Health inspection·February 20, 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** Residents Affected - Few Based on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to make certain that residents are free from significant medication errors for one of three residents (Resident R1). Findings include: Review of facility policy Administering Medication dated 8/1/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Review of facility policy Resident Rights dated 8/1/24, indicated that all residents shall be treated with kindness, respect, and dignity. Resident will be informed of his or her medical condition and of any changes in his or her condition. Review of Resident R1's admission record indicated resident was admitted on [DATE], and discharged home on 2/7/25. Review of Resident R1's MDS assessment (minimum data set - a periodic assessment of resident care needs) dated 1/28/25, indicated diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), high blood pressure, and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of Resident R1's care plan dated 1/22/25, indicated to give medications as ordered by the physician. Review of Resident R1's discharge orders from acute hospital stay dated 1/22/25, indicated to provide the following medication: Carbidopa-Levodopa (medication used to threat Parkinson ' s Disease) 25/250mg two tablets by mouth three times a day. Review of Resident R1's Physician orders and Medication Administration Record (MAR) dated 1/22/25 through 2/7/25 indicated the following: Carbidopa-Levodopa 25/250 mg one tablet by mouth three times a day. Page 1 of 2 395845 395845 02/20/2025 Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

F 0760 Level of Harm - Minimal harm or potential for actual harm During a review of pharmacy recommendations completed on 2/6/25, indicated that the pharmacy requested clarification of Carbidopa-Levodopa dosage to be given. Documentation provided by facility indicated Carbidopa-Levodopa 25/250 mg- order on discharge papers was taking 2 tablets three times a day. This was entered in Resident R1's physician orders as Carbidopa-Levodopa take 1 tab three times a day. Residents Affected - Few During an interview on 2/20/25, at 11:20 a.m. Certified Registered Nurse Practitioner (CRNP) Employee E1 stated I am usually here when a new admission comes. I sign off on the orders from the discharging facility and then the nurse puts the orders into the computer. I only see that Resident R1 only took one pill of his Carbidopa-Levodopa three times a day during his stay. He was only given half his dose while at the facility. CRNP Employee E1 confirmed that the facility failed to input the correct medication dosage into Resident R1's physician orders. During an interview on 2/20/25, at 11:50 a.m. Director of Nursing (DON) stated that Resident R1 was only getting half of his Parkinson ' s medication during his stay at the facility, which totaled 17 days. DON stated that multiple checks should have been completed and this medication error should have been caught and corrected at admission. During an interview on 2/20/25, at 12:01 p.m. the DON confirmed that the facility failed to make certain that Resident R1's medication regimen was free from significant medication errors. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing Services 395845 Page 2 of 2