Health inspection·November 18, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that residents were free of significant medication errors for one of five newly admitted resident reviewed (Resident R1). Residents Affected - Few Findings Include: Review of facility policy titled Medication and Treatment Orders and dated July 2016, revealed the following; 15. Upon admission, the admitting nurse will review the transfer record of the newly admitted patient. The admitting nurse will then notify the attending physician or on-call physician to review admission medications on the transfer record. After medications are reviewed with the physician, the admitting nurse or designee will input the approved medications from the transfer record into the PCC Emar system. The admitting nurse will need to review the transfer record against the Emar record after all medications have been transcribed to ensure all medications are transcribed correctly. Review of the clinical record for Resident R1 revealed that the patient was admitted to the facility on [DATE], for skilled nursing care following discharge from an acute care hospital. The admitting diagnoses included cerebral edema (swelling of the brain), pulmonary embolism (a blockage in the lungs caused by a blood clot), diabetes (inability of the body to produce enough insulin or to use it effectively), seizure disorder (abnormal electrical activity in the brain), cushing's syndrome (caused by prolonged exposure to group of medications known as glucocorticoids). Review of the hospital discharge summary revealed that the list of prescribed medications included Depakote 500 milligrams 1,000 two tablets by mouth every 12 hours. The last time the medication was administered was on October 20, 2024 at 8:51 a.m. Review of Resident R1's nursing note dated October 20, 2024 at 3:30 p.m. revealed New order received to continue medication as per hospital discharged summary papers. Review of Resident R1's October 2024 Medication Administration Record revealed that the medication Depakote 500 milligrams was not transcribed into the resident's orders and Medication Administration Record per physician instructions. An interview was conducted with Interim Director of Nursing, Employee E4 on November 7, 2024, at 11:00 a,m. Employee E4 confirmed that the the transcription error. 28 Pa. Code 211.9 (a)(1) Pharmacy Services (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 2 Event ID: 395135 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 395135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pennypack Rehab and Care Center 8015 Lawndale Avenue Philadelphia, PA 19111 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)