Health inspection·January 2, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident the right to personal privacy and confidentiality of his/her personal and medical records for one of one resident reviewed (Resident 2). Residents Affected - Few Findings Include: Review of the facility policy, titled Release of Information, with a last revision date of December 12, 2023, revealed It is the responsibility of the Facility to protect the privileged information contained within the record. Review of Resident 1 clinical record revealed that they were in the process of applying for Medical Assistance. Based on document review, it was revealed that Resident 1's responsible party was sent a Medical Assistance application with another reident's information on it. Email communication received from the Nursing Home Administrator (NHA) on December 27, 2023, at 10:33 AM, indicated that the business office is responsible for sending/mailing Medicaid applications. She indicated that there was never an instance where a Medicaid application was mailed to the wrong person. She further indicated that Resident 1 asked to complete their own Medicaid application. In a follow-up email communication received from the NHA on December 27, 2023, at 3:01 PM, the NHA indicated After further review of the business office email, this did occur. I was unaware of this allegation until you brought to my attention. I will report to HIPAA compliance with our company. Email communication received from the NHA on December 27, 2023, at 3:28 PM, the NHA provided email communication confirmation to show that Resident 2's Medical Assistance application was emailed to the Responsible Party of Resident 1 and provided a copy of the application that showed the presence of Resident 2's personal and financial information being contained on the application. 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.5 (b) Clinical records Page 1 of 23 395395 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 30 residents reviewed and failed to provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident ' s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary for four of four resident's reviewed (Residents 1, 3, 4 and 5). Findings include: Review of facility policy titled Interim/Baseline Care Planning Policy with a last revision date of August 11, 2020, revealed that the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The policy also indicated D. The facility will provide the resident and their representative with a summary of the baseline care plan or the actual baseline care plan (with explanations if needed). Review of Resident 1's clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic pain, adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction), severe protein- calorie malnutrition (the state of inadequate food intake), hypertension (high blood pressure), and adjustment disorder with depressed mood (a strong emotional or behavioral reaction to stress or trauma). Review of Resident 1's clinical record revealed that the only concern identified on their care plan within 48 hours of admission was a problem for potential alteration in skin integrity that was dated October 28, 2023. Their nutritional care plan was noted as being developed on October 31, 2023. A falls care plan was developed on November 6, 2023, after Resident 1 experienced a fall. The rest of Resident 1's care plan was established on November 7, 2023, after their comprehensive assessment was completed which then included Resident 1's mood disorder until November 7, 2023. Review of Resident 1's clinical record also failed to reveal any evidence that they and their representative had been provided a summary of the baseline care plan or the actual base line care plan. Review of Resident 3's clinical record revealed that they had been re-admitted to the facility on [DATE], after a hospital stay from [DATE]-22, 2023, with new diagnoses that included pressure ulcers (wound of the skin caused by pressure over a bony prominence that extends to the subcutaneous tissue), osteomyelitis (infection of the bone), critical limb ischemia (severe blockage in the arteries of the lower extremities which markedly reduces blood flow), and severe peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident 3's care plan on December 27, 2023, at approximately 10:00 AM, revealed that the 395395 Page 2 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care plan in place was the one that was established prior to their hospitalization with the most recent revision date of December 7, 2023, except for their nutritional problem that was revised on December 25, 2023. Resident 3's care plan did not contain any of their new diagnoses/problems when reviewed. Review of Resident 3's clinical record also failed to reveal any evidence that they and their representative had been provided a summary of the baseline care plan or the actual base line care plan. Review of Resident 4's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included stroke (damage to the brain from interruption of its blood supply), dementia (brain damage caused by multiple strokes which causes memory loss in older adults), hypertension (high blood pressure), staphylococcus infection, chronic non-pressure ulcer of right calf, venous insufficiency (improper functioning of the vein valves in the leg(s) causing swelling and skin changes), chronic kidney disease (medical condition referring to damage to the kidneys due to chronic high blood pressure), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 4's clinical record revealed that the only concern identified on their care plan within 48 hours of admission was a problem for potential alteration in nutrition that was dated December 22, 2023. This review of the care plan also revealed that there were no other care plan problems noted. A final review of Resident 4's care plan on January 2, 2023, at 11:30 AM, revealed that Resident 4's care plan still had no other problems noted other than the one for nutritional risk which was developed on December 22, 2023, and had a revision date of December 28, 2023. Review of Resident 4's clinical record also failed to reveal any evidence that they and their representative had been provided a summary of the baseline care plan or the actual base line care plan. Review of Resident 5's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included sepsis (potentially life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), hypertension (high blood pressure), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 5's clinical record revealed that the only concern identified on their care plan within 48 hours of admission was a problem for potential for alteration in skin integrity which was developed on November 2, 2023. The rest of Resident 1's care plan was established on December 18 and 19, 2023. Review of Resident 5's clinical record also failed to reveal any evidence that they and their representative had been provided a summary of the baseline care plan or the actual base line care plan. Email communication received from NHA on December 28, 2023, at 12:15 PM, indicated that the facility develops resident care plans when they are admitted and that they are done timely. 