Health inspection·May 28, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility staff failed to provide medications and treatments as ordered by the physician for two of 6 residents (Resident R1 and Resident R2). Residents Affected - Few Findings include: Review of facility policy Administering Medications, reviewed August 2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted to prepare, administer and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including required time frame. Review of facility policy Medication and Treatment Order, reviewed August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to such an order. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that the refills are readily available. Review of facility policy Wound Care, reviewed August 2024, indicated the procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care 5. Any changes in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. Page 1 of 5 395845 395845 05/28/2025 Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

F 0684 8. Any problem or complaints made by the resident related to the procedure. Level of Harm - Minimal harm or potential for actual harm 9. In the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Residents Affected - Few Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/23/25, indicated diagnoses of rectal cancer, muscle wasting, and diabetes mellitus (group of disease that affect how the body uses blood sugar). Section M1040: Other Ulcers, Wounds, and Skin problems indicated that Surgical wound(s) was marked with and X. Section N0415: High Risk Drug Classes indicated that antidepressant medication was being used and indication for use noted. Review of Resident R1's physician order dated 4/30/25, and discontinued 5/14/25, indicated the wash buttocks with mild soap and water, rinse and pat dry. Lightly pack wound with 1/4 in (inch) plain packing soaked in 1/4 strength Dakins (broad/spectrum antimicrobial cleanser used for wound care) making sure to reach end of wound. Leave tail on outside to ensure complete removal. Apply Calmoseptine (topical ointment used to treat and prevent minor skin irritations) to peri wound. Covered with silicone bordered foam dressing. Change dressing twice daily every day and evening shift for wound care. Review of Resident R1's Treatment Administration Record (TAR) for May 2025, indicated five occurrences of twice daily physician ordered wound treatment was not provided on 5/2/25, 5/3/25, 5/9/25, 5/12/25, and 5/14/25. Review of Resident R1's current physician order dated 5/15/25, indicated Wound care: buttocks every day and evening shift, wash buttocks with mild soap and water, and pat dry. Lightly pack wound with 1/4-inch plain packing soaked in 1/4 strength Dakins making sure to reach end of wound. Leave tail on outside to ensure complete removal. Apply Calmoseptine. Review of Resident R1's Treatment Administration Record (TAR) for May 2025, indicated five occurrences of twice daily physician ordered wound treatment was not provided on 5/18/25, and 5/23/25. During an interview on 5/28/25, at 10:10 a.m., Wound Care Nurse (WCN) Employee E1 confirmed that Resident R1's wound treatments were not provided consistently per physician orders in May 2025. Review of Resident R1's physician order dated 3/20/25, and discontinued 5/22/25, indicated Fluoxetine HCl (antidepressant also known as Prozac) oral tablet 10 mg (milligram), give 30 mg by mouth at bedtime for depression. Review of Resident R1's Medication Administration Record (MAR) for May 2025, indicated seven occurrences documented MP (medication pending delivery) on 5/13/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, and 5/20/25, in which medication was not administered. During an interview on 5/28/25, at 1:34 p.m., the Director of Nursing (DON) confirmed that Resident R1's medication was not administered per physician order on 5/13/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, and 5/20/25. 395845 Page 2 of 5 395845 05/28/2025 Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

F 0684 Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, low back pain, and arthritis due to bacteria of the left knee. Residents Affected - Few Review of Resident R2's physician order dated 4/25/25, indicated to provide wound care to left knee every day shift. Make sure wound remains free from drainage and steri strips (adhesive bandages) stay in place until they fall off. Notify wound care of any changes or signs and symptoms of infection. Review of Resident R2's May 2025 TAR indicated that wound treatments were not provided on 5/11/25, and 5/23/25, as ordered. During an interview on 5/28/25, at 12:55 p.m. the DON confirmed that Resident R2's wound treatments were not provided on 5/11/25, and 5/23/25, as ordered. During an interview on 5/28/25, at 2:45 p.m., the DON confirmed that the facility staff failed to provide medications and treatments as ordered by the physician for two of 6 residents (Resident R1 and Resident R2). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395845 Page 3 of 5 395845 05/28/2025 Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

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, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy Administering Medications dated August 2024, indicated that the individual administering the medication records in the resident medical records the following information: · The date and time the medication was administered. · The dosage · The route of administration. · The injection site (if applicable). · Any complaints or symptoms for which the drug was administered. · Any results achieved and when those results were observed: and · The signature and title of the person administering the drug. Review of facility policy Medication and Treatment Orders dated August 2024, indicated that drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/23/25, indicated diagnoses of high blood pressure, cancer, and pain in left knee. 395845 Page 4 of 5 395845 05/28/2025 Cranberry Place 5 Saint Francis Way Cranberry Township, PA 16066

F 0760 Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated 3/20/25, indicated to inject 10 milligrams of Fondaparinux Sodium (a blood thinner used to prevent blood clots) subcutaneously (under the skin) one time a day. Review of Resident R1's May 2025 Medication Administration Record revealed the scheduled medication was not administered on the following dates: Residents Affected - Few - 5/22/25 Morning medication pass, the documented reason was Medication pending delivery. - 5/23/25 Morning medication pass, the documented reason was Medication pending delivery. During an interview on 5/28/25, at 1:34 p.m. the Director of Nursing confirmed that the facility failed to ensure that Resident R1 received his medication as ordered and that residents were free of significant medication errors for one of three residents reviewed (Resident R1) as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. 395845 Page 5 of 5