Health inspection·December 12, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on review of facility financial and accounting documentation and interview with administrative staff, it was determined that the facility failed to demonstrate the maintenance of a complete, separate, and accurate accounting of each residents personal funds entrusted to the facility on the residence behalf for one of 24 residents reviewed (resident R28). Findings include: Review of facility policy Titled Personal Funds revealed If the facility has been designated to handle the personal funds of the resident, the business office will maintain a full complete and separate accounting according to generally accepted accounting principles of each resident's personal fund entrusted to the facility. A copy of the quarterly statement will be submitted to the resident, or the residents designated representative on a quarterly basis and or at the request of the designated representative or resident. Review of information submitted to the Department revealed that On October 21, 2024, nursing home administrator employee E1 became aware that resident R28 alleged that there were inaccuracies with her most recent quarterly statement including charges she did not recognize. Continued review of this event revealed that resident R28 had questions about her statement and the director of nursing, employee E2, presented a withdrawal receipt to resident R28 of funds received with Residents R28's signature. The NHA, employee E1, interviewed the previous business office manager who stated that resident R28 withdrew sums of 100 dollars 200 dollars and 300 dollars. The NHA employee E1 determined that resident R28 had inconsistencies with the relaying information of use of the funds and the facility was unable to substantiate the residence funds have been misappropriated. Interview with resident R28 on December 09, 2024, at 09:55 a.m. revealed that she had concerns regarding her financial statement. Resident R28 stated she never withdrew any money other than the allotted $45 dollar allowance monthly. This resident was given her monthly statements and did not recognize the withdraws of money. Interview with Business office manager E4 on December 11, 2024, at 3:45 pm, revealed that is it the facility's protocol of when a resident requests money, the business director will withdraw the requested amount of money and provide a receipt to be signed by the resident confirming that they have received the money. This employee stated that there is a scheduled banking day once a month for residents to requests funds, if any resident should request funds other than on the banking day, they are to contact employee E4 and requests a transaction, the resident will then sign a statement that they are withdrawing from their account and the resident is then given the funds and a receipt. Page 1 of 24 395354 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Continued interview with business officer manager employee E4 on December 12, 2024, at 10:00 a.m. revealed that she recently started the position of business office manager and has no knowledge of the above event. Employee E4 was unable to locate any copies of receipts of money paid out to resident R28. Interview with Nursing home administrator employee 1 on December 12, 2024 at 3:10 p.m. revealed there were only two dates of question regarding withdraw funds on resident R28 statement. The facility was unable to locate one of the receipts therefore reimbursing the resident for the money total of $300. 28 pa code 201.18(e)(1) management 395354 Page 2 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with resident and staff, review of clinical records, and facility policy, it was determined that the facility failed to ensure one of 24 residents records reviewed were free from abuse/neglect (Residents 25). Findings include Review of the facility's employee abuse education received from the Nursing [NAME] Administrator defines abuse as the willful infliction of injury, unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish. The documentation defines types of abuse and explains Mental/Emotion abuse, verbal or nonverbal acts which causes humiliation, shame, degradation, intimidation, fear and agitation. Review of the same documentation states verbal abuse is a type of mental abuse that can be oral, written, gestured language or sounds. It can be directed at or within hearing distance of the resident. Examples included: Harassment, mocking, yelling, intimation, talking disrespectfully and scolding. Review of clinical records revealed Resident R25's last admission to the facility was on October 17, 2023, diagnosed with acute and chronic respiratory failure with hypoxia (lacking oxygen), chronic obstructive pulmonary disease (restricted airflow), shortness of breath, and ordered continuous oxygen therapy 3 liters a minute via nasal canula requiring the tubing to be changed weekly or as needed. Resident R25 was also diagnosed with mental health illnesses that included anxiety disorder, major depressive disorder, severe with psychotic symptoms, and dissociative fugue (a loss of memory and identity ) On December 9, 2024, at approximately 11:00 a.m. surveyor observed Resident R25's care nurse Licensed Practical Nurse (LPN) Employee E18 remove the resident's spare oxygen cannula from his room. The LPN began to yell at Resident R25 from the nurses' station to the resident that was standing near his doorway, seen with oxygen in use and tubing near the length of his room. Nurse yells, Stop it! Just stop! You know I take great care of you, stop being manipulative! Resident R25 appeared upset that he no longer had his spare oxygen tubing. Still standing in the doorway, the resident's voice quivered as he says to the nurse, It's mine, I need it to walk, it's mine and you took it The LPN's sternly yells at the resident, No! Just stop! You have a tube in your nose! The resident looked anxious as he paces his doorway and again said, I need it for when I walk. The nurse appears to lose her patience, raises her voice, and continues to yell at the resident. No! No means no! Just stop! You will get one when you walk! Stop! You're not walking anywhere right now. Stop. Just stop! The LPN informs the surveyors that Resident R25 has anxiety and behaviors and needs to be frequently redirected. The resident is now requesting cold water, LPN E18 tells the resident to, Wait. Everyone's about to get water, being anxious isn't going to make them move faster. During this time Resident R25 was interviewed and stated the night nurse gave him an extra tubing. Look at this! Wanting the surveyor to look closely at his nasal canula/tubing, What happens if it breaks at night the resident asked, implying he would not have any oxygen to breathe. The resident further said that Employee E18, was not nice, She opened the drawer and took it (oxygen