395395 Page 3 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Email communication received from NHA on December 28, 2023, at 3:00 PM, the NHA confirmed that the facility had not been providing baseline care plans to the Residents or their responsible parties and that they had not been conducting an initial care plan meeting. She indicated that according to the new Director of Nursing they were not trained on this, but that training would be completed in January. In a follow-up email communication received from NHA on December 28, 2023, at 3:15 PM, the NHA confirmed that she would expect the baseline care plan to have been developed and provided to the resident and their representative within 48 hours of admission as per the regulation. 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 395395 Page 4 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to develop a comprehensive person centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for six of six records reviewed (Residents 1, 2, 3, 5, 6, and 7). Findings include: Review of facility policy, titled Comprehensive Care Planning Policy, with a last review date of July 19, 2019, revealed [in part]: H. A Facility Resident Care Plan Coordinator (must be a nurse appointed and supervised by the Director of Nursing) is responsible for the Resident Assessment, the Resident Care Plan, and the Resident Care Plan Conference; . J. Residents scheduled for the Resident Care conference include: 1) New admissions who MDS [MDS-Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] was completed within the previous seven days. 2) Residents who have returned from the hospital in the past week. Their previous MDS and Care Plan must be reviewed and updated. 3) Residents who have had a significant condition change and MDS was completed in the past week. 4) Residents who have had a 90 day review assessment or an annual full assessment completed within the previous seven days. M. The facility designee is responsible for delivering to each resident who is scheduled for conference an invitation to attend the meeting; N. The facility designee is responsible for mailing an original letter of requested participation to an appropriate family member or legal representative of all residents scheduled for review who have been deemed legally incompetent or have been charted as being medically incompetent by their attending physician. Review of Resident 1's clinical record revealed diagnoses that included chronic pain, adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction), severe protein-calorie malnutrition (the state of inadequate food intake), hypertension (high blood pressure), and adjustment disorder with depressed mood (a strong emotional or behavioral reaction to stress or trauma). Review of Resident 1's clinical record revealed that they had an admission comprehensive assessment with an assessment reference date (last day of assessment period) of October 31, 2023. Review of Resident 1's care plan revealed that they had 22 active care problems identified. Further review of Resident 1's care plan revealed the following: 1) one care plan problem had a start date of October 28, 2023, with a last review date of October 28, 2023; 2) one care plan problem had start date of October 31, 2023, with a last review date of October 31, 2023; 3) one care plan problem had start date of November 6, 2023, with a last review date of November 6, 2023; and 395395 Page 5 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4) nine care plan problems had a start date of November 7, 2023, with a last review date of November 7, 2023. Review of Resident 1's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with the Resident or their Resident Representative to establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. Review of Resident 2's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left dominant side; major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypertension (high blood pressure). Review of Resident 2's clinical record revealed that they had a quarterly assessment with the assessment reference date of October 13, 2023; and a quarterly assessment with the assessment reference date December 19, 2023. Review of Resident 2's care plan revealed that they had 18 active care problems identified. Further review of Resident 2's care plan revealed that all identified 18 care plan problems were last reviewed on November 7, 2023. Review of Resident 2's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with the Resident or their Resident Representative to establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); and vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults). Review of Resident 3's clinical record revealed that they had an annual comprehensive assessment with the assessment reference date of September 7, 2023; a quarterly assessment with the assessment reference date of October 18, 2023; and a quarterly assessment with the assessment reference date of November 14, 2023. Review of Resident 3's care plan revealed that they had 23 active care problems identified. Further review of Resident 3's care plan revealed that 17 of these identified care plan problems were last reviewed on December 7, 2023; one was last reviewed on December 19, 2023; one was last reviewed on December 26, 2023; one was last reviewed on December 28, 2023; and three new care plan problems were identified on December 28, 2023. Review of Resident 3's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with the Resident or their Resident Representative to 395395 Page 6 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. Review of Resident 5's clinical record revealed diagnoses that included sepsis (potentially life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), hypertension, and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 5's clinical record revealed that they had an admission comprehensive assessment with the assessment reference date of November 6, 2023. Review of Resident 5's care plan revealed that they had 21 active care problems identified. Further review of Resident 5's care plan revealed that one of these identified care plan problems was last reviewed on November 2, 2023; one was last reviewed on November 6, 2023; one was last reviewed on November 13, 2023; five were last reviewed on December 18, 2023; and 13 were last reviewed on December 18, 2023. Review of Resident 5's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with the Resident or their Resident Representative to establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. Review of Resident 6's clinical record revealed diagnoses that included Alzheimer's dementia (a chronic neurodegenerative disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) , anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), diabetes mellitus type II, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), unspecified systolic congestive heart failure (heart failure that occurs when the left ventricle in the heart cannot pump enough blood), and chronic pain. Review of Resident 6's clinical record revealed that they had an admission comprehensive assessment with the assessment reference date of August 3, 2023; and a quarterly assessment with the assessment reference date of November 3, 2023. Review of Resident 6's care plan revealed that they had 20 active care problems identified. Further review of Resident 6's care plan revealed that 19 of these identified care plan problems were last reviewed on December 18, 2023; and one was last reviewed on December 27, 2023. Review of Resident 6's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with their Resident or their Resident Representative to establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. 