Linwood Nursing And Rehabilitation Center

February 25, 2024, daughter in agreement with same and would continue to visit daily and provide

The facility did not report this sexual abuse to the State Survey Agency within 24 hours and submit a

with the DON on June 26, 2024, at 11:25 a.m.

The Nursing Home Administrator (NHA) confirmed on June 27, 2024, at 11:35 a.m., that the above instances of sexual abuse perpetrated by Resident 8 should have been reported to the State Survey Agency within 24 hours and completed abuse investigations, PB22, within five working days of the incident.

Refer F-F600 28 Pa.

Code 201.14(c) Responsibility of licensee 28 Pa.

Code 201.18(e)(1) Management 28 Pa.

Code 201.29(a)(c) Resident Rights

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Review of the clinical record further revealed that Resident 48 received a shower on February 2, 9,

observation and/or demonstration that care was provided to Resident 48 according to her plan of care.

There was no documented evidence that the facility had thoroughly investigated the potential origin of Resident 48's fracture to her left ankle to rule out abuse, neglect or mistreatment as the potential cause of the injury.

During an interview with the Director of Nursing (DON) on June 28, 2024, at approximately 8:15AM, confirmed that there was no evidence that the facility had thoroughly investigated Resident 48's ankle fracture of unknown origin.

Refer F-F697, F-F713 28 Pa.

Code 201.29(a)(c)(d) Resident rights 28 Pa.

Code 201.14(a) Responsibility of Licensee 28 Pa.

Code 201.18(e)(1) Management

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

resident representative with a written notice of the facility-initiated transfer and reason for the

minimal harm An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 27,

Resident 2, 7, 24, 53, 72, and 188 and their representatives.

The NHA and DON also confirmed that the facility was not currently providing information regarding the notification of facility-initiated resident transfers to a representative of the Office of the State Long-Term Care Ombudsman. 28 Pa.

Code 201.29 (a)(c.3)(2) Resident rights

28 Pa Code 201.29 (a) Resident rights

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

According to the RAI User's Manual regarding Section N0410 for Medications Received, the facility would record the number of days a medication was received by the resident at any time during the 7-day look back period.

A review of Resident 12's quarterly MDS assessment dated [DATE], Section N 410 indicated that the resident received an anticoagulant medication 7 days in the 7 day look back period.

A review of the Resident 12's physician orders revealed that the resident did not have a physician order for an anticoagulant medication during the 7 day look back period.

Review of the resident's May 2024 and June 2024 Medication Administration Records revealed that there were no anticoagulant medications administered to the resident during the 7-day look back period.

Interview with the Registered Nurse Assessment Coordinator on June 28, 2024, at approximately 9:00 AM confirmed the quarterly MDS Assessment was inaccurate with respect to Medications Received.

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During observation of resident medication administration with Employee 10, licensed practical nurse, the medication cart was left unlocked and unattended when Employee 10 took medications into a resident room to administer to resident.

The cart was left against the wall across from where the resident's room was located and out of the nurse's view.

Further observation of the medication cart revealed that the keys to the cart, which allow access to both the medication cart and narcotic drawer within, were left unattended on top of the cart.

Multiple residents were observed ambulating/self-propelling out in the hallway at the time of this observation.

During an interview with the Director of Nursing on June 28, 2024, at 8:50 AM confirmed the potential accident hazard and the presence of independently mobile residents in the area at that time, creating the potential for unauthorized access to the med cart and its contents. 28 Pa.

Code 211.12 (d)(5) Nursing Services.

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During an interview with the Director of Nursing on June 27, 2024, at 1:30 p.m., confirmed that the facility failed to timely identify and address the resident's decline in bowel continence.

The Nursing Home Administrator (NHA) on June 27, 2024, at 1:50 p.m., confirmed that the failed to ensure that Residents 51, 15, and 2 toileting needs were fully assessed and plans to meet the resident's bowel and bladder needs were developed and consistently implemented. 28 Pa.

Code 211.10 (a)(c)(d) Resident care policies 28 Pa.

