Health inspection·April 9, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement a system to assure timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent loss and potential drug diversion. Finding include: Review of facility policy entitled, Disposal/Destruction of Expired or Discontinued Mediation, date revised [DATE], revealed that facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. In Pennsylvania, discontinued and unused medications and medications of discharged or deceased residents shall be immediately removed from the medication cart and brought to nursing supervisory staff. Discontinued and unused medications shall be disposed of at least quarterly. Facility should dispose of discontinued medication, outdated medications, or medications left in Facility after a resident has been discharged in a timely fashion or no more than 90 days. During an observation of the facility's second floor medication room on [DATE], at approximately 9:05 AM accompanied by Employee 2 (Registered Nurse RN - Unit Manager) revealed resident medications stored in the drawers below the counter that included antibiotics, potassium, diabetes, anti-inflammatory, hypertension, pain, and diuretic medications. These medications were in bubbled, blister cards with a preprinted pharmacy label noting the medication, dosage, quantity, and resident names. Located on top of one of the stacks of blister cards, was a white, unlined, piece of paper, with a handwritten note that said all need to take turns as read by Employee 2 RN. A prelabeled bubbled, blister card of Macrobid, noted the dosage and amount of the medication, but lacked a resident's name, which appeared to have been scratched off the label as observed by Employee 2, RN. The label noted Macrobid (an antibiotic) 100 mg, give (illegible- written over) capsules (300 mg) by mouth 2 times a day for UTI for 3 days. Prep date [DATE]. Handwritten was *direction change* 100 mg BID. Located within the labeled bubbled, blister card were 11 capsules, as counted by Employee 2, RN, at that time. Resident CR3 had a physician order for Rifampin (an antibiotic medication) oral capsule 300 mg, give 1 capsule by mouth 2 times a day for joint infection right knee until [DATE], start date [DATE], and discontinued [DATE]. Resident CR3 was transferred to another skilled nursing facility on [DATE]. The resident's medications were located within the labeled bubbled, blister card were 8 capsules, as (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 395265 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 395265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at St Luke Village, The 1000 Stacie Drive Hazleton, PA 18201 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)