Health inspection·April 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment for residents on two of two nursing units. (South Wing and North Wing) Findings include: Observation throughout the facility during all days of the survey revealed the following: There was a hole in the wall near the door inside room [ROOM NUMBER]. The privacy curtain in room [ROOM NUMBER] was coming off the hooks. In room [ROOM NUMBER] there was a cracked floor tile. Metal ceiling tiles were stained and damaged in the hallway between rooms 95 to 119. Air conditioner vents contained debris and dirt in rooms 95, 96, 97, 99, 107, and 113. In room [ROOM NUMBER] the bedside cabinet doors were falling off. Tile was missing from the wall and there was dirt and debris on the floor around the air conditioning unit. In the bathroom, there was a discolored towel at the base of the toilet. The ceiling vent was dusty. In room [ROOM NUMBER] the bedside cabinet door was broken. The closet door was missing a door knob. In the bathroom, the faucet and base of sink were stained. The ceiling tiles, floor molding and heater had a built up of dirt. In room [ROOM NUMBER] there was a stained ceiling tile and missing floor tile. The closet was missing the right side door. In room [ROOM NUMBER] there was a stained ceiling tile. The bathroom had a large hole in the wall. The toilet tank cover did not fit properly and the bathroom door was marred. In room [ROOM NUMBER] there was no light cover on the over bed light. There was dirt and debris around the air conditioner base. The bathroom door was marred. In room [ROOM NUMBER] there was a used glove on the floor next to a trash can. The privacy curtain was stained and the drawstring was frayed. In the bathroom, the floor was stained and there was black dirt around the base of the toilet. The bathroom door was marred. Page 1 of 5 395405 395405 04/14/2023 Quakertown Center 1020 South Main Street Quakertown, PA 18951

F 0584 Level of Harm - Minimal harm or potential for actual harm In room [ROOM NUMBER] the closet was missing both doors. The bedside cabinet door was falling off. The bathroom door was marred and there were two holes in the wall. 28 Pa. Code 201.18(b)(3) Management. Residents Affected - Some 395405 Page 2 of 5 395405 04/14/2023 Quakertown Center 1020 South Main Street Quakertown, PA 18951

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. 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 one of 25 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had a Minimum Data Set assessment completed on February 9, 2023. According to the assessment the resident had difficulty communicating. According to the Care Area Assessment (CAA) summary dated May 22, 2022, the facility identified that communication was a problem area for the resident and should have been included on the resident's comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area. In an interview on April 13, 2023, at 9:23 a.m., the Director of Nursing confirmed that there was no care plan interventions developed to address R42's communication needs. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. 395405 Page 3 of 5 395405 04/14/2023 Quakertown Center 1020 South Main Street Quakertown, PA 18951

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on policy review, observation, and staff interview, it was determined that the facility failed to ensure that the facility environment remained free of accident hazards in one shower room. (North Hall) Residents Affected - Few Findings include: Review of the facility policy entitled, Storage and Expiration dating of Medications and Biologicals, reviewed on January 26, 2023, revealed the facility should ensured that all medications and biologicals, including treatment items, are securely stored in a locked cart inaccessible by residents and visitors. During multiple observations of the shower room from April 11, 2023, at 11:30 a.m., to April 13, 2023, at 9:55 a.m., two treatment carts were observed to be unlocked. One cart contained topical pain relief gel, triple antibiotic cream, first aid antiseptic and assorted medicated dressings, sterile gauze pads and bandages. The first drawer of the second cart contained single use razor blades. The other drawers contained an assortment of resident identified prescription medicated shampoos and creams. On April 12, 2023, at 12:53, the Director of Nursing (DON) provided documentation that ten residents resided on North Wing who were ambulatory and cognitively impaired. During an interview on April 14, 2023, at 11:35 a.m., the DON stated the treatment carts should have been locked. 28 Pa. Code 211.12(d)(5) Nursing services. 395405 Page 4 of 5 395405 04/14/2023 Quakertown Center 1020 South Main Street Quakertown, PA 18951

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for one of 25 sampled residents. (Resident 44) Findings include: Clinical record review revealed that on December 23, 2023, the consultant pharmacist recommended that the physician consider decreasing psychotropic medications. There was no documentation that the attending physician had acknowledged or acted upon this recommendation. In an interview on April 13, 2023, at 1:34 p.m., the Director of Nursing confirmed that the medication review recommendation was not addressed by the physician. 28 Pa. Code 201.18(e)(1)(3)(6) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395405 Page 5 of 5