Code 211.12 (d)(3)(5) Nursing services

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Administrator (NHA) on June 27, 2024, at 1:35 p.m., confirmed that the facility failed to ensure that

28 Pa.

Code 211.5 (f) Medical Records

28 Pa.

Code 211.12 (d)(3)(5) Nursing services

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Review of nurse's note dated February 10, 2024, at 12:44 PM revealed that the resident continued to

signs/symptoms of pain or discomfort.

Continue to monitor and medicate with pain meds as needed.

Nurse's note dated February 10, 2024, at 7:01 PM indicated that Resident 48 exhibited signs/symptoms of pain during transfers and repositioning, was medicated with Tylenol with good effect and was cooperative with care.

Review of MAR revealed that the resident was medicated with Tylenol at 5:42 PM for evidence of pain rated at a 3 on the pain scale.

Further review of the MAR revealed that staff administered the prn Tylenol 650 mg on February 10, 2024, at 3:35 PM, February 12, 2024, at 7:15 PM, February 14, 2024, at 6:14 PM, February 16, 2024, at 6:46 PM, on February 17, 2024, at 2:12 PM, February 21, 2024, at 7:30 PM, and on February 22, 2024, at 6:09 AM.

Review of Pharmacy Review Note dated February 19, 2024, at 4:49 PM revealed that the physician was made aware of request for pain management, no change.

There was no evidence that the physician responded to the pharmacist's identified concern related to the management of Resident 48's pain.

Review of the clinical record revealed that there was no evidence that the facility staff performed a Pain Evaluation for effectiveness of current pain medication regimen when a change in condition and increased pain was identified on February 5, 2024.

Review of clinical record revealed that on February 17, 2024, swelling of the resident's left leg was identified by the resident's family which was subsequently identified as a left ankle fracture on February 21, 2024.

An interview the Director of Nursing (DON) on June 28, 2024, at approximately 2:00 PM confirmed the facility failed to implement an effective pain management program designed to promote the resident's comfort and meet the goals for effective pain relief consistent with current standards of practice.

Refer F-F610, F-F713 28 Pa.

Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa.

Code 211.10 (c)(d) Resident care policies

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

28 Pa.

Code 201.18 (e)(1)(3) Management

28 Pa.

Code 211.2 (d)(3) Medical Director

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During an interview on June 27, 2024, at 10:00 AM, Resident 21 stated that sometimes she waits a long time for care from nursing staff.

She stated that she waits 20 minutes for nursing staff to provide her care and longer when the facility is short on staff. Resident 21 stated that a few weeks ago, there was an incident when she rang her call bell for staff assistance to be changed, but nursing staff told her she had to wait to be changed. Resident 21 stated that she felt disappointed because she was treated in that manner.

During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility investigation identified that Resident 21 rang her call bell because she soiled her brief but was not provided care because Employee 16, NA, was completing documentation.

A review of Resident 80's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures)and transient ischemic attack [(TIA) is a short period of symptoms similar to those of a stroke. It's caused by a brief blockage of blood flow to the brain]. Resident 80's clinical record revealed a nurse note dated June 7, 2024, at 7:27 a.m., indicating that the facility contacted the resident's (RP) and advised her that the resident's appointment with neurosurgery that was scheduled that day at 11:00 a.m. today had to be rescheduled because the facility did not have enough nursing staff to have a nurse aide available to accompany the resident to the appointment.

The RP said that she didn't have anyone to go to the appointment either and called the neurosurgery department to reschedule the resident's appointment.

During an interview with the Director of Nursing (DON) on June 28, 2024, at 11:00 a.m., confirmed that the facility didn't have enough nursing staff to accompany Resident 80 to her to her scheduled follow up appointment with neurosurgery and that the appointment had to be canceled and rescheduled delaying the resident's follow-up. 28 Pa.

Code 211.12 (c)(d)(4)(5)(f.1)(2)(4) Nursing services 28 Pa.

Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During an interview with the facility's RN/Staff Development on June 28, 2024, at 10:30 p.m., revealed that she educates all facility staff on abuse by means of an electronic educational platform and developed materials.

However, the facility's actual abuse prohibition policy and procedures was not included in that online training.