395395 Page 7 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident 7's clinical record revealed diagnoses that included chronic kidney disease (medical condition referring to damage to the kidneys due to chronic high blood pressure), chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), chronic systolic congestive heart failure (heart failure that occurs when the left ventricle in the heart cannot pump enough blood), and hypertension. Residents Affected - Some Review of Resident 7's clinical record revealed that they had a quarterly assessment with the assessment reference date of August 27, 2023; a quarterly assessment with the assessment reference date of November 29, 2023; and a significant change assessment completed on December 18, 2023. Review of Resident 7's care plan revealed that they had 16 active care problems identified. Further review of Resident 7's care plan revealed that all 16 of these identified care plan problems were last reviewed on January 3, 2023. Review of Resident 7's clinical record and care conference report documentation failed to reveal any documentation of a care plan meeting with the Resident or their Resident Representative to establish their person centered care plan at the time of the aforementioned assessments and care plan review dates. During an interview with the Nursing Home Administrator (NHA) on December 26, 2023, at 1:10 PM, the NHA indicated that the facility had a change in their electronic health record with the change in ownership in July of 2023. She indicated that the care plan meetings with Residents and/or their representatives were not held. She further stated that all resident care plans were reviewed and updated by December 22, 2023. She confirmed that she would expect the meetings to have taken place and that residents and/or their representatives should have been invited to attend the meetings. During a follow-up interview with the NHA and Director of Nursing (DON) on December 29, 2023, at 10:49 AM, the NHA again confirmed that the facility was not completing care plan meetings with residents and/or their representatives. She said that when the facility changed their electronic health record at the time of the change in ownership in July 2023, the facility had to stop the meetings. She indicated that the interdisciplinary team (IDT) reviewed any residents who had experienced a fall, a dietary/nutrition issue, or a new wound in their morning meeting, but that the IDT did not meet to review a resident's full care plan. She also indicated that residents nor responsible parties were invited to attend a care plan meeting. She indicated that residents' care plans were updated accordingly. and that the facility will be reaching out to all residents/ responsible parties in January to conduct a care plan meeting, and then they would be held according to each residents' assessment schedule. She further indicated that the facility did meet with families if they had requested meetings. 28 Pa. Code 211.11(a)(c)(d)(e) Resident Care Plans 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services 395395 Page 8 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm Based on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure care and services were provided including skin and wound assessments in accordance with professional standards of practice, resulting in development and deterioration of wounds and subsequent transfer to the hospital with a diagnosis of wound infection and sepsis, requiring an above the knee amputation for one of three residents reviewed (Resident 3). Residents Affected - Few Findings include: Review of facility policy, titled Skin and Wound Care Best Practices, with a last revised date of June 10, 2022, revealed, in part, the following: CNA's (Certified Nurse Aide) fill in shower sheet with each bath/shower and review with licensed nurse . The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistant's shower sheet skin reviews. The policy continued, Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. Use of a consulting wound care provider for management of wounds is recommended for the following: a stage 3 or greater pressure area; complicated vascular wounds; complicated diabetic wounds; wounds which are worsening; wounds which are not healing even with treatment changes; infected wounds; when assistance with correctly staging or categorizing a wound is needed. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults); and bullous pemphigoid (a rare skin condition causing large fluid filled blisters that usually appears on the belly, chest, arms, legs, groin, or armpits). Further record review revealed wound areas to the Resident's right lateral knee, left lateral ankle, left lateral upper arm, and abdomen. Review of Resident 3's clinical record revealed physician orders for: clobetasol ointment 0.05 % apply small amount topically to rash on right wrist twice daily, dated December 10, 2023; fluocinonide cream 0.05 % apply small amount topically to right wrist every day for bullous pemphigoid, dated December 16, 2023; fluocinonide cream 0.05 % apply small amount topically to blistered area(s)/rashes topically on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen every day as needed related to bullous pemphigoid, dated August 23, 2023; triamcinolone acetonide cream; 0.1 % apply a small amount topically twice a day to rashes on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen related to bullous pemphigoid, dated August 1, 2023; and tacrolimus ointment 0.1 % apply a small amount topically every shift to blistered area(s)/rashes on the bilateral upper extremities, bilateral lower extremities, chest, and abdomen related to bullous pemphigoid, dated August 9, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment of their skin for the extent, number, or description of these blistered areas and/or rashes. Further review of Resident 3's clinical record revealed physician orders for: Cleanse open area to right lateral knee with normal saline, apply xeroform gauze, and cover with foam every shift, dated 395395 Page 9 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0684 Level of Harm - Actual harm Residents Affected - Few August 21, 2023; Check placement of dressing to right lateral knee and reapply utilizing as needed treatment order if soiled or dislodged, dated June 29, 2023; Cleanse open area to left lateral upper arm with normal saline, apply triple antibiotic ointment, cover with non-adherent pad, and wrap with kling daily and as needed, dated June 29, 2023; Cleanse two small open areas to lower abdomen with normal saline, allow to dry, apply xerform gauze, and cover with foam daily and as needed, dated June 29, 2023; Cleanse open area to Left Lateral Ankle with normal saline or wound cleanser and pat dry; apply a piece of Collagen AG to the wound bed, cut to fit, and cover with border foam dressing every evening shift, dated November 21, 2023; and consult dermatology for bullae (fluid filled sacs) and multiple open areas, dated July 17, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment (measurements, description, characteristics, or status [healing, worsening, infected]) of the identified open areas on the right lateral knee, the left lateral upper arm, the lower abdomen, or the left lateral ankle. Review of Resident 3's care plan revealed a care plan problem for skin integrity related to diagnosis of bullous pemphigoid, with a start date of September 28, 2023, and a last edited date of December 7, 2023. Interventions included: conduct a systematic skin inspection weekly with tub bath/shower, dated