Health inspection·November 27, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of clinical records, facility documentation, observations, and interviews with staff, it was determined the facility failed to ensure residents were free from neglect by failing to provide sufficient nursing staff to ensure nursing care, safety, and related services for 39 residents on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. The facility failed to provide necessary nursing services to 39 out of 39 residents due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. (Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39) Findings Include: Observation upon arrival at the nursing home on November 22, 2024, at 3:53 p.m. revealed there was one Nursing Assistant (NA), one Licensed Practical Nurse (LPN) and one Registered Nurse (RN). Observations of the nursing unit upon entrance to the facility on November 22, 2024 at 3:53 p.m. revealed all 39 residents, Resdients Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, were in bed and a strong odor of urine was noted throughout the facility and observed to be unkept with unwashed hair and soiled clothing. Observations of Resident R3's room on November 22, 2024 at 4:36 p.m. revealed the trashcan was overflowing with trash. Observation of Resident R6's room on November 22, 2024 at 4:39 p.m. revealed crumbs next to the bed. Obervations of Resident R4's room on November 22, 2024 at 4:45 p.m. revealed the trashcan was overflowing with trash and there were small pieces of paper on the floor. Observation of both the East and [NAME] hallways revealed the floors were dirty with food particles, dried liquids and trash. Interview with Licensed Nursing Employee E2 on November 22, 2024 at approximately 4:00 p.m. revealed the staff member's concern of lack of staff scheduled for the 3 p.m. to 11 p.m shift on November 22, 2024 or for the night shift 11 p.m to 7 a.m hours on November 22-23, 2024. Continued interview with Licensed nurse Employee E2, revealed the Nursing Home Administrator (NHA) Page 1 of 10 395827 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many was aware of the lack of staff scheduled for November 22, 2024 since the beginning of the 7 a.m. to 3 p.m. shift but nursing staff were only able to get in touch with the NHA via text messaging. Employee E2 revealed the staff did not have any communication with the Administrator throughout the day and were not aware if any staff were coming for the 3-11 shift. Continued Interview with Registered Nurse (RN) Employee E2 revealed, the facility did not have a Director of Nursing (DON) since the previous DON suddenly resigned on Wednesday November 20, 2024 and staff were instructed not to contact the corporate representative, Employee E4, who had removed all contact information from the building. Continued interview with Registered Nurse (RN), Employee E2 revealed that when no staff showed up for the shift starting at 3 p.m., the current staff remained in the facility. Employee E2 stated the facility had no current nursing contracts with staffing agencies due to outstanding bills. Further interview with RN, Employee E2 and Licensed Practical Nurse, Employee E3 revealed their belief the facility's failure to pay it's employees timely has led to multiple staff members resigning recently. Additional interview with Employee E2 and Employee E3 at 4:25 p.m. revealed the residents are receiving their medications, but the administration of the medications is longer than the two-hour window (hour before or hour after set administration time) due to the lack of staff and nurses needing to respond to the needs of the residents. Licensed Nursing Employees E2 and E3 revealed, they believed the residents at the facility were in an unsafe situation due to the lack of staff currently in the facility, and inability to determine when more staff were to arrive. Interview with Resident R3 on November 22, 2024 at 4:36 p.m. revealed concerns due to staffing shortages, and indicated staff were unable to provide showers or bed baths, assist with change of clothes, perform incontinence care timely or respond to call bells. Interview with Resident R4 on November 22, 2024 at 4:42 p.m. revealed Resident R4 had not received a shower or bed bath in serval days due to a lack of staff. Interview with the Nursing Home Administrator via telephone on November 22, 2024 at 5:10 p.m. revealed she had taken the day off and was working from home but was aware of a lack of staffing for the 3-11 shift. Administrator further indicated, the facility currently had no contacts with nursing staffing agencies to provide RNs (Registered Nurse) or LPNs (Licensed Practical Nurse) to the facility. Administrator indicated she called one sister facility, but they were unable to provide any staff. Administrator indicated there was a nurse on her way to the facility that was to relieve one of the nurses currently working and there were two nurse aides now, to care for 39 