Health inspection·July 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, review of clinical records and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for two of three medication carts observed. (Medication Cart 3rd Floor B Front and Medication cart 3rd Floor B Back) Findings: Review of facility narcotic book for Medication Cart 3rd Floor B Front conducted on July 10, 2024, at 8:52 p.m., during medication administration observation with licensed nurse, Employee E5 revealed an entry for July 10, 2024, with time written 1900 (7:00 p.m.). Further, the column for Nurse going off duty for July 10, 2024, with time written for 1900 had a signature. Interview with licensed nurseEmployee E5 conducted at the time of the observation, revealed that licensed nurses work a 12-hour shift and that between shifts, the outgoing and incoming nurses count the narcotics together and that the once they are done counting the controlled substances in the cart, the outgoing nurse signs the outgoing column of the narcotic book for that date and the incoming nurse also signs the incoming column of the narcotic book for that date. Further interview with Employee E5 revealed that licensed nurse Employee E5 was the one who counted the narcotics at the beginning of the day shift on July 10, 2024. Interviewed with Employee E6 conducted at the time of the observation, confirmed that at the beginning of the day shift for July 10, 2024, he pre signed the column for Nurse going off duty for July 10, 2024, for which the time 19:00 was written. Further Employee E6 also revealed that he pre signed it because he was going to be the one to sign it at the end of his shift anyway. Further review of the narcotic book for Medication Cart 3rd Floor B Front revealed that on: June 6, 2024 at 7:00 (1.m.), the column Nurse going off duty did not have a signature. June 22, 2024, at 11:00 p.m., the column Nurse coming on duty did not have a signature. June 23, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 25, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. Page 1 of 4 396101 396101 07/11/2024 Rehab at Shannondell 5000 Shannondell Drive Audubon, PA 19403

F 0755 June 30, 2024, at 5:45 a.m., the column Nurse coming on duty did not have a signature. Level of Harm - Minimal harm or potential for actual harm Further review of the facility narcotic book for Medication Cart 3rd Floor B Back revealed that on: June 6, 2024, at 7:15 a.m., the column Nurse going off duty did not have a signature. Residents Affected - Few June 19, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 22, 2024, at 5:00 a.m., the column Nurse coming on duty did not have a signature. June 22, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 29, 2024, at 7:00 p.m., the column Nurse coming on duty did not have a signature. July 4, 2024, at 7:00 p.m., the column Nurse coming on duty did not have a signature. July 10, 2024, at 7:00 a.m., the column Nurse coming on duty did not have a signature. Review of the facility narcotic book for Medication cart 3rd Floor B Back conducted during medication administration on the 3rd floor unit on July 10, 2024, at 9:12 a.m. with Employee E6 and Employee E8 revealed that the on July 10, 2024, at 7:00 a.m. the incoming column did not have a signature. Interview with licensed nurse Employee E8 conducted by Employee E6 at the time of the observation in the presence of the surveyor, confirmed that Employee E8 did not sign the column for Nurse coming on duty at the beginning of her shift for July 10, 2024 28 Pa. Code 201.18(b)(2) Management 29 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396101 Page 2 of 4 396101 07/11/2024 Rehab at Shannondell 5000 Shannondell Drive Audubon, PA 19403

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility failed to have a medication error rate less than five percent (Residents R9 and R244). Residents Affected - Few Findings include: Review of the facility's medication policy dated 2/2017 states, All medications are administered safely and appropriately to all residents and to follow 6 Rights of Medication Administration during medication pass (right resident, right medication, right dose, right route, right time, right documentation). The facility's medication error rate was 8 % based on 25 medication opportunities with two medication errors. Review of Resident R9's physician orders instructed to take Cyanocobalamin (Vitamin B-12) 1,000 mcg sublingual route (placed under your tongue to dissolve) once daily. Observation of a medication administration pass on July 11, 2024, at 9:08 a.m. with Registered Nurse, Employee E3 revealed the nurse administered Cyanocobalamin by mouth to Resident R9. Review of Resident R244's physician orders instructed to take Cyanocobalamin 1,000 mcg sublingual route once daily. Observation of a medication administration pass on July 11, 2024, at 9:38 a.m. with Licensed Practical Nurse, Employee E4 revealed the nurse administered the Cyanocobalamin by mouth to Resident R244. Interview with the Director of Nursing on July 11, 2024, at 12:30 p.m. confirmed the nurses did not follow the physician's order for Cyanocobalamin and did not administer the medication sublingually. 28 Pa. Code 211.12(d)(1)(5) Nursing services 396101 Page 3 of 4 396101 07/11/2024 Rehab at Shannondell 5000 Shannondell Drive Audubon, PA 19403

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, reviewof facility policy, observation, and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of three medication carts observed (Med cart 3rd B back) and one of two medication rooms observed (Third-floor medication room). Findings include: Review of facility policy for medication administration dated February 2017, revealed that under section Policy: all medications are administered safely and appropriately to all residents. Under section Process: Check medication for expiration date and discard if indicated and check multi dose vials for date when opened and discard if indicated. Observation of med cart 3rd B back conducted during medication administration on the 3rd floor unit on [DATE], at 9:12 a.m. with Licensed nurses, Employee E6 and Employee E8 revealed a Glucagon injection (an emergency medication used to treat severe hypoglycemia (low blood sugar) in diabetes patients) in the top drawer of the medication cart. Further observation revealed that the Glucagon injection had an expiry date of [DATE]. Interview with Licensed nurse, Employee E6 conducted at the time of the observation confirmed that an expired Glucagon injection in the top drawer of the medication cart had an expiration date of [DATE]. Observation of the third-floor medication room conducted on [DATE], at 10:09 a.m. with Licensed nurse, Employee E7 revealed an open vial of Tuberculin PPD 5TU/0.1ml (used in a skin test to help diagnose tuberculosis) in the refrigerator did not have a date opened affixed to the vial or the box. Interview with Licensed nurse, Employee E7 conducted at the time of the observation confirmed that an open vial of tuberculin PPD 5TU/0.1ml in the refrigerator did not have a date opened affixed to the vial or the box. 28 Pa. Code 201.18(b)(l) Management 28 Pa. Code 211.12(d) Nursing services 28 Pa. Code 211.9(i) Pharmacy services 396101 Page 4 of 4