Inspection·February 1, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility documents, observations, interviews with residents and staff, it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for two of 12 residents' records reviewed. (Resident R1 and Resident R2) Finding include: Review of facility policy titled Medication Administration/ Disposition last revised September 6, 2023, revealed If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and use the corresponding code on the EMAR to indicate the medication was not given and the reason for not administering. Further review of the policy revealed that if the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of Resident R1's clinical record reveals a diagnosis of hyperthyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream. This makes your metabolism slow down. Also called underactive thyroid, hypothyroidism can make you feel tired, gain weight and be unable to tolerate cold temperatures. The main treatment for hypothyroidism is hormone replacement therapy.) Review of Resident R1's February 2024 physician orders revealed an order for the medication Levothyroxine sodium 150 mcg, (a hormone replacement therapy used to treat hypothyroidism.) The order was for this medication to be given by mouth in the morning on an empty stomach one time daily. Interview with Resident R1 on February 1, 2023, at 7:55 a.m. revealed that this resident had not received her medication Synthroid at the ordered time. Resident R1 stated that Employee E4 did not give her medication as ordered to be administered in the morning on an empty stomach. Resident R1 stated that she was asleep, and Employee E1 did not wake her to give her the medication Synthroid. Interview with Employee E4 on February 1, 2023, at 7:30 a.m. revealed that this employee had not withheld any resident's medication. Employee E4 stated that if a resident is asleep at time of medication administration, this employee will wake the resident to administer the medication. Review of facility documentation of the facility investigation of this resident's allegation of missed medications revealed that Employee E4 was found to have missed the administration of resident R1's medication. The facility investigation revealed that Employee E4 returned to the facility the day of incident and administered the missed medication. (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: 395380 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 395380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saunders Nursing and Rehabilitation Center 100 Lancaster Avenue Wynnewood, PA 19096 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)