Health inspection·November 17, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide resident privacy and dignity regarding an exposed urinary catheter (a tube placed and held in the bladder to drain urine) drainage bag for two of five residents reviewed for catheters (Residents R88 and R47). Findings include: Review of a facility policy entitled, Indwelling Urinary Catheter dated 2/23/23, indicated .drainage bag should be placed in a position lower than the bladder , policy also indicated The catheter bag should have a privacy cover applied at all times Review of Resident R88's clinical record revealed an admission date of 10/9/23, with diagnosis that included, Obstructive and Reflux Uropathy (a condition that will not let the urine drain naturally), Diabetes (condition of inadequate insulin levels and blood sugar control), and Hypertension (high blood pressure). Review of Resident R88's foley catheter care plan revealed an intervention for position catheter bag and tubing below the level of my bladder, without kinks and secure with leg strap - facing away from the entrance to my room. Observation on 11/14/23, at 12:44 p.m. revealed Resident R88 sitting in his/her wheelchair in his/her room and his/her urinary catheter drainage bag visible from the hallway without a privacy cover. Observation on 11/15/23, at 11:55 a.m. revealed Resident R88 sitting in his/her wheelchair in his/her room and his/her urinary catheter drainage bag was hanging from the arm rest on his/her wheelchair visible from the hallway without a privacy cover. Further observations on 11/16/23, at 9:00 a.m. revealed Resident R88 sitting in his/her wheelchair in the dining area, which is a common area within the facility, with his/her urinary catheter drainage bag hanging from the back of his/her wheelchair visible without a privacy cover. During an interview on 10/15/23, at 11:55 a.m. Licensed Practical Nurse Employee E1, confirmed that the urinary catheter drainage bag should be placed below the resident's bladder and covered to ensure resident privacy and dignity. Review of Resident R47's clinical record revealed an admission date of 2/01/23, with diagnoses that included paraplegia (loss of use of the lower body), lack of coordination, and abnormal posture. Page 1 of 3 395593 395593 11/17/2023 Quality Life Services - Grove City 400 Hillcrest Avenue Grove City, PA 16127

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 11/15/23, at 2:10 p.m. revealed Resident R47 in the front lobby, which is a common area within the facility, with their urinary catheter drainage bag containing urine hanging on his/her wheelchair without a privacy cover. During an interview on 11/15/23, at 2:15 p.m. the Director of Nursing confirmed that R47's urinary catheter drainage bag lacked a privacy cover and that there should have been a privacy cover in place. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395593 Page 2 of 3 395593 11/17/2023 Quality Life Services - Grove City 400 Hillcrest Avenue Grove City, PA 16127

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed (third floor pantry). Findings include: Review of a facility policy entitled Food brought in from outside sources dated 2/23/23, indicated that items brought into the facility must be labeled with the resident's name and the date prepared. The policy also indicated condiment type foods may be kept for 2 months or until factory marked date whichever is first. Review of a facility policy entitled Food Storage dated 2/23/23, indicated that food is stored by methods designed to prevent contamination or cross contamination. Observations on 11/15/23, at approximately 10:30 a.m. a refrigerator in the pantry for resident use on the third floor revealed three bottles of Pepsi with no resident name, an open container of 2.0 Cal med pass (a supplement given to resident during medication administration) with no open date, an open half empty bottle of parmesan cheese with no resident name and an expiration date of 7/24/23, a chef salad with no resident name and a best by date of 11/4/23, an open bottle of salad dressing with no resident name and an unreadable expiration date, and an open container of cream cheese with no open date. Further observation of the freezer revealed an ice pack that was used for treatments on resident's bodies, next to ice cream and a breakfast sandwich. During an interview at the time of observation with Licensed Practical Nurse Employee E1 he/she confirmed that items in the refrigerator should be labeled and dated. He/she also confirmed that items should be discarded if expired or unable to read expiration dates and that the ice packs that were used on resident's bodies should not be stored in the resident food freezer. 28 Pa. Code 201.14(a) Responsibility of licensee 395593 Page 3 of 3