tubing) That 395354 Page 3 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0600 was mine. Level of Harm - Minimal harm or potential for actual harm Review of Resident R25's is care planned for unwanted behaviors included compulsiveness and anxiety. Intervention included anticipating and meeting the resident's needs and that the caregivers are to provide opportunities for positive interactions and attention dated May 2, 2023. Resident R25 was care planned for impaired thought processing related to his respiratory issues. Interventions include asking yes/no questions to determine the residents needs, dated August 10, 2022. Continue review of the resident's care plan revealed the resident was on continuous oxygen and that the resident requests using a long oxygen tubing to walk in his room and hallway. Residents Affected - Few Review of psychological Services notes from the Licensed Clinical Social Worker (LCSW) dated October 8, 2024, noted symptoms of helplessness irritable and anxiety. Behavior challenges included attention seeking (Complaintive/Demanding), and uncontrolled anxiety . The LCSW stated significant developments since last session, session gains, additional recommendations, comments in the notes. The resident appeared irritable, and anxious and called the therapist in his room, he was not happy with his meal choice and insisted the counselor get him a sandwich. Resident R25 became Increasingly anxious and demanding. The same note indicated that Nursing said, 'he would hide his sandwich for later' and stated in her notes that that is not allowed for several reasons. The goal is to decrease anxiety and manage mental health symptoms, more appropriately within the facility and decrease impulsivity. Psychological services note from LCSW dated October 24, 2024, notes, Therapist empathized with client and offered ways to manage mental health symptoms when they come on. Client's mood seemed to improve by the end of the session . Resident's and counselor's goal is to decrease depressive/anxious symptoms and increase mental and emotional functioning. On December 9, 2024, at approximately 12:00 p.m. Nursing Home Administrator (NHA) was informed of the incident surveyors witnessed indicating the nurse appeared to have escalated Resident R25's anxiety . The NHA determined the nurse did not have the authority to take the tubing out of his drawer without asking and Resident R25 was allowed to have an extra set of tubing in his drawer as long as it was unopened. After, the nurse, Employee E18 was reeducated for Abuse Training. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident Rights. 395354 Page 4 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, clinical record and and policy and procedure reviews, it was determined that the facility failed to evaluate each resident for their discharge needs upon admission and throughout the resident's stay to ensure a successful individualized discharge plan was implemented for three of seven residents reviewed. (Residents R11, R34 and R46) Residents Affected - Few Findings include: A review of the facility's policy and procedure titled Discharge Summary and Plan dated December, 2016 revealed that all residents would have a discharge plan developed to assist the resident to adjust to his/her living environment. The policy also indicated that every resident was to receive evaluation by the interdisciplinary care team to develop a plan for discharge to the community or to another facility with the resident and their family member. The policy indicated that each resident and representative would be asked about their interest in returning to the community or other plans for transferring to another skilled nursing facility, home health agency, long term care hospital or inpatient rehabilitation facility. The policy indicated that the facility staff was responsible for referring the resident to local agencies and support services to accommodate the resident's post discharge preferences. Clinical record review for Resident R11 revealed a quarterly comprehensive assessment MDS(an assessment of care needs dated October 18, 2024 that indicated that this resident was cognitively intact and able to express his needs to staff. Clinical record review for Resident R34 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 6, 2024 that indicated that this resident was cognitively intact and capable of letting staff know his needs. Clinical record review for Resident R46 revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 23, 2024 that indicated that this resident was alert, oriented and cognitively intact expressing her needs to staff. Interviews with Residents R11, R34 and R46 throughout the days of the survey December 9, 10, 11 and 12, 2024 revealed that these residents were interested in a discharge plan to the community. Clinical record review for residents R11, R34 and R46 revealed lack of development of goals and implementation of an interdisciplinary discharge care plan for these residents. Clinical record review for Resident R46 revealed a social service progress note dated May 2, 2023 to indicate that this resident desired discharge plans to the community with her cousin. There was no further documentation related any discharge plans as Resident R46 preferred. Clinical record review revealed that on June 5, 2024 Resident R46 was physically aggressive with Resident R81. Residents R46 and R81 were observed physically pulling hair, scratching and punching each other. The follow-up to this abusive incident was to seek a transfer to another facility in the community, for Resident R46. The other facility was an adult group home, specializing in the care of behavioral wellness for Resident R46. There was no documented update for this discharge plan for Resident R46. Clinical record review revealed that Resident R46 had diagnoses of major depressive 395354 Page 5 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0660 disorder, anxiety disorder, post traumatic stress disorder and schizo-affective disorder. Level of Harm - Minimal harm or potential for actual harm Clinical record review for Resident R34 revealed that this resident was admitted to the facility on [DATE]. There was no discharge care plan established for the resident upon admission and updated throughout the resident's stay, despite the resident's preference to return to the community and closer to his family who live in Delaware and Northeastern Philadelphia. Residents Affected - Few Clinical record review for Resident R11 revealed that this resident was requesting a transfer to another nursing home closer to his brother. The resident had made a statement on May 29, 2024 that he wanted to leave the facility against medical advice. There was no documentation to indicate that the social worker had assisted this resident with discharge planning after it was documented on August 9, 2024 that the resident wanted