Health inspection·June 18, 2024

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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of four residents reviewed (Resident 1), and failed to transcribe physician's orders for one of four residents reviewed (Resident 4). Residents Affected - Few Findings include: A policy regarding medication administration, dated January 10, 2024, revealed that individuals administering medication will verify the resident's identity before giving the resident their medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 16, 2024, revealed that the resident rarely understands and is rarely understood, was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included Alzheimer's disease. A nursing note for Resident 1, dated May 29, 2024, at 7:30 a.m., revealed that the resident had been given another resident's medication. The crushed medication included 50 milligrams (mg) of Lopressor (used to treat high blood pressure), 8.6 mg of Senna (treats constipation), 120 mg of Cardizem (used to treat high blood pressure), 100 mg of Gabapentin (a medication to treat seizures), and 50 mg of Seroquel (an antipsychotic medication). Vital signs were checked, and the medical doctor was notified. A nursing note for Resident 1, dated May 29, 2024, at 7:32 a.m., revealed new orders to check the resident's vital signs in one hour and to monitor the resident. A nursing note for Resident 1, dated May 29, 2024, at 8:16 a.m., revealed a blood pressure of 82/44 mmHg, a heart rate of 63 beats per minute, and respirations of 12 per minute. Resident 1 was not easy to wake up, and the medical doctor was notified. A nursing note for Resident 1, dated May 29, 2024, at 8:16 a.m., revealed that the medical doctor was notified and new orders were received to send the resident to the hospital. A nursing note for Resident 1, dated May 29, 2024, at 3:15 p.m., revealed that a report was received from the hospital and the resident was being admitted into ICU for observation for bradycardia (low heart rate), hypotension (low blood pressure), and nosocomial overdose (an overdose that did not happen in the hospital). Page 1 of 2 395896 395896 06/18/2024 Homewood Living Martinsburg, Inc 437 Givler Drive Martinsburg, PA 16662

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A nursing note for Resident 1, dated May 30, 2024, revealed an update. The resident is on dopamine (a medication that regulates blood flow) to keep vital signs regulated. A nursing note for Resident 1, dated May 31, 2024, revealed that the resident returned to facility. Interview with the Director of Nursing on June 18, 2024, at 11:10 a.m. confirmed that Resident 1 received another resident's medication and that the medication nurse did not identify the resident prior to administering the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 21, 2024, revealed that the resident understands and is understood, was cognitively impaired, required extensive assistance with daily care needs, had diagnoses that included Alzheimer's disease. Physician's orders for Resident 4, taken verbally by Registered Nurse 1 on April 24, 2024, included an order for 50 mg of Zoloft (a medication to treat depression) with a start date of April 24, 2025. A nursing note for Resident 4, dated May 8, 2024, revealed that the resident's Zoloft had been discontinued in error and upon reorder the incorrect date was written. The resident did not receive the Zoloft for two weeks. Interview with the Director of Nursing on June 18, 2024, at 11:10 a.m. confirmed that the registered nurse should have verified the medication transcription for Resident 4 to ensure the correct start date. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395896 Page 2 of 2