Inspection·February 25, 2025

F 0678 should be stopped. Level of Harm - Minimal harm or potential for actual harm The facility policy entitled, Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], stipulated that is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Guidelines included that CPR certified staff will be available at all times, and staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification, which includes an online knowledge component, yet still requires in-person skills demonstrations to obtain certification or recertification, is also acceptable. Residents Affected - Few Closed clinical record review for Resident CR2 revealed nursing documentation dated February 22, 2025, at 9:25 AM that Employee 1 (registered nurse supervisor) was called to Resident CR2's bathroom. Resident CR2 had decreased respirations to six (average normal range 12 to 20 breaths) and a thready, pulse of 45 (average normal range 60 to 100). The documentation indicated that the on-call physician was notified, and staff obtained an order to send Resident CR2 to the emergency room. Staff then noted that Resident CR2 was without a pulse and respirations. Staff called 911 (emergency medical personnel) and nursing staff started CPR. CPR continued until paramedics intubated (inserted a tube into the airway to perform artificial respirations) Resident CR2, started an intravenous line, and assumed ACLS (Advanced Cardiac Life Support, refers to a set of clinical interventions established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions). The paramedics obtained a physician's order to stop CPR and pronounce Resident CR2 deceased . Order administration documentation dated February 22, 2025, at 9:35 AM revealed that Employee 2 (licensed practical nurse) noted that Resident CR2 was deceased at 9:25 AM. A Code (CPR) Documentation form (document the facility utilized to record the sequence of events during a CPR event) dated February 22, 2025, for Resident CR2 revealed that Employee 1 recorded the sequence of events during Resident CR2's medical crisis on February 22, 2025. Employee 1 was the registered nurse in charge. Staff initiated CPR at 8:31 AM, and the AED was delivered at 8:45 AM. Comments documented on the form indicated that, Code called at 8:31 AM, CPR initiated at 8:31 AM, 911 activated at 8:31 AM, CPR continued, and paramedic and EMS arrived at 8:45 AM, AED applied, CPR continued. The available documentation did not indicate that facility staff applied the AED to Resident CR2, but that the AED was applied after EMS personnel arrived. Review of available facility personnel documentation for Employee 1 revealed that she completed the American Red Cross CPR/AED online training and was eligible for the skills session within 90 days; however, there was no indication that she completed the skills portion of the training to obtain her certification. Interview with the Nursing Home Administrator on February 25, 2025, at 3:02 PM confirmed that Employee 1 did not have CPR/AED certification. The interview with the Nursing Home Administrator indicated that the facility had an AED machine on each of the three floors of the building. The facility did not provide evidence that facility staff, not EMS personnel, applied the AED timely to Resident CR2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395586 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bradford Hills Nursing & Rehabilitation Center 15900 Route 6 Troy, PA 16947 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone interview with the Nursing Home Administrator on February 26, 2025, at 9:35 AM confirmed the above findings. The facility failed to ensure that licensed nursing staff maintained current CPR certification for healthcare providers through a CPR provider whose training included hands-on practice and in-person skills assessment. 201.19(3) Personnel policies and procedures 201.20(a)(1)-(6) Staff development 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395586 If continuation sheet Page 3 of 3