Health inspection·April 10, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure that call bells were accessible for one of 28 sampled residents. (Resident 13) Residents Affected - Few Findings include: Clinical record review revealed that Resident 13 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body), contracture of muscle (stiffness in the connective tissues of the body), and muscle weakness. The Minimum Data Set assessment, dated February 7, 2025, revealed Resident 13 was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. Review of the care plan revealed that the resident had a self-care deficit due to physical limitations and contractures, and was a risk for behavioral symptoms. An intervention was for staff to provide Resident 13 with a handbell to call for assistance. On April 8, 2025, at 10:00 a.m., Resident 13 was observed in bed without a handbell. In an interview at that time, Resident 13 stated that she could not find her handbell. Resident 13 was observed again at 11:40 a.m. and at 1:30 p.m., in bed without a handbell. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed that the handbell should have been provided for Resident 13 to call for assistance. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 8 395402 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and interview, it was determined that the facility failed to ensure that information regarding how to contact State agencies and advocacy groups, including a statement that the resident may file a complaint with the State Survey Agency, was accessible to all residents, visitors, and staff. Findings include: In a confidential family interview on April 8, 2025, at 10:15 a.m., it was revelaed that information regarding how to contact State agencies and advocacy groups, including the State Survey Agency, was not available and posted for all residents, visitors and staff. In addition, observation revealed there was no information posted that included a statement that the resident may file a complaint with the State Survey Agency. In an interview on April 9, 2025, at 1:30 p.m., the Administrator confirmed that the names and phone numbers of various advocacy groups, including the State Survey Agency, was not posted and available to residents, staff, and visitors. 28 Pa. Code 201.29(a)(c.1) Resident rights. 395402 Page 2 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 28 sampled residents. (Residents 45, 77) In addition, the facility failed to develop and implement interventions to address bowel incontinence in the resident's comprehensive care plan for one of 28 sampled residents. (Resident 129) Findings include: Clinical record review revealed that Resident 45 was admitted to the facility on [DATE], and had diagnoses that included diabetes, heart disease, and hypertension (high blood pressure). The Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) summary dated September 10, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 45's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 77 was admitted to the facility on [DATE], and had diagnoses that included diabetes, urinary tract infection, and hypertension. The MDS CAA summary dated November 27, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 77's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 129 was admitted to the facility on [DATE], and had diagnoses that included diabetes and hypertension. The MDS dated [DATE], indicated the resident was alert, frequently incontinent of bowel, and required assistance from staff for toileting. Review of the resident's care plan revealed the facility did not develop interventions to address Resident's 129's bowel incontinence. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed there was no documented evidence that interventions for urinary or bowel incontinence were included in the aforementioned care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 3 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 ensure that safety interventions were in place for one of seven sampled residents at risk for falls. (Resident 45) Clinical record review revealed that Resident 45 had diagnoses that included diabetes, muscle weakness, dizziness, and giddiness (feeling of imbalance and lightheadedness). The Minimum Data Set assessment dated [DATE], revealed that Resident 45 required staff assistance for bed mobility and transfers. Review of progress notes dated March 23, 2025, revealed that the resident was found on the floor in his room by his bed. Review of the care plan identified that the resident was at risk for falls related to impaired mobility. The intervention was for staff to place floor mats on both sides of the bed while the resident was in bed. Multiple observations on April 8 and April 9, 2025, between 9:40 a.m. and 2:00 p.m., revealed Resident 45 was in bed and the floor mats were not in place. In an interview on April 11, 2025, at 9:10 a.m., the Director of Nursing confirmed that the fall mats should have been in place. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 4 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for three of four sampled residents. (Residents 45, 77, 129) Findings include: Review of the facility policy entitled, Continence Management, last reviewed March 31, 2025, revealed that facility staff was to complete a urinary incontinence assessment and/or bowel incontinence assessment upon admission and re-admission and with a change in condition or change in continence status. Staff would review the pre-admission history, assess the resident's current bladder and bowel elimination problem, and identify causes of incontinence. If there was a change in urinary and/or bowel incontinence, staff would provide appropriate treatment and services to restore continence to the extent possible and implement a toileting diary to determine a resident's voiding pattern for assistance in decision-making and development of a toileting program. Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses that included diabetes, heart disease, and hypertension (high blood pressure). A bowel and urinary incontinence evaluation was completed on September 2, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated March 10, 2025, the resident needed assistance from staff for toileting, was always incontinent of urine, and was not on a toileting program. Review of the current care plan revealed that Resident 45's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. Clinical record review revealed that Resident 77 was admitted to the facility on [DATE], and had diagnoses that included diabetes, urinary tract infection, and hypertension. A review of the MDS assessments dated November 24, 2024, and February 19, 2025, revealed that Resident 77 was able to make her needs known and needed assistance from staff for toileting. The assessments further indicated that the resident was frequently incontinent of urine and bowel and was not on a toileting program. Review of the current care plan revealed that Resident 77's type of urinary and bowel incontinence was not identified and there were no specific interventions developed to address Resident 77's urinary and bowel incontinence. There was no documented evidence that a bowel and urinary incontinence evaluation, an assessment to determine the type of incontinence, and an appropriate incontinence program had been completed. Clinical record review revealed that Resident 129 was admitted to the facility on [DATE], and had diagnoses that included diabetes, kidney failure, and hypertension. A review of the MDS assessment January 7, 2025, revealed that Resident 129 was able to make his needs known and needed assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and bowel, and was not on a toileting program. A review of the MDS assessment, dated April 7, 2025, revealed that Resident 129's bowel incontinence had changed from frequently to always incontinent of bowel. There was no documentation in the clinical record to support that the resident's urinary and bowel incontinence were assessed by the facility upon admission and upon a change in Resident's 129 incontinence to determine if normal bladder and bowel function could be restored. There 395402 Page 5 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was no documented evidence that a toileting diary was completed upon identification of a change in the resident's incontinence status. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 45's toileting program was implemented or that Residents 77 and 129's bowel and urinary incontinence was evaluated and addressed after a change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 6 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **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 provide appropriate services and treatment in a timely manner for one of four sampled residents who exhibited behavioral and mood symptoms. (Resident 27) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included congestive heart failure, schizoaffective disorder, and auditory hallucinations. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, had mood issues that included feeling down, had trouble falling asleep, was tired, and had bad feelings about herself. The assessment also indicated that she had a diagnosis of Post-Traumatic Stress Disorder (PTSD) and was prescribed antidepressant, antianxiety, and antipsychotic medications. Review of a psychiatric consultation report dated April 3, 2025, revealed that the resident was being treated for an increase in depressive and anxiety symptoms. There was a recommendation made to discontinue the current physician ordered antidepressant (Lexapro) and to order a different antidepressant (Zoloft) to be administered every day. Review of the current Medication Administration Record for March 2025, revealed that as of April 9, 2025, the resident was still receiving the Lexapro and that the Zoloft recommendation had not been reviewed and/or ordered by the physician. In addition, there was no care plan developed with a problem area and specific interventions to address the diagnosis and condition of PTSD. In an interview on April 10, 2025, at 11:45 a.m., the Director of Nursing stated that the recommendation for the medication change had not been done timely and that there had been no care plan developed to address the PTSD diagnosis for this resident. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395402 Page 7 of 8 395402 04/10/2025 Pottstown Skilled Nursing and Rehabilitation Cente 724 North Charlotte St Pottstown, PA 19464

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times in one of four medication rooms. (First Floor) Finding include: Review of the facility policy entitled, Medication Storage Controlled Medication Storage, last reviewed on March 31, 2025, revealed that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were to be separately locked in permanently affixed compartments, including those controlled substances stored in refrigerators. Observation on April 9, 2025, at 12:31 p.m., revealed that the first floor medication room refrigerator contained 12 vials and two bottles of a Schedule IV anti-anxiety medication (lorazepam). The medication was not secured in a locked, permanently affixed compartment in the refrigerator. In an interview on April 9, 2025, at 10:20 a.m., the Director of Nursing stated that the controlled medications should have been locked within a separate, locked, and permanently affixed compartment of the refrigerator. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395402 Page 8 of 8