Health inspection·December 30, 2024

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure correct installation, use, and maintenance of bed rails for one resident (Resident 1) Findings include: Review of Title 42 Code of Federal Regulations (CFR) §483.25(n) - Bed Rails states, If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements, Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails). Review of the facility policy Use of Side Rails dated August 28, 2018, indicated that the resident will be checked frequently for safety. Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with the following diagnoses: chronic respiratory failure with hypoxia (low oxygen levels in the blood), Hemiplegia, unspecified affecting left nondominant side (one-sided paralysis or weakness of the face, arm, or leg), Tracheostomy status (a surgical airway management procedure which consists of making an incision on the anterior front of the neck and opening a direct airway through an incision in the windpipe as a site for a tracheal tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth). Review of Resident 1's side rail/restrain enabler evaluation assessment dated [DATE], revealed at this time side rails are indicated to provide safety. Interview conducted on December 30, 2024, at 9:41 a.m. with Resident 1 revealed the side rail located next to Resident 1's left hand was not properly secured to the bed and was unusable for turning and repositioning. At 9:47 a.m. the Nursing Home Administrator (NHA) accompanied the surveyor to Resident 1's room. The NHA confirmed the bedrail/side rail was not properly secured to the bed and nursing staff should have regularly performed inspections on Resident 1's bedrails/ side rails. 28 Pa. Code 201.14(a) Responsibility of Licensee. Page 1 of 2 395827 395827 12/30/2024 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0700 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)(5) Nursing services. Residents Affected - Few 395827 Page 2 of 2