dietician stated weights should be completed on admission, 24 hours later, and then weekly for 3 weeks. Review of the facility Matrix for Resident R5 did not show the resident triggering for significant weight loss. The dietician provided weights from the dialysis dietician at 1:15 p.m. for Resident R5 that showed the following post dialysis weights; August 9, 2024- 71kg equal to 156.52 pounds August 16, 2024- 70.4kg equal to 155.20 pounds August 21, 2024- 70kg equal to 154.32 pounds August 23, 2024-70.5kg equal to 155.42 pounds August 28, 2024-72.3kg equal to 159.39 pounds There was no post-dialysis weights recorded for Resident R5 for August 12, 14, 19, 26, and 30, 2024. The dietician explained that based on the weights provided by the dialysis dietician the resident has a stable weight since admission. At this time the surveyor requested that Resident R5 be weighed today to confirm the higher weight. At 1:25 p.m. Resident R5 was brought to the scale by nurse aide Employee E6. Also present for the weight was facility dietician Employee E3. Resident R5 was not able to stand on the scale with assistance from nurse aide Employee E6 therefore he was weighed in his geri-chair. In the geri-chair Resident R5's weight was 208.8 pounds. The nurse aide Employee E6 weighed the geri-chair empty and it weighed 73 pounds. After calculation is was determined that Resident R5's current weight was 135.8 pounds. Facility dietician Employee E3 confirmed the weights sent electronically from the dialysis dietician are inconsistent and inaccurate. Review of Resident R5's Weight Summary record on September 5, 2024 at 2:00 p.m. revealed there were additional weights added to the residetn's clinical record today by licensed nurse Employee E7 with the following weights; August 7, 2024- 117 pounds July 29, 2024- 114 pounds 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. 211.6(a) Dietary services 395334 Page 5 of 7 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two residents reviewed. (Residents R2 and R5) Residents Affected - Few Findings Include: Review of the facility policy titled, Dialysis Management (Hemodialysis) with a revision date of March 28, 2024 revealed, It is policy of the facility to ensure that residents who require outpatient hemodialysis treatment have appropriate arrangements made by the facility with an outpatient treatment center in order to provide such services as directed by the physician. Further review of the policy states, If Dialysis is provided at off-site Dialysis Center: 5. Develop a resident binder/folder to send to dialysis with the resident. Communication form is placed in the binder after completion of the pre dialysis assessment. 6. Facility to complete Pre-dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and facility. 7. Dialysis center personnel to complete Dialysis communication form and return to facility. Dialysis Center may provide HER documentation vs manual documentation of treatment on communication form. 8. Upon return from Dialysis Center, review information provided on Dialysis communication form/HER. Communicate and address as appropriate. 9. Facility to complete post-dialysis information/date and place in resident's medical record. Review of Resident R2's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Morbid obesity, end stage renal disease, dependence on renal dialysis, muscle weakness, heart failure and cognitive communication deficit. Review of Resident R5's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: elevated blood cell count, acute embolism and thrombosis, depression, dementia, chronic kidney disease, metabolic encephalopathy, spondylosis, cardiomyopathy, hyperparathyroidism, and hepatomegaly. Review of Resident R2's dialysis communication records on September 5, 2024 at 11:18 a.m. revealed the for the months of July, August, and September 2024 revealed the communication records were incomplete. For the three months reviewed the dialysis book was missing a communication record form for the following dates: September 2, September 4, August 30, August 28, August 23, August 21, August 19, August 16, August 12, August 9, August 7, August 5, August 2, July 31, July 29, July 26, July 22, July 10, July 5, and July 1. Interview with the licensed nurse Employee E4 on the unit at 11:22 a.m. revealed any communication records completed should have been placed in the binder for both Resident R2 and Resident R5. For the three months reviewed the dialysis book was missing a communication record form for the following dates: July 1, July 8, July 10, July 12, July 15, July 17, July 26, August 5, August 9, August 12, August 14, August 19, August 21, August 26, August 28, August 30, September 2, and September 4. Review of Resident R5's of the dialysis communication records on September 5, 2024 at 11:18 a.m. revealed the for the months of July, August, and September 2024 revealed the communication records were incomplete. 395334 Page 6 of 7 395334 09/05/2024 Chestnut Hill Lodge Health and Rehab Ctr 8833 Stenton Avenue Wyndmoor, PA 19038

F 0698 Interview with the Director of Nursing Employee E2 at 2:07 p.m. confirmed the above findings and stated there were no other communication records found for Resident R2 or Resident R5. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.5(f)(ix) Clinical records Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395334 Page 7 of 7