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

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

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R1). Findings include: Review of facility policy dated 8/2024, entitled Oxygen Administration indicated that Verify physician order for desired oxygen saturation and oxygen flow rate. And do not change the oxygen flow rate on fixed flow orders or titrate outside ordered parameters without contacting the physician and obtaining appropriate orders. Resident R1's clinical record revealed an admission date of 8/16/24, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R1's clinical record revealed a physician's order dated 8/16/24, for Oxygen via Nasal Cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) 3 lpm (liters per minute) at all times. Observation on 9/4/24, at 10:30 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm. Observation on 9/4/24, at 12:25 p.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and liter flow rate set at 2 lpm. Observation on 9/5/24, at 8:50 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm. During an interview on 9/5/24, at 12:50 p.m. Registered Nurse Employee E2 confirmed that Resident R1's supplemental oxygen was on and set at 2 lpm and the provision of their respiratory services was not consistent with the physician's order dated 8/16/24, for oxygen at 3 lpm. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator. Findings include: A facility policy entitled, Management of Controlled Drugs dated 8/2024, revealed, Storage and maintenance of Controlled drugs: Store and maintain controlled drugs properly according to federal, state, or local regulations. Observation on 9/4/24, at 1:05 p.m. of the medication room refrigerator revealed several vials of controlled scheduled II-V medications in a separately locked container that was attached to a removable shelf, therefore it was not permanently affixed to the refrigerator, this was witnessed and confirmed by the Licensed Practical Nurse Employee E1. Interview with the Director of Nursing on 9/4/24, at approximately 1:30 p.m. confirmed that the controlled scheduled II-V medications should be stored in a separately locked permanently affixed compartment, and not attached to a removable shelf. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R63). Findings include: Review of facility policy entitled, Psychotropic Drug Management dated 6/2023, states If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. Review of Resident R63's clinical record revealed an admission date of 9/16/23, with diagnoses that included physical deconditioning, Diabetes type II, hypertension (high blood pressure), and anxiety. The clinical record revealed that on 9/16/2023, Resident R63's physician ordered Lorazepam (medication ordered to treat anxiety) one milligram (mg) three times a day PRN for anxiety. Review of the September 2023 and October 2023 Medication Administration Record (MAR) for Resident R63 revealed that the PRN Lorazepam was used on 9/16/23, 9/17/23, 9/22/23, 9/23/23, 9/24/23, 9/25/23, 9/27/23, 9/29/23, 9/30/23, 10/1/23, 10/2/23, and 10/3/23. Review of September 2023 and October 2023 MAR, clinical records, and progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the nine administrations in September 2023 and the three administrations in October 2023. During an interview on 10/04/2023, at 10:25 a.m. Registered Nurse Employee E1 confirmed that R63's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services