Health inspection·February 19, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of grievances, select facility policy and resident and staff interviews it was determined the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for one resident out of 5 sampled. (Resident 1) Findings include: A review of the facility policy entitled Grievances/Complaints, dated as reviewed April 29, 2024, revealed, residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. Any resident, family or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including rationale for the response. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. The resident or person filling the grievance and/or complaint on behalf of the resident, will be informed, verbally and in writing, of the findings of the investigation and the actions that will be taken to correct any identified problems. The administrator, or designee, will make such reports orally within 5 (five) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include a history of falls, anxiety and a need for rehabilitation therapy services. The resident was discharged to home on January 21, 2025. An admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 30, 2024 revealed the resident to have a BIMS score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and required assistance of staff for activities of daily living. A review of Physicians orders dated December 24, 2024, revealed Xanax (antianxiety medication) 1 mg by mouth every 8 hours as needed for anxiety for 14 days. Page 1 of 3 395466 395466 02/19/2025 Milford Rehabilitation and Healthcare Center 264 Route 6 & 209 Milford, PA 18337

F 0585 Corresponding medication administration records dated December 2024 indicated that the resident received the as needed Xanax on: Level of Harm - Minimal harm or potential for actual harm December 28, 2024 - 8:55 P.M. Residents Affected - Few December 30, 2024 - 5:03 P.M. December 31, 2024 - 5:53 P.M. January 1, 2025 - 8:55 P.M. January 5, 2025 - 7:16 P.M. January 6, 2025 - 8:00 P.M A review of a grievance lodged by Resident 1, dated January 5, 2025, revealed Resident 1 reported to staff that Employee 3 (RN Supervisor) failed to administer their prescribed Xanax when requested and exhibited unprofessional behavior. This grievance was reported to Employee 1(LPN) and Employee 2 (RN Supervisor) who filled out the grievance form at that time for the resident. The resident stated that on January 4, 2025, at the change of shift (7:30 P.M.), the resident asked Employee 3 (7 P.M. to 7 A.M. RN Supervisor) for a Xanax (antianxiety medication). The staff member did not give the medication to her. The staff member had a very bad attitude. Staff members documented the grievance and noted previous complaints from other residents and staff about Employee 3's behavior, including inattentiveness and inappropriate phone use during shifts. A review of education entitled Conduct and Behavior revealed that Employee 3 (RN Supervisor) received this training in response to the above noted grievance. This education was dated as completed on January 26, 2025. The complaint remarks revealed, Patient was discharged , notified by phone. The resident was discharged home on January 21, 2025. There was no evidence at the time of the survey the resident was notified verbally and in writing within 5 working days, as stipulated in facility policy. During an interview on February 19, 2025, the Director of Nursing (DON) confirmed that the resident and their family were only verbally notified by phone after the resident's discharge on [DATE]. No written documentation of the grievance resolution or outcome was provided, violating the facility's policy requiring both verbal and written communication within 5 working days. A review of a facility grievance form dated January 17, 2025, revealed that Resident 1's daughter filed a complaint regarding concerns about the resident's care. The form was completed by Employee 4 (RN Supervisor) and the Assistant Director of Nursing (ADON). However, the grievance form did not provide any additional details about the specific concerns raised by the resident's family. Furthermore, there was no documentation of an investigation conducted by the facility. The plan to resolve the complaint simply stated that staff would receive education on providing proper care. The grievance form indicated the facility considered the complaint resolved on January 17, 2025. Despite this, there was no documented evidence the resident or her family had been informed of the 395466 Page 2 of 3 395466 02/19/2025 Milford Rehabilitation and Healthcare Center 264 Route 6 & 209 Milford, PA 18337

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few grievance outcome. Additionally, the resident's daughter did not sign any acknowledgment confirming receipt of the facility's response or awareness of the actions taken to address the issue. In an interview conducted with the Nursing Home Administrator (NHA) on February 28, 2025, at approximately 4:00 PM, the NHA was unable to provide documentation confirming the facility had followed up with the resident or her representative in a timely manner. There was also no evidence to show the facility evaluated whether its efforts effectively resolved the grievance. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident rights 395466 Page 3 of 3