Health inspection·April 25, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to notify each resident's responsible party of a significant weight loss for two of eight sampled residents. (Residents CL1 and 3) Findings include: Review of the facility policy entitled, Weight Management Guidelines, dated January 6, 2025, revealed that nursing staff were to report unexplained significant weight changes to the family/responsible party. Clinical record review revealed that Resident CL1 had diagnoses that included Alzheimer's dementia and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was rarely understood. Review of the resident's weights revealed that on February 6, 2025, the resident weighed 178.6 pounds (lbs). On March 2, 2025, Resident CL1 weighed 167.8 lbs, which was confirmed with a reweigh on March 4, 2025. This reflected a six percent weight loss in one month. There was no documented evidence that Resident CL1's family/responsible party was notified of the significant weight loss. Clinical record review revealed that Resident 3 had diagnoses that included dementia and dysphagia. Review of the MDS assessment dated [DATE], revealed the resident was rarely understood. Review of the resident's weights revealed that on January 2, 2025, the resident weighed 138.8 lbs. On February 4, 2025, Resident 3 weighed 131.2 lbs. On March 4, 2025, Resident 3 weighed 131.4 lbs. This reflected a 5.4 percent weight loss between January and February that continued through March. There was no documented evidence that Resident 3's family/responsible party was notified of the significant weight loss. In an interview on April 25, 2025, at 4:21 p.m., the Administrator confirmed that there was no documented evidence that Residents CL1 and 3's families were notified of the significant weight loss, and they should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 2 395006 395006 04/25/2025 St Joseph's Manor 1616 Huntingdon Pike Meadowbrook, PA 19046

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of eight sampled residents. (Residents 3 and 5) Residents Affected - Few Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypertension (high blood pressure). A physician's order dated March 12, 2025, directed staff to administer a medication (lisinopril) one time a day for hypertension. Staff was not to administer the medication if the resident's blood pressure (BP) was less than 110 over 65 millimeters of mercury (mm/Hg). Review of Resident 3's medication administration records (MARs) revealed that staff administered the medication one time in March 2025, and two times in April 2025, when the resident's BP was less than 110 over 65 mm/Hg. Clinical record review revealed that Resident 5 had diagnoses that included hypertension. On April 17, 2025, the physician ordered staff to administer a medicine (metoprolol tartrate) two times a day for hypertension. Staff was not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mm/Hg). Review of Resident 5's MARs revealed that staff administered the metoprolol tartrate four times in April 2025, when the resident's SBP was less than 100 mm/Hg. In an interview on April 25, 2025, at 3:40 p.m., the Administrator confirmed that the medication was administered outside the established parameters for Residents 3 and 5. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395006 Page 2 of 2