Health inspection·April 4, 2025

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on review of clinical records and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for four of four residents reviewed for bed holds (Residents R5, R8, R15, and R40). Findings include: Resident R5's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/12/25, and returned to the facility on 3/17/25, with a diagnosis of a urinary tract infection (infection in any part of your urinary system). Resident R8's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/25/25, and returned to the facility on 3/26/25, with a diagnosis of a cardiac event and orders to be place with a cardiac monitor. Resident R15's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/16/25, and returned to the facility on 3/21/25, with a diagnosis of acute respiratory failure (when the lungs aren't properly exchanging gases, causing low oxygen in the blood). Resident R40's clinical record revealed that he/she was transported/admitted to the acute care hospital on 2/17/25, and returned to the facility on 2/19/25, with a diagnosis of a fractured left leg. The clinical records of Residents R5, R8, R15, and R40, lacked evidence to support that the resident and/or resident representative was provided a written notice of the bed-hold policy upon or following transfer to the hospital. During an interview on 4/3/25, at 8:30 a.m. the Administrative Nurse Employee E1 confirmed that the bed-hold policy was not provided to Residents R5, R8, R15 or R40 and/or their representative as required. 28 Pa. Code 201.14(a) Responsibility of licensee Page 1 of 2 396071 396071 04/04/2025 Clepper Manor 959 East State Street Sharon, PA 16146

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to care and treatment of residents with urinary drainage catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 12 residents observed with drainage catheters (Resident R2). Residents Affected - Few Findings include: Review of Resident R2's clinical record revealed an admission date of 3/17/25, with diagnoses that included osteolysis (condition where bone tissue is broken down), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and urinary tract infection. Observation on 4/1/25, at 4:15 p.m. revealed Resident R2 lying in bed with his/her catheter drainage bag and tubing extended out and lying on the floor next to the bed. There was no cover over the drainage bag that was directly on the floor. During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the catheter drainage bag and tubing was laying on the floor without a covering on 4/1/25, at 4:16 p.m. and that the drainage bag and tubing should not be laying on the floor or touching an unclean surface. During an interview on 4/2/25, at 3:15 p.m. the Nursing Home Administrator confirmed that catheter bags should not be lying on the floor and should have a covering over the catheter drainage bag. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 396071 Page 2 of 2