September 28, 2023; and treat skin condition per MD order, Dermatology Consult as needed, and follow by wound team, dated September 28, 2023. Further review of Resident 3's clinical record failed to reveal any documentation that a systematic skin inspection was completed weekly with tub bath/shower, nor was there any documentation that Resident 3's known areas of skin breakdown were being evaluated on a weekly basis. Review of Resident 3's clinical record revealed a note dated December 18, 2023, at 9:45 AM, that indicated This writer asked MD to see resident r/t (related to) his Bullous Pemphigoid and ulcers that resident has been having treated on his lateral left lower leg. MD felt that resident should be sent out to the hospital. Review of Resident 3's clinical record revealed a note dated December 19, 2023, at 8:46 AM, that indicated the Resident was admitted to the hospital with a diagnosis of sepsis, wound infection, and critical limb ischemia (severe blockage in the arteries of the lower extremities which markedly reduces blood flow). Review of Resident 3's hospital admission history and physical dated December 18, 2023, at 4:17 PM, indicated, in part, Per nursing at Colonial Park Care Center (River's Bend), the wounds have been present for several months with worsening over the last several weeks; . MRI was concerning for osteomyelitis of the fibula. Podiatry recommended vascular surgery consult. Vascular surgery recommended AKA (above knee amputation) as patient has multiple wounds, decreased blood supply. General surgery is following patient and planning for left AKA. Facility provided a copy of Resident 3's wound assessment from hospital that was completed by a Wound Ostomy Continence Nurse on December 19, 2023, at 10:10 AM. This report indicated the presence of the following skin areas: 1) several superficial circular wounds noted on right forearm with beds red/yellow; 2) right hip presents with a stage 3 pressure injury with wound bed yellow/pink and moist. Several 395395 Page 10 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0684 circular superficial pink open wounds noted of peri-wound skin (skin surrounding the wound bed); Level of Harm - Actual harm 3) sacrum presents with an unstageable pressure injury with center brown/black, edges red/yellow; Residents Affected - Few 4) left lateral knee presents with a stage 3 pressure injury with wound bed pale yellow/pink and moist; and 5) unstageable pressure injury noted on left lateral lower leg extending to the lateral ankle with wound bed brown with tan and red, bone exposed over the ankle. Further review of Resident 3's hospital notes revealed a physician progress note dated December 21, 2023, at 12:46 PM, that indicated Patient was found to have osteomyelitis of the left fibula. General surgery is following and planning for left AKA on Friday. Cardiology is consulted for preop clearance. Further review of Resident 3's hospital record revealed a note dated December 21, 2023, at 1:34 PM, that indicated Given patient's comorbidities and severe dementia I do not think he is a good candidate for surgical intervention with AKA. Resident 3's family opted for comfort care with hospice and was transferred back to the facility on December 22, 2023. Email was sent to the Nursing Home Administrator (NHA) on December 26, 2023, at 1:35 PM, requesting information regarding a weekly assessment with measurements of Resident 3's identified skin areas. Email response received from NHA on December 26, 2023, at 1:37 PM, indicated that there were no weekly assessments with measurements because Resident 3 was being seen by dermatology. Review of facility provided dermatology visit note from November 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Review of facility provided dermatology visit note from December 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Email communication received from NHA on December 26, 2023, at 1:42 PM, the NHA confirmed that there were no assessments of Resident 3's skin conditions that the facility could locate. Email communication received form NHA on December 27, 2023, at 1:03 PM, the NHA indicated that staff are to document weekly skin checks on a form called Weekly Observation. She further indicated that she noted that Resident 3 did not have an order for this weekly observation to be completed and that an order had now been placed in system. The NHA confirmed that she would expect staff to have complete weekly assessments of Resident 3's known skin conditions and document the findings. During an interview with the NHA and Director of Nursing (DON) on December 29, 2023, at 10:24 AM, the NHA confirmed that the dermatologist had only assessed Resident 3's right arm and forehead and had not assessed Resident 3's lower extremity open areas. The DON indicated that the facility process was that an order would be entered upon admission for all residents to have a weekly skin 395395 Page 11 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0684 Level of Harm - Actual harm Residents Affected - Few assessment, and that this assessment would be completed by the charge nurse on that assignment on the scheduled day. She indicated that this would either be a Registered Nurse or a Licensed Practical Nurse and that wound characteristics and measurements would be documented on a form called Weekly Observation. She confirmed that Resident 3 had no order for a weekly skin check. When asked if Resident 3 had been seen by the facility wound team as indicated on their care plan, the DON indicated that the wound team only assesses pressure area wounds and confirmed that Resident 3's skin conditions (open areas, rashes, blisters) had not been assessed by the facility wound team. When asked how a nurse would know when to report a concern with the skin condition, the DON indicated the nurse doing the treatment should notice the changes in the wound/ skin condition and should notify their superior. When specifically asked if, to her knowledge, Resident 3 was receiving a weekly skin assessment by a nurse, the DON replied, Not that's documented. When asked if the facility has a specialized wound care consultant that visits the facility on a routine basis to assess residents with noted skin conditions such as open areas, the DON indicated that they do not have an in-house provider and that they send residents to a wound care provider on an as needed basis. She confirmed that Resident 3 had not been seen by a specialized wound care provider for his ongoing skin conditions (open areas, rashes, blisters). When asked if Resident 3's physician was aware of the extent of Resident 3's skin conditions and had assessed the areas prior to December 18, 2023, she indicated, not that I am aware. