Health inspection·September 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review clinical records, facility provided documentation, and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality and assures each resident is treated with dignity as evidenced by experiences reported by 11 residents out of 20 interviewed (Residents 8, 36, 26, 38, 34, 110, 115, 120, 128, 165, and 166). Findings include: A review of resident clinical records, and a facility provided BIMS (brief interview mental status - to assess cognitive status) report, and random interviews conducted on September 13, 2023, with 20 alert and oriented residents, to include 8 residents residing on the 100 unit, 1 resident residing on the 200 unit, 7 residents residing on the 300 unit, and 4 residents residing on the 400 unit, revealed that 11 residents' interviews voiced concerns regarding staff behavior towards residents and while providing direct care. During interviews the residents relayed that while providing care to residents, nursing staff speak to each other in their primary language of Spanish, which is not the residents primary language and the residents do not understand what is being said between the employees while caring for the resident. The residents stated that this makes them uncomfortable and uneasy because they do not understand the employees and what they may possibly being saying in front of the residents. The residents also reported that nursing staff speak on their personal cell phones while performing direct hands on care to residents. The residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system. Of those residents interviewed on September 13, 2023, 5 of 8 residents residing on the 100 unit, 4 of 7 residents residing on the 300 unit, and 2 out of 4 residing on the 400 unit, expressed similar concerns as described above. Interview with Resident 36 on September 13, 2023, at approximately 9:38 AM, revealed that the resident stated that he believes that the facility could use more help, stating that he waits 30 - 45 minutes for staff to respond to his bell and provide assistance. The resident stated that these waits occur on all shifts of nursing duty. Interview with Resident 8 on September 13, 2023, at approximately 9:50 AM, revealed that the resident stated he waits a pretty long time for staff to answer his call bell at times. The resident stated that these waits occur mostly on 1st shift (dayshift), and that there have been times he has Page 1 of 3 395464 395464 09/13/2023 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0550 soiled himself while waiting for the call bell to be answered. Level of Harm - Minimal harm or potential for actual harm Interview with Resident 26 on September 13, 2023, at approximately 9:56 AM, Residents Affected - Some revealed that she feels that short staffing is a problem in the facility because she waits up to 45 minutes for staff to answer her call bell. The resident stated that these waits occur mostly on 3rd shift (nightshift) of nursing duty. Resident 26 also stated that at times she would approach nursing staff for assistance at nursing station on the unit, but the nursing staff are on their personal cell phones, and they would act like you're an interruption to them. Interview with Resident 38 on September 13, 2023, at approximately 10:03 AM, revealed that she waits at least 30 minutes for staff to answer her call bell. The resident stated that these waits occur daily, on all shifts of nursing duty, and believes the facility could use more help. Resident 38 also stated that every other day she observes staff answering their personal cell phones while on the unit, and when entering resident rooms. Interview with Resident 34 on September 13, 2023, at approximately 10:15 AM, revealed that she waits at least 30 minutes for staff to answer her call bell. The resident stated that these waits occur on 1st shift (dayshift). Resident 34 also stated that staff have been speaking on their personal cell phones while providing direct hands - on - care to her. Interview with Resident 115 on September 13, 2023, at approximately 1:20 PM, revealed that staff speaks in a language (Spanish) not understood by the resident, while providing direct hands on care to her, and that she don't appreciate it, its not right, and doesn't understand them. Interview with Resident 110 on September 13, 2023, at approximately 1:30 PM, revealed that the resident stated that he waits 30 minutes to an hour for staff to answer his call bell at times because the facility needs more staff. The resident stated that these waits occur on 3rd shift (nightshift) of nursing duty. Interview with Resident 120 on September 13, 2023, at approximately 1:36 PM, revealed that the resident stated that she waits 30 minutes to an hour for staff to answer her call bell, and these waits occur daily on all shifts of nursing duty. She also stated that staff speaks Spanish while providing her care, which she doesn't understand. The resident stated don't like it because don't know what they are saying. In addition, Resident 120 stated that staff have been speaking on their personal cell phones while providing her direct care. Interview with Resident 128 on September 13, 2023, at approximately 1:46 PM, revealed that staff speak Spanish, while providing her care and she doesn't understand what they're saying. The resident stated that she would prefer they don't do it. She also stated staff have been speaking on their personal cell phones while providing direct care to her. Interview with Resident 166 on September 13, 2023, at approximately 1:53 PM, revealed that she waits at least 30 minutes for staff to answer her call bell. The resident stated that these waits occur daily on 1st shift (dayshift), and there have been times she has soiled herself while waiting for the call bell to be answered. She also stated that staff speak in a different language that she does not understand. The resident stated that they are speaking to each other in Spanish, while providing direct care to her, and she doesn't like it because she doesn't know what they are saying. 395464 Page 2 of 3 395464 09/13/2023 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident 165 on September 13, 2023, at approximately 1:58 PM, revealed that staff Spanish while providing her care, and she does not understood and also speaks on their personal cell phones while providing direct care to her, which she feels is wrong. The facility failed to demonstrate that all activities and interactions with residents by any staff, is focused on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and when providing care and services, staff must respect each resident's individuality, as well as honor and value their input. Interview on September 13, 2023, at approximately 2:50 PM with the Nursing Home Administrator (NHA) confirmed that residents should be provided care in a respectful manner. 28 Pa. Code 201.29 (d) Resident Rights 395464 Page 3 of 3