Inspection·February 21, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medications for one of 12 residents reviewed (Resident R19). Residents Affected - Few Findings include: Review of facility policy entitled Self-Administration of Medications dated 1/10/25, revealed that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: Ability to read and understand medication labels; Comprehension of the purpose and proper dosage and administration time for his/her medications; Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; Ability to recognize risks and major adverse consequences of his/her medications. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications. Resident R19's clinical record revealed an admission date of 11/01/19, with diagnoses that included Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), Asthma (a condition that causes a person's airway to become inflamed, narrow, swell and make it difficult for a person to breath), and muscular dystrophy (a genetic disease that causes progressive weakness and loss of muscle mass). Observations on 2/18/25, at 2:40 p.m., on 2/19/25, at 9:48 a.m. and again on 2/20/25, at 12:15 p.m. revealed Resident R19 with a Ventolin HFA Inhalation Aerosol Solution (inhaler medication to treat asthma) on the bedside tray table. During an interview with Resident R19 on 2/18/25 at 9:48 a.m. he/she stated I always have my inhaler on my bedside table, I just tell the nurse if I have used it. During an interview with Resident R19 on 2/19/25, at 9:48 a.m. he/she stated I haven't used my inhaler in a long time, maybe a few months. Resident R19's clinical record revealed a physician's order dated 11/10/23, for Ventolin HFA Inhalation Aerosol Solution 108 MCG [micrograms]/ACT 2 puffs inhale orally every 4 hours as needed for SOB (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395877 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 395877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland View Rehabilitation & Healthcare Center 90 Main Street Brockway, PA 15824 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)