to discharge to another nursing home that had no available beds. Interview with Resident R11 at 11:30 a.m., on December 9, 2024 revealed that this resident was fearful that Resident R41 would punch him. Resident R11 said that Resident R41 passes by his room and gives him a look as to not come near him. Interview with Resident R41 at 2:30 p.m., on December 11, 2024 confirmed that if Resident R11 hand gestures negatively toward him or spits on him that he may punch him. Resident R41 also said that he and resident R11 had a confrontation with spitting and slapping in March, 2024 where the nursing staff changed rooms for resident R11 to room [ROOM NUMBER]. Clinical record review for resident R41 revealed a comprehensive assessment MDS (an assessment of care needs) dated November 14, 2024 that indicated that resident was alert and cognitively intact. Interview with the director of nursing, Employee E2 and social work staff, Employee E17, at 3:00 p.m., on December 12, 2024 confirmed the lack of interdisciplinary care planning for discharge to the community or transfers to another facility for continuum of healthcare and safe environment, as preferred by Residents R11, R34 and R46. 28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 PA. Code 211.10(a)(b)(c)(d) Resident care polies 28 PA. Code 211.5(f)(ii)(iii)(ix)(xi) Medical records 395354 Page 6 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews with residents and staff, observations of care and services and policy and procedure reviews, it was determined that for one of three residents reviewed the facility failed to provide safe and comfortable adaptive equipment to ensure activities of daily living were maintained for mobility. (Resident R34) Residents Affected - Few Findings include: A review of the policy titled Activities of Daily Living, Supporting dated March of 2018 revealed that the facility was responsible for providing care, services and treatment to maintain or improve a residents' ability to carry out activities of daily living (hygiene, mobility, elimination, dining or communication). This policy indicated that the care and services was to be provided for residents who were unable to carry out ADL's independently. Clinical record review for Resident R34 revealed a quarterly comprehensive assessment dated [DATE] that indicated this resident was cognitively intact. The assessment also indicated that this resident was dependent on staff to transfer from the bed to the chair. Interview with Resident R34 at 10:15 a.m., on December 9, 2024 revealed that this resident was supposed to be getting assistance from the nursing and physical therapy staff daily with mobility (transfer and ambulation) out of bed. Resident R34 reported that he had not been getting the assistance he needed for his mobility needs. Observations of resident R34's room revealed a manual wheel chair. The resident confirmed that staff have to use a mechanical lift to transfer him from the bed to his manual wheel chair. Clinical record review revealed a physical therapy assessment dated [DATE] that indicated that resident R34 required maximum assistance from staff to roll side to side in bed. This assessment also indicated that Resident R34 required maximum assistance of staff for transfers supine to sit to participate in activities of daily living. Interviews with the nursing staff, licensed practical nurse, Employee E12 and nursing assistant, Employee E13 at 2:00 p.m., on December 10, 2024 revealed that the nursing staff were most familiar with Resident R34 and his mobility care needs. The nurses explained that it was difficult and unsafe to transfer Resident R34 with the available wheel chair in his room; because the back of the wheel chair was not adjustable. The nursing staff demonstrated that they have to tilt the chair backward to try to align Resident R34 in a center position in the wheel chair. The staff explained that they need a chair with a reclining and adjustable back so that after the transfer into the wheelchair they could position the resident properly and comfortably. The nursing staff reported that they have been reluctant to transfer Resident R34 from the bed to the wheelchair; for their safety and the safety of the resident, fearing that the wheel chair could tip over from the poor and awkward position of Resident R34. Interview with the physical therapist, Employee E16 at 11:00 a.m., on December 11, 2024 revealed 395354 Page 7 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that a wheel chair with a reclining back was an option for the mobility of Resident R34. The physical therapist said that the rehabilitation department did not order the safe and adjustable adaptive equipment (reclining/adjustable wheel chair) for Resident R34; since they were unaware of the problems the nursing staff were encountering with transferring Resident R34 properly. The physical therapist reported that there were no observations of the actual attempts, by the nursing staff to transfer Resident R34 form the bed to the wheelchair; since August, 2024. Interview with the director of nursing at 9:30 a.m., on December 12, 2024 confirmed the lack of providing adaptive equipment for the nursing staff to performing their transfers of Resident R34 safely out of bed and into a comfortable wheelchair as care planned to meet his mobility needs. 28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 PA. Code 211.10(a)(b)(c)(d) Resident care polies 28 PA. Code 201.219(c) Use of outside resources 28 PA. Code 201.18(b)(e)(1) Management 395354 Page 8 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records and facility documentation and policies it was determined that the facility failed to provide the necessary treatment for opioid addiction for two residents (Resident R56 and R61) in a timely manner which resulted in and/or a potential to cause the residents experiencing unwanted discomfort and withdrawal symptoms and failed to adequately assess a resident (Resident R61) in accordance with professional standards of practice and failed to inform the medical director when services were not rendered for two residents reviewed (Resident R56 and R61) and failed to properly assess and provide bowel care for one resident (Resident R81) of the 24 resident records reviewed. Residents Affected - Few Findings include: Review of facility policy for Medication Shortage/Unavailable Medication revised April 2018 states when medications are not received for the resident the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. If unable to obtain a response from the attending physician in a timely manner notify the nursing supervisor and contact the Medical Director for orders/directions. During a group session on December 10, 2024, at approximately 10:30 a.m., Resident R56 and R61 both agreed there are times the facility fails to have their medication Suboxone. Resident R61 said it happens