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395395 Page 12 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, and failed to assess residents to identify pressure ulcers for one of four residents reviewed (Resident 3), resulting in the development of pressure ulcers. Residents Affected - Few Findings include: Review of facility policy, titled Skin and Wound Care Best Practices, with a last revised date of June 10, 2022, revealed, in part, the following: CNA's (Certified Nurse Aide) fill in shower sheet with each bath/shower and review with licensed nurse . On admission the nurse will complete a full body assessment. A second full body assessment will be scheduled in the first 24 hours of admission . The licensed nurses will complete a Weekly Skin Check. This review is in addition to the nursing assistant's shower sheet skin reviews . Any resident leaving the facility for an appointment, LOA [leave of absence], dialysis, etc., will have a Departure/Return assessment before the resident leaves the facility and upon return to the facility. The licensed nurse will complete the assessment(s) in the health record. The policy continued, Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. Use of a consulting wound care provider for management of wounds is recommended is recommended for the following: a stage 3 or greater pressure area; complicated vascular wounds; complicated diabetic wounds; wounds which are worsening; wounds which are not healing even with treatment changes; infected wounds; when assistance with correctly staging or categorizing a wound is needed. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults); and bullous pemphigoid (a rare skin condition causing large fluid filled blisters that usually appears on the belly, chest, arms, legs, groin, or armpits). Review of Resident 3's clinical record revealed physician orders for: Cleanse open area to right lateral knee with normal saline, apply xeroform gauze, and cover with foam every shift dated August 21, 2023; Check placement of dressing to right lateral knee and reapply utilizing as needed treatment order if soiled or dislodged, dated June 29, 2023; Cleanse open area to left lateral upper arm with normal saline, apply triple antibiotic ointment, cover with non-adherent pad, and wrap with kling daily and as needed, dated June 29, 2023; Cleanse two small open areas to lower abdomen with normal saline, allow to dry, apply xerform gauze, and cover with foam daily and as needed, dated June 29, 2023; Cleanse open area to the Left Lateral Ankle with normal saline or wound cleanser and pat dry; apply a piece of Collagen AG to the wound bed, cut to fit, and cover with border foam dressing every evening shift, dated November 21, 2023; and consult dermatology for bullae (fluid filled sacs) and multiple open areas, dated July 17, 2023. Review of Resident 3's clinical record failed to reveal any documentation of an assessment (measurements, description, characteristics, or status [healing, worsening, infected]) of the identified open areas on the right lateral knee, the left lateral upper arm, the lower abdomen, or the left 395395 Page 13 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 lateral ankle. Level of Harm - Actual harm Review of Resident 3's care plan revealed a care plan problem for skin integrity related to diagnosis of bullous pemphigoid, with a start date of September 28, 2023, and a last edited date of December 7, 2023. Interventions included: conduct a systematic skin inspection weekly with tub bath/shower, dated September 28, 2023; and Treat skin condition per MD order, Dermatology Consult as needed, and follow by wound team, dated September 28, 2023. The care plan failed to include actual skin impairment as identified by the multiple wounds. Residents Affected - Few Further review of Resident 3's clinical record failed to reveal any documentation that a systematic skin inspection was completed weekly with tub bath/shower to determine if there were any pressure ulcers, nor was there any documentation that Resident 3's known areas of skin breakdown being evaluated on a weekly basis. Review of Resident 3's nurse aide point of care documentation revealed that on December 6, 2023, at 2:23 AM, that Employee 2 (Nurse Aide) noted redness and bruising to Resident 3's back, buttock, and leg (no specification as to which leg was given). There was no documentation noted that this identified concern was reported to the licensed nurse. Review of Resident 3's clinical record progress notes failed to reveal any documentation that the aforementioned redness and bruising to their back, buttock, and leg was assessed by a licensed nurse on December 6, 2023. Email communication received from NHA on December 28, 2023, at 4:00 PM, revealed that they were not aware of the bruising and redness being reported to a licensed nurse to assess when identified by Employee 2 on December 6, 2023. Review of Resident 3's clinical record revealed that he had been seen by Employee 3 (Primary Care Physician) on November 10, 15, 29, 2023, and December 6, 13, and 18, 2023. Review of these physician progress notes from the aforementioned visits failed to reveal an assessment of Resident 3's identified skin issues. Review of Resident 3's clinical record revealed that for November 2023 and December 2023, they had been seen by Employee 4 (Certified Registered Nurse Practitioner) on November 2, 3, 6, 7, 10, 13, 14, 16, 17, 24, 28, 2023, and December 1, 5, and 12, 2023. Review of these physician services progress notes revealed new lesions were indicated in the progress notes on November 6, 2023, which was noted as seen by dermatology November 7, 2023. On November 13, 2023, multiple lesions and open areas were reported by nursing and follow-up with dermatology was recommended. On November 14, 2023, in section titled Issues reported by nursing indicated skin lesions. On November 16, 2023, in section titled Issues reported by nursing indicated increased lesions all over, and the assessment/plan indicated bullous pemphigoid with more new lesions. The note also indicated that the charge nurse was asked to contact dermatology regarding the new lesions; On November 17, 2023, stated lesions remain the same. The note also indicated that Resident 3's Prednisone (a steroid medication) dose was increased. Review of Resident 3's progress notes revealed no physical assessment of Resident 3's skin was documented. Notes identified the bullous pemphigoid lesions but failed to complete an assessment 395395 Page 14 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 documenting the characteristics of the wounds. Level of Harm - Actual harm Review of Resident 3's clinical record revealed a note dated December 18, 2023, at 9:45 AM, completed by Employee 5 (Registered Nurse) that indicated This writer asked MD to see resident r/t (related to) his Bullous Pemphigoid and ulcers that resident has been having treated on his lateral left lower leg. MD felt that resident should be sent out to the hospital. Residents Affected - Few Review of Resident 3's clinical record revealed a physician progress note completed by Employee 6 (Physician) dated December 18, 2023, prior to sending Resident 3 to the hospital, indicated the following: Patient with bullous pemphigoid has unstageable lesion over L[eft] malleolus [ankle] ulceration. Ext[ensive] multiple wounds on LLE [left lower extremity]. Unstageable L[eft] ankle ulcer with necrotic [dead] tissue 1) Unstageable left ankle ulceration with necrosis probable OM [osteomyelitis-infection in the bone] elevated white blood cell count, needs debridement [medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue] and IV [intravenous] antibiotics; 2) bullous pemphigoid. Review of Resident 3's clinical record revealed a note dated December 19, 2023, at 8:46 AM, that indicated he was admitted to the hospital with a diagnosis of sepsis, wound infection, and critical limb ischemia (severe blockage in the arteries of the lower extremities which markedly reduces blood flow). Review of Resident 3's hospital admission history and physical dated December 18, 2023, at 4:17 PM, indicated, in part, Per nursing at Colonial Park Care Center (River's Bend), the wounds have been present for several months with worsening over the last several weeks. MRI was concerning