Health inspection·May 2, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 24 sampled was free of chemical restraints (Resident 63). Residents Affected - Few Findings include: A review of Resident 63's clinical record revealed admission to the facility on January 24, 2025, with diagnoses to include cerebral infraction (pathologic process that results in an area of necrotic tissue in the brain), cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). An admission Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated January 24, 2025, indicated that the resident is moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8-12 represents moderate cognitive impairment). A review of resident 63's clinical record revealed that the resident was prescribed Xanax (antianxiety, used to treat anxiety disorders and anxiety caused by depression) Oral Tablet 0.25 MG (milligrams) PRN (as needed) every 8 hours for 30 days, with a start date of February 14, 2025. Additional review of the resident's clinal record revealed an order to administer Nonpharmacological Intervention(s) used before PRN Pain Medication or before PRN antidepressant, antianxiety, antipsychotic or sedative/hypnotic medication Document by number:1 Reposition for comfort 2 massage 3 involve in activity/alt. activity to divert 4 provide quiet setting with reduced stimuli as needed 5 relaxation technique 6 music 7 remove from area 8 direction/distraction with a start date of January 24, 2025. Review of Resident 63's medication administration record (MAR) for the month of March 2025, revealed the facility administered the Xanax to Resident 63 on March 5th 2025, March 12, 2025 and March 14, 2025. Further review of Resdient 63's MAR for March 2025 revealed the facility did not attempt any Nonpharmacological Interventions prior to administering Xanax to Resident 63. Review of Resident 63's progress notes failed to reveal any documentation of nonpharmacological Intervention being attempted prior to the administration of Xanax. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 395952 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 395952 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Naamans Creek Country Manor 1194 Naamans Creek Road Boothwyn, PA 19061 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)