residents. Surveyors were unable to determine the time the second nurse aide arrived at the facility. Review of a list of residents who needed assistance during meals with feeding revealed eight residents needing assistance with eating. Observations of the dinner meal revealed the trays were delivered to the resident timely. Observations conducted on November 22, 2023 at 5:33 p.m. revealed Residents R1 and R2 receiving no assistance with the meal with the meal tray placed at residents' bedside but remained untouched. Review of the shower schedule revealed seven residents were scheduled to be showered on the 7-3 395827 Page 2 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0600 dayshift and seven residents on the evening 3-11 shift on November 22, 2024. Level of Harm - Immediate jeopardy to resident health or safety Interview with Nursing Employees E2 and E3 on November 22, 2204 at 7:35 p.m. confirmed seven residents were scheduled to be showered but anticipating none of the residents would receive a shower today due to lack of sufficient staffing for each resident's care needs except one resident who was able to shower independently. Residents Affected - Many Review of facility staffing schedule for November 22, 2024, on the 3 p.m. to 11 p. m. shift failed to reveal an RN and LPN scheduled with only an asterisk in each slot. Further review of the facility staffing schedule for November 22, 2024 revealed three nurse aides were scheduled from a nursing agency with their names yellowed on the schedule. Interview with Registered Nurse Employee E2 on November 22, 2024 at 11:25 p.m. revealed if a staff's name is yellowed on the schedule, it indicates a need, or the staff member had called off. Further review of the facility staffing schedule failed to reveal an RN or LPN scheduled for November 22 2024 on the 11 p.m. to 7 a.m shift. Interview with the Nursing Home Administrator on November 22, 2024 at 12:30 a.m. confirmed the facility schedules were accurate and open availability for staffing. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and presented to the Nursing Home Administrator on November 22, 2024 at 8:24 p.m. for neglect by failing to ensure sufficient nursing staff available to provide nursing care. This failure resulted in 39 residents not receiving medications timely and the required assistance during meals and adequate ADL (Activities of Daily living) care. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. The facility provided the following Action Plan on November 23, 2024 at 2:11 a.m.: 1. RN assessments were completed on residents to identify clinical needs. Corrections were made immediately. 2. The clinician completed clinical resident rounds to identify medical needs. Corrections were made immediately. 3. Facility staff were re-educated on what to do when staffing levels do not meet regulation requirements. A new Director of Nursing was hired and is working full time hours. 4. The DON or designee will complete clinical rounds weekly x 4 weeks then monthly x 2 months to 395827 Page 3 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many ensure resident needs are being met. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring. After review of facility education documentation, observations of the facility and care provided to residents as well as interviews with six residents and 10 staff members, the implementation of the above stated action plan was confirmed on November 26, 2024, at 4:00 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on November 26, 2024 at 4:00 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 395827 Page 4 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, observations, and staff interviews, it was determined the facility failed to maintain sufficient nursing staff to provide nursing care and related services to assure resident safety on one of one nursing units on November 22, 2024, during the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts. Residents did not receive care and services due to the lack of appropriate nursing levels placing all 39 residents in the facility in an Immediate Jeopardy situation. (Resdients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39) Findings Include: Review of facility policy and procedure titled Emergency Staffing Plan- Kadima at Pottstown, undated, revealed, in the event of a staffing emergency, the first step will be to call all staffing personnel that is not currently in the facility and eligible to work. Staffing bonuses will be offered to entice employees to pick up the open shifts. Sister facilities will be made aware of the staffing needs and bonuses and/or mileage will be offered to entice employees to pick up the open shifts. After Kadima staff have been offered the shifts, staffing agencies will be alerted of the ongoing need to attempt to fill the open shifts with contracted agency staff. In the event that shift coverage cannot be found, staff currently in the facility will be mandated