Health inspection·June 23, 2023

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 facility policy and procedure review, observations, clinical record review, and staff interview it was determined the facility failed to correctly administer and determine a need for medication for one of 3 residents reviewed. (Resident 18) Residents Affected - Few Findings Include: Review of facility policy and procedure titled Medication Pass Policy, revised January 9, 2020, revealed you must have the approval of the nurse before crushing any medications. Remember that not all medications can be crushed. Directions to crush medications will be written on the MAR (medications Administration Record). Observation of medication pass on June 22, 2023 at 8:15 a.m. revealed Licensed Nursing Employee E6 crushed all the medications for Resident 18 and administered the medications to the resident in apple sauce. Included in these medications was Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG (Extended-release blood pressure medication). Review of the medication package the pill was removed from revealed a warning sticker stating the medication should not be crushed. Licensed nursing employee E6 at the time of the observations confirmed the metoprolol 25 mg (milligrams) ER should not have been crushed prior to the administration of the medication to Resident 18. Review of resident 18's physician orders revealed no orders for the medications to be crushed and there were no directions to crush medications on Resident 18's MAR. Review of Resident 18's Medication Administration Record for June 2023 revealed the resident was ordered Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG twice a day and not to be given if the systolic blood pressure (top number of blood pressure reading) is below 100 or a heart rate below 55 at 9:00 a.m. and 5:00 p.m. Further review of Resident 18's May 2023 MAR revealed the medications was not dispensed 16 of 31 times at the 5:00 p.m. time due to a low blood pressure. Review of Resident 18's clinical record revealed no documented evidence the facility had discussed with the physician the resident need for the medications after it not being administered so many times due to parameters or clarification that a 24-hour extended-release medication was being given twice a day and being crushed. Interview with the Director of Nursing on June 23, 2023 at 10:00 a.m. confirmed the medications should not have been crushed during administration and there should have been clarification with the physician about a 24-hour medication being given twice a day and the frequency with the 5:00 p.m. dose not being administered due to low parameters. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396082 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396082 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Lane Post Acute LLC 1619 East Boot Road East Goshen West Chester, PA 19380 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based upon review of facility policy and procedure, review of clinical records and interview, it was determined the facility failed to ensure nutritional status was maintained and failed to ensure the physician was notified of significant weight loss for two of twelve residents reviewed (Resident 11 and Resident 29). Residents Affected - Few Findings include: Review of facility policy and procedure titled Weights Policy, revised 2015, revealed Residents will be weighed as directed by the physician, federal/state regulations or standards of practice. Further review of this policy and procedure revealed Repeat the weight if a significant change has occurred from the previous weight. If weight loss or weight gain has occurred, appropriate follow up is initiated and may include one or more of the following: a) Re-weight the resident at the time of the changed weight; b) notify the physician of the weight loss or gain if significant. Review of Resident 11's Weight Summary revealed Resident 11 weighed 155 pounds on April 3, 2023. Further review of Resident 11's Weight Summary revealed Resident 11 weighed 138.6 pounds on April 10, 2023, indicating a 10.58% weight loss in one week. Further review of Resident 11's Weight Summary failed to reveal evidence that a re-weight was obtained until April 24, 2023. Review of Resident 11's clinical record failed to reveal evidence that Resident 11's physician was notified of Resident 11's significant weight loss. Interview with Employee E5 on June 23, 2023, at 10:10 a.m. confirmed that no re-weight was obtained for Resident 11 and further confirmed that there was no documented evidence Resident 11's physician was notified of the significant weight loss. The facility failed to ensure adequate nutritional maintenance was obtained with regard to Resident 11. Review of Resident 29's clinical revealed the following diagnosis's: Frontotemporal dementia, advanced with agitation and psychotic behavior (Characterized by excessive talking or purposeless motions, feeling of unease or tension, and hostile behavior at times), Unspecified protein -calorie malnutrition (An imbalanced nutritional status resulted from insufficient intake of nutrients to meet normal physiological requirement), dysphagia (difficulty swallowing), Muscle weakness, and difficulty in walking. Review of Resident 29's clinical record revealed the following weights: March 3, 2023: 133.0 Lbs, April 2, 2023: 147.4 Lbs, indicating a 9.77% gain in weight. Further review of Resident 29's clinical medical record failed to find any documentation from the Employee E5 of notifying the physician of Resident 29's significant weight gain. Additionally, there was no evidence of a re-weight being obtained to confirm Resident 29's significant weight gain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396082 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396082 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Lane Post Acute LLC 1619 East Boot Road East Goshen West Chester, PA 19380 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Interview conducted with Employee E5 on June 23, 2023, at approximately 10:22 a.m. confirmed Resident 29 had a significant weight gain of 9.77% and that there was no documented evidence of the physician being notified or a re-weight being obtained. The facility failed to ensure adequate nutritional maintenance was obtained with regard to Resident 29. Residents Affected - Few 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 211.6(d) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396082 If continuation sheet Page 4 of 4