Health inspection·January 24, 2025

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon facility policy review, clinical record review, and interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 134). Findings include: Review of facility records revealed a policy titled [NAME] Rx Policy and Procedures Manual, Subject: Medication Regimen Review, dated June 1, 2023, documenting resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the pharmacy's consulting records and reported to the resident's attending physician, the facility's Medical Director and Director of Nursing as appropriate. The physician will accept and document that the irregularity has been reviewed. The attending physician should document his or her rationale in accordance with federal and state regulations. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue D-Mannose (a dietary supplement used to treat or prevent urinary tract infections), as the resident continues to have urinary tract infections (UTIs). Use should also be avoided in patients with diabetes (disease that affects how the body uses blood sugar) due to effects on blood sugar. Review of R134's clinical record failed to reveal that the above recommendation was addressed by the physician. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Melatonin (a hormone that regulates day and night cycles) for insomnia, as the resident is also ordered Trazadone (an antidepressant) for insomnia. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Glucosamine-Chondroitin (supplement for joint pain) for osteoarthritis, as pain has been uncontrolled with use of this supplement, and it is likely not contributing to pain relief. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue PreserVision AREDS 2 (a multivitamin), as resident is already ordered a daily multivitamin with minerals (Centrum Silver Women 50+). Page 1 of 2 395780 395780 01/24/2025 Fair Acres Geriatric Center 340 N. Middletown Road Lima, PA 19037

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to change timing of Omeprazole (a stomach acid reducer), to 30-60- minutes prior to breakfast to optimize effectiveness. Review of R134's clinical record failed to reveal that the above recommendations were addressed by the physician. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 24, 2025, at 1:30 p.m. when the above information was presented, the DON confirmed there was no documented evidence of a response by the physician to the recommendations made by the consulting pharmacist. 483.45 Drug Regimen Review, Report Irregular, Act on 28 Pa. Code 211.5(f) Clinical records 395780 Page 2 of 2