Health inspection·June 27, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide grooming services to enhance and maintain each resident's dignity for one of two sampled residents. (Resident 51) Findings include: Clinical record review revealed that Resident 51 had diagnoses that included a stroke. The resident was observed on June 25, 2024, at 9:40 a.m., and June 26, 2024, at 10:05 a.m., with facial hair on her lower face. The resident stated that she wanted the facial hair removed, but sometimes staff is busy. The resident's Minimum Data Set assessment dated [DATE], revealed that the resident required moderate assistance with personal hygiene to include shaving. The resident had a care plan for activities of daily living due to a self care deficit and one of the interventions was for staff to assist her with grooming as needed. In an interview on June 27, 2024, at 10:06 a.m., the Director of Nursing confirmed that staff were to assist the resident with grooming as needed. Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 5 395402 395402 06/27/2024 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

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 clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect each resident's current status for two of 24 sampled residents. (Residents 26, 58) Residents Affected - Few Findings include: Clinical record review revealed that Resident 26 had a Braden scale for predicting pressure sore risk dated March 15, 2024, that indicated she was at mild risk for developing pressure sores. Review of a Braden scale dated April 18, 2024, indicated that she was at moderate risk for developing pressure sores. Review of the Minimum Data Set (MDS) assessments dated March 17, 2024, and May 4, 2024, revealed that section M, skin conditions, did not indicate that the resident was at risk for developing pressure sores. Clinical record review revealed that Resident 58 had a diagnosis of atrial fibrillation. On May 18, 2024, a physician ordered for staff to administer an anti-coagulant medication (apixaban). Review of the MDS assessment dated [DATE], indicated that the resident was on an anti-platelet medication in the last seven days, not an anti-coagulant medication. The MDS inaccurately reflected the use of an anti-platelet medication, as the apixaban was an anti-coagulant medication. During interviews on June 27, 2024, at 9:49 a.m., and 10:39 a.m., the Director of Nursing stated that the aforementioned MDS assessments were coded inaccurately and did not reflect the residents' current status. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 2 of 5 395402 06/27/2024 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 24 sampled residents. (Resident 270) Residents Affected - Few Findings include: Clinical record review revealed that Resident 270 had diagnoses that included hypotension (low blood pressure). A physician's order dated June 20, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mm/Hg). Review of Resident 270's June medication administration record (MAR) revealed that staff administered the medication 14 times with no documentation that the blood pressure was assessed prior to medication administration per physician's order. In an interview on June 27, 2024, at 10:20 a.m., the Director of Nursing confirmed there was no documented evidence that Resident 270's blood pressure was taken prior to medication administration per physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 3 of 5 395402 06/27/2024 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to prevent further contractures and limitations in range of motion for one of four sampled residents who had limitations in range of motion. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had diagnoses that included brain traumatic injury, dementia and contractures of the left and right hands. The Minimum Data Set assessment dated April. 1, 2024, indicated that the resident had severe memory impairment and had limitations in range of motion. A review of the care plan revealed that the resident had a deficit in activities of daily living due to physical limitations. There was an intervention for staff to apply a right palm protector in the morning and to remove it at night. Review of an occupational therapy Discharge summary dated [DATE], revealed that staff was to apply a right palm protector for at least four hours a day. The goal was for the resident to achieve normal anatomical alignment of the right hand for four hours using a palm guard in order to achieve proper joint alignment. Observations on June 25, 2024, at 10:00 a.m., 11:48 a.m., and 1:45 p.m., revealed the resident was in bed without the right palm protector in place. On June 26, 2024, at 11:30 a.m., and 12:45 p.m., the resident was again observed in bed without the right palm protector in place. During all of the observations, the right palm guard was on top of the resident's night stand beside his bed. In an interview on June 27, 2024, at 10:40 a.m., the Director of Nursing stated that the resident was to wear the right palm guard as reflected on the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 4 of 5 395402 06/27/2024 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that oxygen tubing was changed and dated in accordance with facility policy and physician's order for one of three residents receiving oxygen therapy. (Resident 64) Residents Affected - Few Findings include: Review of the facility policy entitled, Procedure: Respiratory Equipment/Supply Cleaning/Disinfecting, dated March 24, 2024, revealed that staff was to change the oxygen delivery tubing every seven days and date the tubing when it was changed. Clinical record review revealed that Resident 64 had diagnoses that included chronic respiratory failure and had a tracheostomy (a curved plastic tube placed through a small surgical opening in the front of the neck into the windpipe allowing air to flow in and out) in place to provide oxygen. A physician's order dated August 24, 2023, directed staff to change oxygen tubing weekly every Tuesday night and to label each component with date and initials. Observations on June 25, 2024, at 10:00 and 11:52 a.m., and at 1:00 p.m., revealed that the resident's oxygen tubing was dated May 29, 2024, and the tracheostomy aerosol tubing was not dated or labeled. In an interview on June 27, 2024, at 11:15 a.m., the Director of Nursing confirmed that tubing delivering oxygen should have been labeled with a date and initials per physician's order and facility policy. 28 Pa. Code 211.12(1)(d)(5) Nursing services. 395402 Page 5 of 5