At the time of the survey ending June 28, 2024, the facility failed to provide evidence that they had identified the skills and competencies their staff required to work effectively with Resident 8 to manage his adjustment disorder, inappropriate sexual behaviors and meet his behavioral health needs.

The facility failed to demonstrate the use of a competency-based approach to determine the knowledge and skills required among staff to ensure Resident 8 was able to maintain or attain their highest practicable psychosocial well-being and meet current safety needs of the female residents residing in the facility.

The facility failed to demonstrate consistent monitoring of the effectiveness of the interventions planned to manage Resident 8's behaviors, including timely changing those approaches, if needed, in accordance with current standards of practice, and show evidence of ongoing assessment as to whether those care planned approaches were improving or stabilizing the resident's psychosocial status and de-escalating the resident's behaviors.

Refer F-F600 28 Pa.

Code 201.19 (6)(7) Personnel records 28 Pa.

Code 201.18 (e)(2)(3) Management

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

dental services.

Nursing Home Administrator (NHA) failed to provide evidence that the facility scheduled the required

28 Pa.

Code 211.12 (d)(3)(5) Nursing services 28 Pa.

Code 211.15 Dental services

395717 06/28/2024

Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

noted that the resident had an allergy to lactose and indicated that the resident was to receive a

Subsequently, the resident's tray had vanilla pudding present on the tray and the resident has an

enhance nutrition support due to gradual weight declines and variable intakes.

An interview with the Director of Nursing on June 25, 2024, at 1:00 p.m., confirmed that the facility failed to adhere to a resident's food allergy and failed to provide a planned nutrition intervention and physician ordered supplement on Resident 53's lunch tray.

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Based on a review of the facility's assessment, select facility policies and procedures, and resident

assessment to identify the resources needed to meet the residents, including sufficient staff with the necessary skills and competencies to provide the needed care and services for residents with behavioral health care and dementia care needs.

Findings include: The facility assessment, dated Quarter 1 2024, and reviewed during the survey ending June 28, 2024, revealed the facility's census and acuity and general information regarding the facility's religious denominations, recreation, social services and physical, occupational and speech therapy services.

The facility assessment did not include evidence of an evaluation of diseases, conditions, physical, functional or cognitive status, of the residents that may affect and plan for the services the facility must provide for residents with behavioral health care and dementia care needs.

The facility assessment failed to include the resources needed, including sufficient nurse staffing, and provision of necessary education and training, and competency evaluation for staff providing direct care and assessment of residents with behavioral symptoms to maintain the safety of residents residing in the facility.

Interview on June 28, 2024, at 11:00 p.m. the Nursing Home Administrator (NHA) confirmed that the facility assessment did not address staffing requirements, training and competencies.

The NHA confirmed that the facility's population included multiple residents requiring increased supervision, including one to one supervision, to meet the needs of residents diagnosed with dementia and exhibiting behaviors.

The NHA confirmed that facility staff would benefit from enhanced dementia care, behavioral health and abuse training to better meet the needs of the resident population.

Refer F-F600, F-F609, F-F610, F-F725, F-F741 28 Pa.

Code 201.18 (b)(1)(3)(e)(1)(2) Management

395717 06/28/2024

Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Review of the facility's QA/QAPI committee attendance sheets for the QA meetings held since the last annual survey ending July 23, 2023, through annual survey ending June 28, 2024, revealed that the QA/QAPI committee only held one quarterly meeting that was conducted on April 30, 2024.

Interview with the NHA, at approximately 12:33 p.m., reported that she was unable to locate the QA/QAPI signature sheets to show documented evidence that the facility's QA/QAPI committee met at least quarterly. 28 Pa.

Code 201.18 (e)(2)(3)(4) Management.

395717 06/28/2024

Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

Review of facility policy entitled General Dose Preparation and Medication Administration, last reviewed by the facility on May 10, 2024, indicated that appropriate hand hygiene should be performed before and after direct resident contact.

Medications should not come in contact with any surface except for the medication cup.

Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package.

