Health inspection·February 29, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and staff interviews, it was determined that the facility failed to ensure injury of unknown cause was comprehensively investigated for one two residents reviewed (Resident 1) Residents Affected - Few Findings include: Review of clinical records of Resident 1 revealed Resident 1 was admitted to the facility on [DATE], with diagnosis of Dementia (A term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), and fracture of the left femur (thigh bone). Review of Resident 1's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated December 21, 2023, revealed resident had severe cognitive impairment and required dependent assistance with transferring. Review of facility documentations and clinical records revealed Resident 1 had an unwitnessed fall on December 22, 2023, at 7:18 p.m., and December 24, 2023, at 5:32 p.m. Resident was assessed with no injury observed on both falls. Review of the nursing progress notes dated December 29, 2023, at 6:46 p.m., revealed that the daughter in law requested for an x-ray of the foot because the resident complained of a pain when foot was massaged. An x-ray of the left ankle and foot was ordered. The x-ray result was Acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The resident was medicated with round the clock Tylenol (pain medication). Review of the facility documentation and clinical records failed to reveal that the identified fracture on Resident 1's left foot was investigated. Interview conducted with the Nursing Home Administrator on February 28, 2024, at 1:00 p.m., revealed that left foot fracture identified on December 29, 2023, was not investigated because staff believed the fracture was present from the hospital due to family's report of pain in the hospital and resident saying ouch when left foot was touched. The facility was unable to provide a documentation indicating left foot fracture occurred prior to admission to the facility. The facility failed to investigate Resident 1's left foot fracture of unknown origin. 28 Pa. Code: 211.12(d)(1)(5) Nursing services Page 1 of 4 395595 395595 02/29/2024 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0610 28 Pa Code 201.18(b)(1)(3)(e)(1) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395595 Page 2 of 4 395595 02/29/2024 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

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 records review and staff interview, it was determined that the facility failed to follow a physician's order regarding vital signs monitoring and failed to notify the physician of an x-ray result timely for one of the two residents reviewed (Resident1). Residents Affected - Few Findings include: Clinical records review revealed Resident 1's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), fracture of the left femur (thigh bone), and Pneumonia (infection of the air sacs in one or both the lungs. Characterized by severe cough with phlegm, fever, chills and difficulty in breathing). Review of Resident 1's nursing progress notes dated December 29, 2023, at 6:46 p.m., revealed the daughter-in-law requested an x-ray of the foot because the resident complained of pain when the foot was massaged. An x-ray of the left ankle and foot was ordered. The x-ray result was an Acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The resident was medicated with round-the-clock Tylenol (pain medication). The resident denied pain, the radiology report was placed on the physician's book for review. Review of Resident 1's physician's note dated January 3, 2024, at 11:28 a.m., revealed that a follow-up was made from the last visit where an x-ray of the left foot was ordered with radiology interpreted as There as residuals of acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The physician documented that the physician services were not notified of the radiological findings at the time the results were published. An order for a non-weight bearing and a specialist evaluation was ordered by the physician. Interview was conducted with the Director of Nursing on February 29, 2024, at 1:00 p.m. The DON reported that a fracture from an x-ray result should be reported to the physician by calling them and not by leaving a report in the physician's book. The facility failed to ensure Resident1's physician was timely notified of Resident 1's left foot fracture. Review of Resident 1's physician order dated February 13, 2024, revealed an order to check all vitals two times daily for Pneumonia. Review of Resident 1's clinical record including February 2024 Medication Administration Record and weight and vital records revealed Resident 1's vitals were only checked daily on February 15, 16, 17, 18, 19, 20, and 21, 2024, instead of twice daily as ordered by the physician. Interview with the Assistant Director of Nursing on February 29, 2024, at 2:00 p.m., confirmed that the physician's order to check Resident 1's vitals twice a day was not followed on the above-mentioned dates. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services 395595 Page 3 of 4 395595 02/29/2024 Belvedere Center, Genesis Healthcare, The 2507 Chestnut Street Chester, PA 19013

F 0684 28 Pa Code 201.18(b)(1)(3)(e)(1) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395595 Page 4 of 4