Health inspection·August 22, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and procedure review, staff interview and resident record review it was determined the facility failed to complete skin assessments to monitor skin conditions and prevent pressure ulcers for one of six residents reviewed causing actual harm to Resident 1 when they developed a stage 3 pressure ulcer to the sacrum(Resident 1). Residents Affected - Few Findings Include: Review of facility policy and procedure titled Skin Integrity and Wound Management revealed under practice standards the following Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Identify patient's skin integrity status and need or prevention or treatment interventions through review of all appropriate assessment information. Review of Resident 1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses of a fracture of unspecified part of neck of left femur, Lewy Bodies Dementia (affects chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood), and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of Resident 1's admission Minimum Data Set (MDS-periodic assessment of resident needs) dated May 9, 2024, revealed the resident was at risk for developing a pressure ulcer. Review of Resident 1's admission Braden Assessment completed on May 10, 2024, revealed the resident was at high risk for developing pressure ulcers. Review of Resident 1's baseline care plan on admission, dated May 10, 2024, revealed there was a care plan for the risk of developing pressure ulcers with an intervention of observe skin conditions with ADL care daily; report abnormalities with a date initiated of May 10, 2024. Review of Resident 1's clinical record revealed skin assessments were not completed from May 11, 2024, until June 6, 2024. Further review of the clinical record failed to reveal any progress notes of skin assessments being completed or the development of a stage 3 pressure ulcer (wound that has progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). Review of Resident 1's Initial Wound Care Consult Note completed by the wound specialist, dated June 12, 2024, revealed Resident 1 had developed two DTIs (Deep Tissue Injury- localized area of Page 1 of 3 396144 396144 08/22/2024 Exton Post Acute 501 Thomas Jones Way Exton, PA 19341

F 0686 discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and one stage 3 pressure ulcer of sacral region (bottom of the spine). Level of Harm - Actual harm Residents Affected - Few Interview conducted with the Wound Specialist on August 19, 2024, at 2:05 p.m. stated the facility had not completed multiple skin assessments on Resident 1 which led to the resident developing an avoidable stage 3 pressure ulcer on her sacral. Interview conducted with the Director of Nursing on August 19, 2024, at 2:15 p.m. confirmed the above information. The facility failed to monitor Resident 1's skin resulting in Resident 1 developing a stage 3 pressure ulcer to her sacral. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service 396144 Page 2 of 3 396144 08/22/2024 Exton Post Acute 501 Thomas Jones Way Exton, PA 19341

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 a clinical records review and staff interview, it was determined that the facility failed to ensure that the medications ordered by the physician were available for one of the three residents reviewed (Resident CL1). Findings include: Review of Resident CL1's physician's order dated July 24, 2024, revealed that Alpha-Lipoic oral tablet Give one tablet one time a day for Neuropathy (general term for nerve damage that causes weakness, numbness, and pain). Review of Resident CL1's July and August 2024 Medication Administration Record revealed medication for the resident's Neuropathy was not administered from July 24, 2024, until August 3, 2024. Review of the nursing progress notes dated July 30, 2024, at 12:46 p.m., revealed Alpha-Lipoic medication, awaiting delivery. Interview with the Director of Nursing on August 19, 2024, at 1:00 p.m., revealed that the Alpha Lipoic medication was not administered to Resident CL1 on the above-mentioned dates because the pharmacy did not have it and therefore no delivery was done. Review of Resident CL1's physician's order dated July 26, 2024, revealed Medrol (A medication to treat inflammation and pain) Oral tablet therapy pack 4 mg (titration order). Review of Resident CL1's July 2024, MAR revealed Medrol was not administered on July 26, 2024, at 5:00 p.m., July 27, 2024, at 9:00 a.m., and July 27, 2024, at 5:00 p.m. Interview with the DON conducted on August 19, 2024, revealed that Medrol medication was not administered to Resident CL1 on the above-mentioned dates/time due to the pharmacy not delivering it timely. The facility failed to ensure Resident CL1's ordered medication was made available and administered. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service 396144 Page 3 of 3