Health inspection·November 30, 2023

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 and facility documentation review and resident/staff interview, it was determined that the facility failed to timely treat a burn and failed to follow a physician medication parameter for two of 33 residents reviewed (Residents 32 and 58). Residents Affected - Few Findings include: Interview with Resident 32 on November 28, 2023, at 9:10 a.m. revealed the resident had a burn on her abdomen from spilling coffee in September. Review of Resident 32's progress notes revealed a nurse's note dated September 10, 2023, at 10:31 a.m. which stated: notified by aide that resident had a skin area on upper abdomen. Upon arrival to room, this nurse noted 4x4 gauze pad on abdomen and once removed, a slightly red non-opened area noted (measured 4cm W x 4 ½ L). Resident stated 'I burnt myself with coffee on [September 8] a blister appeared and it popped [September 9, 2023.]' Nursing supervisor notified. Cleansed area with [normal saline], applied [triple antibiotic ointment], and covered with bordered gauze. Review of facility documentation revealed on September 8, 2023, at approximately 11:00 a.m., the resident spilled coffee on herself during a coffee social witnessed by Employee E3. Review of facility documentation dated September 12, 2023, revealed Employee E3 received individualized education for failing to report the burn to nursing. Review of facility witness statement from nurse aide Employee E4 revealed on September 8, 2023, the employee noticed a blister on Resident 32's abdomen while putting the resident to bed. Nurse aide Employee E4 notified licensed nurse Employee E5 about the area. Review of facility documentation dated September 12, 2023, revealed licensed nurse Employee E5 failed to assess Resident 32 after nurse aide Employee E4 notified them about the area. Review of Resident 32's September 2023 Treatment Administration Record revealed that a treatment was not started on the burn until September 10, 2023. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Employee E3's failure to report the burn initially and licensed nurse Employee E5's failure to assess Resident 32 resulted in a two-day delay in treating Resident 32's burn. Review of Resident 58's physician order dated October 25, 2023, revealed an order for Midodrine (medication to treat low blood pressure that causes severe dizziness and fainting) HCL Oral tablet 5mg Page 1 of 4 395519 395519 11/30/2023 Green Meadows Nursing & Rehabilitation Center 283 East Lancaster Avenue Malvern, PA 19355

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few given two tablets by mouth three times a day for Orthostatic Hypotension (A form of low blood pressure that happens when standing up from sitting or lying down). Give if blood pressure is less than 95/60 mmHg. Review of Resident 58's October 2023 Medication Administration Record (MAR) revealed that from October 25, 2023, until October 30, 2023, the medication Midodrine was administered to the resident seven times with a blood pressure above 95/60 mmHg. Interview with the Director of Nursing on November 30, 2023, at 10:00 a.m., confirmed that Resident 58 was administered with Midodrine outside of the ordered blood pressure parameter. The facility failed to follow Resident 58's physician's order regarding blood pressure parameters for Midodrine medication. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services 395519 Page 2 of 4 395519 11/30/2023 Green Meadows Nursing & Rehabilitation Center 283 East Lancaster Avenue Malvern, PA 19355

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records facility documentation review and staff interview, it was determined that the facility failed to timely assess a resident's skin impairment and inform the physician of a newly found skin impairment for one of six residents reviewed (Resident 58). Residents Affected - Few Findings include: Review of Resident 58's clinical records revealed resident was admitted to the facility with a diagnosis of Malignant Prostate Cancer, Diabetes, and Severe Protein Calorie Malnutrition. The admission skin assessment dated [DATE], revealed no skin impairment in the resident's midback area. Review of facility documentation, and staff statement dated November 7, 2023, revealed that on November 3, 2023, a bandage gauze dressing was observed on the resident's upper back which was not present during initial assessment. Review of Resident 58's clinical records failed to reveal a completed skin assessment of the mid-upper back upon observing a bandage gauze dressing on November 3, 2023. Review of Resident 58's clinical records, Physician's order, revealed no treatment order the resident's mid-upper back wound on November 3, 2023. Interview was conducted with the Director of Nursing on November 30, 2023, at 10:00 a.m. The DON was unable to provide documented evidence that Resident 58's mid upper back skin was assessed on November 3, 2023, after observing a bandage dressing. The DON also confirmed that although a bandage dressing was observed on the resident's upper mid back, there was no physician's order for a wound treatment on Resident 58's mid-upper back on November 3, 2023. The facility failed to assess Resident 58's skin and notify the physician upon observing a bandage dressing to the resident's upper mid back on November 3, 2023. 28 Pa Code 211.5 (f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395519 Page 3 of 4 395519 11/30/2023 Green Meadows Nursing & Rehabilitation Center 283 East Lancaster Avenue Malvern, PA 19355

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, it was determined that the facility failed to ensure one of 33 residents reviewed was free of unnecessary medications (Resident 137). Residents Affected - Few Findings include: Review of Resident 137's physician's orders revealed an order dated May 20, 2021, to evaluate for verbal and non-verbal signs and symptoms of pain every shift. Review of Resident 137's July 2023 Medication Administration Record (MAR) revealed the resident reported no pain a total of 78 times. Review of Resident 137's August 2023 MAR revealed the resident reported no pain a total of 48 times. Review of Resident 137's September 2023 MAR revealed the resident reported no pain a total of 42 times. Review of Resident 137's October 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's November 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's clinical record revealed a nurse's note on November 24, 2023, at 8:39 a.m. which stated that the resident approached this writer stating she will not take any of her prescribed medications unless a provider re-enters a script for Percocet [(narcotic pain reliever.)] When asked if resident was experiencing discomfort, she states I don't think you need to worry about that. I have been taking Percocet for longer than you have been alive. You just do what [you] need to do if you want me to take the medication you want me to take. I need those Percocets. Discussed risks of non-compliance with all medications and [resident] disregarded education stating Just get my Percocet. MD (Medical Doctor) aware of resident request and refusals of all other medications and will assess med regimen. Awaiting return call from provider. Further review of Resident 137's progress notes revealed a nurse's note on November 24, 2023, at 8:47 a.m. which stated that the physician called back and wrote an order for Percocet 5-325 milligrams (mg) every 8 hours as needed for 14 days. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Resident 137's refusal to take other medication unless provided with Percocet was not an appropriate reason to continue the resident on narcotic pain medication. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395519 Page 4 of 4