Health inspection·January 2, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of policies, information provided by the facility, and clinical records review, and staff interviews, it was determined that the facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe for one of 27 residents reviewed (Resident 21). Findings include: A nursing note for Resident 21, dated December 7, 2023, revealed that the resident was observed by the nursing assistant with bluish discoloration above left eyebrow ridge. It measured 1.5 centimeter (cm) x 2.5 cm, and the area was slightly elevated. Review of facility investigation dated December 7, 2023, at 4:30 p.m., revealed that the nursing assistant reported bruise to left eyebrow ridge measured 1. 5cm x 2. 5cm. The bruise was dark purple in color. Resident stated he was punched in the face by the person that took me to the get my hair cut. Further review of investigation revealed a statement by Licensed Practical Nurse (LPN), Employee E14, indicated she observe the bruise before lunch time when she was assisting nurse aide, Employee E15, to transfer Resident R21. Employee E14 asked Employee E15 about the bruise, what it was, Employee E15 did not know what it was. The statement did not include any evidence that Licensed Practical Nurse(LPN), Employee E14 reported this allegation to administrator or to the supervisor. Review of a statement by nurse aide, Employee E16, dated December 7, 2023, revealed that she observed a small spot on the corner of his eye when she went into his room to ask him if he wanted a haircut. Review of a statement written by Director of Nursing (DON) dated December 8, 2023, revealed that she noticed a bruise to lateral side of his left eye of Resident R21. She asked Resident R21 what happened, and his response was I was punched, Resident was unable to identify the person but stated It was the little one that took me to get my haircut. Resident also stated, she didn't like something and just punched me. Resident R21 told the DON Please don't tell her I am afraid of her. When asked why resident replied, because she is always rough with me but now I am afraid she's gonna come back and kill me. Review of a corrective action document for nurse aide, Employee E15, dated December 12, 2023, revealed that on December 7, 2023, LPN, Employee E14 noticed a red area on the side of the resident's left eye and questioned Employee E15 who provided care to him. Employee E15 stated nothing unusual Page 1 of 8 395738 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few happened during her shift. Employee E15 was place on investigatory suspension. Continued review of the document revealed that on December 12, 2023, Employee E15 denied anything occurred on her shift. When questioned about LPN's conversation about the resident's area of concern with his left eye she denied anything occurred and did not report this incident. Review of a corrective action document for nurse aide, Employee E16, dated December 14, 2023, revealed that Employee E16 noticed a red area to the side of Resident R21's left eye. Employee E16 failed to report the finding to any nurse or supervisor. It was the responsibility of all staff to report any concerns (inclusive of but limited to falls, injuries, cuts, and/or bruises) to the assigned charge nurse and/or the nursing supervisor. Review of a corrective action document for LPN, Employee E14, dated December 14, 2023, revealed that Employee E14 noticed a red area to the side of Resident R21's left eye. Employee E14 failed to report the finding to any nurse or supervisor. Review of a timeline of the facility camera revealed that LPN, Employee E14 and nurse aide, E15 was in resident's room at 12:08 p.m., (Employee E14 first observed that bruise and questioned Employee E15). At 12:11 p.m., Nurse aide, Employee E16 went into resident's room, she observed the bruise. At 12:17 p.m. resident was taken to the beauty salon. At 2:52 p.m. Nurse aide, Employee E15 left the unit after her shift. At 5:05 nursing assistant, Employee E17, called the nurse to resident's room who called the supervisor at 5:08 p.m., Continued review of facility investigation dated December 7, 2023, revealed that Employee E14, E15, and E16 failed to report Resident R21's alleged injury of unknown origin to the administrator or supervisor as required and failed to initiate an investigation in a timely manner. Interview with the Nursing Home Administrator (NHA) on December 29, 2023, at 11:00 a.m. confirmed that Employee E14, E15, and E16 failed to report Resident R21's bruise to the left eye area in a timely manner. NHA stated Employee E14, E15, and E16 did not report the injury and left for their shift. It was reported by Employee E17, subsequently facility investigation was initiated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395738 Page 2 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included continuous oxygen administration for one of 33 residents reviewed (R41) Findings include: Review of Resident R41's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses that included Heart Failure (a condition that develops when the heart doesn't pump enough blood for the body's needs. This can happen if the heart can't fill up with enough blood. It can also happen when the heart is too weak to pump properly), Atrial Fibrillation (an irregular and often very rapid heart rhythm; it can lead to blood clots in the heart, increases the risk of stroke, heart failure and other heart-related complications), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, it causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body). Review of physician order for Resident R41, dated November 25, 2023, indicated an order to administer Oxygen continuously at 2 Liters/minute, via nasal canula/mask, every shift. Review of the care plan for Resident R41, revealed that there were no focus, interventions, and outcomes (goals) care- planned for oxygen administration. On December 29, 2023, at 10:27 a.m., interview with the Director of Nursing confirmed the above findings. