Inspection·November 15, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2, 2024, at approximately 9:55 PM, revealed that Employee 1, a Registered Nurse (RN), notified the Director of Nursing (DON) of a medication error and possible medication diversion (is the illegal distribution or abuse of prescription drugs or their use for unintended purposes). According to Employee 1, RN's statement, Employee 2, a Licensed Practical Nurse (LPN), had prepared Resident A1's scheduled 9:00 PM medications and requested Employee 1, RN administer the medications to this resident because Employee 2 and this resident had a negative intervention in the past. Employee 1, RN proceeded to prepare to administer the medications to resident A1 however, she noticed and confirmed the medications in the medication cup that was pre poured by Employee 2 were Bactrim (an antibiotic) and Glipizide (an oral diabetic medication that helps to control blood sugar levels) which the resident was not prescribed. Employee 1 did not administer these mediations to the resident The medication at that time should have been oxycodone however there was no oxycodone 5mg (narcotic medication used for pain relief) present in the medication cup at that time. Employee 1 reviewed the resident's medication orders and obtained the medications from the facility's emergency medication box. The resident received his medications as prescribed. Employee 1, RN, and Employee 2 LPN reviewed the narcotic medications and determined the medications were accounted without any discrepancies. According to the findings of the facility investigation, the facility immediately suspended both nursing staff involved and completed a five-panel drug screening that were both negative. Pharmacy was contacted and notified and did a review of narcotics and the narcotic counts were correct. An immediate audit of the medication cart was completed, and the narcotics were counted and all accounted for and free from tampering. The Attorney General's office was notified and local police. The facility conduced immediate staff re-education for licensed staff performing medication administration. The facility concluded the findings of misappropriation of resident A1's narcotic medication, could not be substantiated. Employee 2, LPN failed to submit a statement and was terminated. A review of Employee 1 RN's employee file revealed that she was hired on September 9, 2024. A medication skills checklist, competencies for medication administration was signed as completed on September 9, 2024. A review of Employee 2 LPN's employee file revealed that she was hired on July 14, 2021. A medication skills checklist, competencies for medication administration was signed as completed on April 9, 2024. During an interview with the NHA and DON, and in the presence of the regional NHA, on November 15, 2024, at approximately 1:00 PM, revealed that all licensed nursing staff responsible for administering medications and completing treatments were expected to provide nursing services consistent with professional standards of quality as defined by the PA Code Title 49, Professional and Vocational standards. Additionally, the NHA and DON confirmed that on October 2, 2024, during the 7:00 PM to 7:00 AM shift, Employee 1 and Employee 2 failed to follow the facility's medication administration policies and procedures by pre-pouring medications and ensuring that prepared medications were administered by the licensed nursing staff preparing the medication in efforts to prevent a potential drug diversion and medication errors. The facility failed to ensure that nursing staff had the demonstrated the competencies and skills sets to accurately administer resident medications. and confirmed that Employee 2 (LPN) did prepour medications that that were not prescribed for this resident and omitting a medication triggering an investigation into the potential diversion of medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 2 of 3 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 395484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kadima Rehabilitation & Nursing at Luzerne 463 North Hunter Hwy Drums, PA 18222 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)

F 0726 28 Pa. Code 210.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (d)(1)(2)(5) Nursing Services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395484 If continuation sheet Page 3 of 3