Inspection·October 9, 2024

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 Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for five of five residents (Residents 1, 2, 3, 4, and 5) and provide incontinence care for one of five residents reviewed (Resident 1). Residents Affected - Few Findings include: Clinical record review for Resident 1 revealed physician orders for staff to administer the following medications: Metoprolol Tartrate 25 mg (milligrams) by mouth (PO) twice daily (BID) for hypertension (high blood pressure) Gabapentin 100 mg PO three times daily (TID) for venous insufficiency Hydralazine 25 mg PO TID for hypertension Lasix 60 mg PO in the morning for edema Escitalopram Oxalate 10 mg PO daily (QD) for major depression Aspirin EC Delayed Release 325 mg PO QD for cerebral infarction (stroke) Allopurinol 300 mg PO QD for gout Pramipexole Dihydrochloride 0.25 mg PO QD for restless legs Vitamin D3 25 mcg 5 tablets in the morning for vitamin deficiency Alphagan P Ophthalmic Solution 0.15% 1 drop bilateral (b/l) eyes BID for glaucoma Fluticasone Propionate 50 mcg/act 1 spray both nostrils (nose) BID Review of Resident 1's September 2024 MAR (medication administration record, a form to document medication administration) revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 6:00 AM and 8:00 AM administration times. Clinical record review for Resident 2 revealed physician orders for staff to administer the (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: 395350 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 395350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Locust Grove Retirement Village 69 Cottage Road Mifflin, PA 17058 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)