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). 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 [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

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

Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of fourteen residents reviewed (Resident R144). Findings include: Review of facility policy dated 1/4/23, entitled Catheter Care, Urinary indicated purpose of this procedure is to prevent catheter (a tube placed and held in the bladder to drain urine) associated urinary tract infections and Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident R144's clinical record revealed an admission date of 3/27/23 with diagnoses that included obstructive and reflux uropathy (condition which causes the flow of urine to be blocked), high blood pressure, and gastro-esophageal reflux (stomach acid flow back into the esophagus, which is a tube that connects the mouth and stomach). Observation on 4/3/23, at 3:20 p.m. revealed that Resident R144's urinary catheter drainage bag and tubing were lying on the floor without a cover over the drainage bag. Observation on 4/4/23, at 8:33 a.m. revealed that Resident R144's urinary catheter drainage bag and tubing were lying on the floor without a cover over the drainage bag. During an interview on 4/4/23, at 8:36 a.m. the Assistant Director of Nursing confirmed that Resident R144's urinary catheter drainage bag and tubing should not have been on the floor and should have a cover over the drainage bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 14 residents reviewed (Resident R6). Findings include: Review of Resident R6's clinical record revealed an admission date of 9/16/21, with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), anxiety disorder, and depression. Further review of Resident R6's clinical record revealed that he/she was admitted to the hospital psychiatric unit on 2/19/22, and returned to the facility on 3/04/22, with diagnoses including major depressive disorder, recurrent, severe, with possible psychotic feature, and generalized anxiety disorder, and a physician's order for Perphenazine (anti-psychotic medication used to treat the symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]), manic phase of bipolar disorder, and schizoaffective disorder (mental health problem where you experience psychosis as well as mood symptoms). A Note to Attending Physician/Prescriber from the pharmacy medication record review dated 5/02/22, included a recommendation from the pharmacist to clarify an approved Food and Drug Administration (FDA) diagnosis for the Resident R6's use of Perphenazine. The clinical record revealed a physician's order dated 5/06/22, for a diagnosis of schizophrenia. Resident R6's clinical record lacked evidence of an existing diagnosis of schizophrenia. During an interview on 4/05/23, at 11:45 a.m. the Medical Director confirmed that the diagnosis of schizophrenia was documented in error and that Resident R6's use of Perphenazine was to treat his/her bipolar depression (an FDA approved diagnosis for the use of Perphenazine). 28 Pa. Code 211.5(f) Clinical records