Health inspection·April 1, 2025

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 facility policy, review of facility documentation, observations, interviews with resident, it was determined that the facility failed to provide a safe, clean, comfortable, homelike environment for two of 12 resident reviewed. (Resident R1 and Resident R2) Findings include: Review of facility policy titled Homelike Environment revised 2021, revealed it is the policy of the facility that residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management will maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include: a clean, sanitary and orderly environment. Review of Resident R1's quarterly Minimum Data Set (MDS-a federal mandated assessment for all residents) dated February 17, 2025 revealed that Resident R1 was admitted to the facility January 9, 2025. This resident required assistance for activities of daility living, total assistance for transfers, support of enteral feeding (tube feeding). The resident also used a urinary catheter. Observation of Resident R1's room on April 1, 2025 at 10:30 a.m. revealed a foul oder, two large bags of laundry at the door. The resident's roommate- Resident R2 observed lying on a bed with no sheets, the floor was soiled with food/crumbs, papers, a wallet, upside down radio, a visible soiled cloth and shoes scattered around. Interview with Resident R1 revealed that he is not happy about being old and having to live here. He stated that the staff was good and requested juice. Interview with Nursing aide, Employee E3 at time of the above observation revealed that Resident R2 constantly keeps his room dirty. The staff continually are cleaning up after him. This employee sorted and organized the resident's clothes out his closet today to make the room neater. Resident R2 refused care and often does not allow staff to touch his belongings. This employee and the staff constantly try to clean his room, but as soon as its id clean, he trashes it again. Review of Residents R2's quarterly Minimum Data Set ( MDS- federal mandated assesment for all residents) dated March 6, 2025 revealed that Resident R2 was admitted [DATE] with a diagnosis of diabetes (failure of the body to produce insulin). The resident was assessed with a BIMS (brief interview of mental status) score of 15, indicating the resident cognition was intact. Further review of Residents R2, clinical record revealed that the resident has occupied the room since June 8, 2024. Page 1 of 2 395989 395989 04/01/2025 Providence Rehab and Hlthcare Ctratmercyfitzgerald 600 South Wycombe Ave Yeadon, PA 19050

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R2's nursing notes revealed ongoing behavior concerns related to cleanness and unsanitary conditions as follows: December 11, 2024 Resident offered care with shower and shave He is AAOx3 and able to make his needs known. His environment is cluttered with clothes, trash and feces smear toilet tissue and linen. He was offered shower and shave but refused, he stated he already washed. Currently he is in his bed with his private areas exposed, he is given privacy but continues to pull the curtains back. January 8, 2025 Resident found on rounds with brown formed stool on the entire bed. January 15, 2025 Resident found on rounds wiping his rectum of feces with the linen. January 16, 2025 He has poor safety awareness and is at risk for falls r/t cluttered environment. He also continues to keep his pants and underwear down as he masturbates, privacy given, however he prefers to leave privacy curtain open rather than closed. Nursing will continue to educate the resident on unacceptable aspects of his behavior January 18, 2025 Resident's environment very cluttered and smells awful. Resident use his linen to clean himself after defecating. January 19, 2025 propelling himself down the hall with his pants and underwear down by his knees. He has a sheet slightly covering him and dragging behind him with feces smeared on it. Interview with licensed nurse, Employee E4 on April 1, 2025 at 11:55 a.m. revealed that Resident R2 has displayed these behaviors since she began on the second floor since October 2024. Employee E4 stated that this residents is very non complaint with his medications , insulin, and toileting. The staff try to clean his room multiple times a day , sometimes he refuses. Interview with Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 on April 1, 2025 at 1:25 p.m. confirmed that Resident R1 does not get out of bed and is a high risk for infection. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies 395989 Page 2 of 2