Health inspection·March 22, 2024

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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level in reference to communication for one of 26 residents reviewed (Resident 75). Findings include: Review of facility policy, titled Resident Assessment & Care Planning, effective date November 1, 2019 read, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health -related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient. Review of Resident 75's clinical record revealed admission date of November 2, 2023 with the diagnoses of Corticobasal degeneration (CBD) (a rare neurodegenerative disorder characterized by a progressive loss of nerve cells (neurons) in certain areas of the brain), paralysis of the vocal cords and larynx, bilaterally, [NAME] disease (a rare and progressive neurological disorder that primarily affects the central nervous system, particularly the brain) Review of Resident 75's care plan revealed a focus on increase communication between resident/family/caregivers about care and living. Review of the Resident R75's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated February 11, 2024, indicated that the resident's BIMS (Brief Interview of Mental Status) is cognition intact. On March 20, 2024, at 9:34 a.m. an interview with the unit manager, Employee E3 reported that Resident R75 does communicate via paper and writing, but Resident R75 is nonverbal. On March 21, 2024, at 10:44 a.m. an interview with Resident R75 revealed that the resident prefered the use of paper and pen to communicate. On Resident's R75 tray a communication list was available and when surveyor tried to use it to communicate with Resident R75 became frustrated and started screaming noise. Nursing aide, Employee E8 came in and had to calm Resident R75 down by repeating that Resident R75 needs to write what she desires and not get frustrated. Employee E8 reported that Resident R75 only prefered to use paper and pen to write her needs and wants. Resident R75 did not like to use the communication board nor the ipad that a spouse obtained for her. On March 21, 2024 at 11:15 a.m. an interview was held with speech therapist, Employee E13 who concurred that Resident R75 exhibited a preference for communicating using traditional paper and pen Page 1 of 8 395370 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few rather than utilizing modern communication aids such as a communication board or an iPad. Despite efforts to provide alternative means of communication for quicker expression of needs, the resident remains resistant to these methods and continues to favor the use of paper and pen. On March 21, 2024, at 12:34 a.m. an interview with the unit manager, Employee E3 confirmed that Resident R75 has a strong preference to use paper and pen to communicate her needs and the comprehensive care plan did not provide any preference nor interventions to support the Resident R75 in the communication efforts. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395370 Page 2 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

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 review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss (Resident R65 and R30). Residents Affected - Few Findings include: Review of the facility policy titled Weight Monitoring and Tracking dated November 1, 2019, revealed the procedure for weight loss is as follows: the director of nursing is responsible for ensuring patients are weighed in a timely manner using proper techniques, an electronic system will be utilized for recording tracking and reporting weights and weight variances, weight will be verified within five days of a weight variance of five pounds since last weight or when a significant weight loss is identified , the significant weight loss will be identified and discussed by a interdisciplinary team, and the committee will investigate the possible causes of weight change, discuss interventions and document a progress note in the residents medical record. Review of Resident R65's clinical record revealed that Resident R65 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder bipolar type (a mental health disorder that is marked by a combination of schizophrenia mood disorder of bipolar disorder), chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), COPD (Chronic obstructive pulmonary disease is a chronic disease that causes obstructed airflow from the lungs), type 2 diabetes (long term medical condition in which the body does not use insulin properly, resulting in unusual blood sugars), chronic kidney disease(also known as chronic kidney failure, a gradual loss of kidney function), chronic diastolic (congestive ) heart failure (a clinical syndrome of heart failure with a preserved left ventricular ejection fraction) peripheral vascular disease(a circulation disorder caused by narrowing, blockage or spasms in blood vessels), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness) and as of February 6, 2024 an above the knee amputation of her right leg. Continued review of Resident R65's clincial record revealed a critical weight loss presented in the resident's documented history of vitals. Resident R65 had a documented weight loss begining on November 10, 2023, the resident's weight was documented as 190.2 pounds. The next weight documented for Resident R65 was December 6, 2023, which the significant loss was evident, the resident weight 164.4 pounds (a weight loss of 25.8 pounds in one month). The resident was re-weighed five days later and on December 11, 2023, and still exhibited weight loss at a weight documented of 163.8pounds. Resident R65 was not re-weighted until January 6, 2024 at that time, revealed a continued trend of weight loss, the resident weighed 155 pounds (a loss of 35.2 pounds). Resident R65 continued to show gradual weight loss as of March 4, 2024. Resident R65's documented weight was 141.0 pounds. Further review of Resident R65's dietary note dated December 20, 2023, two weeks after documented weight loss of twenty-five pounds, revealed that resident R65 was triggered for significant weight loss. The notation declared that Resident R65 weight loss was unplanned and unfavorable. It has been evident that Resident R65 has had decrease of intakes at meals. Likely contributing to the weight loss. The professional recommendation of this weight loss was to recommend adding magic cup 4oz three times a day (290kcal, 9g each) at meals to meet kcal needs. The goals of this dietary intervention were that the resident will maintain current weight without any significant changes and the Resident 395370 Page 3 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

