Health inspection·December 21, 2023

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 33 residents with weight loss reviewed (Resident R25). Residents Affected - Few Findings include: Review of clinical documentation for Resident R25 revealed that that the resident was admitted to the facility September 13, 2023, with diagnoses of hyperlipemia (excessive amounts of fat and fatty substances in the blood), difficulty in walking and muscle weakness. Review of the resident's weight documentation revealed that on September 20, 2023, Resident R25 weighed 133.1 pounds and on December 19, 2023, the resident weighed 116.8 pounds which was unplanned weight loss of a -12.25% in three month, which met the criteria of a significant weight loss. On December 20, 2023 at 11:15 a.m. an interview with the Registered Dietician, Employee E4 revealed that dietician did evaluate Resided R25 and implemented weight gain interventions; however, clinical record had no evidence that the physician assessment was completed related to unplanned weight loss. Interview with the Nursing Home Administrator and the Director of Nursing on December 20, 2023, at 11:15 p.m. confirmed that there was no validating documentation from admission date of September 20, 2023 through December 20, 2023 that physician had assessed the resident in regards to weight loss. 28 Pa. Code:211.12(d)(5) Nursing services. 28 Pa. Code:211.2(a) Physician services. 28 Pa. Code 211.5(f) Clinical records Page 1 of 2 395757 395757 12/21/2023 Edgehill Nursing and Rehab Cen 146 Edgehill Road Glenside, PA 19038

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, review of clinical documentation, observation, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices related to medication administration for one of three residents reviewed (Resident R21). Residents Affected - Few Findings include: Review of facility policy titled General Dose Preparation and Medication Administration, most recently revised January 1, 2022, revealed that Facility staff should not touch the medication, and if medication which is not in a protective container is dropped, Facility staff should discard it according to Facility policy. Review of facility policy titled Medication Administered through Certain Routes of Administration, dated January 1, 2022, revealed that for subcutaneous (under the skin) injections, before preparing the dose staff should Cleanse hands. Wear gloves. Review of clinical documentation revealed that Resident R21 was to receive the following medication by mouth during morning medication pass: Baclofen 10 milligrams (mg) tablet for muscle spasm, Colace 100 mg caplet for constipation, Famotidine 20 mg tablet for GERD (Gastroesophageal reflux disease), Allegra 180 mg tablet for allergies, Gabapentin 800 mg tablet for diabetic neuropathy, Lisinopril 40 mg tablet for hypertension, Loratadine 10 mg tablet for allergy symptoms, Omega 3 1000 mg caplet as a supplement, 2 Senna-S 8.6-50 mg tablets for constipation, and 2 Vitamin D3 1000 unit tablets for deficiency. The resident also was to receive 88 units of Levemir injected subcutaneously for type 2 diabetes. Observations conducted on December 20, 2023, at 9:50 a.m. revealed that during preparation of medication for Resident R21, Licensed Nurse, Employee E7 spilled the cup of pills onto the surface of the medication cart. Employee E7 then scooped the pills back into the cup with her hands and administered the medication. While drawing Levemir into the syringe in preparation for administration. Employee E7 then touched the side of the needle with an ungloved finger. Employee E7 then administered the injection without putting on gloves. Interview with Employee E7 at that time confirmed that the preparation and administration of medications for Resident R21 did not follow infection control standards. Interview with the Director of Nursing, Employee E2 on December 20, 2023, at 1:00 p.m. confirmed that the above observations were not in compliance with infection control standards or facility policy. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.01(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395757 Page 2 of 2