Health inspection·April 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on a review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agencies for three of nine residents reviewed (Residents R1, R2, and Resident R3). Findings include: Review of facility policy Abuse Prevention/ Reporting revised April 2022, revealed that the facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13. Review of Resident R1's progress note of March 9, 2023, revealed that Resident R1 was admitted to the hospital. Review of Resident R1's Individual Patient Controlled Substance Administration Record revealed that one tablet of Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 milligrams (mg) was signed out on March 10, 2023, by licensed staff Employee E3. Review of Resident R2's physician's orders included an order for Tramadol (opioid used to help relieve moderate to severe pain) 50 mg one tablet twice a day. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. and 6 p.m. Review of Resident R2's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 12, 2023 at 3:00 a.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Tramadol at 3:00 a.m. on March 12, 2023. Review of Resident R3's physician's orders included an order for Oxycodone/APAP 5/325 mg (Percocet used to help relieve moderate to severe pain) two tablets once daily. Review of the March 2023 Medication Administration Record (MAR) revealed that it was to be administered at 9:00 a.m. Review of Resident R3's Individual Patient Controlled Substance Administration Record revealed that one tablet was signed out on March 10, 2023 at 1:15 a.m. and two tablets on March 11, 2023, at 11:30 p.m. by licensed staff Employee E3. Further review of the clinical record revealed no evidence that the resident received Oxycodone/APAP at those times. Interview with the Director of Nursing (DON) on April 27, 2023, at 10:45 a.m. revealed that the DON was notified that Employee E3 had signed out medication for Resident R1 while Resident R1 was hospitalized and that Employee E3 was not always documenting on the resident MARs. Employee E3's agency was made aware of the issues and was asked to not return to the facility. The DON confirmed that the allegation of misappropriation was not reported to the Department of Health. Page 1 of 3 395815 395815 04/27/2023 St Martha Center for Rehabilitation & Healthcare 470 Manor Ave Downingtown, PA 19335

F 0609 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition Level of Harm - Minimal harm or potential for actual harm Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 201.14(a) Responsibility of licensee Residents Affected - Few Previously cited 3/10/23 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa Code 211.10(a)(d) Resident Care Policies Previously cited 3/10/23 395815 Page 2 of 3 395815 04/27/2023 St Martha Center for Rehabilitation & Healthcare 470 Manor Ave Downingtown, PA 19335

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for three of nine residents reviewed (Residents R4, R5, and R6). Findings include: Review of Resident R4's physician's orders included an order for Oxycodone/APAP5/325 milligrams(mg) (Percocet - used to help relieve moderate to severe pain) one tablet every eight hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 11, 2023, at 6:45 p.m. and March 12, 2023, at 2:50 a.m.; however, the administration was not documented on the electronic Medication Administration Record (MAR). Review of Resident R5's physician's orders included an order for Oxycodone IR (opioid used to help relieve moderate to severe pain) 5 mg one tablet every four hours as needed for pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 11:15 p.m., March 10, 2023, at 4:40 a.m., and March 11, 2023, at 11:45 p.m.; however, the administration was not documented on the electronic MAR. Review of Resident R6's physician's orders included an order for Oxycodone IR 5 mg one tablet every six hours as needed for severe pain. Review of the Individual Patient Controlled Substance Administration Record revealed that the medication was administered on March 9, 2023, at 4:10 p.m. and 10:30 p.m.; however, the administration was not documented on the electronic MAR. Interview with the Director of Nursing on , April 27, 2023, at 10:45 a.m. confirmed that the medications should be documented on both the controlled substance record and the MARs, but were not documented on the MARs. 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/10/23 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 3/10/23 395815 Page 3 of 3