for osteomyelitis of the fibula. Podiatry recommended vascular surgery consult. Vascular surgery recommended AKA (above knee amputation) as patient has multiple wounds, decreased blood supply. General surgery is following patient and planning for left AKA. Facility provided a copy of Resident 3's wound assessment from the hospital that was completed by a Wound Ostomy Continence Nurse on December 19, 2023, at 10:10 AM. Review of this report indicated that, upon admission, the presence of the following pressure areas were identified: 1) right hip presents with a stage 3 pressure injury with wound bed yellow/pink and moist. Several circular superficial pink open wounds noted of peri-wound skin (skin surrounding the wound bed); 2) sacrum presents with an unstageable pressure injury with center brown/black, edges red/yellow; 3) left lateral knee presents with a stage 3 pressure injury with wound bed pale yellow/pink and moist; 4) unstageable pressure injury noted on left lateral lower leg extending to the lateral ankle with wound bed brown with tan and red, bone exposed over the ankle; 5) left medial ankle presents with a deep tissue injury with area maroon and intact. There is an unstageable pressure injury over left posterior heel with bed dry and black. Further review of Resident 3's hospital record revealed a note dated December 21, 2023, at 1:34 PM, that indicated Given patient's comorbidities and severe dementia I do not think he is a good candidate for surgical intervention with AKA. Resident 3's family opted for comfort care with hospice and 395395 Page 15 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 was transferred back to the facility on December 22, 2023. Level of Harm - Actual harm Review of Resident 3's clinical record revealed a progress note dated December 22, 2023, at 12:49 AM, that indicated, in part, Resident admitted .diagnosis is left leg osteomyelitis .As per hospital report family decided on comfort measures .has several bruises all over his body with multiple wounds on sacral, lower extremity, and back . Hospice was called. Residents Affected - Few Email was sent to the Nursing Home Administrator (NHA) on December 26, 2023, at 1:35 PM, requesting information regarding a weekly assessment with measurements of Resident 3's identified skin areas. Email response received from NHA on December 26, 2023, at 1:37 PM, indicated that there were no weekly assessments of Resident 3's skin issues with measurements because Resident 3 was being seen by dermatology. Review of facility provided dermatology visit note from November 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Review of facility provided dermatology visit note from December 7, 2023, revealed that an examination was performed including the head and that a full skin check was offered, but declined by resident. The report revealed that the dermatologist noted an area to the forehead and the right proximal dorsal forearm. Email communication received from NHA on December 26, 2023, at 1:42 PM, the NHA confirmed that there were no assessments of any of Resident 3's skin conditions that the facility could locate. Email communication received from NHA on December 27, 2023, at 1:03 PM, the NHA indicated that staff are to document weekly skin checks on a form called Weekly Observation. She further indicated that she noted that Resident 3 did not have an order for this weekly observation to be completed and that an order had now been placed in system. The NHA confirmed that she would expect staff to have complete weekly assessments of Resident 3's known skin conditions and document the findings. During further correspondence with the NHA, she stated that, upon readmission to the facility, Resident 3 had a pressure area noted to the sacrum extending to buttock measuring 5.2 centimeters (cm - unit of measure) x 7 cm with the depth unstageable. She indicated that a wound sheet for this wound was not completed on admission and that the agency nurse left measurements on paper. She further indicated that the measurements will be placed in the computer that day, on December 27, 2023. In response to the concern about care plan interventions of follow by wound team dated September 28, 2023, not being implemented, the NHA indicated wound nurse starts Tuesday (January 2, 2024). Follow-up review of Resident 3's clinical record on December 28, 2023, at 3:41 PM, revealed that a Wound Management Detail Report was completed by the DON on December 27, 2023, at 2:35 PM; a total of five days after Resident 3's readmission to the facility. This report indicated the presence of a pressure ulcer to their sacrum and was described as: Length - head to toe direction: 5.2 cm Width - side to side direction: 7 cm 395395 Page 16 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 Can depth be measured?: No Level of Harm - Actual harm Exudate Amount: Moderate Residents Affected - Few Exudate color and consistency: Serosanguineous (pale red to pink, thin and watery) Stage: Unstageable - Slough and/or Eschar Tissue Type: Necrotic Tissue Comments: Upon readmission resident noted with unstageable pressure ulcer to sacrum/extending into bilateral buttocks. Resident now comfort care and awaiting hospice consult. 90% thick adherent yellow slough noted to wound bed with 10% dry black eschar tissue. Moderate serosanguineous draining with slight odor noted. No s/sx (signs or symptoms) of pain when wound is assessed. Peri-wound WNL [within normal limits]. Wound cleansed with NSS [normal saline solution], calcium alginate with Ag [silver] placed to wound bed and covered with foam. Review of a progress note dated December 28, 2023, at 2:59 PM, (six days after Resident 3's readmission to the facility) by the DON, indicated Full body assessment completed on resident: Following are his current wounds/measurements. Right hip lesion: measures 0.4 cm x 0.2 cm, no depth, with light serous drainage; Right lateral back lesion: 1.5 cm x 2.7 cm, no depth, with light serous drainage; Right lower back lesion: 0.8 cm x 1.2 cm, no depth, with light serous drainage; Right upper lateral shin lesion: 1 cm x 1 cm, no depth, with light serous drainage; and Right lower lateral shin lesion: 1 cm x 1.4 cm, no depth, with light serous drainage Right shin: four intact scabs Right thigh: Intact fluid filled blister 1 cm x 0.7 cm, with surrounding skin intact and no discoloration. Continued review of the DON's progress note revealed multiple areas of deep discoloration, intact eschar tissue, etc., to the left lower extremity, related to critical limb ischemia and severe PVD. The progress note revealed the following area assessments were noted related to the Resident's left lower extremity: Heel: 7.5 cm x 6 cm, noted with a mixture of black eschar tissue and deep purple areas with no drainage; Medial ankle: 1 cm x 1.5 cm, intact deep purple area with surrounding skin reddened; Medial foot: 1.4 cm x 1.5 cm, intact deep purple area with surrounding skin reddened; Distal medial foot: 1.5 cm x 1.3 cm, intact deep purple area with surrounding skin reddened, 395395 Page 17 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 Reddened area noted to medial aspect of left great toe; Level of Harm - Actual harm Medial skin: 1.6 cm x 1 cm, with light serous drainage; Residents Affected - Few Medial upper knee: 2.5 cm x 1.8 cm, with light serous drainage; Medial lower knee: 3.5 cm x 2.5 cm, with light serous drainage; Distal lateral foot: 1.8 cm x 2.3 cm, intact deep purple tissue; Lateral foot: 1.2 cm x 1.3 cm, intact eschar