Health inspection·August 25, 2023

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 observations, interviews with staff and residents, review of facility policy and review of clinical records, it was determined the facility failed to obtain a medication order from the resident's physician and that a resident did not self-administer medications for one of sixteen residents reviewed. (Resident R268) Residents Affected - Few Findings Include: Review of facility policy, Medication Administration dated November 22, 2022 states, Medication will be administered to residents according to their physician's order by licensed nursing personnel, residents who are cognitively intact with appropriate BIMS score may self-administer their medication. The purpose to safely administer medication to residents for treating and preventing medical illness or condition. Number 10. Administer oral medication and remain with resident while he/she takes the medication. Number 11. Document in the eMAR (electronic medical record) immediately following giving the medication to the resident. Review of Resident R268's clinical record revealed the diagnosis of nonrheumatic aortic (valve) stenosis, presence of prosthetic heart valve, hemoperitoneum (a type of internal bleeding in which blood gathers in your peritoneal cavity), Type 2 diabetes mellitus (failure of the body to produce insulin), paroxysmal atrial fibrillation (irregular hear beat), anemia, acute embolism and thrombosis, gastrointestinal hemorrhage and acute kidney failure. Interview with Resident R268 on August 22, 2023 at 10:43 a.m. revealed the resident had recently been to her renal doctor and she was prescribed two new medications. Upon observation of the room there was a small pill bottle and one loose pill on a napkin on the resident's table in her bedroom. The resident stated she had gotten Torsemide 20 milligrams and Potassium Chloride that the facility will not give to her. The resident indicated that she administers it one time a day with lunch. Interview with Unit Manager, Employee E3 on August 22, at 11:57 a.m. revealed that he did not know the resident currently had the medications in her possession. Review of Resident R268's nursing progress note revealed a note from August 15, 2023 Resident returned from renal appointment. New order Potassium Chloride and Torsemide, scripts sent to [local pharmacy] pharmacy. Resident will be dropping meds off. Continued review of Resident R268's clinical record revealed no documented evidence that an order was obtained from the physcian from Torsemeide and Potassuin Chloride, and no medication administration record on file for the new orders of Potassium Chloride and Torsemide. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395121 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Simpson House Inc 2101 Belmont Avenue Philadelphia, PA 19131 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)