Health inspection·April 24, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate medical records for eight of 10 records reviewed (Resident R2, R3, R4, R5, R6, R7, R8, R10). Findings include: Review of the April 2024 Treatment Administration Record (TAR) documentation for resident R2 revealed that an order to Check placement of [NAME]-chip (a wearable tracking device designed to prevent cognitively impaired residents from wandering from designated, staff monitored areas) to right ankle .every shift for elopement, ordered on March 21, 2024, had not been signed off as completed on day shift on April 16 and 22, on evening shift on April 1-3, 5-8, 10-12, 15-17, 19, and 20, or on night shift on April 1, 5, 7-10, 12, 15, 17, and 22. Review of the April 2024 TAR documentation for Resident R3 revealed that an order for Silvadene External Cream 1% (a cream prescribed for wound healing) .apply to left gluteal fold topically every day shift, ordered on March 26, 2024, and discontinued on April 10, 2024, had not been signed off as completed on April 8, 2024. Review of the April 2024 TAR documentation for Resident R4 revealed that an order for suprapubic catheter (a tube surgically inserted into the bladder through the abdominal wall care Q (every) shift, ordered on June 26, 2023, had not been signed off as completed on evening shift on April 9, 2024. Review of the April 2024 TAR documentation for Resident R5 revealed that an order for Silvadene External Cream 1% apply to right buttock topically every day shift, had not been signed off as completed on April 8, 2024. Review of the April 2024 TAR documentation for resident R6 revealed that an order for cleanse left heel with NSS (normal saline solution) apply Santyl ointment (an ointment prescribed for wound healing) cover with calcium alginate (an absorbent wound dressing) cover with foam every day shift, ordered on April 2, 2024, had not been signed off as completed on April 14, 2024 and April 19, 2024. An identical order for the right heel had not been signed off as completed on April 14, 2024 and April 19, 2024. Review of the April 2024 TAR documentation for Resident R7 revealed that an order for Mupirocin External Ointment 2% (an ointment prescribed for wound healing) apply to L (left) lower extremity ulcers every day shift and an identical order for the right lower extremity, both ordered on January 10, 2024, had not been signed off as completed on April 3, 2024. (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: 395282 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 395282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Center for Rehabilitation & Healthcare 1412 Lansdowne Avenue Darby, PA 19023 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)