Health 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 Page 1 of 3 395877 395877 02/21/2025 Highland View Rehabilitation & Healthcare Center 90 Main Street Brockway, PA 15824

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [shortness of breath]/wheezing. Resident R19's clinical record lacked a self-administration of medication assessment or a physician's order to keep the Ventolin Inhaler at the bedside. During an interview on 2/20/25 at 12:15 p.m. the Nursing Home Administrator confirmed that Resident R19's Ventolin Inhaler was on his/her bedside table and that his/her clinical record lacked a self-administration assessment of medication and self-administration order. 28 Pa. Code 211.5(f)(i)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services 395877 Page 2 of 3 395877 02/21/2025 Highland View Rehabilitation & Healthcare Center 90 Main Street Brockway, PA 15824

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 observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications in one of one medication storage rooms. Findings include: Observation on 2/18/25, at 1:15 p.m. in the medication storage room, revealed an opened vial of Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an opened date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded. At the time of the observation, Licensed Practical Nurse Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing confirmed on 2/18/25, at 2:37 p.m. the PPD vial should have been noted with an opened date to indicate after 30 days of use, the vial would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services 395877 Page 3 of 3