Health inspection·January 17, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm observed for signs and symptoms of pain. Education is being completed on the following: current staff on the abuse policy, with focus on misappropriation, on the chain of custody of receiving narcotics, and on the shift to shift count form. To monitor for ongoing compliance the following will occur: Residents Affected - Few -interview 5 random capable residents weekly x 4 then monthly x 2 to ensure they are receiving their pain medication, observe 5 random incapable residents weekly x 4 then monthly x 2 to ensure residents who receive pain medication have no s/s of pain, audit the chain of custody documentation weekly x 4 then monthly x 2 to ensure the process is in place and being followed, and Audit the shift to shift count sheet weekly x 4 then monthly x 2 to ensure the form is filled out correctly to prevent drug diversions. Department of State will be updated. PB 22 investigation to follow. A local detective was in facility on January 2, 2024 to conduct investigation and interview staff. The Detective left facility to conduct interview with Employye 1 (LPN) at police headquarters where Employee 1 (LPN) confessed to stealing the resident's medications. A police report was pending completion. This LPN did have drug testing on file upon hire and was not noted to be or reported by staff to have shown signs or symptoms of intoxication during working hours. Employee 1 (LPN) was terminated by facility. A report with Department of State was submitted to reflect the updated information including LPN's confession. DEA representative to be in the facility on January 3, 2024. A review of Employee 1's emailed to the facility statement dated December 28, 2023, at 11:26 AM revealed that the nurse stated I worked short hall on December 25, 2023, from 7 AM to 3 PM. I do not recall seeing 10 mg card oxycodone for 9 w (Resident 3). There were 19 cards at the beginning of my shift. The sheet said 20 (cards of narcotics) due to a paper (narcotic record sign out sheet) that was zero' d out (all the pills adminstered from the card) on another shift by the ADON (assistant Director of Nursing) that was left in the (narcotic) book. When I counted the cards, I never changed the 20 (cards of narcotics) to 19 (cards of narcotics) before my shift ended. Five cards were taken out for a hospitalized resident and I zero' d out one card on my shift. There were 13 cards at the end of my shift. Employee 1 (LPN) subsequently confessed to taking the oxycodone 10 mg care and the narcotic utilization record during an interview with the local police on January 2, 2024. Upon conclusion of the facility's investigation, Employee 1 was terminated for misappropriation of Resident 3's narcotic medication oxycodone. An interview with the NHA on January 19, 2023, at approximately 11:30 AM confirmed the facility failed to ensure all residents were free from misappropriation of resident property, dispensed medications. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: To identify like residents that have the potential to be affected, -The DON/designee reviewed manifestation sheets going back 7 days to ensure all narcotic delivered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 2 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0602 to the facility were accounted for Level of Harm - Minimal harm or potential for actual harm - The DON/designee interviewed capable residents who receive narcotic medication to ensure they are receiving their pain medication and have no pain. Residents Affected - Few -to identify like residents that have the potential to be affected incapable residents who receive pain medication were observed for signs/symptoms of pain -the facility will develop and implement appropriate plans of action to correct deficiencies and regularly review and analyze data, including data collected under the QAPI program and data specifically related to controlled substance reconciliation. -The DON/designee educated current staff on the abuse policy, with focus on misappropriation, the chain of custody of receiving narcotics, educate licensed nurses on shift to shift count form -facility corporation staff will educate the Nursing Home Administrator and interdisciplinary team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's Quality Assurance Improvement Program, and its participants, implement effective systems to correct deficiencies. -the DON/designee will interview 5 random capable residents weekly x 4 then monthly x 2 to ensure residents are receiving their pin medications -DON/designee will observe 5 random incapable residents weekly x 4 then monthly x 2 to ensure residents who receive pain medication have no signs/symptoms of pain -the DON/designee will audit the chain of custody documentation, the shift to shift count sheet, weekly x 4 then monthly x 2 to ensure the process is in place and being followed. -the DON/designee will interview 5 employees on the abuse policy weekly x 4 then monthly x 2 with focus on misappropriation -the NHA/designee will audit ad hoc QAPI plans weekly x 4 then monthly x 2 related to pharmacy services (accountability of controlled substances), the results of the auditing and ongoing monitoring reviewed at the Quality Assurance Performance Improvement meetings will be reviewed by the corporate regional vice president of operation to ensure adequate implementation of QAPI plans to maintain ongoing compliance. This plan was completed by January 11, 2024. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 3 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select reports and staff interviews it was determined that the facility failed to consistently monitor a resident's skin integrity during use of a therapeutic device to prevent the development of multiple unstageable pressure sores and a Stage II pressure sore, for one resident (Resident 1) and failed to provide timely and necessary care to prevent the development of bilateral heel pressure sores, deep tissue injuries, for one resident (Resident 2) at risk for pressure sores out of three residents sampled. Residents Affected - Few Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 1 was most recently admitted to the facility on [DATE], with diagnoses that included dementia, diabetes and after care for a fractured left tibia. admission physician orders dated October 26, 2023, included an immobilizer brace to the resident's left lower extremity at all times, which staff may remove for hygeine and skin checks every shift. An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 30, 2023, revealed that the resident was severely cognitively impaired, dependent on staff assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development. Resident 1's care plan initiated October 27, 2023, revealed that the resident was at risk for skin breakdown related to decreased mobility, weakness, diagnosis of diabetes and an immobilizer in place to the resident's left lower extremity. The planned interventions were for nursing staff to assess the resident for increased edema when giving care, provide diet as ordered, incontinence products per routine and as needed, a pressure reducing surface to the resident's bed and chair, provide/assist/encourage resident to turn in bed frequently and prn (as needed), and to float heels intermittently as the resident allows. A nursing note dated October 27, 2023 at 9:31 PM revealed that the resident sustained an abrasion to the right inner ankle caused by bumping the immobilizer on left lower extremity. The RN assessed the abrasion on the resident's right inner ankle and treatment as provided. The immobilizer was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 4 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0686 padded to prevent further incident. The physician was updated and a referral made to Physical Therapy for evaluation of the immobilizer brace. Level of Harm - Actual harm Residents Affected - Few When reviewed at the time of the survey ending January 17, 2024, there was no documented evidence that physical therapy had evaluated the resident's use of the immobilizer brace as noted following the abrasion to the resident's right ankle on October 27, 2023. Nursing noted on November 14, 2023, at 10:40 P.M. that three new pressure injuries were found on the resident's left lower leg under the immobilizer. Nursing noted that the resident was anxious with frequent moaning and calling out. Evidence of pain was noted to the resident's right foot, left lower legion, with verbal signs of pain noted. The resident's daughter was present when the new pressure injuries to left lower leg were found under the immobilizer. Wound care was provided and the physician was notified and a treatment was ordered. There was no nursing assessment of the three new pressure sores documented at the time of identification to include size and appearance. A review a skin and wound note dated November 15, 2023, at 11:50 AM revealed three pressure areas were found under Resident 1's left leg immobilizer/brace: -area #1, an unstageable pressure area on the left medial leg measuring 3 cm x 1.5 cm x 0.1 cm, covered in 100% slough ( dead skin, yellow/white in color) with scant amount of serous (Serous drainage is a clear to yellow fluid that leaks out of a wound with tissue damage) and a faint odor; -area #2, an unstageable pressure area on the left posterior lower leg, measuring 3.5 cm x 2 cm , covered in 100% eschar (Eschar, dead tissue that sheds or falls off from the skin. It ' s commonly seen with pressure ulcer wounds. Eschar is typically tan, brown, or black, and may be crusty); and -area #3, a stage 2 pressure area on the left posterior ankle measuring 2.5 cm x 2.5 cm x 0.1 cm with scant serous drainage. A review of a treatment administration record for October 2023 and November 2023 revealed nursing staff documented, once a shift, that the resident wore the Immobilizer Brace to Left Lower Extremity for the closed fracture of the left tibia at all times and that it may be removed for hygiene and skin checks, every shift, since October 26, 2023. However, there was no documented evidence at the time of the survey ending January 17, 2024, that prior to the development of the multiple pressure areas that nursing staff had consistently removed the left lower leg brace to inspect the resident's skin to timely identify skin impairments and prevent the development of the unstageable and stage 2 pressure sores under the brace. A review of facility provided information indicated that the root cause for the development of the pressure area was an ill fitting immobilizer had been provided to the resident prior to admission to the facility for her fractured left leg. There was no evidence at the time of the survey that the facility's therapy staff had assessed the resident's use of the immobilizer after the initial right ankle abrasion on October 27, 2023. During an interview on January 17, 2024 at approximately 2 PM the Nursing Home Administrator confirmed that the facility did not have evidence that nursing staff had removed Resident 1's immobilizer to conduct skin checks prior to the discovery of the three pressure areas on November 15, 2023. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 5 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0686 NHA also confirmed that therapy had not conducted the evaluation of the resident's use of the brace as noted on October 27, 2023. Level of Harm - Actual harm Residents Affected - Few Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses of dementia and hypertension. A physician order was noted upon admission, dated January 2, 2024, to elevate the resident's heels off the bed, as tolerated, every shift for preventative measures to prevent skin breakdown. The resident's care plan noted that the resident was at risk for skin breakdown related to decreased mobility and weakness dated January 3, 2024, with interventions to keep the resident's skin clean and dry, monitor for skin breakdown and pressure reducing surface to bed and chair. The care plan did not specifically identify the physician order to elevate the resident's heels off the bed as tolerated, dated January 2, 2024. An MDS assessment dated [DATE], revealed that Resident 2 was cognitively impaired, required staff assistance for activities of daily living including transfers and bed mobility and was at risk for the development of pressure areas. A review of the resident's January 2024 TAR (treatment administration record) revealed that nursing staff documented completion of the task of elevating the resident's feet daily during each shift of nursing duty. A change in condition note dated January 10, 2024 at 02:59 AM revealed that The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition, Noted drainage of right heel, blister of bottom of heel opened,with clear drainage noted. Area cleansed and a dressing applied. There was no documented evidence at the time of the survey ending January 17, 2024, of any additional nursing assessment, including the size of the pressure area documented in the resident's clinical record at the time of change in condition on January 10, 2024. A wound and skin note dated January 12, 2024, at 04:15 AM revealed that the resident had developed an additional pressure sore on the left heel. Pressure, a blister located on the left planter area of the foot (incorrect area noted in this entry, the pressure sore was actually located on the resident's left heel) measuring 0.3 cm x 0.4 cm, in house acquired. Wound bed appearance is pink, area is noted as a blood blister. The physician was contacted and a treatment as well as apply heel bows while in bed ordered. Skin impairment was not present on admission. During an interview January 17, 2024 at 11 AM the Director of Nursing confirmed that the wound and skin note was incorrect, as it noted that the Wound Location was the left plantar area of left foot and verified at the time of the interview that the pressure sore was a left heel blood blister. A review of a wound note dated January 12, 2024, at 07:51 AM revealed that on assessment, DTIs (deep tissue injuries) were noted to the resident's bilateral heels. Location: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 6 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0686 -LEFT HEEL Pressure, DTI, 2.5 cm x 2 cm x 0 cm. Calculated area is 5 sq cm. Level of Harm - Actual harm Wound Base: Localized area of maroon intact skin Residents Affected - Few Wound Edges: Attached Periwound: Intact - RIGHT LATERAL HEEL Pressure Stage/Severity: DTI Wound Status: New Size: 3 cm x 4 cm x 0.1 cm. Wound Base: 1-24% epithelial , Localized area maroon skin - small opening with epithelial tissue exposed Wound Edges: Attached Periwound: Intact Exudate: Scant amount of Serous A review of a facility investigation report dated January 12, 2024, at 9:40 A.M. revealed that on January 10, 2024, a change in condition was completed for the identified blood blister to the resident's right heel that had opened and was draining serous fluid. The immediate action taken by the facility was that the nurse completed the change in condition form on January 10, 2024, notified the physician of the identified area and received an order for a treatment. An interdisciplinary meeting note dated January 12, 2024, revealed that the entry was status post identification of the area to resident's right heel on January 10, 2024, and the left heel on January 12, 2024. On January 10, 2024 a change in condition was completed for a blood blister to the right heel that opened and was draining serous fluid. On January 12, 2024, a report was completed for a blister on the left heel. Nursing noted an intact blister to the left plantar area measuring 0.3 cm x 0.4 cm. The wound care nurse practioner was in the facility and assessed both heels and documented that both were deep tissue injuries. The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels. Interview with the Director of Nursing on January 17, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the bilateral heel pressure areas for a resident at risk for skin breakdown. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 7 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for two of five residents sampled (Resident 3 and 4) . Finding include: A review of the clinical record revealed that Resident 3 had a physician order dated January 13, 2023, for Oxycodone (a narcotic opioid pain medication) 5 mg Tablet, 2 tablets every 4 hours, as needed for severe pain, pain scale 7-10 (a pain scale, 1-10, 1 least pain, 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on December 20, 2023, at 8:30 P.M, December 21, 2023, at 4 P.M, December 21, 2023, at 8 P.M., December 22, 2023, at 5 P.M., December 23, 2023, at 5 P.M., nursing staff signed out a dose of the resident's supply of Oxycodone 5 mg . However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. A review of a November 2023 MAR revealed that nursing signed out a dose of Resident 3's supply of Oxycodone 5 mg according to the MAR on the following dates: -November 18, 2023 at 11:50 A.M., November 19, 2023 at 07:56 A.M., November 25, 2023 at 08:03 A.M. and November 26, 2023 at 08:31 A.M. --October 1, 2023 at 8 A.M., October 1, 2023 at 12:20 P.M., October 3, 2023 at 8:08 A.M., October 3, 2023 at 1:30 P.M., October 4, 2023 at 5:50 P.M., October 5, 2023 at 4 P.M., October 5, 2023 at 9:30 P.M., October 10, 2023 at 8 A.M and October 10, 2023 at 1 P.M. --September 16, 2023 at 8 A.M., September 16, 2023 at 12:15 P.M., September 17, 2023 at 07:59 A.M., September 17, 2023 at 12:27 P.M., September 19, 2023 at 8:30 A.M., September 19, 2023 at 1:30 P.M., September 25, 2023 at 8:17 A.M. --August 5, 2023 at 08:01 A.M., August 5, 2023 at 12:25 P.M., August 6, 2023 at 07:39 A.M., August 6, 2023 at 1:05 P.M., August 8, 2023 at 07:36 A.M., August 8, 2023 at 1:01 P.M., August 10, 2023 at 4:43 P.M., August 15, 2023 at 08:31 A.M., August 16, 2023 at 08:08 A.M., August 16, 2023 at 1:31 P.M., August 17, 2023 at 5 P.M., August 17, 2023 at 9:01 P.M., August 22, 2023 at 1 P.M., August 24, 2023 at 08:11 A.M., August 24, 2023 at 1 P.M., August 29, 2023 at 07:51 A.M., August 29, 2023 at 1:04 P.M., August 30, 2023 at 3:20 P.M. There were no narcotic sign out records available at the time of the survey ending January 29, 2024, for the months of August 2023, September 2023, October 2023 and November 2023 to reconcile the accounting of the resident's supply of the controlled drug. According to the Medication Administration Records, Employee 1, LPN administered all the doses of Resident 3's prn Oxycodone 5 mg during August 2023, September 2023, October 2023 and November 2023 MARS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 8 of 9 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 395644 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Valley Health Care Center 81 Sturges Road Peckville, PA 18452 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 0755 Level of Harm - Minimal harm or potential for actual harm During an interview, January 17, 2024, at approximately 2 PM the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for the above resident and confirmed the narcotic drug records were missing for the above months and not available to reconcile with the quantity dispensed for the resident and to verify administration to the resident on those date and times. Residents Affected - Some A review of a facility investigation report dated January 9, 2024, at 3 P.M. revealed that on this date and time during shift to shift narcotic count, the day shift RN and the evening shift RN had noticed that one pill from Resident 4's supply of the medication Lacosamide ( a controlled substance, for seizure treatment) 200 mg pills was missing from the from the card and the nursing staff made the Director of Nursing (DON) aware. The DON visualized the controlled substance utilization record as well as the physical card of Lacosamide 200 mg. On the bubble pack in slot 25 there was no pill visible. Bubble packets 26, 27 and 28 were visibly removed and accounted for on the controlled substance utilization record. The remaining pockets were visualized and all pills accounted for. The DON contacted the pharmacy and spoke to the pharmacist to notify them of the incident. The missing pill was identified as a Pharmacy fill error. A review of a pharmacy order invoice revealed that Lacosamide 200 mg by mouth, give one tablet twice daily for seizures. The form indicated that 27 pills were dispensed and delivered to the facility. During an interview January 17, 2024, at 2:15 P.M., the DON confirmed the Pharmacy error and that the licensed nursing staff receiving the controlled medications did not ensure the correct count of the controlled meds upon receipt of the meds at the facility. He also confirmed that licensed nurses completing the shift to shift count of the meds did not ensure all the medications were in the card. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)(2)(k) Pharmacy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395644 If continuation sheet Page 9 of 9