During an observation of medication administration on June 28, 2024, at approximately 8:15 AM., with Employee 10, licensed practical nurse, Employee 10 was observed preparing medications for administration to a resident.

Employee 10 was observed handling each medication, nine in total, with her bare hands prior to placing in the plastic medication cup.

Employee 10 was not observed to perform hand hygiene prior to handling the medications.

During verification of medications for accuracy with the surveyor, Employee 10 poured all the medications from the plastic medication cup into her bare hand, counted them, and placed them back into the plastic medication cup.

One of the nine medications was very small, so Employee 10 picked it up from her bare hand with her long acrylic fingernails and placed into the cup.

Employee 10 then administered the medications to the resident.

The employee did not perform hand hygiene, prior to handling or administering the medications.

Observation of the medication cart used by Employee 10, during this med pass revealed a [NAME] cup and personal cell phone on top of the medication cart.

The observations were confirmed by the Director of Nursing on June 28, 2024, at 8:25 AM.

Interview with the Director of Nursing on June 28, 2024, at 8:45 AM confirmed that Employee 10 failed to adhere to infection control practices during medication administration to prevent the potential spread of infection. 28 Pa.

Code: 211.12 (c)(d)(1)(5) Nursing Services 28 Pa.

Code 211.10 (a)(d) Resident care policies

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

p.m., revealed that Cefdinir (antibiotic that is used to treat many different types of infections caused

A review of Resident 188's Medication Administration Record [(MAR, or eMAR for electronic

On February 21, 2024, at 3:47 p.m., the attending physician was notified that the resident did not void during that shift and ordered to stop Cefdinir for UTI, and that he would be in tomorrow to see resident.

A review of nurse progress notes dated February 22, 2024, at 6:59 a.m., revealed that the resident voided a moderate amount of dark amber urine time one this AM with no complaints of urinary discomfort.

Employee 8, a RN, noted on February 22, 2024, at 1:52 p.m., that the resident's attending physician was in and assessed the resident and reviewed results of labs and U/A C & S results.

Resident asymptomatic (producing or showing no symptoms) and afebrile (without fever).

Physician ordered IV (intravenous) Zosyn [is used to treat many different infections caused by bacteria, such as stomach infections, skin infections, pneumonia, and severe uterine infections] for five days. Resident 188's MAR for dated February 2024, revealed that the resident received only one dose of Zosyn and refused administration of other prescribed doses.

Employee 8 noted that the attending physician was notified at that time and updated on the resident's status.

Resident remained asymptomatic and afebrile 97.1 A new order was noted to discontinue Zosyn.

The resident's urinalysis was within normal limits.

Resident was comfortable, no signs or symptoms of distress.

The results of the the culture and sensitivity results dated March 3, 2024, at 9:22 a.m., revealed that less than 10,000 colonies/ml normal flora and greater than 100,000 colonies/ml Enterococcus species were present in urine and resistive to ampicillin. A new order was noted to start Macrobid 100 mg orally twice daily for seven days.

Interview with the facility's Infection Preventionist (IP) on June 28, 2024, at 10:10 a.m., revealed that Resident 188's received doses of unnecessary antibiotic due to the resident's attending physician not adhering to McGeer's criteria for infection surveillance and prescribing practices and that staff failed to complete the necessary steps of ATB Stewardship to deter unnecessary antibiotic use.

There was no evidence that the facility consistently followed McGeer Criteria prior to initiating antibiotic therapy for Resident 2 and Resident 188 by failing to follow its Antibiotic Stewardship policy to improve antibiotic prescribing, administration, and management practices to reduce inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. 28 Pa.

Code 211.10(a)(d) Resident care policies 28 Pa.

Code 211.12 (c)(d)(1)(3)(5) Nursing services

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During an interview with the Nurse Educator on June 28, 2024, at 10:00 a.m., revealed that the facility utilizes an on-line education platform for staff to complete mandatory education and additional education topics were provided as needed on paper and offered a variety of educational methods present topics.

The Nurse Educator provided the educational content on which staff received for their annual abuse prevention education program.

The education failed to include the facility's specific procedures for identifying and reporting abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention.

