Health inspection·February 27, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, clinical records, and interviews with staff and residents it was determined the facility failed to ensure the transportation vehicle had a safety inspection from [DATE], until February 4, 2025, during which time the vehicle was used to transport seven residents on 11 separate occasions to medical appointments. Additionally, staff using the transport van had not been trained in safety procedures. This resulted in an Immediate Jeopardy which had the potential to cause residents discomfort or pain and to jeopardize the health and safety of residents. Findings include: Review of facility documentation revealed the facility's wheelchair accessible van had a state safety inspection completed on [DATE]. Further review of facility documentation revealed the next safety inspection was completed on February 4, 2025. Telephone interview conducted on February 26, 2025, at 11:03 a.m. with representative from the automotive establishment that completed the state safety inspection on [DATE], revealed the safety inspection sticker expired on [DATE]. Review of Resident 1's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated [DATE], revealed resident had a BIMS (brief interview for mental status) indicating resident was cognitively intact. The MDS also indicated the resident had a diagnosis of Hemiplegia (paralysis) following cerebral infarction (stroke) affecting the left non-dominate side. Resident 1 had a functional limitation in range of motion on one side for the upper and lower extremity and used a wheelchair for mobility. Review of facility documentation dated [DATE], revealed, resident was being transported to pain management this am 0820 [8:20 a.m.], (he/she) slid from (his/her) wheelchair to the floor of the van, the driver stopped (Employee E3) and repositioned back into the wheelchair, fastened the seat belts, and continued on to (his/her) appointment, after determining that there was not injury sustained during the fall. Review of Employee E3's written statement obtained [DATE], revealed at 8:20 a.m. in the transport van, Resident 1 fell out of (his/her) wheelchair onto the floor of the van. Employee E3 indicated that they had slowed down to allow a car (opposing traffic) to pass by on the road. As we slowed down (going down hill) a loud thud was heard. The resident reported (he/she) slid out of (his/her) wheelchair onto the floor of the van. Employee E3 indicated the wheelchair locks and brakes were placed on wheelchair prior to leaving facility. Van does not have seatbelt for resident. Page 1 of 5 395827 395827 02/27/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Inteview with Resident 1 on February 26, 2025, at 1:10 p.m. revealed that when being transported in the van there was a loud noise and abrupt braking. Resident R1 stated (he/she) was wearing a seatbelt, but (he/she) slid from the wheelchair onto the floor. Further review of Resident 1's clinical record revealed a progress note of [DATE], indicated the resident left for an urology appointment. Progress note of [DATE], revealed resident has gone for an urology appointment. Additional progress note of February 24, 2025, revealed pt [patient] went out for CT [imaging test] abdomen. Review of Resident 2's progress note of [DATE], revealed patient returned to facility around 1700 from appointment. Review of Resident 3's progress note of [DATE], revealed Pt [patient] returned from (his/her) appointment from the kidney specialist. Review of Resident 4's progress note of [DATE], revealed resident on LOA [leave of absence] at 1pm for a GI [gastrointestinal] appt [appointment]. Review of progress note of [DATE], revealed resident on LOA with PT (physical therapy) transport to appointment. Review of Resident 5's medication administration note of [DATE], revealed resident out for oncology follow up and progress note revealed resident returned to facility around 1900. Review of progress note of [DATE], revealed resident is out to (his/her) appointment with transportation services. Review of Resident 6's progress note of [DATE], revealed resident is out to (his/her) neuro [neurology]appointment with transport services. Review of Resident 7's progress note of [DATE], revealed resident was out for an orthopedic appointment. Interview with the Nursing Home Administrator (NHA) on February 26, 2025, at 1:05 p.m. revealed there was no documented evidence that Employee E3 had received any training in safety procedures. The NHA also confirmed the facility did not use an outside contractor for transportation during the time period of [DATE], to present, indicating the above residents were transported using the facility transportation vehicle. Interview with Employee E4 on February 26, 2025, at 12:30 p.m. revealed, Employee E4 drove Resident 