Health inspection·April 5, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain weights as ordered by the physician for eight of 11 residents reviewed (Residents 2, 6, 7, 9, 10, 12, 13, 14). Residents Affected - Some Findings include: The facility's policy for weights, dated March 16, 2023, indicated that upon admission, residents would have an admission weight done to record baseline weight. Residents will then be set up on a biweekly weight schedule unless otherwise ordered by physician or deemed necessary by registered nurse. All weights would be documented in the electronic record and on the report sheet. Physician's orders for Resident 2, dated March 22, 2023, included and order for the resident to be weighed every Wednesday and Saturday. A review of Resident 2's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 6, dated March 29, 2023, included an order for the resident to be weighed daily. A review of Resident 6's weight records from admission on [DATE], until April 5, 2023, revealed that the resident was not weighed seven out of seven days. Physician's orders for Resident 7, dated March 28, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 7's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed two out of two days. Physician's orders for Resident 9, dated March 25, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 9's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 10, dated March 18, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 10's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed five out of five days. Physician's orders for Resident 12, dated March 30, 2023, included an order for the resident to be weighed every Monday and Thursday. A review of Resident 12's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed two out of two days. Page 1 of 3 396102 396102 04/05/2023 Conemaugh Memorial Medical Center Tcu 320 Main Street Johnstown, PA 15901

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Physician's orders for Resident 13, dated March 21, 2023, included an order for the resident to be weighed every Tuesday and Friday. A review of Resident 13's weight records from admission on [DATE], to April 5, 2023, revealed that the resident was not weighed four out of four days. Physician's orders for Resident 14, dated March 24, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 14's weight records from March 24, 2023, to April 5, 2023, revealed that the resident was not weighed four out of four days. Interview with the Director of Nursing on April 5, 2023, at 9:20 a.m. confirmed that Residents 2, 6, 7, 9, 10, 12, 13 and 14 should have been weighed per their physician's orders and they were not. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 396102 Page 2 of 3 396102 04/05/2023 Conemaugh Memorial Medical Center Tcu 320 Main Street Johnstown, PA 15901

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. Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly stored in the medication cart. Findings include: A policy for Pharmacy Services, dated March 16, 2023, indicated that medications should be secured in the proper medication cart for administration. Observations during medication administration on April 5, 2023, at 7:50 a.m. revealed that Registered Nurse 1 prepared Atenolol 50 milligrams (mg), Bupropion 300 mg, Lexapro 10 mg, Metformin 1000 mg, and Potassium Chloride 10 milliequivalents (mEq) for Resident 9 and left the blister packs of medications unsecured and unattended on top of the medication cart while he entered the resident's room to administer the medications to the resident. When Registered Nurse 1 entered the resident's room, the medication cart was out of his line of sight and was left unlocked with the keys to the medication cart hanging in the lock. An interview with Registered Nurse 1 at that time revealed that he should have put all medication in the cart, locked the cart, and removed the keys prior to entering the resident's room. Interview with the Director of Nursing on April 5, 2023, at 12:10 p.m. confirmed that medications should not have been left unattended and unsecured on the medication cart and the medication cart should have been locked and the keys removed. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services. 396102 Page 3 of 3