Health inspection·March 14, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to implement procedures to exercise reasonable care for the protection of residents' property from loss for three of five residents reviewed (Residents CR1, CR3, and CR4). Findings include: The facility policy entitled, Personal Property, last reviewed/revised [DATE], revealed that a documented inventory of all residents' personal belongings will be completed upon admission by the nursing department, or another department identified by the facility. The inventory sheet will be updated when new items are acquired if the facility has been notified by the responsible party. The resident's personal belongings and clothing will be inventoried and documented upon admission and as such items are replenished. Missing items should be reported immediately to a staff member on the unit and placed on a concern/grievance form with follow through based on the concern grievance policy. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Personal belongings will be sent home with the resident upon discharge or within 30 days of discharge. Closed clinical record review for Resident CR1 revealed that the facility admitted him on [DATE]. A Disposition of Resident's Personal Effects form revealed that the facility inventoried items (e.g., wallet, dentures, and glasses); however, did not inventory clothing on this form. Items noted as acquired after Resident CR1's original admission included a phone (without description of type) and charger. Resident CR1 signed this form on [DATE]. Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the facility does not record personal clothing on the Disposition of Resident's Personal Effects form; but sends all clothing to the laundry department who inventories the clothing and begins a different form. Only the laundry staff sign this form. The resident/responsible party do not acknowledge the accuracy of the inventory. An untitled graph form provided by the facility with Resident CR1's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (more than a month after Resident CR1's admission to the facility). Nursing documentation dated February 18, 2025, at 8:09 AM revealed that Resident CR1 experienced Page 1 of 3 395586 395586 03/14/2025 Bradford Hills Nursing & Rehabilitation Center 15900 Route 6 Troy, PA 16947

F 0584 Level of Harm - Minimal harm or potential for actual harm mental status changes, staff contacted his physician, and the physician provided an order to send Resident CR1 to the emergency department for evaluation. Nursing documentation dated February 18, 2025, at 9:52 PM revealed that the emergency department admitted Resident CR1 to the hospital. Residents Affected - Few Review of Resident CR1's census information revealed that the facility discharged him on February 22, 2025. Resident CR1's closed clinical record contained no documentation as to the disposition of Resident CR1's property. Neither Resident CR1 or his representative signed the Disposition of Resident's Personal Effects form after his discharge from the facility. A Resident Grievance/Complaint form dated [DATE], at 1:00 PM indicated that Resident CR1 was missing his phone. Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the Director of Nursing interviewed a nurse aide who stated that Resident CR1's responsible party picked up Resident CR1's personal property. Resident CR1's responsible party later reported that Resident CR1's phone was unaccounted for. The Director of Nursing confirmed that no staff had Resident CR1's responsible party attest to the collection of his property on discharge, there was no date when she came, and no progress note in the closed clinical record. Closed clinical record review for Resident CR3 revealed that the facility admitted him on [DATE]. A Disposition of Resident's Personal Effects dated [DATE], indicated that Resident CR3 had no property (e.g., clothing). An untitled graph form provided by the facility with Resident CR3's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (four days after Resident CR3's admission to the facility). Neither Resident CR3 or his representative attested to the accuracy of the clothing inventory. Census information for Resident CR3 revealed that the facility discharged him on [DATE]. A late entry progress note created by the registered nurse the next day on [DATE], at 7:28 AM revealed that Resident CR3's family arrived for his discharge. The documentation indicated that Resident CR3 stated that he had all his belongings. Resident CR3's closed clinical record did not contain evidence that Resident CR3, or his representative signed the Disposition of Resident's Personal Effects form upon his discharge. Interview with the Director of Nursing on [DATE], at 2:10 PM confirmed the above findings for Resident CR3. Closed clinical record review for Resident CR4 revealed that the facility admitted him on February 12, 2025. Nursing documentation dated February 12, 2025, at 3:19 PM indicated that the transport company left Resident CR4's belongings in the facility's reception area. Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's 395586 Page 2 of 3 395586 03/14/2025 Bradford Hills Nursing & Rehabilitation Center 15900 Route 6 Troy, PA 16947

F 0584 property on a Disposition of Resident's Personal Effects form. Level of Harm - Minimal harm or potential for actual harm Nursing documentation dated February 23, 2025, at 10:09 PM revealed that Resident CR4 expired at the facility. Residents Affected - Few Documentation by the Nursing Home Administrator dated February 24, 2025, at 12:52 PM revealed that the writer received a telephone call from Resident CR4's responsible party that she would be at the facility to pick up Resident CR4's belongings. The same documentation indicated that Resident CR4's sister confirmed that she received all his belongings that included pictures in his room. Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's property upon his discharge or that staff or Resident CR4's responsible party signed a Disposition of Resident's Personal Effects form. Interview with the Director of Nursing on [DATE], at 2:27 PM confirmed the above findings for Resident CR4. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency [DATE] 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.24(e)(5) admission policy 28 Pa. Code 211.12(d)(3) Nursing services 395586 Page 3 of 3