Health inspection·February 2, 2024

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 the facility failed to notify the physician of missed medication doses for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Residents Affected - Some Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R1's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023. Review of Resident R2's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023. Review of Resident R3's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023. Review of Resident R4's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023. Review of Resident R5's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100mg (used to Page 1 of 3 395307 395307 02/02/2024 Kendal at Longwood Box 100 Kennett Square, PA 19348

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023. Review of Resident R6's clinical record revealed the physician was not notified of the missed does of medication. Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy and the physician was not notified per policy when the medications were unable to be administered as ordered. This has been identified as a past non-compliance situation. This was identified by the facility and a plan of correction was developed and put into place including audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance. 28 Pa. Code 211.12(5) Nursing Services 28 Pa. Code 201.14(a)(b) Responsibility of licensee 395307 Page 2 of 3 395307 02/02/2024 Kendal at Longwood Box 100 Kennett Square, PA 19348

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on clinical record review and staff interview it was determined the facility failed to provided pharmacy services by not obtaining needed medications for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023. Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023. Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023. Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023. Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100 mg (used to treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023. Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy. This has been identified as a past non-compliance situation. This was identified by the facility and a plan of correction was developed and put into place including Audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance. 28 Pa. Code 211.9(a)(1) Pharmacy Sevices 28 Pa. Code 211.12(3)(5) Nursing Services 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18. Management 395307 Page 3 of 3