Health inspection·September 22, 2023

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interview, it was determined that the facility failed to display the Department of Health (DOH) Hotline (toll-free telephone number) number in a prominent/accessible location for residents, resident representatives, and other visitors to observe and access in the facility. Findings include: Observations throughout the facility between 9/19/23, and 9/22/23, revealed that the DOH Hotline phone number was not posted for residents, resident representatives, and other visitors. During an interview on 9/22/23, at 10:20 a.m. the Regional Clinical Specialist confirmed the facility failed to display the DOH Hotline phone number for residents, resident representatives, and other visitors. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e) (2.1) Management Page 1 of 8 395700 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 17 residents reviewed (Resident R2). Findings include: Review of a facility policy entitled Comprehensive Care Plan dated 12/13/22, indicated that services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and will be periodically reviewed and revised by a team of qualified persons after each assessment, and that services provided or arranged by the manor will meet professional standards of quality. Review of Resident R2's clinical record revealed an admission date of 5/12/19, with diagnoses that included left-sided weakness related to stroke, obesity, depression, anxiety, high blood pressure, and Type 2 Diabetes (condition that affects how the body uses glucose [sugar]). The clinical record also revealed a care plan entitled, potential to demonstrate physical/verbal behaviors related to anger dated 10/21/19. The care plan had not been updated with new interventions since 9/14/20, and a care plan entitled, depression and dated 2/24/21, indicated that it had not been updated with new interventions since 4/06/22. Review of Resident R2's Behavior Monitoring and Intervention Report from 9/01/23, to 9/21/23 (20 days), revealed nine incidents of displaying targeted behaviors and the attempted interventions were ineffective (9/03/23, 9/13/23 twice, 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/19/23, and 9/20/23). Review of facility documents provided on 9/21/23, from the Behavior Committee Meeting Minutes revealed: that on 5/11/23, Resident R2 exhibited behaviors 34 times in a 14-day lookback and the recommendation was to respond timely, communicate and educate; on 7/18/23, Resident R2 exhibited behaviors 52 times in a 30-day lookback and the recommendation was to have night staff get music and football on his/her TV. Review of contracted psychological staff evaluation of Resident R2 dated 5/20/23, revealed that Resident R2 had reported significant symptoms related to depression, and to follow-up in one month or sooner if needed. There was no evidence that Resident R2 was evaluated as per the evaluation. During an interview on 9/22/23, at 11:55 a.m. the Regional Clinical Specialist confirmed that Resident R2's behavior and depression care plans were not updated when interventions were not effective. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395700 Page 2 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on review of clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate behavioral health services/interventions to address behaviors for one of 17 residents (Resident R2). Findings include: Review of the facility's Skilled Nursing Facility Resident Handbook dated 3/2017, reviewed 12/13/22, Code of Conduct section indicated that all residents, family members and visitors should act and behave in a manner that is both respectful of and courteous towards the other residents living in the home as well as towards the staff members who provide care and services to such residents on a daily basis. Review of Resident R2's clinical record revealed an admission date of 5/12/19, with diagnoses including left-sided weakness related to stroke, obesity, depression, anxiety, high blood pressure, and Type 2 Diabetes (condition that affects how the body uses glucose [sugar]). The clinical record revealed that Resident R2 received his/her Skilled Nursing Facility Handbook on 5/13/19. Review of Resident R2's most recent Minimum Data Set (MDS- periodic evaluation of resident health and mental status) dated 8/07/23, Section C0500 Cognitive Patterns revealed that his/her Brief Interview for Mental Status (BIMS) scored a 13 (cognitively intact), Section E0100 revealed no hallucinations or delusions, and Section E0200 verbal symptoms directed towards others and not directed toward others occurred one to three days in a seven day lookback period. Further review of Resident R2's clinical record revealed a care plan entitled, potential to demonstrate physical/verbal behaviors related to anger and dated 10/21/19. Review of Interdisciplinary Meeting documentation dated 7/27/23, and 8/09/23, revealed that Resident R2 was in attendance and that the Code of Conduct was reviewed. Review of Resident R2's Behavior Monitoring and Intervention Report from 9/01/23, to 