During an interview on June 28, 2024, at 11:15 a.m., the Nursing Home Administrator (NHA) stated that prior to survey that it was identified that the mandatory annual abuse training and new hire abuse training failed to include the complete training on the facility's specific-abuse prohibition policy and procedures. 28 Pa.

Code 201.20 (b) Staff development

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Linwood Nursing and Rehabilitation Center 100 Linwood Avenue Scranton, PA 18505

During an interview on June 27, 2024, at approximately 1:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) failed to provide evidence that the facility scheduled the required dental services for Resident 7.

28 Pa.

Code 211.12 (d)(3)(5) Nursing services

28 Pa.

Code 211.15 Dental services

395717

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395717 B.

Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

Findings included:

A review of facility policy titled General Dose Preparation and Medication Administration, reviewed last by the facility on May 10, 2024, revealed that during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to, the following: administer medications within timeframes specified by facility policy or manufacturer's information.

A clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 23, 2024 revealed that Resident 7 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

The resident had a physician order for Metoprolol Succinate extended-release oral tablet 24 hour 50 mg (a beta blocker medication that relaxes the blood vessels and slows heart rate to improve blood flow and decrease blood pressure) by mouth two times a day related to hypertension (high blood pressure) initiated May 19, 2024; Tramadol HCL oral tablet 50 mg (an opioid medication that changes how the body feels and responds to pain) by mouth two times a day for pain management initiated on May 19, 2024; Eliquis oral tablet 5.0 mg (apixaban- an anticoagulant medication that helps to prevent the body from forming blood clots) by mouth two times a day related to atrial fibrillation dated May 19, 2024; and Cefdinir Oral Capsule 300 MG (an antibiotic medication) 300 mg by mouth two times a day for a urinary tract infection for 7 days initiated on June 20, 2024.

A review of Resident 7's Medication Administration Record for June 2024 revealed that nursing staff failed to timely administer Metoprolol Succinate extended release oral tablet 24 hour 50 mg to Resident 7 on the following dates:

June 1, 2024, at 9:15 AM (one hour and 15 minutes late)

June 2, 2024, at 9:23 AM (one hour and 23 minutes late)

395717

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395717 B.

Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

According to the note, a call was placed to the physician, and message left.

Nurse's note dated February 18, 2024, at 1 PM indicated that a follow-up call placed to physician's answering service regarding swelling on resident's left ankle.

Voicemail left with answering service requesting call back.

Nurse's note dated February 21, 2024, at 1:33 PM indicated that another follow-up call placed to physician regarding family concern over swelling noted on left ankle.

Message left with answering service.

Review of nurse's note dated February 21, 2024, at 3:47 PM, revealed that orders were received from the physician, four days after initial concern identified.

The physician ordered an x-ray of the left ankle.

On February 21, 2024, at 7:52 PM, documentation indicated that Resident 48 had fracture(s) of the left ankle and orders were obtained to apply an Ace wrap, to the left ankle, elevate, apply ice to the area, and for resident to see orthopedics on February 22, 2024.

There was no evidence that the facility attempted to reach an on-call physician or contact the facility's medical director in the absence of a timely response to Resident 48's change in condition.

Nursing noted that Resident 48 was transferred to the emergency roiagnom on [DATE], from the orthopedics office and was admitted .

According to nurse's note dated February 25, 2024, at 10 AM, resident was readmitted to the facility after being hospitalized for a fractured leg, pain management, and exacerbation of cardiac condition.

395717

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395717 B.

Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505

Review of the facility's QA/QAPI committee attendance sheets for the QA meetings held since the last annual survey ending July 23, 2023, through annual survey ending June 28, 2024, revealed that the QA/QAPI committee only held one quarterly meeting that was conducted on April 30, 2024.

Interview with the NHA, at approximately 12:33 p.m., reported that she was unable to locate the QA/QAPI signature sheets to show documented evidence that the facility's QA/QAPI committee met at least quarterly.

28 Pa.

Code 201.18 (e)(2)(3)(4) Management.

395717

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 395717 B.

Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Linwood Nursing and Rehabilitation Center 100 Florida Avenue Scranton, PA 18505