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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395013
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eldercrest Rehabilitation & Healthcare Center
2600 West Run Road
Munhall, PA 15120
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395013
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eldercrest Rehabilitation & Healthcare Center
2600 West Run Road
Munhall, PA 15120
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395013
If continuation sheet
Page 3 of 3