Health inspection·December 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for one of 19 records reviewed (Residents 27). Residents Affected - Few Findings include: Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 27's care plan revealed a care plan focus for an activities of daily living (ADL) self-care performance deficit related to impaired vision, cognitive impairment, and non-ambulatory (unable to walk), with a revision date of August 27, 2023. Interventions included, but were not limited to, uses a Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with bilateral wings, bilateral footrests, and a foam cushion with a pommel. She requires staff to push her in her chair for all mobility. Observation of Resident 27 on December 4, 2023, at 11:22 AM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. Observation of Resident 27 on December 5, 2023, at 10:38 AM, revealed they were seated in their Broda chair, with their legs crossed and dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with the Director of Nursing (DON) and the Chief Performance Improvement Executive on December 6, 2023, at 11:10 AM, the aforementioned observations were shared for further follow-up. Observation of Resident 27 on December 6, 2023, at 12:38 PM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with Employee 2 on December 6, 2023, at 12:42 PM, Employee 2 was asked about Resident 27's footrests. Employee 2 immediately searched Resident 27's room and located the footrests in the top of Resident 27's closet. Employee 2 indicated that they were not sure if the footrests Page 1 of 6 395583 395583 12/07/2023 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed to be in place, because, at one point, they were a fall risk concern for Resident 27 because they were attempting to stand up on them. Employee 2 further indicated that Resident 27 had a recent hospitalization and that their condition had declined. She confirmed that Resident 27's legs were dangling and then placed the footrests on Resident 27's Broda chair. During a follow-up interview with the DON and the Chief Performance Improvement Executive on December 6, 2023, at 1:45 PM, the DON confirmed that there had been some concerns in the past with Resident 27's footrests, but that she would look into the concern. During a follow-up interview with the Chief Performance Improvement Executive on December 7, 2023, at 9:43 AM, he indicated that he and the physical therapist had looked at Resident 27's seating and positioning. He confirmed that the footrests should have been present on Resident 27's Broda chair as indicated in their care plan. 28 Pa. Code 211.11(d) Resident Care Plans 395583 Page 2 of 6 395583 12/07/2023 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, record review, and staff interview, it was determined that the facility failed ensure the resident received care consistent with professional standards to prevent pressure ulcers for one of 21 residents reviewed (Resident 91). Residents Affected - Few Findings Include: Review of facility policy, titled Dressing: Dry-Clean Technique, reviewed March 2023, revealed, 5. Remove the soiled dressing and discard into appropriate receptacle. 6. Remove soiled gloves. Perform hand hygiene and don clean gloves. 7. Clean the wound with the ordered cleaning solution. Review of Resident 91's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and pressure ulcer of the sacral region, stage 3 (ulcer on the skin with full thickness tissue loss). Observation of a dressing change to the dorsum of the right foot (top of foot) of Resident 91 on December 7, 2023, at 10:04 AM, revealed Employee 1 removed the dressing from Resident 91's foot and then cleansed the wound without first performing hand hygiene and donning clean gloves. Interview with the Nursing Home Administrator on December 7, 2023, at 12:48 PM, revealed that she would expect the facility policy to be followed during dressing changes. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395583 Page 3 of 6 395583 12/07/2023 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the main kitchen and in one of two nourishment refrigerators. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with last review date of October 5, 2021, revealed the following: 9135.13 Receiving guidelines C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out and in subsection, titled The following rules for dry storage will apply in the Dietary Department and in the Storeroom, indicated, in part, at 9135.15 All items will be dated upon receiving. Review of facility policy, titled 9138 Foods with Best By or Use By Dates, with last review date of October 5, 2023, revealed the following: 9138.3 All food items will be stored with labels or markings designated content, received date and either manufacturer information (date/lot) or relevant disposal dates; 9138.5 Foods marked with a best by, use by, freshest until date will be kept an utilized for the time period after this date as recommended by the manufacturer or government resources; Additional information can be obtained from Foodkeeper App FoodSafety.gov. Tour of the main kitchen on December 4, 2023, at 9:47 AM, with Employee 3 (Dietary Manager) revealed the following: 1) in the produce walk-in cooler: a case diced green peppers with a noted Use By Date of November 29, 2023, and a case of oranges with no dates indicated; 2) in the dry storage room: one container of Quaker Oats, unopened, with a Best Before date of May 27, 2023; a container of Quaker Oats, marked with an opened date of March 2023, with a Best Before date of May 27, 2023; and a case containing three 98 ounce cans of evaporated milk with no date marked on the case other than a shipping label dated September 14, 2022; and 3) in the cooks refrigerator: two individual serving size containers of butterscotch pudding with a Best By Date of November 13, 2023. During an immediate interview with Employee 3, Employee 3 indicated that all items should be dated when they are received into the facility. Employee 3 also indicated that they were not sure how long items could be used after their Best Before or Best By dates. Observation of the nourishment refrigerator in the treatment room on unit 6B on December 5, 2023, at 10:40 AM, revealed three Mighty Shakes (a nutritional supplement) that were not dated with a thaw date. Each individual carton indicated that the shake was to be used within fourteen days of thawing. Email communication received from the Chief Performance Improvement Executive on December 5, 2023, at 3:11 PM, included information from Foodkeeper App at FoodSafety.gov for evaporated milk which indicated for freshness and quality, this item should be consumed within 12 months if in the pantry from the date of purchase. 395583 Page 4 of 6 395583 12/07/2023 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Chief Performance Improvement Executive on December 6, 2023, at 1:47 PM, he confirmed that the mighty shakes should have been dated with a thaw date. He further indicated that they need to look at their process to determine guidelines to follow in regards to Best By/ Best Before dates. He also added that they would have to do a lot of research to determine when the case of evaporated milk arrived at the facility, but confirmed that the shipped date on the case was September 14, 2022. During a follow-up interview with the Director of Nursing and the Chief Performance Improvement Executive on December 7, 2023, at 10:34 AM, the Chief Performance Improvement Executive confirmed that the other items in question were not dated upon arrival to the kitchen which could have helped identify the true date the items needed discarded. He again indicated that the facility would be looking at their process in regards to the Best By/ Best Before dates and the appropriate timeframe for discarding. 28 Pa code 211.6(b)(d) - Dietary Services 395583 Page 5 of 6 395583 12/07/2023 South Mountain Restoration Cen Building #1 South Mountain, PA 17261

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required committee members attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022- February 2023). Residents Affected - Some Findings include: Review of facility's Quality Assurance and Performance Improvement Program, last reviewed March 21, 2023, indicated the QAPI Committee is composed of at least the following individuals: QAPI Director (Chairperson) QAPI Specialist Chief Executive Officer QAPI Coordinator Medical Director RN Assessment Coordinator Chief Operating Officer Chief Social & Rehab Executive Infection Control Preventionist Director of Nursing A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of December 2023 through November 2023, revealed that the Infection Control Preventionist was not in attendance for the December 2022, January 2023, or February 2023 QAPI meeting. During an interview on December 7, 2023, at 11:06, the QAPI Chief performance Executive Director informed the surveyor there is not a designated mandatory quarterly meeting date because they hold monthly meetings. During an interview on December 7, 2023, at 12:45 PM, the QAPI Chief performance Executive Director confirmed that the individuals noted on the sign-in sheets were the only ones in attendance at the corresponding meetings, and confirmed that the facility failed to ensure that all required individuals were in attendance for the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022-February 2023). 28 Pa. Code 201.18(e)(1)(2)(3) Management 395583 Page 6 of 6