Health inspection·November 6, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of policies, staff statements and clinical records, as well as resident and staff interviews, it was determined that the facility failed to notify the physician of lab services failing to draw labs for one resident (Resident 37). Findings include: Review of Resident 37's clinical record including progress notes dated October 19, 2023 (6:41 p.m.) revealed Follow up call placed to Aculabs due to technician not showing up to draw blood. Additional review of Resident 37's progress notes revealed documentation on October 19, 2023, at 9:35 p.m. states contacted dispatch who again stated there is no tech in the area to draw blood. Further review of Resident 37's clinical record failed to find any documentation of staff notifying the physician that Aculabs failed to draw labs (Drawing blood from a patient) for Resident 37. Interview conducted with the Director of Nursing on November 3, 2023, at 12:48 p.m. confirmed there is no documentation that Resident 37's physician was not notified of Aculabs failing to draw labs from Resident 37. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Page 1 of 12 395827 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to the resident or resident's representative for two of three records reviewed (Residents 5 and 33). Residents Affected - Few Findings include: Review of form titled Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (notice that informs the recipient when care receive from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) instructs that a Medicare provider must be delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. Review of the form title Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs. Review of facility documentation revealed that Resident 5 was discontinued from Medicare Part A on April 22, 2023, with benefit days remaining. There was no documentable evidence that the resident or resident's representative was provided the required NOMNC. Review of facility documentation revealed that Resident 33 was discontinued from Medicare Part A on October 17, 2023, with benefit days remaining. There was no documented evidence that the resident or resident's representative was provided the required SNF-ABN form. Interview with the Nursing Home Administrator on November 3, 2023, at 12:40 p.m. confirmed that there was no evidence that the NOMNC and SNF-ABN notices were provided to the above residents or their representative. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 395827 Page 2 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff and resident interviews it was determined that the facility failed to maintain a temperature range between 71 to 81 degrees Fahrenheit in random selection of rooms and common areas occupied by residents resulting in immediate jeopardy to the residents. Findings include: Interview conducted with Resident 4 on November 1, 2023, at 12:30 p.m. and Resident 11 on November 2, 2023, at 9:30 a.m. revealed the residents were cold. Observations of residents residing in the facility revealed residents had multiple layers of clothing, including blankets and hats. Observation of resident rooms revealed multiple blankets on residents' beds. Observation of facility staff revealed staff wearing long sleeves under working attire (scrubs). Observations of the thermostats in the northwest hallway revealed temperatures of 69 and 67 degrees with additional observation of the front lobby with a temperature of 68 degrees. Interview with Maintenance Director revealed, the facility's boiler(heater) did not function properly, and a wire was recently fixed, but the boiler/heating unit malfunctioned again. The Maintenance Director only contacted a HVAC company after being informed by surveyors that temperatures on the thermostats were below required minimum standards of 71 degrees. Observation conducted with the Maintenance Director on November 2, 2023 at 9:45 a.m. revealed the following temperatures from the following locations using an infrared thermometer: Southwest hallway registered 68 degrees, room [ROOM NUMBER] registered 67.2 degrees, room [ROOM NUMBER] registered 64.5 degrees, room [ROOM NUMBER] registered 62.8 degrees, west hallway registered 58.1 degrees, room [ROOM NUMBER] registered 66.7 degrees, room [ROOM NUMBER] registered 66.2 degrees, and the activities room registered 68.1 degrees. Outside temperature at the time of the readings was 23 degrees Fahrenheit. Interview with Maintenance Director revealed the facility did not have temperatures logs documenting room or common area temperatures. Interview with the Nursing Home Administrator and the Director of Nursing on November 2, 2023 at 11: 45 a.m. revealed they were informed by Resident 4 on October 22, 2023 that the resident was cold. The Nursing Home Administrator went to the thermostat and raised the temperature. There was no communication of the resident being cold made to the Maintenance Director and there were no air temperatures conducted in the resident rooms to ensure a properly working HVAC (Heat Ventilation and Air Condition) system. The facility was asked to provide logs that air temperatures had been obtained to ensure safe temperature levels in the resident living areas. The Nursing Home Administrator and the Director of Nursing revealed that the current Maintenance Director was new and had not been routinely obtaining room temperatures and that they were unable to find logs from the previous Maintenance Director. 395827 Page 3 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many An Immediate Jeopardy situation was identified by the facility having temperatures that were cold and unsafe, the facility had no process in place to monitor and ensure temperatures were at a safe level. The facility also had received complaints from residents of being cold and Administration failed to notify maintenance or put intervention's into place to ensure a properly working HVAC system. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator on November 2, 2023, at 12:50 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility. On November 2, 2023, at 4:15 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. The facility created a warm zone in the activities/dining room. Staff were instructed to provide residents with warm clothing and/or blankets. A warm drinking station was also set up in the activities/dining room. 2. A heating company was contacted to evaluate and correct the heating malfunction (boiler control switch). 3. The facility will conduct initial audit of all resident rooms and then monitor temperatures hourly. The facility will conduct audits every 2 hours for 24 hours to ensure temperatures are within specified range of 71-81 degrees. 4. Nursing Home Administrator/designee will educate staff on maintaining appropriate heating in facility of 71-81 degrees. 