Health inspection·April 28, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents reviewed (Resident 1). Residents Affected - Few Findings Include: Review of facility policy, titled Controlled Drugs, Accountability and Responsibility, updated November 30, 2018, revealed The Controlled Drug Record, specific to the drug being administered, is to be signed by the nurse at the time the drug is given to avoid medication errors and discrepancies. Review of Resident 1's clinical record revealed diagnoses that included quadriplegia (paralysis of all four limbs) and hypotension (low blood pressure). Review of Resident 1's physician orders revealed an order for oxycodone (narcotic pain medication), 2.5 mg (milligrams) every four hours as needed for moderate pain and oxycodone, 5 mg, every four hours as needed for severe pain. Review of Resident 1's controlled drug record for the oxycodone (a form used to maintain accurate records of all controlled substances that are being administered) revealed a signature for the nurse dispensing the medication, the date, time and amount dispensed, and the amount of medication remaining. Further review of the form revealed 17 times the oxycodone was documented as being dispensed, between March 4, 2025, and April 14, 2025. Review of Resident 1's MARs (medication administration record), dated March 2025 and April 2025, revealed only eight times that the oxycodone was signed off as being given. Further review of the MAR revealed that two of the eight administrations were documented on the MAR well after the time that the oxycodone was documented as being dispensed; and three of the eight administrations were documented as being administered prior to the time documented as being dispensed. Review of the oxycodone drug record revealed the oxycodone was signed out as being dispensed on the following dates and times, with review of the corresponding [DATE] for those dates and times: March 4 at 11:00 PM- not signed off on the MAR as being administered; Page 1 of 2 396122 396122 04/28/2025 Fox Subacute at Mechanicsburg 120 South Filbert St Mechanicsburg, PA 17055

F 0658 March 4 at 2:30 AM- not signed off on the MAR as being administered; Level of Harm - Minimal harm or potential for actual harm March 4 at 9:00 AM- signed off as being administered at 9:14 AM; March 4 at 4:00 PM- signed off as being administered at 3:42 PM, prior to the medication being dispensed; Residents Affected - Few March 4 at 8:30 PM- not signed off on the MAR as being administered; March 5 at 1:00 AM- not signed off on the MAR as being administered; March 11 at 11:28 PM- signed off as being administered at 11:28 PM; March 13 at 12:48 PM- signed off as being administered at 12:47 PM, prior to the medication being dispensed; March 14 at 11:00 AM- not signed off on the MAR as being administered March 18 at 9:00 PM- not signed off on the MAR as being administered; March 19 at 6:00 PM- not signed off on the MAR as being administered; March 22 at 11:00 AM- signed off as being administered at 12:31 PM, one hour and 31 minutes after the medication was dispensed; March 29 at 1:30 PM- signed off as being administered at 7:39 PM, six hours and 9 minutes after the medication was dispensed; March 31 at 1:00 AM- not signed off on the MAR as being administered; April 5 at 10:47 PM- signed off as being administered at 10:47 PM; April 12 at 9:45 PM- signed off as being administered at 9:10 PM, prior to the medication being dispensed; April 14 at 12:00 PM- not signed off on the MAR as being administered. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing on April 28, 2025, at 1:02 PM, they stated that when staff dispense a controlled substance, they should be signing it off on the controlled drug record with the date and time it is dispensed, and then documenting it on the MAR when the medication is administered. They stated they have no additional information as to why the oxycodone was not always being signed off on the MAR. In a follow up interview with the Nursing Home Administrator and DON on April 28, 2025, at 2:02 PM, it was stated that nursing staff should be documenting on the MAR when a medication is administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396122 Page 2 of 2