Health inspection·January 9, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, clinical records, and review of facility documentation, it was determined the facility failed to investigate an incident that occurred as a result of possable abuse/neglect for one of one resident reviewed (Resident 52). Residents Affected - Few Findings include: Review of facility policy and procedure titled Resident Abuse/Neglect/Misappropriation of Property Prevention, revised December 2023, revealed All reports of abuse, as well as any situation where abuse is suspected, must be reported immediately to the Charge Nurse, and the Director of Nursing or supervisor on duty at the time. An investigation will be initiated immediately. Further review of the facility policy revealed Neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care including but not limited to: nutrition, medication, therapies and activities of daily living. Review of Resident 52's care plan for continence at the time of the fall revealed Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m. Review of Resident 52's progress notes dated December 28, 2024, at 11:30 a.m. revealed Firbank East [FE] nurse heard a loud thump from lounge area, when FE nurse walked over to see what the noise was, FE nurse discovered [Resident 52] on the floor, laying on right side in front of Broda chair, laying parallel to TV stand. Resident stated I don't feel good. I feel dizzy. Resident assessment: oriented to self at baseline, lethargic, difficulty opening eyes and following commands, PERRL [pupils equal and reactive to light], large hematoma to right forehead measuring approximately 6 centimeters [cm] x 6 cm, c/o [complaining of] buttock pain, c/o dizziness and upset stomach. Education completed with FE staff regarding toileting care plan. Injuries: right forehead hematoma, skin slightly abrased but no bleeding or drainage. Further review of Resident 52's progress notes revealed Resident 52's power of attorney was notified, and it was agreed to send Resident 52 to an acute care facility to rule out a bleed in the head. Review of Resident 52's progress notes dated December 28, 2024, at 9:58 p.m. revealed spoke with ER [emergency room] nurse at [acute care facility]. Report received - EKG [electrocardiogram] stable; CT scan of head and neck completed; both scans were negative. Resident cleared to return to facility. Page 1 of 5 395388 395388 01/09/2025 Crosslands 1660 East Street Road Kennett Square, PA 19348

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 52's progress notes dated December 29, 2024, at 1:33 a.m. revealed Resident returned from [acute care facility] at 00:10 a.m. to room [ROOM NUMBER]. Resident awake and alert, at baseline with mentation; resident denies pain; bruising to right temple and right outer orbital. Resident had CT scans at [acute care facility] of head without contrast and of cervical spine. Head CT showed no acute intercranial abnormality, CT to spine showed no acute fracture. Resident was assessed. Resident had smear of feces to bilateral buttocks on return and was cleaned and brief put in place. Review of facility documentation revealed Resident 52 was seen earlier in the morning by an RN at the facility at the dining room table. Resident 52 was scooching towards the edge of the Broda chair and was repositioned at that time. Further review of facility documentation revealed Resident 52 was seen approximately 30 minutes prior to the fall by two staff persons. At that time, Resident 52 was also attempting to move forward in the Broda chair. The two staff persons repositioned Resident 52 in the Broda chair. Review of documentation revealed the cause of the fall was failure to follow Resident 52's toileting care plan. Interview with Licensed Employee E3 on January 9, 2025, at 11:37 a.m. revealed that when a resident's care plan is not followed, the facility re-educates facility staff on following the care plan and confirmed that staff was re-educated, however, no further investigation was conducted. This interview further revealed that abuse/neglect was not considered and an investigation into abuse/neglect was not conducted. 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(a)(d)(5) Nursing services 395388 Page 2 of 5 395388 01/09/2025 Crosslands 1660 East Street Road Kennett Square, PA 19348

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 24 residents reviewed (Resident 58). Residents Affected - Few Findings include: Review of Resident 58's discharge MDS (Minimum Data Assessment - periodic assessment of resident needs) assessment dated [DATE], Section A2105 Discharge Status, indicated that the resident was discharged to an acute hospital. Review of Resident 58's clinical record including the discharge/transfer summary dated December 5, 2024, revealed that the resident was discharged home on that date. During an interview with the RNAC , Employee E4, on January 9, 2025, at 11:50 a.m. confirmed that the resident was discharged home and that the MDS assessment was marked incorrectly. 483.20 Resident Assessments Previously cited 12/28/23 28 Pa. Code 211.5(f) Clinical records Previously cited 12/28/23 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/28/23 395388 Page 3 of 5 395388 01/09/2025 Crosslands 1660 East Street Road Kennett Square, PA 19348

