Health inspection·July 1, 2025

F 0760 Ensure that residents are free from significant medication errors. 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, review of facility provided documentation and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of four residents (Residents R1 and R2). Residents Affected - Some Findings include: Review of facility policy Medication Administration dated 4/30/25, indicated that medications will be administered in accordance with prescriber orders, including any required timeframe. Staffing Schedules are arranged to ensure that medications are administered without unnecessary interruptions. medications are administered within one hour of their prescribed time unless otherwise specified(before and after meals). The facility meal times posted indicated 7:15 a.m., 12:00 p.m., and 5:00 p.m. Review of the National Library of Medicine information, indicated insulin Lantus(glargine) is an injectable medication used to treat diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). It further stated, Lantus can cause side effects , including low blood sugar (hypoglycemia). Review of the National Library of Medicine information, indicated insulin Lispro as a fast acting injectable medication use to treat diabetes. It further stated Lispro insulin begins to exert its effects within 15 minutes and should be 30 to 45 minutes before meals. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnosis of diabetes. Review of the physician orders May 2025, indicated to give Resident R1 insulin Lantus(glargine) 7 units inject subcutaneously every day, timed at 9:00 a.m. Review of the Medication Administration Record(MAR) indicated Resident R1 was given Lantus insulin as follows: 5/10/25, at 12:21 p.m. 5/18/25 at 1:04 p.m. 5/31/25 at 1:34 p.m. 5/16/25, at 1:46 p.m. 5/21/25 at 1:14 p.m. 5/17/25, at 12:19 p.m. 5/30/25 at 12:53 p.m. Page 1 of 3 395013 395013 07/01/2025 Eldercrest Rehabilitation & Healthcare Center 2600 West Run Road Munhall, PA 15120

F 0760 Review of the physician orders date May 2025, indicated to give Resident R1 Lispro insulin before meals and at bedtime according to a blood glucose reading following the sliding scale: Level of Harm - Minimal harm or potential for actual harm 70-140=0 units Residents Affected - Some 141-180=1 unit 181-220=2 units 221-260=3 units 261-300=4 units 301-340 5 units Review of the MAR for May 2025, the readings and coverage are documented as following: 5/3/25, glucose reading at 11:00 a.m, was 168, coverage was not documented as given until 3:01 p.m. 5/4/25, glucose reading at 4:00 p.m., was 156, coverage was not given until 6:23 p.m. 5/16/25, glucose reading at 11:00 a.m., was 212, coverage was not given until 1:50 p.m. 5/17/25, glucose reading at 4:00 p.m., was 164, coverage was not given until 7:30 p.m. 5/19/25, glucose reading at 11:00 a.m., was 163, coverage was not given until 12:54 p.m. 5/30/25, glucose reading at 11:00 a.m., was 160, coverage was not given until 12:53 p.m. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnosis of diabetes. Review of the physician orders for May 2025, indicated to give Resident R2 Lispro insulin 32 units with meals and timed for 8:00 a.m., 12:00 p.m., and 5:00 p.m. Resident R2 was also ordered Lispro insulin before meals and at bedtime according to a blood glucose reading per sliding scale: 141-180=3 units 181-220=6 units 221-260=9 units 261-300=12 units 301-340=15 units 341-999=18 units Review of the MAR for May 2025, for Resident R2 also indicated Lantus insulin 40 units every 12 395013 Page 2 of 3 395013 07/01/2025 Eldercrest Rehabilitation & Healthcare Center 2600 West Run Road Munhall, PA 15120

F 0760 hours and timed for 9:00 a.m. and 9:00 p.m. Level of Harm - Minimal harm or potential for actual harm Review of Resident R2 MAR for May 2025 indicated the following: Residents Affected - Some 5/29/25, the lispro 32 units at 5:00 p.m. and the sliding scale coverage dose for blood glucose of 249 of 9 units were given at 6:48 p.m. 5/30/25, the 8:00 a.m. lispro 32 units, the coverage dose of a blood glucose reading of 9 units were both given at 10:31 a.m. 5/30/25, the 11:00 a.m. glucose reading was 173, the coverage dose of 3 units and the 9:00 a.m. Lantus insulin dose of 40 units were both given at 2:21 p.m. On 5/30/25, at 5:00 p.m., Resident R2 was found diaphoretic and not feeling well. a blood glucose was obtained and indicated as 36, the nurse followed the hypoglycemic protocol and the physician was notified. Resident R2 blood glucose returned to 110. Resident R2 ate his dinner and was rechecked at 5:30 p.m. and blood glucose was 132 however, Resident R2 stated he still felt funny and insisted on going to the hospital and was sent. The facility submitted and event and investigation indicating the morning nurse as the perpetrator. During an interview on 7/1/25, at 10:09 a.m., the Director of Nursing and Assistant Director of Nursing confirmed that insulin administrations do not fall under the facility's medication administration policy, and further confirmed that the facility failed to make certain that residents are free of significant medication errors for two of four residents. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395013 Page 3 of 3