Health inspection·August 13, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of an as needed (PRN) psychotropic (mind altering) medication beyond 14 days and 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 psychotropic medication for two of six residents reviewed (Residents R17 and R29).Findings include: A facility policy entitled Psychotropic Drug Management dated 4/21/25, revealed PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. Identify non-pharmacological interventions that can be utilized to use the lowest possible dose and to work in conjunction with the goal of reduction or discontinuation. Documentation will reflect attempts to implement care-planned, non-pharmacological approaches and ongoing effectiveness of these interventions. Resident R17's clinical record revealed an admission date of 7/25/25, with diagnoses that included hypertension (high blood pressure), congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping). A physician's order dated 7/25/25, identified to administer clonazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth two times a day PRN for anxiety, this order was discontinued on 8/6/25. A new physician's order dated 8/6/25, identified to administer clonazepam 0.5 mg by mouth two times a day PRN for anxiety and lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R17's July 2025 and August 2025 Medication Administration Records (MAR) revealed that the PRN clonazepam was used on 7/30/25, 7/31/25, 8/3/25, 8/4/25, 8/7/25, 8/8/25, 8/9/25, 8/10/25, and 8/11/25. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN clonazepam for two administrations in July 2025 and for eight administrations in August 2025. Resident R29's clinical record revealed an admission date of 8/7/25, with diagnoses that included respiratory failure, heart failure, and chronic kidney disease. A physician's order dated 8/7/25, identified to administer clonazepam 3 mg by mouth PRN for restlessness at bedtime. Review of the August 2025 MAR for Resident R29 revealed that the PRN clonazepam was used on 8/7/25, 8/9/25, 8/10/25, and 8/11/25. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN clonazepam for four administrations in August 2025. During an interview on 8/12/25, at 2:10 p.m. Registered Nurse Employee E1 confirmed that Resident R17's clonazepam lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and that Resident R17's and Resident R29's clinical records lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN clonazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 2 395966 395966 08/13/2025 UPMC Northwest Transitional Care Unit 100 Fairfield Drive Seneca, PA 16346

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 policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of one medication carts reviewed.Review of facility policy entitled Multi Dose Medication-A dated 4/21/25, indicated all multiple use (multi-dose) medications should be labeled by the facility with the date first use so that expiration dates or date for last use can be determined, and discard any vial found opened without being dated. Review of facility policy entitled Expiration Dates dated 4/21/25, indicated injectable diabetes product storage recommendations, Humalog insulin pen opened expires in 28 days. Review of manufacturer's guidelines revealed that an open pen of Humalog Insulin must be used within 28 days after opening or be discarded, even if the vial still contained insulin. Observation of drug storage on 8/11/25, at 3:55 p.m. of the medication cart revealed an open Humalog Insulin pen with no resident name or date indicating when the insulin pen was opened. During an interview on 8/11/25, at the time of observation Licensed Practical Nurse (LPN) Employee E2 confirmed that the open Humalog insulin pen lacked a resident name and an open date, and staff were unable to determine the discard date. LPN Employee E2 also confirmed that the insulin pen 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 395966 Page 2 of 2