3 to an appointment in [NAME] and the tire pressure light was on in the vehicle. An additional interview on the same date at 2:20 p.m confirmed that Employee E4 had not received any training in safety procedures related to the transportation vehicle. Observations and interview with Employee E5 on February 26, 2025, confirmed the transportation vehicle was inspected on February 4, 2025. Additional interview on the same date at 2:05 p.m confirmed Employee E5 had driven the transportation vehicle, but had not received any training in safety procedures. Based upon the above information immediate jeopardy to the health and safety of the residents was identified and relayed to the Nursing Home Administrator on February 26, 2025, at 2:25 p.m. for failing to ensure that the transportation vehicle had a safety inspection while transporting residents to appointments and failing to provide training in safety procedures for transporting residents. The 395827 Page 2 of 5 395827 02/27/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0689 NHA was provided with the Immediate Jeopardy template and an immediate action plan was requested. Level of Harm - Immediate jeopardy to resident health or safety The facility provided the following Action Plan on February 26, 2025 at 5:11 p.m.: Residents Affected - Some Facility vehicle will inspected by a mechanic at least annually. Regular maintenance (such as oil changes) will be maintained by the facility. Calendar for monthly checks was established to verify if preventative maintenance items are needed. 1. 2. Corporate representative is now monitoring expiration dates of facility owned vehicles and will put vehicles out of service if they do not have a current vehicle inspection by a mechanic. A corporate contract with IMT (transportation company) was established for transportation services. 3. Facility designated drivers and back-up drivers will receive re-education and competency training on properly securing residents in wheelchairs to the vehicle. The facility will have at least three individuals designated as competent vehicle operators. 4. NHA or designee will complete an audit of staff competencies daily before appointments x 4 weeks. The audit will then transition to once weekly x 4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring. After review of facility education documentation and interviews with three staff members, the implementation of the above stated action plan was confirmed on February 27, 2025, at 3:30 p.m. and the NHA was informed that the Immediate Jeopardy situation was lifted. Immediate Jeopardy was lifted on February 27, 2025, at 3:30 p.m. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa Code 201.18(a) Management Previously cited [DATE] 28 Pa Code 201.18(b)(1) Management Previously cited [DATE] 28 Pa Code 201.18(b)(3) Management Previously cited [DATE] 395827 Page 3 of 5 395827 02/27/2025 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 - Some 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 the safety of the residents being transported to appointments through the use of a facility transportation vehicle. 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 F689 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/30/24, 11/27/24 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. Previously cited 11/27/24 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 11/27/24 395827 Page 4 of 5 395827 02/27/2025 Kadima Rehabilitation & Nursing at Pottstown 3031 Chestnut Hill Road Pottstown, PA 19464

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for one of eight residents reviewed (Resident 1). Residents Affected - Few Findings include: Review of Resident 1's progress note of January 30, 2025, revealed resident returned to facility via transport van from pain management facility. Review of progress note of January 31, 2025, at 6:53 a.m. revealed resident is 2/9 (two of nine shifts) s/p (status post - condition or status after a specific event) fall. Further review of the clinical record revealed no documentation indicating that the resident had a fall. Review of facility documentation dated January 30, 2025, revealed that resident was being transported to pain management this am 0820 [8:20 a.m.], he slid from his wheelchair to the floor of the van, the driver stopped (COTA-L [certified occupational therapist - licensed] and repositioned back into the wheelchair, fastened the seat belts, and continued on to his appointment, after determining that there was not injury sustained during the fall. Interview with the Nursing Home Adminstrator on February 27, 2025, at 3:35 p.m confirmed that there was no documentation in the clinical record that the resident had sustained a fall. 28 Pa. Code 211.5(f) Clinical records Previously 10/25/24 28 Pa. Code: 211.12(d)(1) Nursing services 395827 Page 5 of 5