to stay to cover the shift. The call-in off-duty policy will be followed to allow for additional staff. Department heads and those in ancillary departments may be asked to cover nonclinical resident care needs. Observation upon arrival at the nursing home on November 22, 2024, at 3:53 p.m. revealed there was one Nursing Assistant (NA), one Licensed Practical Nurse (LPN) and one Registered Nurse (RN). Continued observation of the skilled nursing facility failed to reveal any additional staff members including staff members from departments such as therapy, housekeeping, or social work. Observations of the nursing unit revealed all residents who were dependent on staff for care were in bed and the residents observed to be unkept with unwashed hair and soiled clothing. Continued observations of the skilled nursing facility revealed a strong odor of urine noted throughout the facility. Interview with Registered Nurse (RN) Employee E2 on November 22, 2024, at approximately 4:00 p.m. revealed no additional staff were scheduled for the evening 3 p.m. to 11 p.m. shift on November 22, 2024, or the night shift 11 p.m. to 7 a.m. November 22-23, 2024. The Nursing Home Administrator (NHA) had been aware of staffing concern since the beginning of the 7 a.m. to 3 p.m. shift. Continued interview with Employee E2 revealed, the nursing staff were only able to get in touch with the Nursing Home Administrator via text and had not talked to her through the day and were unaware if replacement staff were coming for the 3-11 shift or not. Continued interview with RN, Employee E2 revealed the lack of a Director of Nursing (DON) as the previous DON suddenly resigned without notice Wednesday November 20, 2024, and the staff were instructed not to contact the corporate representative, Employee E4, who removed all contact information from the building. 395827 Page 5 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Continued interview with Registered Nurse, Employee E2 revealed, when no additional staff came for the evening shift (3 p.m. to 11 p.m.); the current staff remained in the facility. Employee E2 further stated the facility had no current contracts with staffing agencies due to outstanding bills. Further interview with Registered nurse Employee E2 and Licensed nurse Employee E3 revealed their belief of facility's failure to pay its employees has led to multiple staff members resigning their positions recently. Additional interview with Registered Nurse Employee E2 and Licensed nurse Employee E3 at 4:25 p.m. revealed the residents are getting their medications, but the administration of the medications is longer than the two-hour window(hour before scheduled administration time and hour after scheduled administration time) due to the lack of staff and the nurses needing to respond to the needs of the residents. Continued interview with Registered nurse, Employee E2 and licensed nurse, Employee E3 revealed, they believed the residents at the facility were currently in an unsafe environment due to lack of staff currently in the facility and inability to determine when more staff were to arrive. Interview with Resident R3 on November 22, 2024, at 4:36 p.m. revealed concerns due to staffing shortages, and indicated staff were unable to provide showers or bed baths, assist with changing of clothes, perform incontinence care timely or respond to call bells. Interview with Resident R4 on November 22, 2024, at 4:42 p.m. revealed Resident R4 had not received a shower or bed bath in serval days due to a lack of staff. Interview with the Nursing Home Administrator via telephone on November 22, 2024, at 5:10 p.m. revealed she had taken the day off and was working from home but was aware of the lack of staffing for the 3-11 shift. Administrator indicated the facility currently had no contacts with nursing staffing agencies to provide RNs or LPNs to the facility. She reported she called one sister facility, but they were unable to provide any staff. There was a nurse on her way in that was to relieve one of the nurses that was currently there and there were two NAs in the building now. Surveyors were unable to confirm the time of the second nurse aide's arrival at the facility. Review of the shower schedule revealed seven residents were scheduled to be showered on the 7-3 dayshift and seven residents on the evening 3-11 shift on November 22, 2024. Interview with Nursing Employees E2 and E3 on November 22, 2024, at 7:35 p.m. confirmed there were seven residents scheduled to be showered but none of the residents would receive a shower today due to lack of sufficient staffing to safely conduct the activity except for one resident who was able to shower independently. Review of a list of residents who needed assistance during meals with feeding revealed eight residents needing assistance with eating. Observations of the evening meal on November 22, 2024, revealed meal trays were delivered to the residents timely. Further observation of the