a lot. Resident R56 stated recently went three days during Thanksgiving when the medication didn't come in. Suboxone is a prescription drug (Buprenorphine HCl-Naloxone HCl Dihydrate) used to treat opioid dependence. Withdrawal symptoms from Suboxone can occur when the medication is missed. Physical symptoms may include nausea vomiting headaches muscle aches, digestive distress, anxiety, irritability, fever, chills and sweating when the dose is missed approximately 12 hours after last dose. Review of Resident R56's physician orders revealed the resident was admitted to the facility on [DATE], diagnosed with opioid abuse, and ordered Suboxone Sublingual Film 4-1 mg. instructed to give 1 film sublingually two times a day for withdrawal at 9:00 a.m. and 5 p.m. Further interview with Resident R56 on December 10, 2024, at 11:00 a.m. stated, Its nothing to them if they don't have my medication. A few weeks ago, around Thanksgiving they didn't have my medication for days. After a couple missed doses, I started getting sick. I had stomach pains and was achy and sweating. The feeling is worse than coming off the actual drug (opiates). When I missed the Suboxone nursing didn't check on me to see if I was sick. Review of the nursing medication administration notes and the narcotic ledger for Resident R56's Suboxone revealed on November 27, 2024, the resident's 5:00 p.m. dose was not administered, on November 28, 2024, both doses were not administered, and on November 29th both doses were not administered until it was delivered by the pharmacy that night at 11:10 p.m. Facility documentation dated Wednesday, November 27, 2024, revealed DON request to physician for Suboxone prescription for Resident R56 indicating Used last one this morning. Friday, November 29, 2024, at 10:28 a.m. DON notifying physician that Pharmacy has not yet received the prescription for (Resident R56) and he is out of his Suboxone. 395354 Page 9 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R61's physician orders revealed an active order of Suboxone Film 8-2 MG (Buprenorphine HCl-Naloxone HCl) since July 28, 2022, instructed to give two times a day at 9: a.m. and 9:00 p.m. Further interview with Resident R61 on December 10, 2024, at 10:30 a.m. stated, After a day without the medication you really don't' feel well. All you can do is keep asking for your medication and go to the nurses' desk to see if it arrived. They would tell me, 'It will be here later on' but when it doesn't come, you don't know what to do, you're stuck. Resident R61 indicated during the times her medication is missed nursing has not asked about feeling ill or having withdrawal symptoms. Review of Resident R61's nursing medication administration notes revealed the medication was not administered for both doses on May 27, 2024, due to Waiting for script to be filled and Ordered. May 28, 2024, at 8:35 a. m. noted nursing was awaiting pharm. Review of the nurses' narcotic ledger for Resident R61's suboxone revealed no documented evidence the 9:00 a.m. and the 9:00 p.m. dose was administered on May 27 and May 28, 2024. Facility documentation dated May 28, 2024, at 12:07 p.m. revealed DON request to physician for refill prescription of Suboxone for Resident R61. Indicating to the physician Resident R61 Been without for 3 days. Further review of Resident R61's clinical record did not revealed nursing notes and/or assessments during the time the medication was not administered. Interview with the Director of Nursing on December 13, 2024, at 10:00 a.m. stated the residents were not receiving the Suboxone medication because either the physician doesn't send the prescription to the pharmacy in a timely manner or we are waiting on the pharmacy to deliver the medication. Clinical record review for resident R81 revealed that this resident had a hospital stay on July 31, 2024 and was treated for stomach distention. The hospital record indicated that Resident R81 was given antibiotic therapy and normal saline solution while nothing was given to the resident by mouth. Clinical record review revealed that the physician gave Resident R81 a diagnosis of constipation on August 6, 2024. Resident R81 was ordered Colace 100 mg orally two times a day for prevention of constipation on August 6, 2024. Resident R81 was ordered senna 8.6 mg by mouth at bedtime to prevent constipation on August 6, 2024. Resident R81 had physician's orders for the nursing staff to administer four ounces of prune juice instead of milk if resident had no bowel movement for two days to prevent constipation on August 6, 2024. Resident R81 had physician's orders for the nursing staff to administer milk of magnesia suspension 30 ml by mouth if no bowel movement every 72 hours. to prevent constipation. Clinical record review revealed that Resident R81 had no bowel movement documented for December 6, 7, 8 and 9 2024. There was no docmentation to indicate that the nursing staff followed the physician's orders for prune juice administration or milk of magnesia administration as ordered by the physician for December 6, 7, 8, 9, 2024. The lack of following the bowel protocol for Resident R81 was confirmed by the registered nurse, Employee E5, at 10:00 a.m., on December 12, 2024. Clinical record review of the bowel record for December, 2024 for Resident R81 revealed that the established care plan to include the bowel protocol was not implemented as planned for this resident on December 6, 7, 8, 9, 2024, despite the nursing staff documenting that the resident had no bowel movements on these days. Clinical record review revealed that on December 10, 2024 Resident R81 was sent to the hospital for a stomach ache and vomiting. The nursing progress note on December 10, 2024 for Resident R81 395354 Page 10 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0684 indicated that the resident was sent to the hospital for further evaluation and to rule out small bowel obstruction. Level of Harm - Minimal harm or potential for actual harm 28 PA. Code 211.12(c)(1)(2)(3)(5) Nursing services Residents Affected - Few 28 PA. Code 211.5(f)(i)(iii)(vi)(vii)(ix) Medical records 395354 Page 11 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of facility documentation, clinical records, staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for two of 24 residents reviewed. (Resident R56 andR61). Findings include: Review of facility policy for Medication Shortage/Unavailable Medication revised April 2018 states when medications are not received for the resident the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. If unable to obtain a response from the attending physician in a timely manner notify the nursing supervisor and contact the Medical Director for orders/directions. During a group session on December 10, 2024, at approximately 10:30 a.m., Resident R56 and R61 both agreed there are times the facility fails to have their medication