5. Nursing Home Administrator/Designee will conduct two temperature audits a day/each resident room for one week then conduct daily temperature audit for 30 days for each resident room. Facility will conduct a temperature audit once a month for two months to ensure ongoing compliance. After review of facility temperature logs, observations of all resident room ambient temperatures, three resident interviews and seven staff interviews, the implementation of the above stated action plan was confirmed on November 4, 2023, at 12:50 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 395827 Page 4 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0584 Previously cited on 12/9/21 Level of Harm - Immediate jeopardy to resident health or safety 28 Pa Code 201.18(e)(1) Management Previously cited on 12/9/21 Residents Affected - Many 395827 Page 5 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record review and staff interview it was determined that the facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing and with required transfer information for one of 5 resident records reviewed (Residents 139). Findings include: Review of Resident 139's clinical record revealed diagnoses of Bipolar II Disorder (condition defined by periods of extreme mood disturbances that affect mood, thoughts, and behavior), Anxiety Disorder (mental illnesses that cause constant fear and worry), Panic Disorder (recurring and regular panic attacks), Major Depressive Disorder (persistently low or depressed mood and a loss of interest in activities), Unspecified Focal Traumatic Brain Injury without Loss of Consciousness (Injury to the brain caused by an external force), and Post-Traumatic Stress Disorder (a serious mental condition that some people develop after a shocking, terrifying, or dangerous event). Review of Resident 139's clinical record revealed that on September 24, 2023, Resident 139 was transferred out of the facility to the hospital for active suicidal ideations. On November 2, 2023, at approximately 1:25 p.m. the Director of Nursing (DON) was asked to provide evidence of the facility providing the Office of the State Long-Term Care Ombudsman of Resident 139's transfer to the hospital. On November 3, 2023, at approximately 12:16 p.m. the DON reported that the staff member who notifies the Office of the State Long-Term Care Ombudsman left her position in early September before Resident 139 was transferred to the hospital. The DON reported that the facility has not sent any notification in writing to the Office of the State Long-Term Care Ombudsman since mid-September. 28 Pa. Code 201.14(a) Responsibility of licensee. 395827 Page 6 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to complete clinal assessments completely and accurately for 13 of 16 residents reviewed. (Residents 2, 4, 5, 6, 7, 8, 10, 11, 22, 25, 26, 27, and 139) Residents Affected - Some Findings Include: Review of Resident 2's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated September 11, 2023, revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 4's Annual MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 5's Significant Change MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 6's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 7's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 8's Annual MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 10's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 11's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 22's Annual MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 25's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 26's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 27's Annual MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 139's Quarterly MDS, dated [DATE] revealed Sections C for cognitive assessment and section D for mood were not completed. 395827 Page 7 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0641 Interview with the Director of Nursing on November 1, 2023 at 12:15 p.m. confirmed that sections C and D on Residents 2, 4, 5, 6, 7, 8, 10, 11, 22, 25, 26, 27, and 139 were not completed. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5(f) Clinical records Residents Affected - Some 28 Pa. Code: 211.12(d)(1)(5) Nursing services 395827 Page 8 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician, and or clarify physician, orders regarding Medication Administration for one of eight residents reviewed (Resident 139). Residents Affected - Few Findings include: Review of Resident R139's physician orders revealed on order for Oxycodone 5 mg (milligrams), two tabs PO (by mouth) QID (four times a day) for pain, with a start date of June 6, 2023. Review of Resident 139's clinical record revealed a progress note dated October 21, 2023, at approximately 6:48 a.m. stated 3/9 charting for monitoring med error. On November 3, 2023, the Director of Nursing provided this surveyor a copy of a Medication Incident form. The form stated that Resident 139 was given two tabs of Oxycodone 10 mg at 9:00 a.m. and 12:00 p.m. instead of two tabs of Oxycodone 5 mg. Interview conducted with the DON on November 3, 2023, at approximately 2:15 p.m. confirmed the above and provided evidence of the staff member receiving retraining on medication administration. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services. 395827 Page 9 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed to protect residents from potentially unsafe environmental condition in the facility. Residents Affected - Many Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. Review of the job description for the Director of Nursing revealed the purpose of the job position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administration and the Medical Director, to ensure that the highest degree of quality of care is maintained at all times. The findings in this report identified the facility failed to consistently maintain an environment that maintained safe temperature levels or had a process in place to ensure the facility was maintained at the safe temperature levels. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F584 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. 395827 Page 10 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of the facility assessment and employee interview it was determined the facility failed to update the facility assessment at least annually. Findings Include: November 6, 2023. Interview with the Nursing Home Administrator on November 6, 2023 at 9:30 a.m. revealed the facility assessment had not been provided to the surveys due to not having been updated since December 6, 2021 and the NHA was currently in the process of updating it. The facility failed to update the facility assessment as need and at least annually. 28 Pa. Code 201.18(b)(1)(3) Management 395827 Page 11 of 12 395827 11/06/2023 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews it was determined the facility failed to have a certified infection preventionist. Residents Affected - Many Findings Include: Interview with the Director of Nursing and the Nursing Home Administrator during entrance on October 31, 2023 at 9:45 a.m. revealed the NHA was the infection Preventionist. Interview with the NHA on November 3, 2023 at 12:45 p.m. confirmed the NHA was not certified as an infection preventionist and there was no other staff in the building qualified as infection preventionist. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(3)(6) Management 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 395827 Page 12 of 12