Health inspection·December 12, 2024

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 a review of facility policy, resident interview, observations, and staff interview it was determined the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents (Resident R1 and R2). Residents Affected - Few Findings include: Review of facility policy Self-Administration of Medications last reviewed 1/30/24, indicated 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. If it is deemed safe and appropriate for a resident to self-administer medications it is documented in the medical record and the care plan. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness, and chronic obstructive pulmonary disease (COPD caused by swelling and irritation in the airways that limit air going in and out of the lungs). Review of a physician order dated 11/18/24, instructed to give Trelegy Ellipta Inhalation aerosol (used to treat COPD) one puff inhale orally one time a day. During an interview and observation on 12/12/24, at 9:35 a.m. Resident R1 was in bed with her Trelegy inhaler on her over-the-bed table. Review of Resident R1's clinical record revealed it did not contain a physicians order for self-administration, a self-administration assessment, or care planning for self-administration of medications. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included diabetes, muscle weakness, and high blood pressure. Review of a physician order dated 12/5/24, instructed Latanoprost ophthalmic solution 0.005% (eye drops used to treat certain kinds of glaucoma [eye condition that damages the optic nerve leading to vision loss or blindness]) one drop in right eye at bedtime. During an interview and observation on 12/12/24, at 9:40 a.m. Resident R2 was in sitting beside her bed, a bottle of opened Latanoprost eye drops and an open bottle of Muro 5% eye medication (used to Page 1 of 4 396066 396066 12/12/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0554 Level of Harm - Minimal harm or potential for actual harm reduce swelling of the cornea [front surface of eye]) on Resident R2 ' s nightstand. Resident R2 stated she was unable to correctly use the eye drops due to being legally blind in one eye. Review of Resident R2's clinical record revealed it did not contain a physicians order for self administration, a self-administration assessment, or care planning for self-administration of medications. Residents Affected - Few During an interview on 12/12/24, at 9:50 a.m. Licensed Practical Nurse Employee E2 confirmed the medications were left at the bedside while she continued to pass medication to other residents; further stated Resident R1 was in the bathroom, so she left the inhaler for her to use when she was finished; stated Resident R2 was not scheduled eye medication in the day, she was unsure when or how long they were on the nightstand. During an interview on 12/12/24, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to assess the clinical appropriateness of medication self-administration for two of 14 residents. 28 Pa. Code: 211.9(d) Pharmacy services. 396066 Page 2 of 4 396066 12/12/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of seven residents (Resident R3). Residents Affected - Few Findings include: Review of the facility policy Abuse Prohibition reviewed on 1/30/24, indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will initiate and investigation within 24 hours. Review of the facility policy Accidents and Incidents - Investigation and Reporting reviewed 1/30/24, indicated all accidents or incidents involving residents, employees, vendors, etc., occurring on our premises shall be investigated and reported by the administrator. A review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, dislocation of right shoulder joint, and diabetes. A review of facility records indicated on 11/27/24, Resident R3 fell while transferring with assistance of one staff in the bathroom, hitting her head and right shoulder. Resident R3 was sent to the local emergency room for evaluation. Witness statements were not completed. The incident was not fully investigated to rule out abuse or neglect. During an interview on 12/12/24, at 11:00 p.m. the Director of Nursing confirmed Resident R3 ' s incident was not fully investigated, and witness statements were not obtained from Resident R3 or staff involved. 28 Pa. Code: 201.149(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management 396066 Page 3 of 4 396066 12/12/2024 Whitehall Borough Post Acute 505 Weyman Road Pittsburgh, PA 15236

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 policy, observations, and staff interviews it was determined that the facility failed to properly secure medication in one medication refrigerator (Family Conference room), and one of three medication carts observed (ARU 1 nursing unit). Findings include: Review of the facility policy Medication Labeling and Storage reviewed 1/30/24, indicated the facility stores all medications and biologicals in locked compartments. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Medications requiring refrigeration are stored in a refrigerator located in the medication rooms at the nurse ' s station or other secured location. During an observation on 12/12/24, at 9:00 a.m. an unlocked medication refrigerator located in the Family Conference room by the front lobby, was accessible to visitors, family, and residents. The refrigerator contained three unopened vials of influenza vaccine, one opened vial of influenza vaccine, three unopened boxes of 10 pre-filled influenza vaccine syringes, and one opened box of nine pre-filled syringes. During an interview on 12/12/24, at 9:06 a.m. Front Desk Employee E1 confirmed the Family Conference room was never locked and was accessible to residents, family, and visitors at any time of the day and night. During an interview on 12/12/24, at 9:15 a.m. the Nursing Home Administrator confirmed the medications should not have been in the refrigerator, stating she was unsure why the refrigerator was in the conference room and the key was unable to be located to secure it. During an observation on 12/12/24, at 9:42 a.m. a medication cart was unsecured, unattended, with the computer screen open and accessible to residents, family, and visitors. During an interview on 12/12/24, at 9:45 a.m. Registered Nurse Employee E2 confirmed the cart was left unsecured and unattended. During an interview on 12/12/24, at 10:45 a.m. the Director of Nursing confirmed the facility failed to properly secure medications in a medication cart. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services. 396066 Page 4 of 4