Health inspection·March 12, 2024

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. Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for four of eighteen residents reviewed. (Residents R1, R11, R12, R24) Findings include: Interview held with Nursing Home Administrator Employee E1 on March 11, 2024 at 1:00 p.m. The Nursing Home Administrator, Employee E1 revealed the facility was having an issue with accomdating staffing preferences for several females at the facility requesting male nurses aide. The facility stated that they are trying to accomodate preferences but have been unable to accomdate in some cases. When asked how many residents are preferring males caregivers the Nursing Home Administrator Employee E1 stated alot. Interview with Resident R1 on March 11, 2024 at 10:20 a.m. indicated that she prefers female nurse aide over male nurse aide, stating I don't feel as clean when hygiene care is provided by male nurse aide. Review of Resident R1's MDS Minimum Data Set revealed a BIMS Brief Interview for Mental Status of 14. Observations of R1 during morning medication administration on March 11, 2024 at 10:25 am, revealed R1 voicing her concern regarding male nurse aides to licensed nurse, Employee E3. E3 replied that she will bring resident's concern again to administration. Resident Council meeting was held on March 11, 2024 at 1:00 p.m. with eight awake, alert and oriented residents. During the resident council discussion the topic was brought up regarding male caregivers. Residents R11, R12, and R24 all stated that they prefer to have a female nurse aide give personal care such as bathing or toileting but sometimes are given a male nurses aid. The group discussed how this was brought up to the Nursing Home Administrator Employee E1 during previous Resident Council meetings and and Nursing Home Administrator reiterated that this is what it is and we need to get more comfortable with having males as aides because that is who is applying and qualified. Review of R1, R11, R12 and R24's care plan show no description of the resident's preferring a female caregiver over a male caregiver. Review of Resident Council Meeting Minutes from February 2024 described having males as aides as being a concerned discussed. Page 1 of 3 395821 395821 03/12/2024 Little Flower Manor 1201 Springfield Road Darby, PA 19023

F 0656 28 Pa Code 211.10( c)(d) Resident care policies Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services Residents Affected - Few 395821 Page 2 of 3 395821 03/12/2024 Little Flower Manor 1201 Springfield Road Darby, PA 19023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 interview it was determined that the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy revealed products transferred from the manufacturers ' original packaging or opened must be stored and labelled in accordance with the manufacturers after opening instructions. Perishable foods must have limited shelf life and must be refrigerated. This is normally 72 hours for in-unit produced foods. An initial tour of the Food Service Department was conducted on March 8, 2024, at 9:30 a.m. with Employee E4, Assistant Food Service Director. Observations of the reach in refrigerator revealed the following food items stored in facility containers: pureed red velvet cake dated 2/26, cranberry sauce dated 2/19, and multiple bowls of apple sauce with no dates. Observations in the dish area revealed dietary staff preparing to clean meal trays from breakfast. Interview with Employee E4, Assistant Food Service Director, revealed the dish machine used was a high temperature dish machine (sanitizes dishes using extremely hot water during their rinse cycle to remove pathogens. The water is heated to at least 180 degrees Fahrenheit). Observations of the dish machine revealed the wash temperature was reaching 135 degrees Fahrenheit and the final rinse temperature was reaching 120 degrees Fahrenheit. Interview with Employee E4, Assistant Food Service Director, confirmed these temperatures were not appropriate for proper sanitation of the dishes. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management 395821 Page 3 of 3