Health inspection·January 21, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff interview, and review of the facility policy, it was determined the facility failed to ensure physician orders were followed for one of the three residents reviewed (Resident CL1). Residents Affected - Few Findings include: Review of facility policy titled Administering Medication updated October 2022 revealed Medication shall be administered in a safe and timely manner and as prescribed. Under policy interpretation bullet #2 it further stated Medication must be administered in accordance with the order including any required time frames. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], at approximately 12:38 p.m. with a diagnosis of hospice care. Review of Resident CL1's physician order dated January 6, 2025, revealed an order of -Morphine Sulfate (concentrate) Oral Solution 20 MG/ML give 0.25 ml by mouth every 2 hours as needed for moderate pain, scale 4-6. - Morphine Sulfate (concentrate) Oral Solution 20 MG/ML give 0.5 ml by mouth every 2 hours as needed for severe pain, scale 7-10. Interview conducted on January 21, 2025, at 10:30 a.m., with Unit Manager, Employee E3, revealed that per Resident CL1's Medication Administration Record (MAR) Morphine Sulfate (Concentrate) Oral Solution 20 mg/mL, 0.25 mL by mouth, was administered to Resident CL1 on January 6, 2025, at 9:08 p.m. for a reported pain level of 3. Review of the resident's controlled medication sheet with the Unit Manager, Employee E3, revealed the administration of Morphine Sulfate (Concentrate) Oral Solution 20 mg/mL. The records indicated that a 0.25 mL dose was given on January 6, 2025, at 3:00 p.m. and 7:30 p.m. However, no pain level was documented for either administration. Review of clinical record of Resident CL1 Medication Administration Record revealed on January 7, 2025, Resident CL1 was given 0.5 ml by mouth that Morphine Sulfate for pain level 5 at 4:51 a.m. then pain level 6 at 11:32 a.m. Then on January 8, 2025, pain level 6 at 5:31 p.m. Continued review of Resident CL1's MAR revealed on January 7, 2025, Resident CL1 was given 0.25 ml by mouth that Morphine Sulfate for pain level 3 on January 6, 2025, at 9:08 and on January 8, 2025, Page 1 of 2 395791 395791 01/21/2025 Complete Care at Harston Hall LLC 350 Haws Lane Flourtown, PA 19031

F 0684 at 11:19 for pain level 3. The pain levels were outside the parameters specified in the physician's order. Level of Harm - Minimal harm or potential for actual harm On January 21, 2025, at 1:36 p.m. an interview with the Infection Control and Training license nurse, Employee E2 confirmed that facility did not follow the physician orders. Residents Affected - Few On January 21, 2025, at 2:00 p.m., an interview with the Administrator, Employee E1, confirmed that the facility failed to follow the physician's orders by not documenting the pain level for dosages on January 6, 2025, and by not administering the correct medication dosage within the appropriate pain level parameters. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 395791 Page 2 of 2