Health inspection·December 20, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed to indicate the code status as Full Code (CPR[cardiopulmonary resuscitation]/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 18 residents reviewed (Resident R26). Findings include: No facility policy was provided regarding a physician's order in the electronic medical record (EMR) for a resident. Resident R26's clinical record revealed an admission date of [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a condition where the lungs are unable to provide oxygen to the body), cardiac heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus type one (a condition where the pancreas makes little or no insulin to carry the blood sugar into the cells of the body resulting in high blood sugars), and constipation. Resident R26's EMR lacked a physician's order to indicate a code status as either a Full Code or DNR. During an interview on [DATE], at 11:10 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that he/she would refer to the EMR where all the physician's orders could be readily accessed when a resident had a change in condition and the code status would need to be referenced. LPN Employee E1 further confirmed that R26's EMR lacked a physician's order for code status, but the header of the resident's EMR stated as DNI which LPN Employee E1 indicated was a Do not initiate. During an interview on [DATE], at 11:30 a.m. the Director of Nursing confirmed that Resident R26's EMR lacked a physician's order to indicate a code status as Full Code or DNR. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records Page 1 of 4 395550 395550 12/20/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

F 0578 28 Pa. Code 211.10(a) Resident care policies Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395550 Page 2 of 4 395550 12/20/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

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 facility policy and clinical records, and staff interview, 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 a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R24). Findings include: A facility policy entitled Behavioral Assessment, Intervention, and Monitoring dated 11/02/24, indicated that non-pharmacological approaches will be used to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and that other approaches and interventions will be tried prior to the use of antipsychotics medications. Resident R24's clinical record revealed an admission date of 5/07/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Resident R24's clinical record revealed a physician's order dated 11/12/24, with a discontinuation date of 11/20/24, that identified to administer Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth twice daily PRN for anxiety. A physician's order dated 11/20/24, with a discontinuation date of 12/04/24, identified to administer Lorazepam 0.5 mg po twice daily PRN for anxiety. A physician's order dated 12/06/24, with a discontinuation date of 12/19/24, identified to administer Lorazepam 0.5 mg po twice daily PRN for anxiety. Resident R24's November 2024 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used seven times (11/12/24, 11/23/24, 11/16/24, 11/18/24, 11/20/24, 11/17/24, and 11/18/24). Review of the November MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam seven of the seven times it was used. Resident R24's December 2024 MAR revealed that the PRN Lorazepam was used nine times (12/03/24, 12/06/24, 12/07/24, 12/09/24, 12/10/24, 12/15/24,12/16/24, 12/17/24, and 12/18/24). Review of the December MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam nine of the nine times it was used. During an interview of 12/19/24, at 1:45 p.m. the Director of Nursing confirmed that Resident R24's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395550 Page 3 of 4 395550 12/20/2024 Dr Arthur Clifton McKinley Ctr 133 Laurelbrooke Drive Brookville, PA 15825

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. Based on review of facility policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were discarded in a timely manner for one of two medication rooms observed (1st floor medication room) Findings include: A facility policy entitled Medication Labeling and Storage dated 11/02/24, indicated that multi-dose vials that have been opened or accessed (example - needle punctured) are dated and discarded within 28-days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's recommendations for Tubersol PPD (solution used to test for tuberculosis) indicated that vials which are entered and in use for 30-days should be discarded. Observation of drug storage on 12/18/24, at approximately 10:01 a.m. in 1st floor medication storage room refrigerator revealed an opened vial of Tubersol PPD with and an open date of 11/15/2024, making the discard date 12/15/24. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the open Tubersol PPD vial was past 30-days and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services 395550 Page 4 of 4