9/21/23 (20 days), revealed nine incidents of displaying targeted behaviors and the attempted interventions were ineffective (9/03/23, 9/13/23 twice, 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/19/23, and 9/20/23). Review of facility documents provided on 9/21/23, from the Behavior Committee Meeting Minutes revealed: that on 5/11/23, Resident R2 exhibited behaviors 34 times in a 14-day lookback and the recommendation was to respond timely, communicate and educate; on 7/18/23, Resident R2 exhibited behaviors 52 times in a 30-day lookback and the recommendation was to have night staff get music and football on his/her TV. Review of a contracted psychological staff evaluation of Resident R2 dated 5/20/23, revealed that Resident R2 had reported significant symptoms related to depression, and to follow-up in one month or sooner if needed. There was no evidence that Resident R2 was evaluated as ordered. Review of Resident R2's clinical record revealed the following sample of departmental progress notes: -7/24/23, 2:01 p.m. yelling out with repetitive commands fix my TV, change the channel, find me a 395700 Page 3 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0740 football game, 'empty my urinal, continued to yell out while repeatedly pushing his call bell. Level of Harm - Minimal harm or potential for actual harm -8/02/23, 7:46 p.m. yelling out help several times, provided call light, urinal, and TV remote. Resident continued to yell at staff calling them names, refusing medications stating, I don't want that s*** and threatened to call the state when staff was going to leave the room. Residents Affected - Some -8/02/23, 8:11 p.m. yelling shut the f****** light off, you people are stupid, I am turning you guys in tomorrow fat f****** cow, stupid b******. -8/02/23, 8:15 p.m. yelling you mother f****** liars, you stupid b******, and surrounding residents are upset and yelling at him/her to shut up, Resident R2 responding you shut the f*** up a*******. -8/02/23, 8:17 p.m. yelling die b******, go to hell now, f******die, get outta here you f****** liar. -8/04/23, 9:20 a.m. yelling for additional regular sugar for his/her cereal after having received two packets, when educated on diagnosis of Diabetes, Resident R2 stated I know. I don't care. Yelling out again after breakfast for staff to remove the tray, provided the call bell and continued to yell out for staff assistance. -8/19/23. 10:18 p.m. yelling and pushing call light continuously, getting very angry about not being able to watch football, peanut butter and jelly sandwiches. -8/22/23, 9:47 a.m. yelling out for the spoon, more sugar, straw, cutting up meat, moving the cup, stated understanding to use call bell but continued to yell. -9/16/23, 6:24 a.m. yelling at staff fat m*****f*****. Interviews between 9/19/23, and 9/21/23, with six alert and oriented residents with rooms near to Resident R2 confirmed the following: -As long as staff stops what they are doing and get to him/her quick enough there is a chance that the yelling and swearing will stop. -There have been times they stop getting me ready to go to him/her. If not he/she will yell and swear all evening. -It's embarrassing and offensive when he/she yells like that. -I just feel so bad for the staff, they take the brunt of it. -I don't talk like that, and don't feel I should hear others talk like that, especially screaming it in the hallways. -The administration has not done anything to stop the vulgar language from him/her. Staff are verbally abused daily. -I am hard of hearing, but I can hear that he/she is upset often and screams loudly in the hallway and from his/her room at staff and other residents. 395700 Page 4 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0740 Level of Harm - Minimal harm or potential for actual harm During an interview on 9/21/23, at 2:30 p.m. the Director of Nursing confirmed that this is who the resident is, staff are doing better about getting to him/her quicker, there's nothing they can do about him/her, staff do attempt the interventions, and that there is nowhere to turn when they fail, and that they all realize this is just the way he/she is and there is no behavior management program in place. Residents Affected - Some 28 Pa. Code 201.18 (b)(1)(2) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395700 Page 5 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