F 0692 R65 will consume >75% of each meal without refusals. Level of Harm - Minimal harm or potential for actual harm Interview with Register Dietician, Employee E6 and Regional Registered Dietician, Employee E5 on March 21, 2024 at 2:05 p.m., revealed that they were both aware of Resident R65 weight loss , it was believed to be contributed by the resident's leg amputation. Residents leg amputation was two months after the initial weight loss. Employee E6 was unable to comment to why this weight loss was not assessed and lack of any intervention in a timely manner. Residents Affected - Few Review of Resident R30's quarterly Minimum Data Set (MDS - federally mandated resident assessment) dated February 4, 2024, revealed the resident had diagnoses of dementia (loss of cognitive functioning that interferes with daily life and activities) and dysphagia (swallowing difficulties). Review of Resident R30's comprehensive care plan revised March 19, 2024, revealed the resident was at risk for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) related to dementia, dysphagia, and low BMI (body mass index - a measure of body fat based on height and weight). Review of Resident R30's weight history revealed a documented weight of 170.4 pounds on September 6, 2024. Review of Resident R30's clinical record revealed the resident was readmitted to the facility, from the hospital, on September 25, 2024. Review of Resident R30's nutrition assessment dated [DATE], completed by Employee E6, Registered Dietitian, revealed the readmission weight was pending and would further assess when available. Further review of the assessment revealed the resident was at risk for malnutrition and interventions included to monitor weekly weights as ordered. Review of Resident R30's physician order summary revealed weekly weights were ordered September 25, 2024. Review of Resident R30's clinical record revealed no documented evidence weekly weights were completed as ordered. Review of Resident R30's clinical record revealed the facility did not obtain a re-admission weight for the resident until October 2, 2024, seven days after readmission. readmission weight obtained on October 2, 2024, revealed the resident weighed 160.4 pounds, reflecting a significant weight loss of 10 pounds and 5.8% in one month. Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until October 18, 2024, sixteen days after the identified weight loss. Further review of Resident R30's clinical record revealed the resident had a documented weight of 143 pounds on January 8, 2024, reflecting a 10 pound and 6.5% significant weight loss in one month (in comparison to a documented weight of 153 pounds on December 5, 2023). Review of Resident R30's clinical record revealed nutrition note dated January 15, 2024, by Registered Dietitian, Employee E6. Review of the nutrition note revealed it did not address Resident R30's 395370 Page 4 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few significant weight loss on January 8, 2024. Resident R30's nutritional status was not accurately assessed to identify and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status. Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until January 24, 2024, 16 days after the identified weight loss. Interview was conducted with the Registered Dietitian, Employee E6, on March 13, 2024, at 2:13 p.m. Registered Dietitian, Employee E6, was unable to explain why the weights and nutritional status were not being monitored or addressed in a timely manner. 28 Pa. Code 201.18 (b) Management 28 Pa. Code 211.10 (c) Care policies 28 Pa. Code 211.12 (d)(5) Nursing services 395370 Page 5 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

