Health inspection·June 14, 2024

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 interview and clinical record review failed to ensure that residents attend medical appointments using reliable transportation service for two of three residents reviewed (Residents R1 and R3). Residents Affected - Few Findings include: Review of Resident R1's clinical record including eMedication Administration Note dated May 20, 2024 (9:14 a.m.) revealed Orthopedic follow up .transport did not take. Further review of Resident R1's clinical record failed to reveal reason for missed transportation to medical appointment. Review of Resident R3's clinical record revealed diagnoses including but not limited to following: Peripheral Vascular Disease; Depression; Prostatic Hyperplasia w/ lower urinary tract symptoms; Muscle weakness; Diabetes Mellitus II; Muscle wasting and Atrophy; Anemia; Urinary Retention; and Pulmonary Hypertension (high blood pressure). Interview with Resident R3 on June 11, 2024, approximately 5:24 p.m. was conducted. Resident R3 indicated that he/she missed medical appointments, including veteran's appointments due to the transportation issues. Resident stated that he/she was at an eye doctor appointment and was told they (resident and transportation personnel) had to leave before the appointment was finished due to a conflict with another resident's medical appointment. The resident further stated that one of the medical appointments was rescheduled due to transportation driver had personal conflict. Review of Resident R3's nursing progress note dated June 4, 2024 (12:44 p.m.) Pt returned from [Physician] optometry. Eyes dilatated and injection of Avastin given. Pt (Patient) noted with severe non proliferative diabetic retinopathy and macular edema to R (right) eye and proliferative diabetic retinopathy to L (left) eye. F/U (follow/up) in 4 weeks. LVM at office tocall back to schedule follow up. Review of Resident R3's nursing progress note dated May 21, 2024 (13:58/1:58 p.m.) Nephrology appt cancelled due to transport conflict. Administrator spoke to office who states patient can get missed labs at (his/her) urology appt 6/18 and then nephrology will let us know when f/u is to be rescheduled. Further review of Resident R3's nursing progress note dated April 30, 2024 (09:16 a.m.) Patient upset with missed GI appointment. Nurse speaking with (him/her) and (he/she) began to yell and then states I'm not yelling, I am raising my voice. Page 1 of 2 395827 395827 06/14/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R3's nursing progress note dated April 30, 2024 (08:18 a.m.) No transport available for patients 0830 GI appt with [Physician]. Appt (appointment) rescheduled for 5/30 @ 8am with [Provider, Nurse Practitioner]. Pt (Patient) aware. (Doctor) aware. Additional review of Resident R3's nursing progress note dated April 26, 2024 (11:13 a.m.) Spoke with [Physician office representative] office as resident states [resident] did not have full appointment yesterday. Per [office representative], patient had most of the tests done but the aide had him leave because he had to pick up someone else so he did not see the doctor. Appointment rescheduled for 5/14/24 @ 1420. Pt (patient) and PCP (primary care physician) aware. Review of Resident R3's nursing progress note dated April 25, 2024 (7:55 a.m.) Pt to go OOF (out of facility) today for cataract surgery consultation. Review of Resident R3's nursing progress note dated April 25, 2024 (16:15/4:15 p.m.) Pt came back from ophthalmology appointment, no paperworks, no follow ups sent with the pt. Pt said his appointment for dilation of his eye needs to be rescheduled. Interview conducted on June 11, 2024, at approximately 6:56 p.m. with the Nursing Home Administrator when the above information was discussed. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services 395827 Page 2 of 2