Health inspection·February 16, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on review of clinical records and staff interviews, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (affecting the mind) medication for two of six residents reviewed for unnecessary medications (Residents R36 and R39). Findings include: Review of Resident R36's clinical record revealed an admission date of 11/26/22, with diagnoses that included high blood pressure, chronic obstructive pulmonary disease (a group of disease causes breathing difficulties), and anxiety. A physician order dated 2/6/23, identified to administer Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every six hours as needed (PRN) for agitation. Review of Resident R36's February 2023 Medication Administration Record (MAR) revealed that he/she received PRN Ativan on 2/6/23, and 2/12/23. Review of February 2023 Behavioral Intervention Monthly Flow Record and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan two of two times the Ativan was utilized in February 2023. During an interview on 2/14/23, at 11:00 a.m. Licensed Practical Nurse Employee E2 stated that non-pharmacological interventions should be documented on the Behavioral Intervention Monthly Flow Record and/or in the clinical record progress notes. During an interview on 2/14/23, at 3:20 p.m. the Nursing Home Administrator confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan two of the two times it was administered in February 2023. Review of Resident R39's clinical record revealed an admission date of 4/23/20, with diagnoses that included morbid obesity, atrial fibrillation (irregular heartbeat), anxiety, and major depressive disorder. A physician order initiated 12/30/22, identified to administer Ativan 0.5 mg by mouth every 24 hours PRN for anxiety. Review of Resident R39's January 2023 MAR revealed that he/she received PRN Ativan on 1/5/23, 1/14/23, 1/19/23, 1/20/23, and 1/27/23. Review of the January 2023 Behavioral Intervention Monthly Flow Record and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan the five of five times the Ativan was utilized in January 2023. During an interview on 2/15/23, at 1:00 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Ativan five of the five times it was administered in January 2023 for Resident R39. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 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 395355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Brmc, The 200 Pleasant Street Bradford, PA 16701 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, it was determined that the facility failed to appropriately label over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on one of two medication carts (2nd floor). Findings include: During medication pass observation on 2/13/23, between 4:14 p.m. and 4:50 p.m. Residents R28 and R3 received Colace (medication for constipation) per physician orders and Resident R37 received [NAME]-Bid (probiotic) per physician orders from an over-the-counter stock bottle. Inspection of the Colace and [NAME]-Bid bottles revealed that they lacked any resident names for use. During an interview at the time of observation, Licensed Practice Nurse (LPN) Employee E1 confirmed that both the Colace and [NAME]-Bid bottles lacked any resident names. Observation of 2nd floor medication cart on 2/14/23, at 11:42 a.m. revealed that the cart contained open stock medication bottles of Calcium Antacid, Multi-Vitamins with Minerals, Antacid Liquid, Tylenol Liquid, and Vitamin D that lacked any resident names for use. During an interview at the time of observation, LPN Employee E2 confirmed the bottles lacked any resident names. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395355 If continuation sheet Page 3 of 3