Suboxone. Suboxone is a prescription drug used to treat opioid dependence. Withdrawal symptoms from Suboxone occur when the medication is missed in approximately 12-24 hours after the first missed dose. Physical symptoms may include nauseas vomiting headaches muscle aches, digestive distress, anxiety, irritability, fever, chills and sweating. Review of Resident R56's physician orders revealed the resident was admitted to the facility on [DATE], diagnosed with opioid abuse, and ordered Suboxone Sublingual Film 4-1 mg. (Buprenorphine HCl-Naloxone HCl Dihydrate) instructed to give 1 film sublingually two times a day for withdrawal at 9:00 a.m. and 5 p.m. Review of the nursing medication administration notes and the narcotic ledger for Resident R56's Suboxone revealed on November 27, 2024, the resident's 5:00 p.m. dose was not administered, on November 28, 2024, both doses were not administered, and on November 29th both doses were not administered until it was delivered by the pharmacy that night at 11:10 p.m. Review of Resident R61's physician orders revealed an active order of Suboxone Film 8-2 MG (Buprenorphine HCl-Naloxone HCl) since July 28, 2022, instructed to give two times a day at 9: a.m. and 9:00 p.m. Review of Resident R61's nursing medication administration notes revealed the medication was not administered for the 9: a.m. and 9:00 p.m. doses on May 27, 2024, due to Waiting for script to be filled and Ordered. May 28, 2024, at 8:35a.m. noted nursing was awaiting pharm. An interview with the Director of Nursing on December 13, 2024, at 10:00 a.m. stated the residents were not receiving the Suboxone medication because the physician either doesn't send the prescription to the pharmacy in a timely manner or we are waiting on the pharmacy to deliver the medication. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(f)(2)(4)(g)(h)(k) Pharmacy services. 395354 Page 12 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews with staff and policy and procedure reviews, it was determined that the facility failed to use, monitor and assess one of six residents for continued psychotropic drug use. (Resident R88) Findings include: A review of the policy titled psychotropic drug use dated January 1, 2021 revealed that it was the responsibility of the physician, facility staff, psychiatrist and pharmacist to choose the most effective medication for the resident that had the fewest possible side effects, adverse drug reactions and in the smallest effective dose. The policy indicated that each resident using psychotropic drugs would be monitored for adverse side effects, appropriate drug selection and appropriate drug dose. Clinical record review revealed a physician's ordered for divalproex sodium (depakote) oral capsule delayed release 125 mg give three capsules by mouth two times a day for agitation, since October 30, 2024. Pharmaceutical diagnoses for use of depakote was for epilepsy, mood disorder or migraines. Divalproex sodium was a stable compound of Valproic acid. Clinical record review lacked documentation to indicate that the nurse clarified the order for the depakote with the physican to provide and document adequate indications for its use for Resident R88. Clinical record review revealed a psychiatrist assessment dated [DATE] that indicated resident R88 had diagnoses of dementia with behavioral disturbance. The psychiatrist documented that the resident was exhibiting agitation with aggressive behaviors. The psychiatrist noted that Resident R88 was prescribed depakote and Risperdal as needed. The psychiatrist planned to discontinue the Risperdal (antipsychotic) and start Zyprexa (antipsychotic) for Resident R88. The physician also prescribed Ativan (anti anxiety medication) four times a day as needed for anxiety. Clinical record review revealed that the nurse had not verified the order to clarify the duration, dosage and intended used for Depakote for Resident R88. The nurse failed to clairfy with the physician if the administration of depakote was to be given as needed or in a standard administration twice a day, based on the psychiatrist progress note dated November 21, 2024. Clinical record review for October 30, 2024 through December 9, 2024 revealed that there were no Valproic acid blood levels available for review for Resident R88. There was no documentation to indicate that the nursing staff obtained an order from the physician to adequately monitor the continued use of the use of this medication for Resident R88. Interview with the director of nursing, Employee E2, at 1:00 p.m., on December 11, 2024 confirmed that the nursing staff failed to clarify the adequate indications for use for the medication depakote, obtain an order for adequate monitoring of the drug depakote and ensure the drug (depakote) was not used for an excessive duration for Resident R88. 28 PA. Code 211.12(b)(d)(1)(2)(3)(5) Nursing services 395354 Page 13 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0758 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 PA. Code 211.5(f)(i)(ii)(iii)(vi)(vii)(viii)(ix) Medical records Residents Affected - Few 395354 Page 14 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0760 Ensure that residents are free from significant medication errors. 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, and staff and resident interviews, it was determined that the facility failed to ensure two residents were free from significant medication errors for 2 of 8 residents reviewed. (Residents R69 and R64) Residents Affected - Few Findings: Review of the National Institute of Health article titled Nursing rights of medication administration dated September 2023 revealed that it is standard during nursing education to receive instruction to clinical medication administration and upholding patient safety known as the five rights of medication administration, the five rights are : the right patient, right drug, right route, right time, and right dose. Patient safety and quality of care are essential components of nursing practices and priorities that demand consideration to enable the delivery of high-quality patient centered care and overall, well-being. Review of the Centers for Medicare and Medicaid Services Drugs and biologicals must be prepared and administered in accordance with the federal and state laws, the orders of the practitioner and practitioners' responsibility for the patients care as specific specified under 482 .12 and accepted standards of practice. All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in according to state laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. Basic safe practices for medication administration the patient's identity, the correct medication, the correct dose, the correct route, any appropriate time. Review of resident R 69's clinical record revealed that resident R 69 had medical diagnosis' including heart failure(also know this