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of clinical records, review of facility documentation, and staff interview it was determined the facility failed to follow a resident's care plan resulting in fall with subsequent actual harm of a hematoma requiring transportation to the emergency room for evaluation and treatment of a hematoma for one of three residents reviewed (Resident 52). Findings include: Review of Resident 52's care plan for continence at the time of the fall revealed Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m. Review of Resident 52's progress notes dated December 28, 2024, at 11:30 a.m. revealed Firbank East [FE] nurse heard a loud thump from lounge area, when FE nurse walked over to see what the noise was, FE nurse discovered [Resident 52] on the floor, laying on right side in front of Broda chair, laying parallel to TV stand. Resident stated I don't feel good. I feel dizzy. Resident assessment: oriented to self at baseline, lethargic, difficulty opening eyes and following commands, PERRL [pupils equal and reactive to light], large hematoma to right forehead measuring approximately 6 centimeters [cm] x 6 cm, c/o [complaining of] buttock pain, c/o dizziness and upset stomach. Education completed with FE staff regarding toileting care plan. Injuries: right forehead hematoma, skin slightly abrased but no bleeding or drainage. Further review of Resident 52's progress notes revealed Resident 52's power of attorney was notified, and it was agreed to send Resident 52 to the emergency room to rule out a bleed in the head. Review of Resident 52's progress notes dated December 28, 2024, at 9:58 p.m. revealed spoke with ER [emergency room] nurse at [acute care facility]. Report received - EKG [electrocardiogram] stable; CT (computed tomography -medical imaging test that combines X-ray technology with computer processing to create detailed cross-sectional images of the body) scan of head and neck completed; both scans were negative. Resident cleared to return to facility. Review of Resident 52's progress notes dated December 29, 2024, at 1:33 a.m. revealed Resident returned from [emergency room of local hospital] at 00:10 a.m. to room [ROOM NUMBER]. Resident awake and alert, at baseline with mentation; resident denies pain; bruising to right temple and right outer orbital. Resident had CT scans at [acute care facility] of head without contrast and of cervical spine. Head CT showed no acute intercranial abnormality, CT to spine showed no acute fracture. Resident was assessed. Resident had smear of feces to bilateral buttocks on return and was cleaned and brief put in place. Review of Resident 52's care plan for continence at the time of the fall revealed Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m. Review of facility documentation revealed Resident 52 was seen earlier in the morning by an RN (Registered Nurse) at the facility at the dining room table. Resident 52 was scooching towards the edge of the Broda chair and was repositioned at that time. Further review of facility documentation revealed Resident 52 was seen approximately 30 minutes 395388 Page 4 of 5 395388 01/09/2025 Crosslands 1660 East Street Road Kennett Square, PA 19348

F 0656 prior to the fall by two staff members. At that time, Resident 52 was also attempting to move forward in the Broda chair. The two staff members repositioned Resident 52 in the Broda chair. Level of Harm - Actual harm Residents Affected - Few Review of facility investigative documentation revealed in section titled Post Fall Investigation revealed , Last time toileted (approximately): 0900 (9:00 a.m). Further review of same document revealed enquiry of Continent at time of fall: 'unknown -res (resident) transferred to ER, per FE nurse, resident did feel wet. Additional review of the facility investigative documentation revealed the toileting care plan was not followed and the root cause of the fall was failure to follow Resident 52's toileting care plan. Interview with Licensed Employee E3 on January 9, 2025, at 11:37 a.m. revealed that Resident 52's care plan was not followed and the facility re-educated facility staff on following the care plan. The facility failed to follow Resident 52's toileting care plan, resulting in a fall which required transfer to emergency room for evaluation, testing, and possible treatment due to a large hematoma to Resident 52's face causing actual harm to Resident 52. 28 Pa. Code 211.11(a)(d) Resident care plan 28 Pa. Code 211.12(a)(d)(5) Nursing services 395388 Page 5 of 5