with no drainage; Lateral foot: 6.2 cm x 5.5 cm, intact eschar tissue with no drainage; Lateral lower knee: 3 cm x 1 cm, with light serous drainage; Lateral knee: 1.9 cm x 4.3 cm, with light serous drainage; Lower back: 8 cm x 1 cm, with light serous drainage; Lateral ankle: 8 cm x 5.2 cm, unable to measure depth, wound with 80% thick yellow slough and 20% dry eschar, foul smelling with moderate serosanguineous drainage; Lateral shin: 6.4 cm x 2.5 cm, with 100% dry eschar. The progress note revealed that there was no pedal pulse to the left foot and that the left lower extremity, including the foot, was cool to the touch. Further, it stated that the Resident was currently on comfort care with a Hospice evaluation pending. A follow-up review of Resident 3's clinical record on December 29, 2023, at 9:30 AM, revealed that there were no other Wound Management Detail Reports completed for the other hospital identified wounds. During an interview with the NHA and Director of Nursing (DON) on December 29, 2023, at 10:24 AM, the NHA confirmed that the dermatologist had only assessed Resident 3's right arm and forehead, and had not assessed Resident 3's lower extremity open areas. The DON indicated that the facility process was that an order would be entered upon admission for all residents to have a weekly skin assessment, and that this assessment would be completed by the charge nurse on that assignment on the scheduled day. She indicated that this would either be a Registered Nurse or a Licensed Practical Nurse and that wound characteristics and measurements would be documented on a form called Weekly Observation. She confirmed that Resident 3 had no order for a weekly skin check. When asked if Resident 3 had been seen by the facility wound team as indicated on their care plan, the DON indicated that the wound team only assesses pressure area wounds and confirmed that Resident 3's skin conditions (open areas, rashes, blisters) had not been assessed by the facility wound team. When asked how a nurse would know when to report a concern with the skin condition, the DON indicated the nurse doing the treatment should notice the changes in the wound/ skin condition and should 395395 Page 18 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0686 notify their superior. When specifically asked if, to her knowledge, Resident 3 was receiving a weekly skin assessment by a nurse, the DON replied, Not that's documented. Level of Harm - Actual harm Residents Affected - Few When asked about all the areas that the hospital's Wound Ostomy Continence Nurse identified as pressure area, the DON indicated that the facility only identified the sacral wound as a pressure area, She said that the areas identified on Resident 3's legs and heels were considered vascular wounds since the Resident was diagnosed with PVD and chronic limb ischemia at the hospital. She said that, as for the others identified at the hospital, they are considered blisters that have opened and that they are flat to the skin. She also indicated that some of them were scars from previous bullous pemphigoid areas. When asked about Employee 2's documentation of the redness and bruising to Resident 3's back, buttock, and leg, the DON confirmed that there was no evidence that this was reported to a licensed nurse. When asked if this documented concern by Employee 2 could have been the start of the development of the pressure ulcer, the DON indicated No. When asked specifically if the sacral pressure ulcer should have been identified prior to Resident 3's admission to the hospital, the DON replied, Maybe, we don't know. When asked if a skin assessment was completed prior to Resident 3's transfer out of the facility as indicated in the facility policy, the DON indicated it was not done as this was an emergent transfer. When asked if the facility has a specialized wound care consultant that visits the facility on a routine basis to assess residents with noted skin conditions such as open areas, the DON indicated that they do not have an in-house provider, and that they send residents to a wound care provider on an as needed basis. She confirmed that Resident 3 had not been seen by a specialized wound care provider for his ongoing skin conditions (open areas, rashes, blisters). When asked if Resident 3's physician was aware of the extent of Resident 3's skin conditions and if the physician had actually assessed the areas prior to December 18, 2023, she indicated, not that I am aware. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d)Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395395 Page 19 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, document review, and staff interviews, it was determined the facility failed to ensure that the hospice services were established in a timely manner for one of one residents receiving Hospice services reviewed (Resident 3). Findings include: Review of facility policy, titled Hospice Care Policy, with a last revised date of May 24, 2023, revealed the following: the hospice services and those providing them will meet professional standards and be provided timely . ii. Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC (long term care facility) before hospice care is furnished to any resident. Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side; chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats); and vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults). Review of Resident 3's clinical record revealed that they had returned to the facility on December 22, 2023, after a hospital stay from December 18-22, 2023. Review of Resident 3's Hospital Discharge summary dated [DATE], revealed that a referral had been made to Amedisys Hospice. Review of Resident 3's clinical record progress notes revealed a note dated December 22, 2023, at 11:13 AM, by a facility Social Worker that indicated they received a call from Amedisys Hospice who expressed that they were following Resident at the hospital. Family is interested in Hospice with them and reached out for a referral. Social Worker is waiting on a One Time Contract to be sent over. It was reported that Resident will be back in the facility today. Upon initial review of Resident 3's clinical record on December 26, 2023, at approximately 10:00 AM, there were no documentation or indications of the status of Resident 3's hospice referral status. A follow-up review of Resident 3's clinical record on December 27, 2023, at approximately 10:00 AM, revealed there was still no documentation or indications of the status of Resident 3's hospice referral status. Email communication received from the Nursing Home Administrator (NHA) on December 27, 2023, at 3:16 PM, indicated They are picking him up after the holidays. They still do not have the staff. We will have him on comfort care until they can provide their staffing. They are to bring contract in tomorrow. Phone interview with Employee 1 (Director of Operations at Amedisys Hospice) on December 28, 2023, at 10:40 AM, revealed that they had received the referral for hospice for Resident 3 from the 395395 Page 20 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital on December 22, 2023. She indicated that they had made the physician aware at the hospital that they did not have a contract with the facility (River's Bend) and that they could not admit the Resident until December 26, 2023, because the Christmas schedule was already completed. She indicated that the hospital physician was fine with that and indicated that Resident 3's