congestive heart failure is a condition that develops when your heart doesn't pump enough blood for your body's needs) ,chronic atrial fibrillation(a condition in which the upper chambers of the heart be rapidly and irregularly), left bundle branch block(A condition that occurs when something blocks the electrical impulse that causes the heart to beat, this leads to an abnormal heart rhythm),and essential hypertension(also known as primary hypertension refers to high blood pressure that is preexisting and has no identifiable cause) Review of residence R 69's care plan revealed the resident has potential for bleeding related to anti coagulant therapy with interventions including administer medications as a weather, monitor signs and symptoms of bleeding, and monitor lab studies. Further review of resident R 69's clinical record revealed physician orders for the drug Coumadin. On order of coumadin dated October 12, 2024, with instructions give five milligrams orally once daily. Another order for the medication Coumadin dated on November 5, 2024 revealed an order for six milligrams to be given daily. Review of manufacturers Bristol [NAME] Squibb company medication coumadin package insert revealed product warning this medication can cause major or fatal bleeding. Is more likely to occur during the starting or with a higher dose. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physician signs and symptoms of bleeding. 395354 Page 15 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of resident R 69's clinical record nursing notes dated November 6, 2024, revealed Charge nurse reported that she gave resident 11mg a 5mg tab and a 6 mg tablet of coumadin at hs . when pharmacy delivered medication this morning that she was expecting to receive 5mg and 6mg tablets of coumadin for this resident. When she only received 6mg tablets the nurse went back to check the order from 11/5/24 and noticed resident had 2 different orders for coumadin on the mar one order to give 5mg and one order to give 6mg. Nurse gave both doses. Review of Resident R64's clinical record revealed diagnosis' including diabetes type two (long term condition occurs when the body fails to regulate glucose levels leading to high blood sugar levels) arthritis(condition that causes inflammation or swelling in the joint tissue around the joints or other connective tissue) and low back pain. Further review of resident R 64's clinical record revealed physician orders for the drugs gabapentin 600 milligrams and Metformin 500 milligrams given daily. Review of Manufacturer CSPC Ouyi pharmaceutical Co. drug metformin insert revealed metformin hydrochloride tablets are indicated as an adjunct to diet and exercise to improve glycemic control with type with people with type two diabetes The most common adverse effect is diarrhea nausea vomiting indigestion and headache. Interview with resident R 64 on December 9, 2024, at 10:15a.n. revealed that the nurse gave the resident the wrong medication, the resident required hospitalization. Review of resident R 64's clinical record nursing notes dated July 14, 2024, revealed 203B and 203A both advised me on an 203B given the wrong medication this AM, but he spit it out & refused to take it. Mouth check was done no abnormal findings. Resident refused vitals. Resident stated he was ok but was upset she gave him the wrong medication wanted a supervisor. Further review of resident R 64'sclinical record revealed a nurses note dated August 12, 2024 revealed Medication was given to Resident and received metformin instead of Gabapentin. Resident metformin is due at 8am. Resident did not swallow pill he spit it out. Resident is stable. resident was transferred to [NAME]. 28 Pa. Code 211. 9(d) pharmacy services 28 Pa. Code 211. 12(d)(1)(5) nursing services 395354 Page 16 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

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 the review of facility policies, resident interviews, and interview with staff, it was determined that the facility failed to maintain proper infection control practices related to wound care for one of three residents reviewed for wound care. (Resident R47) Residents Affected - Few Findings include: Review of facility policy titled Wound Care revised October 2010 revealed the purpose of this policy is to provide guidelines for the care of wounds to promote healing. One key element is cleanliness. Items to be used during procedure must be clean and arranged on a clean environment. Review of facility policy titled Enhanced Barrier Precautions Policy, revealed enhanced barrier precautions EBP will be initiated for residents as an applicable in accordance with CMS and or state regulations in accordance with the CDC guidance to reduce the risks of transmission of multiple drug resistant organisms MDROS. Enhanced barrier precautions are applicable for residents with any of the following infection where colonization with an MDRO, wounds, in dwelling medical devices such as central line, urinary cavity, ventilator regardless of colonization status. Enhanced barrier precaution is primarily intended to apply to care that occurs within a residence room where high contact resident care activities are commonly bundled together enhanced barrier precautions should additionally be followed when performing transfers. Review of facility policy titled Infection Control Program revealed the infection prevention and control program is a facility wide effort involving all disciplines and individuals and integral part of the quality assurance and performance improvement program. The infection prevention and control program are coordinated and overseen by an infection prevention specialist. One of the major elements of the infection prevention program is prevention of the infection. Some important facets of infection prevention include identifying possible infections or potential complications of existent infections, instituting measures to avoid complications, educating staff and ensuring that they adhere to proper techniques and procedures, enhance screening for possible significant pathogens, immunizing residents and staff to prevent illness, implementing appropriate isolation precautions when necessary and follow established general and disease-specific guidelines such as those of the Centers for Disease Control CDC. Review of resident R47's clinical record revealed that resident R47 has diagnosis' including ; [NAME] insufficiency ( condition in which means in the legs are damaged, causing blood to flow more slowly and return to the heart), Chronic [NAME] hypertension with ulcer of right lower extremity( condition that occurs when the valves in the leg veins are damaged, causing blood pressure to remain high and leading to ulcers on the ankles, chronic venous hypertension with ulcer of left lower extremity), local infection of the skin and subcutaneous tissue(a condition characterized by the invasion of harmful bacteria or fungi into the skin layers), Localize edema , cellulitis of right lower limb, cellulitis of left lower limb( bacterial infection of the skin and tissue beneath your skin), unspecified intellectual disability (refers to limitations in mental abilities affecting intelligence, learning, and everyday life skills), schizophrenia( mental health condition characterized by hallucinations, delusions, disorganized thinking and behavior), asymptomatic human immunodeficiency virus infection(Also known as chronic HIV infection or clinical latency, is a stage of HIV infection where a person may not experience any symptoms), cognitive communication deficit(A communication difficulty caused by cognitive impairment). 