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395738 Page 3 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and clinical records review, it was determined that the facility failed to ensure that that physician orders were followed related to urinary catheter size for one of one residents reviewed with a urinary catheter. (Resident R42) Findings include: Review of Resident R42's clinical record revealed that Resident R42 was admitted to the facility on [DATE] with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder and Malignant Neoplasm of Right Female Breast (The term malignant means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin). Review of physician order dated December 1, 2023, for Resident R42, indicated an order for suprapubic catheter size 18 French/10cc balloon. On December 29, 2023, at 10:29 a.m., reviewed the suprapubic catheter of Resident R42, in the presence of Licensed nurse, Employee E13, and observation completed at the time revealed that Resident R42 had suprapubic catheter size 16 French, with the balloon size not clear. 28 Pa. Code 211.12(d)(1) Nursing services 395738 Page 4 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Residents Affected - Few Findings include: The facility incurred a medication error rate of 6.25%. Review of R34's physician order revealed an order dated November 1, 2021, to administer Amlodipine Besylate 5 milligrams, give one tablet orally in the morning, for hypertension; hold for systolic blood pressure (SBP) less than 100. (Systolic Blood Pressure indicates how much pressure the blood is exerting against the artery walls when the heart contracts). (Hypertension is high blood pressure; if an individual has high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood). On December 28, 2023, at 9:38 a.m., observed that Employee E13, a Licensed Nurse, administered Amlodipine Besylate 5 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Amlodipine Besylate 5 Mg tablet. Review of Resident R34's physician order revealed an order dated November 1, 2021, to administer Losartan 100 mg tablet, give one tablet orally, in the morning, related to Essential (Primary) Hypertension, hold for Systolic Blood Pressure (SBP) less than 100. On December 28, 2023, at 09:38 a.m., observed that Licensed nurse, Employee E13, administered Losartan 100 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Losartan 100 mg. At the time of the observation, interviewed with Employee E13, confirmed the findings. Pa Code:211.12(d)(1)(2)(5) Nursing Services. 395738 Page 5 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete one of 30 residents reviewed (Resident R77). Findings Include: Review of Resident R77's dietary progress note dated December 28, 2023, revealed that the resident was trending weight loss for past several months. The dietician was monitoring weekly weights, labs, meal intake and tolerance. Review of Resident R77's November 2023 meal intake documentation revealed that on 19 days only one meal intake was documented. December 2023's meal intake documentation revealed that for 12 days only one meal was documented. Continued review of December 2023's meal intake documentation on December 5, 9 and 15, 2023 only two meals were documented. Interview with the Registered Dietician on January 2, 2023, at 12:00 p.m. stated the resident was not on weekly weight when the dietician completed the documentation on December 28, 2023. Dietician also confirmed that the meal intake documentation was not consistently completed for Resident R77. 28 Pa. Code 211.5(f)(ii) Medical records 395738 Page 6 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor). Residents Affected - Few Findings include: A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor. Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway . Every staff, and/or visitor going into COVID room must put on all PPE when going into the resident's room who are diagnosed with COVID. Observation conducted on December 28, 2023, between 10:35 a.m. to 10:40 a.m. on the second floor, revealed Housekeepers, Employee E8 and E9 were going in and out of the COVID rooms without appropriate PPE such as mask N95, and face shield. Also, Employee E9 was observed exiting COVID room without appropriately doffing and putting dirty gown in a clean cart with other clean gowns. When Housekeepers, Employee E8 and E9 were interviewed, they both reported that they were train on PPE to be put on upon entrance and taken prior to exit COVID rooms. On December 28, 2023, at 11:00 a.m. interview with Director of Nursing, Employee E3 and Assistant Director of Nursing, Employee E10, confirmed that all staff and visitor going into COVID rooms must put on all PPE when going into resident's room who are diagnosed with COVID and doffed when exiting by infection control policies and procedures. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 PA. Code 211.12(d)(5) Nursing services 395738 Page 7 of 8 395738 01/02/2024 Paul's Run 9896 Bustleton Avenue Philadelphia, PA 19115

F 0882 Level of Harm - Potential for minimal harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on review of facility policies and staff interviews, it was determined that the facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control. Findings include: Review of facility infection control practice documentations revealed no evidence that the facility employed an Infection Preventionist who completed specialized training in infection prevention and control. A request for a copy of the approved Infection Preventionist specialized training in infection prevention and control certification was made to the nursing home administrator, Employee E1, and Director of Nursing, Employee E2, on December 27, 2023, at 10:42 a.m. Facility Nursing Home Administration did not provide the documentation that the facility employed an Infection Preventionist who completed Infection Preventionist completed specialized training in infection prevention and control. Interview with the Director of Nursing, Employee E2 on January 2, 2024, at 12:08 p.m. confirmed that the Director of Nursing assumed the duties of the Infection Preventionist (IP). The DON confirmed that no facility staff, who was responsible for infection control program, completed the required IP specialized training and education course and was not certified. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395738 Page 8 of 8