Health inspection·June 5, 2024

F 0602 pain of seven to 10, or every hour as needed for dyspnea (shortness of breath). Level of Harm - Minimal harm or potential for actual harm A review of Resident 4's controlled medication record for the Morphine Sulfate revealed a discrepancy was identified in April 2024, after a dose was documented as administered on April 11, 2024, at 11:22 AM with 11 ml remaining in the bottle. The next entry on the controlled medication record was dated April 20, 2024, noting the count was corrected to 9 ml remaining on hand. A 2 ml (8 doses) decrease from the amount remaining on April 11, 2024, with a signature from a registered nurse and Employee 2. Residents Affected - Some A review or Resident 4's April 2024, medication administration record did not indicate any doses of the Morphine Sulfate were administered between April 11 and April 20, 2024, when the discrepancy in the count was noted. A review of the facility staff's investigation into the discrepancy in the Morphine Sulfate counts for Residents 4 and 5 documented on April 20, 2024, or an investigation into the discoloration of Resident 5's bottle of Morphine Sulfate mentioned in the above interviews revealed the following: A registered nurse, Employee 3's, statement dated April 20, 2024, noted the registered nurse counted the narcotic drawer with Employee 4, LPN, on the 6 AM - 2 PM shift identifying the levels on Resident 5's bottle as 12 ml when the sheet read 13.5 ml. A note was on the bottom of the sheet indicating a dose was not checked on April 16, 2024, which was the last known dose, and a second bottle for Resident 4 was found with a content of 9 ml. The narcotic sheet was showing 11 ml with the last known dose charted on April 11, 2024. The statement noted Employee 4 wrote a statement and was given permission to leave by the administrator. Review of a statement from Employee 4 dated April 20, 2024, noted when counting narcotics with the 10 6 nurse (name not noted) prior to starting the 6-2 shift Employee 4 noted the Morphine levels were not compatible to the countdown sheets verses the actual bottles for two residents. The licensed nurse noted immediately reporting the discrepancy to a registered nurse (only listed by first name) who came to the floor and looked at the bottles and noted they did not match and that she would take care of it, and that that another 10-6 nurse found an error where another nurse had not marked it down when a dose was given. Employee 4 noted that the registered nurse placed a sticky note for the missed dose to be signed by the nurse that failed to do so on the sheet and that all was ok. Employee 4 noted both nurses left the floor without the sheets being corrected or initialed by the registered nurse it was reported to. Employee 4 then made the 6AM-2PM registered nurse supervisor aware (noted as Employee 3) of the two bottles of Morphine that had not been corrected, by the 10 PM - 6AM registered nurse. There was no additional documentation provided at the time of the survey into the investigation of the discrepancy of the counts of the Morphine doses in the counts for Residents 4 and 5 identified on April 20, 2024. There were no additional staff interviews provided for any staff with access to the medications between the last confirmed counts and the discrepancy, or the registered nurse Employee 4 noted was first made aware of the discrepancies. There was no evidence facility staff reported an alleged allegation of misappropriation with a completed investigation of Resident 4 or Resident 5's Morphine discrepancies to the Department of Health when the discrepancy in dosage counts were identified on April 20, 2024. A review of email communication between the Nursing Home Administrator and facility pharmacist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395895 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 395895 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley View Rehab and Nursing Center 2140 Warrensville Road Montoursville, PA 17754 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated May 23, 2024, at 12:22 PM revealed a discrepancy in the color of liquid Morphine Sulfate in a bottle was noted as brownish/clear instead of a light blue in color, and questioned if the color could change over time, and if it was safe to use. The pharmacist replied by email at 1:02 PM the same day noting the morphine concentrate should not change color over time, and the change in color reported likely indicates contamination and/or diversion and recommended a new supply be ordered for the resident, and to complete an investigation for possible diversion by inspecting the color of all morphine concentrate bottles in the facility, checking the controlled substance logs and signature sheets, monitor reports from residents of morphine doses being ineffective, document all findings and steps of the investigation, and contact authorities if indicated. In a follow up email to the pharmacist later the same day at 2:42 PM a picture of the discolored bottle beside five additional bottles was attached indicating the color is darker blue on the left, should we destroy? The pharmacist responded at 2:51 PM noting it may be destroyed per protocol once you have documented investigation findings to include the picture of the medication, lot number, expiration date, date opened, and any other notable aspects of the medication. An observation of the photo of the bottle of the discolored Morphine liquid was provided by the Director of Nursing with five additional bottles visible in the photo belonging to other residents on the same unit, which showed a discoloration compared to shades of light blue in the additional bottles. The date on the discolored bottle could be seen as 2/2 as the first parts of the date and the Director of Nursing confirmed the bottle belonged to Resident 5. There was no additional information provided as to any further investigation (i.e., staff interviews) to any prior notice of the resident's medication being a different color, or additional steps to the investigation as recommended by pharmacy prior to the disposal. Review of Resident 5's controlled medication record for the Morphine had not noted any entries of any administration of the medication since the dosage count was corrected as referenced above on April 20, 2024. In an interview with the Director of Nursing on June 5, 2024, at 2:30 PM the Director of Nursing indicated the discolored bottle of Morphine for Resident 5 was discarded and other than the photo comparing the color of the Morphine liquid to other bottles on the unit, there was no other investigation to rule out the potential diversion of the Resident's medication. In the same interview with the Director of Nursing on June 5, 2024, at 2:30 PM the Director of Nursing confirmed there were no additional staff interviews or investigation documentation available for the identified discrepancy in Morphine counts on April 20, 2024, for Resident 4 and Resident 5, to determine a justified reason for the discrepancy, or rule out misappropriation, or rule out potential diversion of the resident's medication. There was no rationale why the investigation was not conducted when it was first reported by Employee 5 to a prior shift registered nurse. The Director of Nursing stated the doses of Morphine liquid is hard to count due to the bottle being marked in 5 ml increments. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 5, 2024, at 3:20 PM. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395895 If continuation sheet Page 3 of 3