death was not imminent. She indicated that Amedisys Hospice was working with the facility's Nursing Home Administrator, Social Worker, and Business Officer Manager to secure the items needed for the contract, but that they still needed specific documents from the facility. Employee 1 indicated that their hospice liaison has reached out on a daily basis since receiving the referral to obtain the documents needed to develop the contract. Employee 1 confirmed that they were prepared to admit Resident 3 on December 26, 2023, and that they were on the schedule, but were unable to do so because the necessary documents had not received for the contract to be processed. Employee 1 indicated that they had also reached out to Palliative Care at the hospital on December 27, 2023, to try and see if they could get the facility to move along with obtaining the required documents so that a contract could be established and services could begin for Resident 3. Email communication was sent to the NHA by surveyor on December 28, 2023, at 2:43 PM, the above conversation was shared. It was shared that Amedisys hospice informed the surveyor that they did not have a staffing issue, but that it was a contract issue. They indicated that the facility was made aware of the hospice provider at the time of the hospital discharge (the same day that they received the referral) and the need for a contract. They further indicated that they have been in daily contact with the facility regarding the items needed for the contract and have spoken to the business office manager, social services, and the NHA to attempt to get this contract processed timely. As of the time of the interview, hospice indicated that they still needed one item from the facility to complete the contract. They also indicated that they have been in contact with Resident 3's family regarding the delay in getting the contract to provide the ordered services. Request was made for any additional information the facility may have regarding Resident 3's delay in acquiring hospice services. Email response communication received from NHA on December 28, 2023, at 3:12 PM, indicated We provided all of the vendor requested information with the W-9 today. I was told by my staff that it was a staffing issue. Follow-up email communication received from NHA on December 28, 2023,at 3:14 PM, indicated I just got off the phone with the business office and they are waiting for additional liability notice but the contract should be able to be signed and service started. Email communication received from NHA on December 28, 2023, 4:04 PM, indicated that the person at hospice that the facility Social Worker spoke to regarding a hospice staffing issue was the hospice liaison. The NHA further indicated The company should have come with the hospice contract when the family chose them in the hospital and not waited until the patient was back here as well. Review of email communication from the Business Office Manager to the facility corporate leadership staff, provided by the NHA on December 28, 2023, at 3:26 PM, revealed that the first time the business office requested the W-9 and Certificate of Liability was on Wednesday, December 27, 2023, at 3:29 PM. NHA provided a copy of an email communication on December 28, 2023, at 3:52 PM, that was sent by facility Social Worker on Friday, December 22, 2023, at 11:08 AM, to facility leadership indicating: I received a call from Amedisys Hospice about picking up [Resident 3] for Hospice. They expressed that he will be leaving the hospital today. 395395 Page 21 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NHA provided a copy of an email on December 28, 2023, at 3:52 PM, that was sent by a facility Social Worker to facility leadership on December 22, 2023, at 2:10 PM, that indicated Amedisys Hospice will not be able to see him until after the holidays. A follow-up phone interview with Employee 1 on December 29, 2023, at 9:04 AM, revealed that they had received an order that morning for hospice for Resident 3. She indicated that they were still in need of the Certificate of Liability from the facility. She said once they receive that all items will be forwarded to their contract department for review and then a contract will be prepared and sent to the facility for signature. She indicated that they now had a tentative plan to admit Resident 3 to hospice services on December 29, 2023. She also indicated the following time line of contact with the facility: December 22, 2023, at 11:17 AM, Amedisys Liaison spoke with Social Worker at facility to inform them of the referral and items needed for the contract to be established; December 26, 2023, at 10:16 AM, still awaiting requested documents from facility-resent list of items needed; December 27, 2023, at 12:57 PM, provided update to facility that they still needed a W-9 and Certificate of Liability and hospital updated on status of referral as well; December 28, 2023, no time indicated, informed hospice liaison to inform Resident 3's family to possibly select another provider with whom the facility already had a contract with such as HCP. She further revealed that they inquired with HCP but that they could not admit the Resident until Sunday, December 31, 2023. Email communication received from NHA on December 28, 2023, at 3:20 PM, indicated: Last piece of contract we were waiting for is arriving. We will send right to company. I would like it noted my staff was told by this hospice company that they were short staff and that was originally the reason they could not pick him up promptly. Email communication received from NHA on December 28, 2023, at 3:25 PM, included a copy of the last remaining hospice requested document. During an interview with the NHA and DON on December 29, 2023, at 10:45 AM, the NHA indicated that they have standing hospice contracts with Compassus Hospice and [NAME] Hospice. The NHA said that she touched base on December 27, 2023, with facility staff on the status of the hospice referral; reached out to the Resident's physician on December 28, 2023, to review medications for comfort care and to discuss comfort care measures with the family. She said that in reviewing Resident 3's record, she noted that their medications had already been reduced to comfort meds at hospital prior to his return to the facility, and that Resident 3 was placed on comfort care upon their readmission. She indicated that typically residents are admitted to hospice services within 48 hours. She said that the delay was that Amedisys Hospice was asking for the Certificate of Liability for 2024, and this was what was causing the delay. She said typically hospice providers would come and do the evaluation of the resident to determine eligibility, and then both parties would sign the contract and the additional items needed by hospice would be provided when obtained. During this interview, the NHA confirmed that she could provide no documentation to support that the facility had reached out to the Resident's Responsible Party to offer or discuss another hospice provider with whom a contract already existed. 395395 Page 22 of 23 395395 01/02/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0849 Level of Harm - Minimal harm or potential for actual harm A final review of Resident 3's clinical record revealed that they were admitted to hospice on December 29, 2023, and ceased to breathe on January 2, 2023, at 12:02 PM. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services Residents Affected - Few 395395 Page 23 of 23