Health inspection·November 20, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined the facility failed to ensure residents were free from significant medication errors for three of five residents reviewed (Resident R1, R2, and R3).Findings Include:Review of undated facility policy Administering Medications revealed medications should be administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label three times to verify the right resident, right medication, and right dosage before giving the medication. The individual administering medications should verify the resident's identity before giving the resident his/her medication.Review of Resident R1's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 31, 2025, revealed the resident was admitted to the facility on [DATE], assessed as cognitively intact, and had diagnoses of atrial fibrillation (irregular heart rhythm), anxiety (definition) and depression (definition).Review of Resident R1's clinical record revealed a physician order dated September 25, 2025, to administer oxybutynin chloride table 5 milligrams (mg) two times a day for bladder spams. The medication was scheduled to be given at 8:00 a.m. and 4:00 p.m. daily. Review of Resident R2's comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], assessed as cognitively intact, and had diagnoses of heart failure, hypertension (high blood pressure), renal insufficiency (impaired kidney function), diabetes mellitus (persistently high levels of sugar in the blood), hyperkalemia (high potassium levels in the blood), anxiety, and depression. Review of Resident R2's clinical record revealed physician orders effective September 28, 2025, including, but not limited to, Coreg oral tablet 25 mg two times per day (used to treat hypertension), hydralazine 50 mg three times per day (used to treat hypertension), allopurinol oral tablet 100 mg daily (used to treat gout), and losartan potassium 100 mg daily (used to treat high blood pressure and reduce risk of stroke). Review of Resident R2's clinical record revealed a nursing note dated September 29, 2025, that the physician assistant was made aware that the resident received a one-time dose of oxybutynin. Review of facility documentation revealed on September 28, 2025, at approximately 5:00 p.m. licensed nurse, Employee E3, pre-poured medications into small cups for roommates, Resident R1 and Resident R2. Licensed nurse, Employee E3, entered the room with both cups and provided Resident R2 with the medication cup that were intended for Resident R1. After taking the medication, Resident R2 realized the name on the cup of medication was for Resident R1. The medication was identified as oxybutynin chloride 5 mg. Review of statement by licensed nurse, Employee E3, dated September 29, 2025, confirmed Resident R2 was given the medication that was prescribed/intended for Resident R1. The medication was identified as oxybutynin chloride 5 mg.Continued review of Resident R1's clinical record revealed a physician order dated September 1, 2025, for Spiriva 10 micrograms (mcg) via inhalation daily (medication that relaxes muscles in the airways and increases air flow to the lungs). Further review of Resident R1's clinical record revealed a nursing note Residents Affected - Some (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: 395483 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 395483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Markley Rehabilitation and Healthcare Center 550 East Fornance Street Norristown, PA 19401 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)