Health inspection·October 6, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility investigative documentation, clinical and hospital records, it was determined that the facility failed to ensure one of 24 residents was free from neglect, which resulted in actual harm to Resident 120, through Employee E3's failure to report a fall to registered nurse, the resident experienced a delay in assessment, treatment, and subsequent hospitalization for intracranial hemorrhage (brain bleed) resulting in death. Findings include: Review of facility policy, Abuse Prohibition, last revised [DATE], revealed: Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Review of Resident 120's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia, Abnormalities of Gait and Mobility, muscle weakness, history of falls, unspecified lack of coordination, and altered mental status. Review of Resident 120's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident had a BIMS score of 09, indicating moderate cognitive impairment. The MDS further indicated the resident required supervised, one person physical assist for all activities of daily living, including transfers, walking in their room, and walking in the corridor on the unit. Review of Resident 120's care plan revealed the resident was identified as at risk for decreased ability to perform activities of daily living, with an intervention added on [DATE], to provide the resident with cuing for safety, and an intervention added on [DATE], to provide the resident with supervision transfers using a stand and pivot transfer. Further review of Resident 120's care plan revealed the resident was identified as a risk for falls on [DATE], with interventions added on the same date to monitor for changes in the resident's condition, keep the resident's environment free of clutter, and encourage the resident to attend activities to maximize their full potential. Review of facility investigation revealed a witness statement from licensed nurse Employee E10 Page 1 of 9 395595 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0600 Level of Harm - Actual harm Residents Affected - Few dated [DATE], which stated that Around 8am I went into her room to give her her medication and she was still asleep. I called her name to notified [(sp.)] her I was there to give her medication and she would not respond or wake up. Due to resident not responding to verbal stimuli I touched her knee and she yelled ouch .I asked her if she could sit up to take her pills she stated 'yes' but would not sit up, so I asked if she want me to come back and she shook her head yes. I returned around 8:30 to attempt to give her her pills again. She would not respond to verbal stimuli so I touched her other knee and she yelled ouch again. I then assisted resident to a sitting position to assess why she kept yelling ouch. During assessment I noted bruising to both her knees. Due to bruising I assessed skin and noted abrasions to her left pinky and ring finger. Resident tried to lay down during assessment and her sleeve went up that's when I noted bruising to her right shoulder going down her arm MD was notified and made aware of new findings. I was ordered to put in x-rays which were placed and later canceled due to resident being sent to the hospital. Review of Resident 120's progress notes revealed a physician's note on [DATE], at 1:55 p.m. which stated: I was asked to see patient by nursing staff today. The patient is noted to have lethargy today. She is also noted to have bruising on right shoulder, bilateral knees. She is not responsive to verbal stimuli but responds to physical stimuli. Further review of the physician's note revealed the resident had been on Eliquis (anticoagulant - blood thinning medication) in the past but not at the time of the change in condition. The physician ordered the resident be sent to the hospital as soon as possible. Further review of Resident 120's progress notes revealed a nurse's note on [DATE], at 8:14 a.m., following up with hospital, which stated the resident had been admitted to the hospital with a diagnosis of altered mental status. Review of facility investigation documentation revealed a witness statement from licensed nurse Employee E3 dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Review of Employee E3's witness narrative indicated, On [DATE] resident was sitting at nurse's station until 10:30 p.m. Resident was eating watermelon and drinking water. At 10:30 p.m. I assisted resident to her room and helped her into bed. I left resident's [wheelchair] beside her bed because that is where she normally keep it. During the night the resident yelled out a few times but when checked on resident was still in bed and did not require any assistance. No bruises were noticed on resident. Further review of facility investigation documents revealed a witness statement from nurse aide Employee E4, dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Employee E4's witness statement revealed the employee last cared for Resident 120 on [DATE], when the employee assisted the resident with a meal on the 3-11 shift. Review of facility documentation revealed a timeline which indicated the facility was informed on [DATE], at 1:30 p.m. by the hospital that Resident 120 had a brain bleed. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with nurse aide Employee E9 on [DATE], at 4:55 p.m. Employee E9 was asked if any residents fell on the 3-11 shift on [DATE]. Employee E9 stated: No one fell but there was a lady who was laying on the floor. When asked who was laying on the floor, Employee E9 identified Resident 120 and stated this happened around 7:30 p.m. Employee E9 stated: Before I went 395595 Page 2 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0600 Level of Harm - Actual harm Residents Affected - Few into the room I called for help and the nurse came down and so did [Nurse Aide, Employee E4.] Employee E9 stated that the nurse did not ask her for a statement and Employee E9 did not know if the nursing supervisor was notified. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with licensed nurse, Employee E11 on [DATE], at 5:40 p.m. Employee E11 was identified as the nursing supervisor for the 3-11 shift on [DATE]. Employee E11 indicated that no one reported any falls, incidents, or behaviors from Resident 120 on [DATE]. Employee E11 was asked if any staff member made Employee E11 aware of anything occurring with Resident 120, and Employee E11 stated: No, the aides did not reach out to me and I saw [Licensed Nurse Employee E3] Monday night when I was down there and she mentioned nothing. Further review of facility investigation documents revealed a follow up witness statement from licensed nurse Employee E10 on [DATE], which stated: [Employee E3] relieved me from the cart on [DATE] at 5 pm. I gave her report on the incident that occurred with [Resident 120.] I asked her if anything happened to her knowledge. She stated, 'No.' Further review of facility investigation revealed a follow up interview conducted with nurse aide Employee E4 by the Nursing Home Administrator and Director of Nursing on [DATE], at 5:00 p.m. Employee E4 admitted to helping pick Resident 120 off the floor on [DATE] at 7:30 p.m. Employee E4 stated that they were not asked to write a statement and they did not know if licensed nurse Employee E3 notified the supervisor. Additional review of facility investigation revealed a follow up interview conducted with licensed nurse Employee E3 by the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 p.m. Employee E3 admitted that Resident 120 was found on the floor on [DATE], at approximately 7:15 or 7:30 p.m. Employee E3 admitted to not completing an incident report or alerting the supervisor of Resident 120 being found on the floor. Review of Resident 120's hospital records from [DATE], through [DATE], revealed that CT scans showed the resident had multiple brain bleeds. The resident was then transported to a trauma center, started on comfort measures, and died on [DATE]. The hospital discharge summary listed that death was due to intracranial hemorrhaging. Interview with the Nursing Home Administrator on [DATE], at 11:50 a.m. confirmed the facility substantiated neglect allegations against licensed nurse Employee E3 and nurse aide Employee E4 for failing to report Resident 120's fall. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.29 (c) Resident Rights 395595 Page 3 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 24 residents reviewed (Resident 38). Residents Affected - Few Findings include: Review of Resident 38's clinical record revealed the resident was receiving dialysis. Review of Resident 38's 5 Day Minimum Data Set (MDS - periodic assessment of resident care needs) dated August 30, 2023, failed to reveal evidence that the resident was coded as receiving dialysis. Interview with licensed nurse Employee E2 on September 28, 2023, at 12:50 p.m. confirmed Resident 38 was receiving dialysis and the resident's MDS was coded incorrectly. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services 395595 Page 4 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor and provide wound treatment timely and consistently resulting in harm of a new pressure ulcer discovered at an advanced stage (Stage 3- Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) for one of nine residents reviewed (Resident 54). Residents Affected - Few Findings include: Review of facility policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed the purpose is to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Further review of the facility's policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed residents will be observed by the NA (nurse aide) daily. Changes or concerns will be reported to the licensed nurse, who will evaluate any reported or suspected skin changes or wounds, and document newly identified skin/wound impairments as a change in condition. Review of Resident 54's current diagnosis list revealed injury of the left hip with ORIF, (open reduction and internal fixation), a surgery used to stabilize and heal a broken bone. Additional review of Resident 54's clinical record included an admission Nursing Evaluation which revealed Resident 54 was