Health inspection·October 25, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on staff interviews and review of facility policy it was determined the facility had no grievance offer to monitor and system in place to ensure the prompt resolution of grievances. Residents Affected - Few Findings include: Review of facility policy titled Grievances, revised February 28, 2018, revealed the facility has a system in place to ensure the prompt resolution of all grievances with regard to the resident's rights. The grievance official shall oversee the grievance process, receive and track grievances through to their conclusion. The evidence of the results of all grievance will be maintained for no less than 3 years from the date the grievance decision was issued. During entrance conference with the Nursing Home Administrator and the Director of Nursing on October 22, 2024 at 9:10 a.m. the facility was asked to provide a list of the last 6 months of grievances. Interview with the Nursing Home Administrator and the Director of Nursing on October 25, 2024 at 10:00 a.m. revealed there was no tracking system at the facility and there was no evidence to show that grievances had been investigated and responded to by the facility or their conclusion. Further interview revealed it is the Social Worker who is designated the grievance official, but that position is currently vacant, and no one is acting in the role of grievance officer currently. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.29(d) Resident rights Page 1 of 9 395827 395827 10/25/2024 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 8 of 16 residents reviewed. (Residents 4, 6, 13, 17, 21, 29, 34, and 38) Residents Affected - Some Findings Include: Review of Resident 4's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated August 29, 2024, 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 13's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 17's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 21's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 29's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 34's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Review of Resident 38's Quarterly MDS, dated [DATE], revealed Sections C for cognitive assessment and section D for mood were not completed. Interview with licensed staff, Employee E3, on October 23, 2024 at 1:56 p.m. confirmed that sections C and D for the above residents were not completed. 483.20 Resident Assessments Previously cited 11/6/23 28 Pa. Code 211.5(f) Clinical records Previously cited 11/6/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 11/6/23 395827 Page 2 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 develop interventions to prevent pressure ulcer for one of two residents reviewed. (Resident 4) Residents Affected - Few Findings Include: Review of Resident 4's Braden assessment dated [DATE] revealed the resident was at risk for the development of pressure ulcers. Review of Resident 4's care plan revealed there was a care plan for the risk of pressure ulcer developed on July 7, 2024 with the only intervention being to apply lotion. Review of Resident 4's skin/wound notes revealed a note by the wound CRNP on September 9, 2024 noting a left heel 4.5 centimeter x 3.5 centimeter dry eschar (black dead tissue) cap forming (unstageable pressure ulcer). Interview with the Director of Nursing and the Nursing Home Administrator on October 25, 2024 at 10:00 a.m. confirmed Resident 4 developed a pressure ulcer on the left heel and there were no interventions developed for the prevention of pressure ulcers prior to the development of the wound other than to apply lotion which was inadequate. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 395827 Page 3 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on clinical record review and staff interview it was determinant the facility failed to ensure proper care for a foley catheter for one of one resident reviewed. (Resident 2) Residents Affected - Few Findings Include: Review of Resident 2's physician orders revealed an order dated September 14, 2024 for a Foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside the body). Review of Resident 2's entire clinical record revealed there was no documented evidence the facility was providing care to the catheter. Interview with the Director of Nursing on October 25, 2024 at 10:00 a.m. confirmed there was no documentation to show the facility was providing care to Resident 2's Foley catheter. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services 395827 Page 4 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on facility policy, clinical record review, and staff interview, it was determined the facility failed to obtain and monitor weights for two of 12 residents reviewed for nutrition (Residents 6 and 24). Residents Affected - Some Findings include: Review of facility policy, Resident Weights, dated January 2020, indicated that weights must be obtained routinely to monitor the parameters of nutrition over time and identify residents at risk for significant weight change. Further review of the policy indicated that re-weights will be obtained within 72 hours of monthly weight if a weight change greater than 3%. Review of Resident 6's clinical record revealed an admission weight on May 30, 2024, of 110.0 pounds. No nutritional assessment was completed on admission. Resident's weight was recorded as 103.7 pounds on July 9, 2024, a loss of 6.3 pounds or 5.7%. Further review of the clinical record revealed that a