Health inspection·March 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review facility policy, review of facility documentation, review of clinical records, interview staff, it was determined that the facility failed to ensure that a resident was free of neglect related to provision of incontinence care for one of twelve residents reviewed. (Resident R12) Findings: Based on review of facility policy titled Abuse Prohibition dated October 24, 2022, revealed the center prohibits abuse mistreatment, neglect, misappropriation of resident property, exploitation for all patients this is includes but not limited to freedom from corporal punishment and voluntary seclusion and any physical or chemical restraint, potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation. Review of facility policy titled Neglect and Abuse revealed neglect is defined as a failure, in difference, or disregard of the center, its employees or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes a failure to implement an effective communication system across all shifts for communicating necessary care and information between the center, patient, practitioners, and patient representatives. Training will be provided to all employees through orientation, code of conduct training, and a minimum of annually which will include the abuse prohibition policy, appropriate interventions to deal with aggressive residents, recognize signs of burnout, frustration and stress that may lead to abuse, effective communication skills with patient's caregivers and patient representatives, what constitutes abuse, neglect and misappropriation of property. Review of Resident R12's clinical record revealed the resident had diagnosis of non-displaced intertrochanteric fracture of left femur (minimal displacement of the upper part of the left thigh bone), chronic embolism and thrombosis of vein (blood clot in the veins) diabetes with neuropathy (nerve damage caused by diabetes), personal history of TIA (transient ischemic attack temporary blockage of blood flow to the brain, minor stroke). Review of Resident R12's admission Minimum Data Set (MDS- assessment of resident's needs) dated February 14, 2025 revealed that the resident was assessed with a BIMS (brief interview of mental status) score of 6, which indicated that the resident had severe cognitive impairment. Review of Resident R12's care plan dated February 11, 2025, revealed that the resident was dependent for toileting hygiene related to left hip fracture, which included the following interventions: to monitor for skin irritation and redness when assisting with personal hygiene with a goal the patient will be able to maintain personal hygiene. Resident is at risk for skin breakdown related and or Page 1 of 3 396009 396009 03/20/2025 Norriton Square Nursing and Rehabilitation Center 1700 Pine Street Norristown, PA 19401

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has actual skin breakdown stage three pressure ulcer of her sacrum dated February 10, 2025, with interventions to turn and reposition everyone to two hours. Review of facility documentation submitted to the State survey agency on February 12 2025, revealed Resident R12 was observed soiled with urine. The charge nurse Employee E5 was performing wound care and found the wound dressing was soiled as well as two briefs and linen. The perpetrator was identified as nursing assistant Employee E3. The facility conducted an investigation and found that the report of neglect was found substantiated and Employee E3 was terminated. Review of statement given by Nursing aide, Employee E3 revealed that I had eighteen patients and may have overlooked the resident (Resident R12) This was unintentional as I need help and there was not enough. Interview with Nursing Home Administrator, Employee E1 one March 20, 2025, at 12:50 p.m. revealed as soon as she was notified of the incident this employee initiated an investigation, interviewed residents cared for on the floor by Nurse aide, Employee E3 during the shift and found the allegation substantiated. This employee stated that Nurse aide, Employee E3 had worked for the facility for years and confirmed she had some prior disciplinary actions related to care concerns. Employee was terminated. 28 Pa. Code 211.12(d) Nursing Services 28 Pa.Code 201.18(e)(1)Management 396009 Page 2 of 3 396009 03/20/2025 Norriton Square Nursing and Rehabilitation Center 1700 Pine Street Norristown, PA 19401

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review facility policy, review of facility documentation, review of clinical records, interview with residents and staff, it was determined that the facility failed to ensure adequate number of nurse aides to meets the needs of residents on one of two nursing floors (2nd Floor) one of twelve residents reviewed. (Resident R12) Findings: Review of Resident R12's clinical record revealed the resident had diagnosis of non-displaced intertrochanteric fracture of left femur (minimal displacement of the upper part of the left thigh bone), chronic embolism and thrombosis of vein (blood clot in the veins) diabetes with neuropathy (nerve damage caused by diabetes), personal history of TIA (transient ischemic attack temporary blockage of blood flow to the brain, minor stroke). Review of Resident R12's admission Minimum Data Set (MDS- assessment of resident's needs) dated February 14, 2025 revealed that the resident was assessed with a BIMS (brief interview of mental status) score of 6, which indicated that the resident had severe cognitive impairment. Review of Resident R12's care plan dated February 11, 2025, revealed that the resident was dependent for toileting hygiene related to left hip fracture, which included the following interventions: to monitor for skin irritation and redness when assisting with personal hygiene with a goal the patient will be able to maintain personal hygiene; resident is at risk for skin breakdown related and or has actual skin breakdown stage three pressure ulcer of her sacrum dated February 10th, 2025, with interventions to turn and reposition everyone to two hours. Review of facility documentation submitted to the state survey agency on February 12 2025, revealed Resident R12 was observed soiled with urine. The charge nurse Employee E5 was performing wound care and found the wound dressing was soiled as well as two briefs and linen. The perpetrator was identified as nursing assistant Employee E3. The facility conducted an investigation and found that the report of neglect was found substantiated and Employee E3 was terminated. Review of statement given by Nursing aide, Employee E3 revealed that I had eighteen patients and may have overlooked the resident (Resident R12) This was unintentional as I need help and there was not enough. Review of daily staffing sheet for February 12, 2025, during the 7-3 shift revealed that nurse aide, Employee E3 was scheduled on the second floor. Continued review of daily staffing sheet revealed that a total of eight nurse aides were schedule for the 7- 3 shift with a census of 95 which was below the required State regulation. Interview with DON employee E2 on March 20, 2025 at 4:00p.m. confirmed on the day February 12, 2025 the facility did not have the appropriate number of staff per ratio. 28 Pa. Code 211.12(d) Nursing Services 28 Pa.Code 201.18(e)(1)Management 396009 Page 3 of 3