Health inspection·April 20, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, clinical records and documentation provided by the facility, it was determined that the facility failed to ensure residents were free from significant medication errors causing harm of hospitaization to one of eighteen residents reviewed (Resident 230). Residents Affected - Few Findings include: Review of facility policy and procedure titled Medication Administration revealed The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical records and if necessary, verifying resident identification with other facility personnel. Additional review of the Medication Administration policy revealed The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review of the Medication Administration policy revealed the following information is checked/verified for each resident prior to administering medications: a) allergies to medications; and (b) vital signs if necessary. Review of Resident 230's diagnosis list revealed diagnoses including acute respiratory failure with hypoxia, Chronic Kidney Disease (failure of the kidneys to function properly), and Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 230's allergy list included allergies to Baclofen (muscle relaxant) and Gabapentin (anti-seizure and nerve pain medication). Review of Resident 230's clinical progress notes dated December 7, 2022, revealed [nurse practitioner] made aware of med error, patient was given another patient's medication. Gabapentin which causes patient to hallucinate and Baclofen which causes restless leg syndrome and insomnia in patient. New verbal order received and noted. RP [representative] needs to be made aware 12/8/2022. Neuro checks time 72 hours. Further review of Resident 230's clinical progress notes dated December 8, 2022, revealed This RN [Registered Nurse] and DON [Director Of Nursing] assessed [resident] this morning. [resident] was laying in her bed appeared to be sleeping, attempts made to arouse her via verbal and tactile stimuli. She was unresponsive, blood sugar 108, BP [blood pressure] 111/59, HR [heart rate] 68, pulse ox (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 2 Event ID: 395326 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 395326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Zerbe Sisters Nursing Center, 2499 Zerbe Road Narvon, PA 17555 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)