Health inspection·January 14, 2026

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 clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of five residents reviewed (Residents 2,3,5).Findings include: The facility's policy regarding medication administration, dated May 14, 2025, indicated that nursing staff who administer medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time the medication was administered. Documentation is to be done immediately after the administration. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 20, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was at risk for pain related to spinal stenosis and discitis (inflammation and infection in the disc space in the spine).Physician's orders for Resident 2, dated October 20, 2025, included an order for the resident to receive 5-325 mg of Percocet (a narcotic pain medication) every six hours as needed for chronic back pain.Review of the controlled drug record for Resident 2, dated October 2025, revealed that one 5-325 mg tablet of Percocet was signed out on October 24, 2025, at 3:30 p.m. and October 25, 2025, at 9:00 a.m. However, there was no documented evidence in Resident 2's clinical record, including the MAR, that the signed-out doses of Percocet were administered to the resident on the above-mentioned dates and times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 27, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was at risk for pain related to spinal stenosis and diabetic neuropathy, was recently admitted to hospice, and was taking an opioid medication (medications with the potential to be abused, used to treat pain).Physician's orders for Resident 3, dated January 10, 2026, included an order for the resident to receive 10 milligrams (mg) of Morphine (a narcotic pain medication) under the tongue, every two hours as needed, for pain or respiratory distress.Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 3, dated January, 2026, revealed that a 10 mg tablet of Morphine was signed out on January 10 at 8:00 a.m., 1200 p.m. and 4:00 p.m. However, there was no documented evidence in Resident 3's clinical record, including the Medication Administration Record (MAR), that the signed-out doses of Morphine were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 5, dated December 29, 2025, revealed that the resident was cognitively intact, had pain occasionally, was taking a routine and as needed pain medication, and was taking an opioid medication.Physician's orders for Resident 5, dated December 29, 2025, included an order for the resident to receive 5-325 mg of Percocet (a narcotic pain medication) every 12 hours as needed for pain.Review of the controlled drug record for Resident 5, dated December 2025 and January 2026, revealed that one 5-325 mg tablet of Percocet was signed out on December 28, 2025, at 6:15 p.m. and January 5, 2026, at 10:30 a.m. However, there was no documented Page 1 of 2 395892 395892 01/14/2026 Kadima Rehabilitation & Nursing at Latrobe 576 Fred Rogers Drive Latrobe, PA 15650

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evidence in Resident 5's clinical record, including the MAR, that the signed-out doses of Percocet were administered to the resident on the above-mentioned dates and times.Interview with the Director of Nursing on January 14, 2026, at 3:57 p.m. confirmed that there was no documented evidence in Residents 2, 3 and 5's clinical records to indicate that the signed-out doses of narcotics were administered to the residents on the above-mentioned dates and times.28 Pa. Code 211.9(a)(1) Pharmacy Services.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395892 Page 2 of 2