Health inspection·July 22, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not ensure physician was notified of change in resident's condition/status. Based on review of clinical record, facility policy, and staff interviews, it was determined that the facility failed to notify the physician of a change in condition/status for one of three residents reviewed (Resident R1). Findings include:Review of facility policy titled Change in a Resident's Condition or Status, revised 2021, revealed the facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more consecutive times);g. need to transfer the resident to a hospital/treatment center;h. discharge without proper medical authority; and/[NAME]. specific instruction to notify the physician of changes in the resident's condition.Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included severe protein calorie malnutrition (inadequate intake of essential nutrients, particularly protein and calories), epilepsy (brain condition that causes reoccurring seizures), and dysarthria (slurred speech). Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated May 13, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition.Interview on July 18, 2025 at 12:05 p.m. with Employee E2, Licensed Practical Nurse, revealed he/she identified Resident R1 had increased slurred speech on the evening of July 17, 2025. Employee E2 confirmed he/she did not notify the physician or document his/her observation due to relating the slurred speech to Resident R1's previous respiratory illness he/she was recovering from since May 2025. Review of Resident R1's clinical record from the months of May 2025 through June 2025 revealed no progress note on slurred speech or worsening slurred speech related to respiratory illness. Interview on July 18, 2025 at 11:55 a.m. with Employee E1, Nurse Practitioner, confirmed when resident has change in condition/status for example slurred speech, staff is expected to document and notify physician. Review of Resident R1's nursing progress note, dated June 16, 2025 at 6:18 p.m., stated resident relative here and concerned as she has seen a dramatic negative change in him since Thursday. Noted by this nursing supervisor a dramatic change in vocal ability. His voice sounds as if his tongue is too big. Was able to follow conversation and was able to change an answer to a question from narrative to yes/no answer when asked about going to hospital for further evaluation. Relative getting guidance from wife. She has confirmed desire for him to be seen. Call out to on-call for confirmation. Review of Resident R1's nursing progress note, dated June Page 1 of 2 395403 395403 07/22/2025 Newport Meadows Health and Rehabilitation Center 41 Newport Avenue Christiana, PA 17509

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 16, 2025 at 6:25 p.m., revealed Resident R1 was transferred to hospital for evaluation.Review of Resident R1's hospital record, dated June 17, 2025, revealed Resident R1 presented with worsening dysarthria, left sided chest pain and left shoulder pain. Patient was found to have elevated Dilantin level of 29.5. Exam notable for confusion, bilateral lower extremity weakness, and severe dysarthria. Further review of Resident R1's hospital record, dated June 18, 2025, stated the patient was found to be less responsive than normal yesterday with worsening slurred speech. Personally called [NAME] Meadows and spoke with Nursing Supervisor who stated she was informed that the patient had a steady decline in his speech over the weekend and when a visitor came to see the patient yesterday (Monday) the visitor thought the speech changes were more pronounced. Resident R1's hospital records revealed Resident R1 was diagnosed with Dilantin toxicity (prescription drug used to treat seizures, but it can cause severe toxicity if the dose is too high or if it interacts with other drugs.The facility failed to notify the physician in a timely manner related to a change in Resident R1's condition/status. Resident R1's family requested resident to be assessed, which resulted in resident being transferred to hospital and diagnosed with Dilantin toxicity. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1) Nursing services. 395403 Page 2 of 2