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. Based on review of facility policy, review of clinical records, and interview with staff, it was determined the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for one of 26 residents reviewed (Resident R45). Findings Include: Review of facility policy Medication Management/Medication Unavailability dated 04/21/2022 revealed the pharmacy provides and maintains written contractual services and procedures that ensure safe and effective drug therapy, distribution, control and use within the facility. If medications are determined to be unavailable for administration, the licensed nurse will notify the provider of the unavailability and request an alternate treatment if possible. The licensed nurse will document notification to the provider of the unavailability in the medical record. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures. Review of Resident R45's physician order summary revealed an order dated February 10, 2024, to administer Pregabalin 50 milligrams (mg) two times a day, in the morning and at night (medication used to treat pain caused by nerve damage). Review of Resident R45's medication administration record revealed the resident did not receive the medication on 2/29/2024 morning dose, 03/01/2024 morning and night dose, 03/03/2024 night dose, and 03/04/2024 morning dose. Review of Resident R45's clinical record revealed nursing notes on the above dates that the medication was not administered because it was unavailable and awaiting delivery from the pharmacy. Continued review of Resident R45's clinical record revealed no documented evidence that the physician was made aware of the missed doses or that an alternate treatment was requested. Further review of the clinical record revealed no documented evidence the licensed nurse activated backup pharmacy process and procedures to obtain and administer the medication. Interview with the Director of Nursing, Employee E2, on March 21, 2024, at 2:24 p.m. confirmed Resident R45 missed doses of his medication and confirmed nursing staff did not follow policy and procedure to acquire and administer medication. 28 Pa. Code 211.9 (a)(1) Pharmacy Services. 28 Pa. Code 211.9 (d) Pharmacy Services. 28 Pa. Code 211.12 (d)(1) Nursing Services. 395370 Page 6 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 documents and resident clinical record reviews and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for four of 4 residents reviewed (Resident R35, R48, R93, R113,). Residents Affected - Few Findings include: A review of the facility policy Binding Arbitration part 17. Revealed The resident and the facility agree that, unless prohibited by applicable federal or Pennsylvania law and except solely for any claims by the Facility regarding the Resident's failure to timely pay all amounts owed to the Facility under this Agreement, for which claim the Facility shall have the right specified in Section 21 and 22 , above any dispute whatsoever between or among the Resident the Responsible Party or any other of the Resident's representatives, guardians, heirs, executors and/or administrations and the Facility and/or its agents shall be resolved by binding arbitration. In the event of a dispute, the Resident and the Facility shall each select an attorney, both of which attorneys shall mutually agree upon an arbitrator who must be an attorney with an office in . Pennsylvania. The arbitrator shall investigate the facts and may, in his/her discretion, hold hearings at which the Resident and/or the Responsible Party may present evidence and arguments, be represented by counsel and conduct cross examination . The arbitrator shall render a written decision on the dispute as soon as practicable after her/his appointment. The arbitrator's decision, which may include equitable relief, shall be final and binding on the parties and judgment upon the decision may be entered in any court of competent jurisdiction. Review of admission record indicated Resident R35 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated February 15, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Review of Resident R35's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on [DATE]. Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Review of Resident R48's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on [DATE] Review of admission record indicated Resident R93 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective 395370 Page 7 of 8 395370 03/22/2024 Luther Woods Nursing and Rehabilitation Center 313 County Line Road Hatboro, PA 19040

F 0847 January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Level of Harm - Minimal harm or potential for actual harm Review of Resident R93's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on [DATE]. Residents Affected - Few Review of admission record indicated Resident R113 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective February 21, 2024, indicated that a Brief Interview for Mental Status (BIMS) score indicated 15 - cognition intact. Review of Resident R35's Binding Arbitration Agreement a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on [DATE]. On March 19, 2024, at 10:08 a.m. during entrance meeting Administrator, Employee E1 who reported that admission Director, Employee E9 is the Lead on the Arbitration process. On March 20, 2024, at 10:30 a.m. a Resident Council meeting was held with 13 alert and oriented Residents (R31, R4, R48, R93, R21, R27, R55, R113, R35, R78, R36, R72). Four residents (R35, R48, R93, R113,) reported facility did not explain in the language that they would understand; therefore, they would like to revoke their signature from the arbitration agreement. On March 21, 2024, at 9:59 a.m. an interview was held with admission Director, Employee E4, who confirmed that the arbitration agreement was missing the key elements of the arbitration it's not a condition of admission', the right to rescind the agreement within 30 calendar days of signing, and agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care ombudsman. Employee E4 also reported that she/he was not aware of the time frame to rescind the arbitration and Employee E4 would read the arbitration agreement to the Residents or Resident Representatives instead of to explain in the language that would they understand. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee 28 Pa. Code: 201.18(e)(1) Management 395370 Page 8 of 8