Health inspection·September 5, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on resident and staff interviews, review of faciltiypolicy and review of the clinical records, it was determined that the facility failed to ensure that residents were provided with the opportunity to participate in the care planning process for 9 out of 9 residents interviewed (Resident R75, R52, 72, R10, R74, R55, R91, R88, R93). Findings include: Review of the facility policy, Resident Care Conference, with a revision date of July 17, 2021, indicated that each resident and /or responsible party shall be, invited to participate in their care conference. If the resident is their own responsible party, the invitation to family members will be at their sole discretion. During a group meeting with residents on August 31, 2023, at 11:00 a.m. when interviewed residents reported not receiving written or verbal notification of any scheduled care plan meeting. Documentation provided from the Registered Nurse Assessment Coordinator, Employee E8 indicated the following dates for resident's care plan meetings: Resident R75 on June 19, 2023; Resident R52, August 28, 2023; Resident R72, August 28, 2023; Resident R10, August 27, 2023; Resident R74, August 3, 2023; Resident R55, July 12, 2023; Resident R91, August 1; Resident R88, June 19, 2023; Resident R93, July 20, 2023. During an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E8 on September 1, 2023, at 9:58 a.m. she reported that she provides the dates of resident care plan meetings to the interdisciplinary team and that the facility front desk receptionist who calls the family to notify them of the meeting. The RNAC also reported that a letter is provided to the residents, but confirmed that none could be found for the referenced residents when asked. The RNAC also confirmed that there was also no documentation to show evidence that residents and/or their responsible parties received any verbal notified of the care plan meetings that were scheduled on the above referenced days. 28 Pa. 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Page 1 of 9 395912 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to provide written notice, including reason for the change, prior to moving a resident to another room, for one of 29 residents reviewed (Resident R78). Findings include: Review of facility policy, Room and Roommate Change Policy dated last revised August 13, 2020, revealed, The facility will notify the resident/resident representative prior to a room or roommate change including the reason for the change. Continued review revealed, The facility will document that notification was completed with reason for change. Review of Resident R78's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 15, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Review of Resident R78's census information revealed that on April 29, 2023, the resident was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]B. Review of progress notes revealed a nursing note, dated April 25, 2023, at 11:25 p.m. which indicated that Resident R78 was moved to room [ROOM NUMBER]B. Continued review revealed another nurses note, dated April 26, 2023 at 6:10 a.m. which indicated that Resident R78 was awake all shift, unable to redirect to bed . resident refused to go into newly assigned room. Continued review of Resident R78's census information that on August 16, 2023, the resident was moved from room [ROOM NUMBER]B to room [ROOM NUMBER]B. Review of progress notes revealed a late entry nurses note, dated August 25, 2023, at 6:00 p.m. which indicated that Resident R78's room was changed. Continued review revealed another nurses note, dated August 25, 2023, at 8:40 p.m. which indicated that Resident R78 was moved from room [ROOM NUMBER] to room [ROOM NUMBER]B and that the resident's guardian was made aware. Further review of Resident R78's clinical record revealed no documented evidence of the reason for the room change, if the resident or her responsible party was notified prior to the room change or if the resident was agreeable or given the opportunity to refuse the room change. Interview on September 1, 2023, at 11:48 a.m. the Nursing Home Administrator and Director of Nursing confirmed that there was no documentation in Resident R78's clinical record available for review at the time of the survey to indicate why the resident's room was changed or if she or her guardian were informed in writing prior to the change. 395912 Page 2 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0559 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management Residents Affected - Few 395912 Page 3 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to ensure that advance directives was reflected on physician's orders for one of 29 residents reviewed. (Resident R38) Findings include: Review of facility protocol on Advance Directives revealed that Advance Directives are written instructions about the future medical care should you become unable to make decisions for example unconscious or too ill to communicate). These are also called health care directives. Upon admission during path meetings, advance directives will be discussed with resident and/or resident representatives to determine if any advanced directives have been chosen, Utilize Interact Advanced Care Planning Tracking Form, once completed, upload to PCC (point click care- the electronic medical record program used by the facility) the document tab. Clinical chart will identify any applicable forms i.e., DNR (Do Not Resuscitate a directive by the resident not to perform measures to re-start the heartbeat should the heart stops beating) form, POLST (Physician Orders for Life Sustaining Treatment) , Living wills, etc., Review of Resident R38's clinical record revealed that Resident R38 was