readmitted to the facility on [DATE], with no other skin impairments other than a left hip surgery wound. Review of the Significant Change/readmission Minimum Data Set (MDS- Standardized assessment tool that measures health status in long-term care residents) dated September 9, 2023, revealed the resident had no pressure ulcers. Review of Resident 54's care plan initiated October 6, 2019, revealed a care plan focus of risk for skin breakdown related to advanced age (greater than 75 years). The skin breakdown care plan interventions were listed as follows: observe skin for signs/symptoms of skin breakdown i.e., redness, cracking, blistering, and skin that does not blanche easily, and provide preventative skin care i.e., lotions, barrier creams as ordered. Further review of Resident 54's clinical record failed to reveal additional interventions were added to the care plan upon readmission on [DATE], after Resident 54's right hip ORIF, (open reduction with internal fixation). Review of Resident 54's clinical record including assessment notes dated September 11, 2023, (4:35 p.m.), revealed a skin check was performed and the following skin injury/wound(s) were previously identified and were evaluated as follows: discoloration(s): description: multiple marks left forearm, right upper arm, right forearm, abrasion(s): description: dime size scratch on right side of face near lower corner of eye. Other wound(s): location(s): sutures left thigh. Review of Resident 54's care plan revealed a revision dated September 12, 2023, documenting the resident being at risk of falls, cognitive loss, lack of safety awareness and previous fall with right 395595 Page 5 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0686 hip ORIF, (open reduction with internal fixation), as well as alteration in comfort related to left hip ORIF, (open reduction with internal fixation). Level of Harm - Actual harm Residents Affected - Few Review of the Braden Scale (tool used to predict risk for pressure sore development) dated September 12, 2023, revealed Resident 54 was AT RISK for developing a pressure sore. Further review of Resident 54's care plan revealed a revision dated September 19, 2023, documenting the resident having impaired skin integrity. Resident 54's care plan also revealed a revision dated September 26, 2023, documenting the resident having risk for skin breakdown related to advanced age, with a September 18, 2023, left heel wound. Further review of Resident 54's clinical record including assessment notes dated September 18, 2023, (6:16 p.m.) revealed a skin check was performed and the following new skin injury/wound(s) were identified: pressure area(s): location(s): (left) heel. Further review of skin assessment dated [DATE], failed to reveal measurements or condition of left heel wound. Skin assessment further revealed the area was cleansed, foam dressing applied, wound team consulted, and heel boot obtained to offload heel. Review of Incident Report dated September 18, 2023, revealed that during morning care a nurse aide reported blood on resident's sock and bed. During assessment a stage 3 ulcer to the left heel with a small amount of blood was discovered. Review of Resident 54's progress notes dated September 19, 2023, revealed a nutrition note indicating the resident has a Stage 3 wound and recommended addition of Liquid Protein 30 ml (milliliter) daily. Review of Resident 54's wound care notes dated September 25, 2023, revealed the heel wound measured 1.9 cm (centimeter) x 1.7 cm x 0.1 cm. The pressure ulcer has moderate amount of drainage. The drainage is serosanguineous, (discharge that contains both blood and serum, a clear yellow liquid.) Interview with the Director of Nursing (DON) and E1 Skin Health Team Lead on September 29, 2023, at 10:11 a.m., confirmed Resident 54's left heel wound was not identified until September 18, 2023, and the wound was diagnosed as Stage 3 upon identification. E1 stated that staff did not recognize the wound until Stage 3 and staff failed to properly prop the resident's heels, which caused the wound. The Director of Nursing confirmed investigation was performed and education was provided to staff. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services 395595 Page 6 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, facility policy and procedure review, facility documentation review and staff interview it was determined the facility failed to provide sufficient supervision to prevent an accident for one of 24 residents reviewed. (Resident 96) Findings Include: Review of facility policy and procedure titled Safe Resident Handling/Transfer Equipment, effective January 1, 2023, revealed Patients will be assessed upon admission and on an ongoing basis to determine the patient's ability to transfer and reposition and the need for safe resident handling equipment. Two trained persons are required to operate a total lift or sit to stand lift regardless if manufacturers instructions state only one person is needed. Review of Resident 96's diagnosis list included a diagnosis of Paraplegia (the loss of muscle function in the lower