Health inspection·July 11, 2024

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 observation, review of clinical records and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for two of three medication carts observed. (Medication Cart 3rd Floor B Front and Medication cart 3rd Floor B Back) Findings: Review of facility narcotic book for Medication Cart 3rd Floor B Front conducted on July 10, 2024, at 8:52 p.m., during medication administration observation with licensed nurse, Employee E5 revealed an entry for July 10, 2024, with time written 1900 (7:00 p.m.). Further, the column for Nurse going off duty for July 10, 2024, with time written for 1900 had a signature. Interview with licensed nurseEmployee E5 conducted at the time of the observation, revealed that licensed nurses work a 12-hour shift and that between shifts, the outgoing and incoming nurses count the narcotics together and that the once they are done counting the controlled substances in the cart, the outgoing nurse signs the outgoing column of the narcotic book for that date and the incoming nurse also signs the incoming column of the narcotic book for that date. Further interview with Employee E5 revealed that licensed nurse Employee E5 was the one who counted the narcotics at the beginning of the day shift on July 10, 2024. Interviewed with Employee E6 conducted at the time of the observation, confirmed that at the beginning of the day shift for July 10, 2024, he pre signed the column for Nurse going off duty for July 10, 2024, for which the time 19:00 was written. Further Employee E6 also revealed that he pre signed it because he was going to be the one to sign it at the end of his shift anyway. Further review of the narcotic book for Medication Cart 3rd Floor B Front revealed that on: June 6, 2024 at 7:00 (1.m.), the column Nurse going off duty did not have a signature. June 22, 2024, at 11:00 p.m., the column Nurse coming on duty did not have a signature. June 23, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 25, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. (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 4 Event ID: 396101 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 396101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab at Shannondell 5000 Shannondell Drive Audubon, PA 19403 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)