admitted to the facility on [DATE]. Resident R38's had a diagnosis of Dementia (progressive degenerative disease of the brain resulting in loss of reality). Review of Resident R38's quarterly MDS (Minimum Data Set, a federally required resident assessment completed at specific interval) assessment section C0100 Should BIMS (Brief Interview for Mental Status) be conducted dated August 16, 2023 revealed that Resident R38 was not assessed. Review of the physician's orders revealed that there was no order for Do Not Resucitated (DNR) for Resident R38. Interview with Director of Nursing, Employee E2 conducted on September 5, 2023, at 9:27 a.m. confirmed that there was no completed POLST form in the paper chart. Further Employee E2 also confirmed that there was no order for Resident R38's DNR status. Interview with the Social Worker, Employee E11 conducted on September 5, 2023, at 9:54 a.m. confirmed that Resident R38's son wanted Resident R38 to be on DNR. 28 Pa. Code 201.29(a) Resident rights 395912 Page 4 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff, it was determined that the facility failed to maintain a comfortable and homelike environment for one of two units observed. (Second floor unit) Findings include: Observation of the second-floor hallway outside room [ROOM NUMBER] conducted on August 30, 2023, at 9:57 a.m. revealed a very strong odor of urine. Further observation revealed that room [ROOM NUMBER] had a very strong odor of urine. Further, the mattress in room [ROOM NUMBER] Bed B (by the window) had stains on it. Interview with ADON (Assistant Director of Nursing), Employee E7 conducted at the time of the observation confirmed that the hallway had a very strong odor of urine. Further, Employee E7 revealed that Resident R56 and Resident R86 refuses their showers and that the smell was coming from them. Follow-up observation conducted on the second-floor hallway and in room [ROOM NUMBER] on August 31, 2023, at 9:46 a.m. revealed that the strong odor of urine was still present in the hallway and in the resident's room. Interview with unit manager, Employee E3 confirmed that the hallway still had a very strong odor of urine. Further Employee E3 revealed that Resident R56 and Resident R86 new mattress was ordered and mattress in room should be changed before end of the day. Interview with facility Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 conducted on August 31, 2023, at 2:06 p.m. revealed that they are aware of the smell and that the mattresses will be changed. Follow-up observation conducted on September 1, 2023, at 2:24 p.m. revealed that the hallway still had smell of urine and room [ROOM NUMBER] still smelled of urine. Interview with Unit manager, Employee E3 conducted at the time of the observation revealed that the mattresses for both Residents R56 and Resident R86 in room [ROOM NUMBER], had already been changed with new mattresses and that the smell was coming from the residents on room [ROOM NUMBER] because they both were non-complaint with their ADL's. Further unit manager revealed that since both residents had the same problems they were roomed in together. Further she revealed that none of the residents complained of the smell in their room. Follow-up observation on the second-floor hallway and room [ROOM NUMBER] conducted on September 5, 2023, at 12:38 p.m. revealed that room [ROOM NUMBER] and the hallway next to room [ROOM NUMBER] still has a smell of urine. 28 Pa. code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 395912 Page 5 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on stafff interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for one resident with a history of suicide attempt for 1 out of 29 residents reviewed (Resident R18). Findings include: Review of the August 2023 physician orders for Resident R18 included the following diagnosis: bipolar (a serious mental illness characterized by extreme mood swings); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); cerebral infarction (a stroke); hypertension (high blood pressure) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a nursing note dated May 8, 2023 at 7:46 a.m. by a licensed nurse indicated that the licensed nurse (Employee E11) went in to answer the resident's call bell and noticed that the resident had the call bell cord wrapped around her neck. The note also documented that the resident was teary and kept saying that she wanted to die. I don't want to live anymore, and was described as very resistant to let go of the cord. Continued review of the clinical record indicated that the resident was admitted into the psychiatric department of the nearby hospital on May 8, 2023 and was discharged back to the facility on May 24, 2023. Review of the resident's person-centered plan of care did not include a plan of care for the resident's suicide attempt on May 8, 2023 to ensure that appropriate care, services and interventions are documented for nursing staff and other treatment providers who provide care and services to the resident. During an interview with the Assistant Director of Nursing, Employee E7 on August 31, 2023 at 10:11 a.m. it was confirmed that there was no care plan for the resident's history of self-harm. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395912 Page 6 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to follow physician orders for oxygen administration for 1 out of 29 residents reviewed (Resident R157). Residents Affected - Few Findings include: Review of the facility's policy, Oxygen Administration (all routes) policy with a revision date of December 16, 2019 indicated that licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. Review of the August 2023 physician orders for Resident R157 included the following diagnosis: asthma; anxiety disorder (an uncomfortable feeling of nervousness or worry about something that is happening or might happen in the future) chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Continued review of the August 2023 physician orders included a physician's order with an order date of July 28, 2023 and monthly thereafter, for Resident R157 to have 2 liters of oxygen administered to her through a nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels) every shift. During an observation on August 20, 2023at 2:00 p.m. in the resident's room, the resident was observed receiving 3 liters of oxygen from her oxygen concentrator in her room, and not the 2 liters as ordered by the physician. During an observation in the complany of licensed nurse (Employee E4) on August 30, 2023 at 2:02 p.m. of the resident's oxygen amount, Employee E4 confirmed that the resident had 3 liters of oxygen, and not 2 liters of oxygen as ordered by the physician. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395912 Page 7 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews, review of facility policy and the review of the clinical records, it was determined that the facility failed to ensure that residents received care and services for the provision of dialysis, related to nutritional supplements for 1 of 2 residents reviewed for dialysis (Resident R53). Residents Affected - Few Findings include: Review of the policy, Hemodialysis Care Policy, with a revision date of August 24, 2023 indicated that staff will administer/hold medications as ordered by the provider and will arrange for a packed meal to be sent if the resident will be gone over a mealtime. Review of the August 2023 physician orders for Resident R53 included the following diagnosis: dementia (a group of symptoms that affects memory, thinking and interferes with daily life); dysphagia (difficulty swallowing); diabetes (a disorder in which the body has high sugar levels for prolonged periods of time); cerebral infarction (a stroke), and end stage renal disease (a condition where the kidney reaches advanced state of loss of function). Continued review of the August 2023 physician orders included a physician order with an order date of November 28, 2022, and monthly thereafter for Resident R53 to receive hemodialysis (treatment for an individual with advanced kidney disease that involves the use of a medical device that filters wastes, salts and fluid from an individual's blood when their kidneys are no longer healthy enough to do this on their own) on Mondays, Wednesday and Fridays, with a starting time of 10:35 a.m. Review of the resident's August 2023 physician orders also included a physician's order with an order date of February 14, 2023, for Resident R53 to have a magic cup (a frozen supplement) one time a day for a nutritional supplement at lunch. The physician orders included instructions for staff to record the percentage of consumption. During an interview with the Registered Dietician (Employee E5) on September 5, 2023 at 10:20 a.m. the registered dietician reported that the supplement was prescribed to increase the resident's calories and protein intake. Review of the resident's Medication Administration/Treatment Administration for the month of August 2023 did not show evidence that the staff ensured that the resident received the supplement on his dialysis treatment days, on August 2, 4, 7, 9, 11, 14, 16, 21, 23, 25, 28, 30, as ordered by the physician. During an interview with the 2nd floor Unit Manager (Employee E3) on September 1, 2023, at 11:02 a.m. it was discussed that no documentation in the clinical record could be produced to show evidence that the resident is received his magic cup, as ordered by the physician on the dates referenced above. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395912 Page 8 of 9 395912 09/05/2023 Suburban Woods Health & Reha 2751 Dekalb Pike Norristown, PA 19401

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview with staff and review of facility policy, it was determined that the facility failed to ensure that controlled substances were stored in a safe and secure compartment for one of two medication rooms observed (second floor medication room) Findings include: Observation of the second-floor medication room conducted on August 31, 2023, at 09:13 a.m. with unit manager Employee E3 revealed that the medication room was locked and can only be opened with a key kept by the charge nurse, Further observation revealed that the refrigerator in the narcotic room was not locked. Interview with Employee E3 confirmed that the refrigerator was not locked. Further observation revealed that there were two permanently affixed boxes inside the refrigerator, one box was a empty plastic box which was locked and one metal box which was unlocked. Further, the unlocked metal box contained one unopened bottle of 30 ml of Lorazepam 2 mg/ml ( Lorazepam is a sedative and a controlled medication) with Resident R46's name affixed to the box of the bottle and one opened vial of Lorazepam 2 mg/ml. containing approximately 22 ml of liquid inside the bottle with Resident R16's name affixed to the box. Further observation revealed that there was no date opened written on the date opened sticker affixed to the opened Ativan bottle with a resident's name on it. Interview with Unit Manager, Employee E3 confirmed that the box containing one unopened bottle of 30 ml of Lorazepam 2mg/ml with resident R46's name affixed to the box of the bottle and one opened bottle of Lorazepam 2mg/ml with approximately 22 ml of liquid inside the bottle with Resident R16's name affixed to the box was not locked. Further interview with unit manager confirmed that there was no date opened written on the date opened sticker affixed to the opened Ativan bottle. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395912 Page 9 of 9