395354 Page 17 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of resident R47's clinical record revealed a physician note dated November 25, 2024, of documentation of resident R47 wounds. The note specified that resident R 47 was assessed with have two lower extremity wounds. Review of resident R 47's physician orders revealed an order for instruction to apply calcium alginate silver dressing to both lower extremities topically every day continued review of resident 47's physician orders revealed an order for the ointment Santyl to be applied daily to resident 47's right lower leg. Interview with resident R64 on December 9, 2024, at 10:00 a.m. revealed that this resident voiced concerns of staff performing wound care on a resident in the resident dining room. Resident R 64 provided video of the reported incident of employee performing wound care in the resident dining room with residents present. Resident 64 stated that he provided the video the the nursing home administrator. Resident stated it was disgusting, unsanitary and had concerns of infections. Interview with infection Preventionist employee E 5 on Wednesday December 11, 2024, at 3:00 pm confirmed that the allegation of improper wound care was attempted in the resident dining room. Employee E 5 stated that resident R47 possessed behaviors and often refused care. There was an opportunity at that time to perform wound care, so employee E5 believed the benefits outweighed the risks. The wound care was not completed at that time due to resident 47 displaying undesirable behaviors. 28 Pa. Code 211.12(d)(1)Nursing Services 28 Pa. Code 201.18(d) Management 395354 Page 18 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility documentation, facility policies, Centers for Disease Control and Prevention (CDC) guidelines and staff interview, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for four or four months of antibiotic stewardship program data reviewed. (August 2024, September 2024, October 2024, and November 2024) Residents Affected - Few Findings include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core Element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with the antibiotic use. 2. The Center for Disease Control and Prevention (CDC)recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outline the seven core elements which are necessary for implementing successful ASPs. 3. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g. acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in support supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate causes of antibiotics such as asymptomatic bacteria or urinary tract infection prophylaxis and implement specific interventions to improve use. Perform reviews on resident medical records for new antibiotics starts to determine whether the clinical assessment, prescription documentation and antibiotics selection were in accordance with facility antibiotic use policies and practices. When conducted overtime, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures provide a snapshot of information, while others, like nursing home-initiated antibiotics starts and days of therapy are calculated and tracked when an ongoing basis. Selecting which antibiotic use measures to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotic based on post prescription review, may not necessarily change the rate of antibiotic starts, but would decrease the antibiotics days of therapy (DOT). 395354 Page 19 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy titled Antibiotic stewardship revised 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility antibiotic stewardship program. If an antibiotic is indicated prescribers will complete antibiotic orders including the following elements drug name, dose, frequency of administration, duration of treatment, root of administration, and indication for use. When a cultural and sensitivity is ordered lab results and the carrying clinical situation will be communicated to the prescriber as soon as available to determine if the antibiotic therapy should be started continued, modified, or discontinued. Review of facility policy titled Infection Control Program reveals that antibiotics stewardship includes cultural reports sensitivity data and antibiotic usage reviews are included in surveillance activities. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. And antibiotic usage is evaluated, and practitioners are provided feedback on review. Surveillance tools are used for recognizing their currents of infections, recording their number and frequency, detecting outbreaks in epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Review of facility antibiotic tracking log from August 1st, 2024, to November 30th, 2024, revealed no documented evidence that the facility utilized any surveillance for antibiotic use for any of the antibiotics ordered. Records did not include consultant pharmacist reports, laboratory reports, infection description, antibiotic dose and duration according to the facility antibiotic stewardship program. Facility did not provide any other information related to the antibiotic stewardship program during this survey. Interview with infection preventionist Employee E5 December 11, 2024 at 3:00 p.m. confirmed that the facility antibiotic stewardship program did not include reports or data from the pharmacist and or laboratory. 28 Pa. Code 211. 