half of the body, including both legs) and Syncope and Collapse (fainting). Review of Resident 96's Significant Change Minimum Data Set (MDS- periodic assessment of resident needs), dated February 14, 2023 revealed the resident needed extensive assistance of two staff members for bed mobility and transfers. Review of Resident 96's care plan for ADLs (Activities of Daily Living) included the intervention, initiated on September 12, 2022, for Provide resident/patient with total assist of 2 (staff) for transfers using a total lift. Review of facility incident report for Resident 96, dated March 22, 2023 at 12:56 p.m. revealed during a sit to stand transfer resident was observed with his knees touching the floor. Resident was placed back into the bed then transferred with a Hoyer lift into the wheelchair. Review of witness narrative from Nursing Employee E7, dated March 22, 2023 revealed Resident 96 requested for me to use the sit-to-stand lift not Hoyer lift. When I used this, he could not stand and his knees went under the bed with his knees on the floor. Interview with the Director of Nursing on September 29, 2023 at 10:30 a.m. confirmed facility staff attempted to transfer Resident 96 from the bed to the wheelchair using a sit to stand lift with one staff when a Hoyer lift with two staff should have been utilized resulting in Resident 96 falling to the floor. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 395595 Page 7 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to assess the resident's continence status after identifying a change for one of the 24 residents reviewed (Resident 61). Findings include: Review of facility policy titled Continence Management, with a revision date of June 15, 2022, revealed that a urinary incontinence assessment and/or bowel incontinence assessment will be completed upon admission or re-admission and with a change in condition or change in continence status. Review of Resident 61's diagnosis revealed Cerebral Infarction (A condition when blood flow to the brain is disrupted due to problems with the blood vessels that supply it). Review of Resident 61's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated September 28, 2022, revealed Resident 61 was cognitively intact. An additional review of the same MDS revealed resident was occasionally incontinent of urine and always continent of bowel. Review of Resident 61's quarterly MDS dated [DATE], revealed resident is frequently incontinent of bladder and always incontinent of bowel, a change in continence status from the previous MDS assessment. The clinical records review failed to reveal continence assessment was completed after identifying a change in Resident 61's continence status. An interview with the Director of Nursing conducted on September 29, 2023, at 10:00 a.m., confirmed Resident 61's continence status was not assessed after a change was identified. The facility failed to ensure Resident's 61's was assessed after a change in continence status was identified. 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395595 Page 8 of 9 395595 10/06/2023 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, and staff interviews, it was determined that the facility failed to maintain, and prepare food by professional standards and maintain sanitary conditions in the kitchen area. Residents Affected - Many Findings include: Observations conducted during initial tour of the kitchen on September 26, 2023, at 9:35 a.m., in the presence Dietary manager, Employee 5 revealed the following: The stainless steel grill machine was observed with a build-up black substance inside the oil trap container and to its surroundings. Dark brown dried substance drips were observed on the side of the same machine; A black sticky substance on the floor, approximately one foot in size in between the ice machine and door; A black sticky substance on the floor surrounding the wall panel near food preparation area; A hole on the wall by the cooking area, a size of a softball with a balled towel used to cover the hole; Another hole on the same area, a size of two baseball, partially covered with an orange hardened foam. Observation conducted of the kitchen on September 28, 2023, at 11:55 a.m., revealed the above observation continued to be present. Interview conducted with the Maintenance Director, Employee E6 on September 28, 2023, at 11:58 a.m., revealed that he/she was aware of the holes in the wall. Employee E6 reported that he/she was notified of the issue (notified verbally, unable to say when) but was not able to get to it yet. Interview conducted with Employee E5 on September 28, 2023, at 12:00 p.m. revealed the above findings were discussed with Employee E5. She/he reported that the grease trap container has been broken (unable to say for how long) causing the grease to leak/drip on the edge/side of the machine. Employee E5 reported that the concern was included in her/his report to have it fixed. The facility failed to ensure the main kitchen was maintained in sanitary condition. 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.6(d) Dietary Services 395595 Page 9 of 9