Continuing Care At Maris Grove

Review of Resident 29's nursing progress notes dated January 9, 2026, at 11:32 a.m., revealed the resident was a new admit with a diagnosis of falls and right sided weakness.

The same note revealed the residents' cognition was intact and able to verbalize needs.

Further review of the notes revealed the resident was continent of bowel and bladder and requires a lift with two staff assistance for transfers.

Review of Resident 29's bowel records revealed that the resident did not have a bowel movement for nine days, from January 8, 2026, until January 16, 2026.

Review of Resident 29's nursing progress notes dated January 10 and 11, 2026, failed to reveal that the resident was assessed for not having a bowel movement for more than 9 shifts.

There was no documentation that the physician was notified that the resident had not had a BM for more than nine shifts. An interview with the Director of Nursing on February 20, 2026, at 10:00 a.m., confirmed that Resident 29's absence of bowel movement for more than nine shifts were not addressed and was not communicated with the physician.

The facility failed to ensure Resident 29's bowel status was appropriately monitored and addressed for not having a bowel movement for more than nine shifts. A review of Resident 54's physician's order dated December 11, 2025, revealed an order for Eliquis (A blood thinner medicine that reduces blood clotting) 5 mg one tablet two times daily for A-fib (Atrial fibrillation-Irregular heartbeat), and pacemaker (A small, battery operated device implanted under the skin, to regulate an irregular heartbeat by sending electrical signals to the heart muscle). A review of Resident 54's, December 2025, Medication Administration Record (MAR) revealed that Eliquis was not administered to the resident on the following dates/times: December 27, 2026, at 8:00 p.m., December 28, 2026, at 8:00 a.m., and 8:00 p.m.

Further review of the same MAR revealed that Eliquis medication was not administered three times due to the reason: awaiting arrival from pharmacy. A review of Resident 54's nursing progress notes dated December 27 and 28, 2026, failed to reveal that the physician was notified of the missed Eliquis doses. A review of the facility's automated dispensing cabinet (A secure computerized units used to store, manage, and dispense medications at the point of care) inventory list revealed that Eliquis medication was available in the facility. An interview with the Director of Nursing on February 20, 2026, at 10:00 a.m., confirmed that Resident 54's Eliquis was not administered three times despite medication being available in the facility's automated dispensing cabinet.

The DON reported that the physician was not notified of the missed doses until December 30, 2026, after an audit identified the medication error that occurred on December 27 and 28, 2026.

The facility failed to ensure Resident 54's Eliquis medication order was followed. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

396123 02/20/2026

Continuing Care at Maris Grove 500 Maris Grove Way Glen Mills, PA 19342

accordance with physician orders for one out of 15 resident reviewed (Resident 26).Findings

hospital after oral surgery with a diagnosis of acute hematogenous osteomyelitis (a bone infection that originates from bacteria traveling through the bloodstream) and sepsis (an illness that occurs when an infection triggers an extreme immune response in the body). Resident 26 was admitted with a double-lumen PICC (a peripherally inserted central catheter with two lines that allows the provider to deliver more than one therapy directly into the blood stream) to the right chest wall.Facility policy Central Vascular Access Device (CVAD) Dressing Change dated January 15, 2004, states: 1.

Perform sterile dressing changes using Standard-ANTT (Aseptic Non Touch Technique, a standardized approach to procedures aimed at reducing healthcare-acquired infections): 1.1 Upon admission, 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label, 1.2 At least weekly.A review of Resident 26's medication administration record revealed orders dated February 1, 2026, for Clindamycin (an antibiotic) 600mg/50ML in 5% dextrose (a fluid used to deliver intravenous medication) intravenous piggyback (a method of delivering medication through an existing intravenous line allowing patients to receive smaller volumes of medication alongside primary intravenous fluids) three times a day for 46 days.A review of Resident 26's medication administration record revealed a physician order dated January 31, 2026, stating Change central line dressing on admission and weekly.Review of Resident 26's medication administration record (MAR) revealed this order was signed off by licensed staff as complete on February 7, 2026, and February 14, 2026, on the evening shift.Observation of Resident 26's picc line site on February 20, 2026 at approximately 1:30PM revealed a dressing dated February 7, 2026.

Two Registered Nurses confirmed this observation (E4 and E5) on February 20, 2026 at approximately 1:40PM.An interview with the DON on February 20, 2026, at approximately 2:30PM confirmed the that dressings should be labeled with the date they are changed and that the dressing was not changed on February 14, 2026 as documented in the MAR.28 Pa.

Code 211.12 (d)(1)(5) Nursing Services