Health inspection·June 27, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, pharmacy contract/agreement, clinical records, and facility documents and staff interviews, it was determined that the facility failed to obtain ordered medications in a timely manner for two of four residents reviewed (Residents R3 and R4). Findings include: A facility policy entitled New Admission/readmission Process revised on 3/19/25, revealed the process included review of orders; physician verification of orders noted, transmitted to pharmacy, and transcribed to the electronic medication administration record/treatment administration record (eMAR/eTAR). Pharmacy contract/agreement effective 7/01/24, included: all controlled substance orders should be communicated to the pharmacy as follows: If the medication is needed before the next scheduled delivery, facility staff should indicate the exact time by which the medication is needed; If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, the facility should fax a request to remove a controlled substance from the emergency medication supply to the pharmacy. Resident R3's clinical record reviewed an admission date of 5/15/25, with diagnoses that included Type 2 Diabetes (chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), lumbago with sciatica (irritation, inflammation, pinching or compression affect one or more nerves that run down your lower back and into your legs), depression, and difficulty walking. Resident R3's eMAR revealed: -Bupropion (antidepressant) missed dose on 5/16/25, due to drug not available. -CoQ-10 (supplement helps with migraines, heart failure and high blood pressure) missed doses on 5/19/25, 5/20/25, 5/22/25, 5/24/25, and 5/27/25, due to drug not available. -Prednisone (steroid) missed dose on 5/16/25, due to drug not available. -Tresiba (anti-diabetic) missed dose on 5/16/25, due to drug not available. -Adult multivitamin gummies missed doses on 5/16/25, 5/19/25, 5/20/25, 5/22/25, 5/24/25, and Page 1 of 2 395536 395536 06/27/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0755 5/27/25, due to drug not available. Level of Harm - Minimal harm or potential for actual harm -Baclofen (muscle relaxant) missed dose on 5/22/25, due to drug not available. Residents Affected - Few Resident R4's clinical record revealed an original admission date of 1/29/25, with diagnoses that included respiratory failure, persistent vegetative state (condition in which a person is awake but lacks awareness of themselves or their surroundings), tracheostomy (surgical hole through the neck and into the windpipe to help air/oxygen reach the lungs), paranoid schizophrenia (subtype of schizophrenia [a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior] that includes intense delusions, and hallucinations, particularly auditory ones, where individuals may hear voices that aren't real), and gastrostomy (tube inserted through the wall of the abdomen directly into the stomach). Resident R4's eMAR revealed: -Atropine sulfate (drug used to block nerve stimulation of muscles and glands to reduce excessive saliva production or tracheal/bronchial secretions, especially when a person has difficulty swallowing) missed dose on 5/15/25, due to drug not available. -Cipro (antibiotic) missed dose on 5/07/25, due to drug not available. -Cefepime (antibiotic) missed dose on 5/04/25, due to drug not available. -Diazepam (treats anxiety, seizures, muscle spasms or twitches) missed doses on 5/22/25 (twice), 5/23/25, 5/28/25 (twice), due to drug not available. During an interview on 6/18/25, at 4:00 p.m. the Nursing Home Administrator (NHA) confirmed that when Resident R3 was admitted to the facility on [DATE], at approximately 7:00 p.m. staff sent the medication orders to the pharmacy at 10:21 p.m. (too late for the routine nighttime delivery on 5/16/25, 11-7 shift); the pharmacy processed the orders on 5/16/25, at 8:37 a.m. (too late for the routine afternoon delivery on 5/16/25, 7-3 shift), therefore Resident R3's medications were not delivered to the facility until the routine nighttime delivery on 5/17/25, 11-7 shift. Interview on 6/18/25, at 4:00 p.m. the NHA confirmed that there was a delay in receiving the above medications for Residents R3 and R4 from the pharmacy due to a lack of instruction in the pharmacy policy/contract for staff and obtaining non-controlled medications before the routine pharmacy delivery time, and that staff failed to request (from the pharmacy) access to the controlled emergency medication supply in the facility. The NHA also confirmed there is no listed alternate pharmacy for the facility to obtain medications needed in an urgent situation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395536 Page 2 of 2