evening meal on November 22, 2024, approximately 5:33 p.m. revealed Residents R1 and R2 were observed receiving no assistance with meal items and meal tray was placed at 395827 Page 6 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0725 residents' bedside but remained untouched. Level of Harm - Immediate jeopardy to resident health or safety Review of facility staffing schedule for November 22, 2024, on the 3 p.m. to 11 p. m. shift failed to reveal an RN and LPN scheduled with only an asterisk in each slot. Residents Affected - Many Further review of the facility staffing schedule for November 22, 2024 revealed three nurse aides were scheduled from a nursing agency with their names yellowed on the schedule. Interview with Registered Nurse Employee E2 on November 22, 2024 at 11:25 p.m. revealed if a staff's name is yellowed on the schedule, it indicates a need, or the staff member had called off. Further review of the facility staffing schedule failed to reveal an RN or LPN scheduled for November 22 2024 on the 11 p.m. to 7 a.m shift. Interview with the Nursing Home Administrator on November 22, 2024 at 12:30 a.m. confirmed the facility schedules were accurate and open availability for staffing. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and relayed to the NHA on November 22, 2024, at 8:24 p.m. for failing to ensure sufficient nursing staff were available to provide nursing care and services by ensuring during a staffing shortage emergency alternative resources could be utilized to ensure an adequate nurse staff level. This failure resulted in 39 residents not receiving medications timely and the required assistance during meals and adequate ADL (Activities of Daily living) care. The NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. The facility provided the following Action Plan on November 23, 2024, at 2:11 a.m.: 1. Agency contracts have been established with Eshyft, Revv, [NAME] and Ready shift. Sister facilities are available to be contacted for staffing support. There is a policy for calling in staff that are not currently in the facility and mandating staff to ensure resident care is completed. 2. Newly approved agency contracts were signed with [NAME] and Ready Shift staffing agency. Emergency protocols will be implemented when staffing drops below acceptable levels. 3. Nursing staff were re-educated on policy and procedure for when staffing levels are below adequate levels. Daily staffing meetings will be held to address needs. 4. The DON or designee will conduct an audit of staff PPD and ratios once/shift daily x7 days, then weekly x4 weeks, then monthly x2 months to ensure adequate staffing levels exist. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring. 395827 Page 7 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0725 Level of Harm - Immediate jeopardy to resident health or safety After review of facility education documentation, observations of the facility and care provided to residents and interviews with six residents and 10 staff members, the implementation of the above stated action plan was confirmed on November 26, 2024, at 4:00 p.m. and the Nursing Home Administrator was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on November 26, 2024, at 4:00 p.m. Residents Affected - Many 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(d)(3) Nursing services 395827 Page 8 of 10 395827 11/27/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation and staff interview it was determined the facility failed to ensure a Director of Nursing was employed full time at the facility. Residents Affected - Many Findings Include: Interview with Licensed Nursing Employee E2 on November 22, 2024 at 3:30 p.m. revealed there was no Director of Nursing (DON) since the last DON resigned on November 20, 2024. Interview with the Nursing Home Administrator on November 22, 2024 at 6:30 p.m. confirmed there has not been a DON employed since November 20, 2024 and there was a new DON starting on November 25, 2024. Interview with Licensed Nursing Employee E19 on November 25, 2024 at 9:30 a.m. confirmed it was the first day as DON and they were completing their orientation. The facility failed to have a full time Director of Nursing from November 20, 2024 to November 25, 2024. 28 Pa Code 201.3 Definitions 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 211.12(b) Nursing Services 395827 Page 9 of 10 395827 11/27/2024 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 ensure proper staffing to care for and protect residents from potentially unsafe 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 ensure sufficient nursing staff were available to provide nursing care and services by ensuring that during an emergency staffing shortage alternative resources could be utilized to ensure an adequate nurse staff level, resulting in inadequate resident care. 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 F600 and F725 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 10