12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a) Resident care policy 395354 Page 20 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations of the Food and Nutrition Services Department, interviews with residents and staff, reviews of clinical records and policies and procedures, it was determined that essential pieces of food service equipment used for the transportation, holding and delivery of hot foods from the dietary services department to the nursing units, resident rooms and dinning areas were not in use, to ensure consistently safe and satisfactory food temperatures of foods for the residents. (Residents R11, R57, R56, R5, R55, R28, R64, R46, R37, R34, R41, R27, R14 and R19). Residents Affected - Many Findings include: A review of the undated facility policy titled resident tray assessment indicated that all hot foods were to be served hot at a temperature greater than or equal to 130 degrees Fahrenheit and served satisfactory for the residents' preferences and dietary care planning. A review of the undated policy titled service of hot liquids to prevent spills revealed that hot beverages were to be served hot and at a temperature less than 140 degrees Fahrenheit to meet the food preferences of the residents. Observations between 11:30 a.m. and 1:00 p.m., on December 9, 2024 of the food delivery service system from the main kitchen of the Food and Nutrition Services Department to the first and second floor nursing units revealed that the facility was not utilizing a complete and standard thermal system to transport, hold and deliver hot foods to the residents. The lack of essential equipment for dietary staff use did not ensure that hot foods were being served safe, palatable and in accordance with residents' appetite satisfaction on a regular basis. Individual interviews with Residents R57, R11 and R34 between 10:00 a.m. and 10:30 a.m., on December 9, 2024 revealed the the temperature and taste of the foods are luke warm and taste was undesirable. The residents described the foods as tasting burnt although at times they don't look black or burnt. The residents reported that the hot beverage was never hot. They said they can not get the powdered creamer to dissolve in the coffee because it was too cold. The residents said that the kitchen staff can not serve a grilled cheese sandwich that was appetizing. The cheese would be served hard and unmelted. One of the residents reported that he mostly eat meals in his room and by the time I get a hot meal it would be cold. Interviews with alert and oriented residents assembled in a group at 9:30 a.m., on December 10, 2024 revealed that the hot foods during breakfast, lunch or dinner meals were always served to them cold. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R11 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated August 31, 2024 for Resident R57 that indicated that this resident was cognitively intact. Clinical record review revealed an annual comprehensive assessment MDS (an assessment of care needs) dated November 10, 2024 for Resident R56 that indicated that this resident was cognitively intact. 395354 Page 21 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0908 Level of Harm - Minimal harm or potential for actual harm Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 2, 2024 for Resident R5 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 5, 2024 for Resident R55 that indicated that this resident was cognitively intact. Residents Affected - Many Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 13, 2024 for Resident R28 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R64 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 23, 2024 for Resident R46 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 25, 2024 for Resident R37 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 6, 2024 for Resident R34 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 14, 2024 for Resident R41 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 13, 2024 for Resident R27 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R14 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 25, 2024 for Resident R19 that indicated that this resident was cognitively intact. Interviews with the director of dietary services, Employee E10 and the registered dietitian, Employee E8 at 1:30 p.m., on December 11, 2024 confirmed that the food and nutrition department's essential equipment was lacking; that was the dietary staff were not using a complete system of standard dietary equipment to transport foods that were being prepared hot in the main kitchen to the residents on the first and second floor nursing unit. 395354 Page 22 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0908 Level of Harm - Minimal harm or potential for actual harm Further interview with the dietary staff, Employees E8 and E10, that were responsible for the delivery of safe and appetizing hot foods for the residents revealed that the equipment that was not in use were the heated pellet and thermal pellet holder. The pellet was heated to 160 to 170 degrees Fahrenheit inside a lowerator. The pellets and lowerator were used to keep hot foods hot for twenty minutes beyond the time the food leaves the kitchen and was transported to the nursing units for the residents. Residents Affected - Many 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1) Management 395354 Page 23 of 24 395354 12/12/2024 Silver Stream Nursing and Rehabilitation Center 905 Penllyn Pike Spring House, PA 19477

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations of the physical environment of the food and nutrition department, reviews of the pest control operators reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program so that the facility was free of common household pests and rodents. Residents Affected - Few Findings include: Observations of the main kitchen of the Food and Nutrition Department in the presence of the director of dietary services, Employee E10, at 9:30 a.m., on December 9, 2024 revealed the following: The industrial sized dish machine and the flooring surrounding this food service equipment was covered with a white/grayish tinted film, resembling hard water deposits of calcium and lime. The boundary of the flooring next to the wall area underneath the dish machine and three compartment sink contained a heavy accumulation of dirt and brown saturated slim. The grouting was missing between the ceramic tiles in the dish room and the food preparation area near the steam table, of the main kitchen. The flooring was porous, not easily cleanable and contained grooves that allowed food debris and pooling of water to accumulate. The grouting was worn away from the continuous use of water in these areas of the kitchen. The water damaged flooring provided a place for food debris, dirt and moisture to settle. The food debris and moisture provided food for pests to live and breed. Many ceramic tiles were totally missing about the flooring in the dish room area. The director of maintenance, Employee E14, reported during an interview at 9:30 a.m., on December 11, 2024 that new plumbing was installed beneath the flooring three months ago. Review of the pest control operator's reports for September, October, November and December, 2024 revealed that the pest control operator was visiting the facility regularly for treatment of common household pests (roaches, fruit flies, drain flies and mice) in the kitchen and dry food storage of the basement. 28 PA. Code 201.18(b)(1)(3)(2.1) Management 28 PA. Code 205.13(b) Floors 28 PA. Code 201.14(a) Responsibility of licensee 395354 Page 24 of 24