re-weight was not obtained. Resident's weight was recorded as 104.2 pounds on August 6, 2024. Weight was 110.0 pounds on September 18, 2024, a gain of 5.8 pounds or 5.3% increase, with no evidence of a re-weight. Further review of the clinical record revealed that a nutritional assessment was not completed until October 12, 2024. Interview with the Director of Nursing (DON) on October 25, 2024, at 11:00 a.m. revealed that nutrition assessments should be completed on admission and quarterly. The DON also confirmed that re-weights should have been obtained for Resident 6. Review of Resident 24's clinical record revealed recorded weights of 128 pounds on April 2, 2024; 125.8 pounds on May 3, 2024; 123.6 pounds on June 6, 2024; 123.4 pounds on July 10, 2024; 122.5 pounds August 12 2024 and 117 pounds on September 18, 2024, a loss of 11 pounds or 8.59%. Further review of Resident 24's clinical record revealed a dietary note dated October 12, 2024, indicating the resident's weight. Further review of the same dietary note failed to reveal recommendations to address the weight loss. Surveyor requested Director of Nursing to reweigh Resident 24 on October 25, 2024, confirming Resident 24's weight of 116 pounds. Interview with the Director of Nursing on October 25, 2024, at 9:53a.m. confirmed that further dietary interventions should have been implemented to address Resident 24's weight loss. 28 Pa. Code 211.5(f) Clinical Records Previously 11/16/23 28 Pa. Code 211.10(c) Resident Care Policies Previously 6/14/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services 395827 Page 5 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0692 Previously 6/14/24 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395827 Page 6 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing. Residents Affected - Many Findings include: Review of facility policy, Low Temperature Dish Machine Temperatures and Sanitizer Testing indicated a minimum wash temperature of 120 degrees Fahrenheit and a minimum rinse temperature of 140 degrees Fahrenheit. Additionally, the policy revealed 'Complete a test run before putting any dishes into machine. If the minimum temperature is not reached complete another test cycle. If the dish machine still does not reach the minimum temperature required, notify the Dining Service Manager and /or Administrator. DO NOT run any dishes through a wash/rinse cycle until the temperature is rectified. Observation on October 22, 2024, at 9:40am. with the Facility Cook, revealed staff using the dish machine, but the gauge was reading 100 Fahrenheit and rose to 110 Fahrenheit on the dish machine. The staff did not run a test cycle and ran the dishes in the dish machine. The Facility [NAME] indicated that the gauge had been changed and the facility was waiting on a booster for the dish machine. Review of the Dish Machine Temperature Log for October 2024 revealed that the wash temperature did not reach 120 degrees Fahrenheit on 17 of 21 occasions. Additional interview with the Nursing Home Administrator (NHA) on October 22, 2024, 01:54 p.m. confirmed that the minimum wash temperatures had not been reached. NHA indicated that earlier in the month the temperature gauge had been replaced, the facility was waiting on the booster for the machine. NHA stated that they are waiting on the repair company. Interview with the Nursing Home Administrator on October 24, 2024, at 10:15 a.m. confirmed that the minimum dish machine temperatures had not been met. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 395827 Page 7 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0838 Level of Harm - Potential for minimal harm 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 staff interview it was determined the facility failed to develop a resident assessment. Residents Affected - Many Findings Include: During entrance conference with the Nursing Home administrator and Director of Nursing on October 22, 2024 at 9:30 a.m. the facility was asked to provide their facility assessment. Interview with the Nursing Home Administrator on October 25, 2024 at 10:00 a.m. revealed the facility did not have a current facility assessment. 28 Pa. Code 201.18(b)(1)(3) Management 395827 Page 8 of 9 395827 10/25/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, staff interviews, and observations it was determined the facility failed to implement enhanced barrier precautions for the entire facility. Residents Affected - Many Findings Include: Review of a training being developed based on facility policy revealed recommendations now include use of Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug-resistant organism status, EBP include the use of gown and gloves when there is a potential for exposure to the affected area. Observations made during all days of the survey revealed none of the residents with chronic wounds or indwelling medical devices had any signs to indicate the implementation of EBP or PPE available for use. Observation of tracheostomy care on October 25, 2024 at 10:30 a.m. with Licensed Nursing Employee E4 revealed while performing the care the staff did not don a gown. Interview with Licensed Nursing Employee E4 at the time of the observation revealed they had never heard of Enhanced Barrier Precautions needing to be implemented and had received no training. Interview with the Director of Nursing on October 25, 2024 at 10:45 a.m. confirmed the facility does not implement Enhanced Barrier Precautions. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services 395827 Page 9 of 9