Bridgeville Rehabilitation & Care Center

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

27 cards in the narcotic drawer and signed the count was correct. On 11/9/25 at approximately 4:45 a.m.

Resident Resident R1 requested the Oxycodone HCL 5 mg. Employee RN E4 was unable to locate the Oxycodone

in the narcotic drawer, both the narcotic card and narcotic sheet was unaccounted for. Review of a statement written by RN Employee E5 dated 11/9/25, indicated I counted with RN Employee E4 at 11:00 p.m. count correct. I never gave Resident Resident R1 a pain pill other than Tylenol as she did not request for anything stronger. RN Employee E5 at approximately 1:00 p.m. on 11/8/25 noted the binder fell off the med cart and RN Employee E5 had to put all the papers back in the narcotic book. Review of a statement written by RN Employee E4 dated 11/9/25, indicated, on 11/9/25 approximately 2306 (11:06 p.m.) Counted narcs (narcotics), TCU cart with RN Employee E5. 27 of 27 narcotic cards. Approximately 4:45 a.m. Resident Resident R1 requested a pain pill oxycodone, and none were signed out on the computer. I looked for the controlled substance tracking sheet and card, there were none. I flipped to the shift change inventory count signoff sheet from the prior day and it was missing. Review of a statement written by Licensed Practical Nurse (LPN) Employee E6 dated 11/9/25. RN Employee E4 asked her opinion with Resident Resident R1 wanting a pain pill however she doesn't have a medication card or paper for the requested narcotic. The resident states

she has been getting pain medication, but it hadn't been documented in the computer as given. LPN Employee E6 and RN Employee E4 reviewed the controlled substance tracking book and RN Employee E4 stated the original tracking sheet had been removed and a new one placed (as the new document didn't have RN Employee E4's documentation of 11/8/25 acknowledgement of the Oxycodone card (receipt), the card identification number, and a count of 29/29 narcotic cards documented. LPN Employee E6 found the missing narcotic count signoff sheet that contained the acknowledgement of the Oxycodone card (receipt) and the card identification number documented by RN Employee E4 folded in half, in the recycle bin, it was unsigned by RN Employee E5 during that shift change (shift change count sheets note nurse coming on shift must verify count of all controlled substances with nurse going off shift and anytime the medication cart keys are exchanged.). LPN Employee E6 stated they did not find the missing Oxycodone or the corresponding drug count record paper that should have been in the binder. During review of facility documents, dated 11/9/25 at approximately 4:45 a.m. the resident requested Oxycodone pain medication and did not receive the medication until 6:00 a.m. on 11/9/25 due to the missing medication and associated medication documents. RN Employee E4 discussed with LPN Employee E6 resident states she has been getting pain medication, but it hadn't been documented in the computer as given. There is no evidence that RN Employee E5 was asked for or provided any statement regarding not signing the shift change count sheet of 11/8/25 at 7:00 a.m. that contained the 29/29 narcotic cards and or how the count changed to 27/27 narcotic cards at 11/8/25 p.m. There is no evidence of an interview being conducted with the resident. Education was completed in November by the facility in response to this event, policy for abuse, neglect and exploitation was conducted and confirmed with staff interviews. During an interview on 12/22/25 at approximately 12:00 p.m. the Director of Nursing confirmed only RN's Employee ‘s E4 and E5 had the keys that access to the medication cart from 11/7/25 at 11:00 p.m. through 11/9/25 at approximately 10:15 a.m. employee RN Employee E5 (left her shift due to a family emergency). The facility determined, they are unable to identify a perpetrator in this event, and the facility did file a report with the local police department. During an interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that residents are free from misappropriation of property for one of four residents (Resident Resident R1). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeville Rehabilitation & Care Center

3590 Washington Pike Bridgeville, PA 15017

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 0610 Level of Harm - Minimal harm or potential for actual harm

at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to investigate misappropriation of resident property for one of four residents (Resident Resident R1). 28 Pa. Code: 201.18(e)(1)(2) Management. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 PA. Code: 211.12(a)(c)(d)(1)(3)(5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeville Rehabilitation & Care Center

3590 Washington Pike Bridgeville, PA 15017

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure stored medications and/or biologicals in two of three medication rooms (TCU and Harmony Unit Medication Rooms).Findings include: Review of facility policy Medication Storage dated 10/27/25, indicated that medications and biologicals that the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. During rounds on 12/22/25, at 10:45 a.m. the Director of Nursing (DON) and surveyor checked the Harmony Unit Medication Room and the TCU Medication Room.

The doors were unlocked with medications that were designated to be returned, sitting on the counter.

These doors require a key to be locked. Education was completed in November by the facility in response to this event, policy for controlled substances administration, ordering, storage, handling and disposal, confirmed with staff interviews. During an interview on 12/22/25, at approximately 9:50 a.m. Licensed Practical Nurse Employee E1 confirmed he had a key to the Harmony Unit Medication Room and that the door should be locked. During an interview on 12/22/25, at approximately 9:55 a.m. Licensed Practical Nurse Employee E2 confirmed she had a key to the Harmony Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door. During an interview on 12/22/25, at approximately 10:00 a.m. Licensed Practical Nurse Employee E3 confirmed she had a key to the TCU Unit Medication Room and that the door should be locked and proceeded to lock the unlocked door. During an

interview on 12/22/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly secure medications and/or biologicals in one of two medication rooms. 28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet