Health inspection·January 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of five residents reviewed (Residents 2, 5). Findings include: The facility's policy regarding Medication Administration, dated May 16, 2024, revealed that staff are required as policy to document the administration of medication in the resident's medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 23, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that include high blood pressure and cerebral palsy (medical condition that affects muscle tone, movement and posture). Physician's orders for Resident 2, dated December 31, 2024, included an order for the resident to receive 325 milligrams (mg) Oxycodone-Acetaminophen (a controlled narcotic pain medication) orally every 12 hours for pain as needed. A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for January 2025 indicated that a dose of 5-325 mg of Oxycodone was signed out on January 8, 2025, at 7:12 p.m. However, the resident's clinical record contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on the dates that were mentioned. A quarterly (MDS) assessment for Resident 5, dated November 27, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included high blood pressure and dementia. Physician's orders for Resident 5, dated April 23, 2023, included an order for the resident to receive 5 mg of Oxycodone every eight hours as needed for pain. A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 5 for January 2025 indicated that a dose of 5 mg of Oxycodone was signed out on January 14, 2025, at 3:10 a.m. However, the resident's clinical record contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on the dates that were mentioned. Page 1 of 2 395618 395618 01/23/2025 Mulberry Healthcare and Rehabilitation Cent 411 1/2 W Mahoning Street Punxsutawney, PA 15767

F 0755 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on January 23, 2025, at 1:14 p.m. confirmed that there was no documented evidence that staff administered Oxycodone to Residents 2 and 5 on the dates mentioned above. 28 Pa. Code 211.9(h) Pharmacy Services. Residents Affected - Few 28 Pa. Code 211.12(d)(1) Nursing Services. 395618 Page 2 of 2