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 review of a 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 (Resident Pantry at main nurse's station, B hall). Findings include: Review of the facility policy entitled Food Brought by Family/Visitors dated 12/13/22, indicated all food requiring refrigeration must be dated and labeled with the resident's name. Review of the facility policy entitled Infection Control/Food Safety dated 12/13/22, indicated only resident food items are stored in nutrition services refrigerators. Observation on 9/19/23, at 5:56 p.m. revealed a refrigerator in the resident pantry at the main nurse's station that contained a bottle of cola that was half empty without a name or date. Observation on 9/19/23, at 5:56 p.m. revealed a freezer in the resident pantry at the main nurse's station containing ice packs that were used for treatments on resident body parts and also ice cream in the same freezer. During an interview at the time of observation with Licensed Practical Nurse Employee E2 he/she confirmed that items in the resident pantry refrigerator should have names and dates on them and that ice packs used on resident's body parts should not be stored in the resident pantry freezer. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 395700 Page 6 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records and staff interview, it was determined that facility staff failed to maintain complete and accurate clinical records for one of 17 residents reviewed (Resident R54). Residents Affected - Few Findings include: Review of facility policy Documentation Policy, dated 12/13/22, indicated that the facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc It also indicated there would be the appropriate information to assist the physician in ordering medications, treatments and diet. Review of Resident R54's clinical record revealed an admission date of 8/18/23, with diagnoses that included pneumonia, diabetes, esophagus cancer and adult failure to thrive. Review of a Nursing admission Screener for Resident R54 dated 8/19/23, revealed a coccyx (small triangular bone forming the lower extremity of the spinal column) pressure area that measured 4.6 centimeters (cm) x 3.0 cm x 1.6 cm Stage III (Full-thickness tissue loss). Review of the Nursing Wound Documentation records for Resident R54 after the admission screener revealed the following: 8/22/23, revealed Resident R54 had an Unstageable (an ulcer that has full-thickness tissue loss but is either covered by extensive necrotic [dead] tissue or by an eschar [hard crust or scab]) sacrum (a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae) pressure area measuring 7.0 cm x 7.5 cm x 0.1 cm 8/29/23, revealed Resident R54's sacrum pressure area measuring 4.0 cm x 2.0 cm x 0.1 cm. Unstageable 9/05/23, revealed Resident R54's sacrum pressure area measuring 4.2 cm x 2.5 cm x 0.1 cm Unstageable 9/12/23, revealed Resident R54's sacrum pressure area measuring 3.5 cm x 2.0 cm x 0.1 cm Stage III 9/19/23, revealed Resident R54's coccyx pressure area measuring 3.5 cm x 1.0 cm x 0.1 cm Stage III Observation of Resident R54's pressure ulcer area on 9/21/23, at 1:30 p.m revealed the sacrum to have a Stage III ulcer. During an interview on 9/21/23, at 11:00 a.m. the Regional Clinical Specialist confirmed that the clinical record lacked consistent documentation regarding Resident R54's sacrum wound regarding measurements and location of the wound 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12(d)(1)(3) Nursing services 395700 Page 7 of 8 395700 09/22/2023 Bradford Manor Nursing and Rehab 50 Lang Maid Lane Bradford, PA 16701

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and facility staff education documents, observations and staff interviews, it was determined that the facility failed to prevent the potential of cross-contamination for one of 17 residents (Resident 28). Residents Affected - Few Findings include: Review of Resident R28's clinical record revealed an admission date of 4/21/2017, with diagnoses that included Dementia (a disease of the brain that is characterized by impairment of judgment and memory loss), Depression, Diabetes Mellitus (condition that affects how the body uses glucose [sugar]), and history of a Traumatic Brain Injury. Review of facility staff education entitled, Skills Demonstration/Evaluation-Insulin Pens dated 11/2013, stated Steps in the Performance Criteria 1. Washes hands and applies gloves. 2. Attaching the needle. 3. Removing the needle cap. 4. Checking the flow of delivery device (air shot). 5. Select the dose prescribed. 6. 2-unit PRIME every time. 7. Push the needle so hub touches skin at a 90-degree angle. 8. Inject dose. 9. Press the push button all the way down-dial will read zero. 10. Hold needle in place for 6 seconds. 11. Withdraw the need from the skin. 12. Recognize the safety lock mechanism has activated automatically. 13. After the injection, remove the needle from the device without replacing the cap. 14. Dispose of needle in a sharp's container. 15. Remove gloves and washes hands. 16. Label prefilled insulin pen with resident's name and date opened and store in appropriate place. During an observation of medication administration on 9/20/23, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E1 did not apply gloves prior to the administration of insulin for Resident R28. During an interview on 9/20/23, at 11:05 p.m. LPN Employee E1 confirmed that he/she failed to apply gloves prior to the administration of insulin for Resident R28. During an interview on 9/20/23, at approximately 2:15 p.m. the Director of Nursing confirmed that LPN Employee E1 should have applied gloves for insulin administration to prevent the potential of cross-contamination. 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 21.12 (d)(1)(5) Nursing services 395700 Page 8 of 8