Inspection·March 13, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and select facility policy and staff interview, it was determined the facility failed to ensure the self-administration of medications was clinically appropriate for one of the 20 residents sampled (Resident 63). Residents Affected - Few Findings include: A review of facility policy titled Self-Administration of Medications, last reviewed by the facility in October 2024, revealed residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. A clinical record review revealed Resident 63 was admitted to the hospital on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 10, 2024, revealed that Resident 63 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed a physician's order for Resident 63 to receive Docusil oral capsule 100 mg (docusate sodium- a laxative medication) with directions to give 100 mg by mouth two times a day for stool softener initiated on December 5, 2024. During an observation on March 13, 2025, at 8:57 AM, Resident 63 was observed lying on his bed. On his bedside table were three red gelcap pills in a small, clear plastic cup. A clinical record review failed to reveal documented evidence indicating Resident 63 was assessed and deemed clinically appropriate and safe to self-administer his own medications. During an interview on March 13, 2025, at approximately 1:30 PM, the Director of Nursing (DON) indicated that the red gel capsules on Resident 63's bedside table were Docusil oral capsules 100 mg. The DON confirmed that there was no documented evidence deeming Resident 63 safe or clinically (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 15 Event ID: 395929 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 395929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976 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)