Health inspection·October 16, 2025

F759 §72313 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The facility had a medication error rate of 22.22% when 6 medication errors occurred out of 27 opportunities during medication administrations for four out of 8 residents (2, 3, 6, and 54). These failures resulted in medications not given in accordance with the prescriber's orders which resulted in several residents not receiving the therapeutic effects of the medications. FINDINGS: 1. During a medication pass observation on 8/25/25, at 11:32 a.m. with registered nurse (RN ) D, RN D obtained Resident 3's blood sugar, and it was 229. RN D set 4 units on Resident 3's insulin pen (which looks like a writing pen except it contains insulin instead of ink, and it uses a needle instead of a pen tip) of insulin lispro (used to treat high blood sugar) 100 units/milliliters (ml, a metric unit of volume) and then administered them to Resident 3 without priming the insulin pen (the process of removing any air bubbles from the needle and insulin cartridge before an injection; this is a critical safety step that ensures the correct dose is delivered and that the pen is functioning properly). During a concurrent interview with RN D, she confirmed that she did not prime Resident 3's lispro insulin pen before administering 4 units of insulin lispro to him. RN D stated she should have primed Resident 3's lispro insulin pen with 2 units of insulin lispro before administering 4 units of insulin lispro to him, otherwise it would have been a wrong dose. Review of the facility's Instruction for Use, "BD AutoShield Duo," indicated "... 1.3 Check if the pen needle is attached correctly - dial 2 units, point the pen up and press the thumb button." 2. During a medication pass observation on 8/25/25, at 12:06 p.m., with RN D, RN D obtained Resident 6's blood sugar, and it was 78. RN D told Resident 6 "no insulin" and did not administer any unit of insulin to Resident 6. Review of Resident 6's physician order, dated 8/8/25, indicated Resident 6 was to receive 10 units of insulin lispro one time a day for lunch time if his blood sugar was less than 120. During an interview with RN D on 8/26/25, at 12:10 p.m., RN D reviewed Resident 6's physician orders and acknowledged that she should have administered 10 units of insulin lispro to Resident 6 when his blood sugar was 78. Review of the facility's policy, "Administering Medications," dated 4/2023, indicated "... 4. Medications are administered in accordance with prescriber orders ..." 3. During a medication pass observation with registered nurse (RN) A on 8/26/25, at 4:02 p.m., RN A obtained Resident 54's blood sugar, and it was 161. RN A stated per the insulin sliding scale (a regimen that adjusts the dose of insulin based on a resident's current blood sugar level), Resident 54 was to receive 1 unit of insulin lispro. RN A stated per physician order, Resident 54 was also to receive 5 units of insulin lispro in conjunction with the sliding scale. So, she should administer a total of 6 units of insulin lispro to Resident 54. Instead, RN A set 6 units on Resident 54's insulin pen of insulin lispro 100 units/ml and administered them to Resident 54 without priming the insulin pen. During an interview with RN A on 8/26/25, at 4:38 p.m., she confirmed that she did not prime Resident 54's lispro insulin pen before administering 6 units of insulin lispro to Resident 54. RN A stated she should have primed Resident 54's lispro insulin pen with 2 units of insulin lispro before administering 6 units of insulin lispro, otherwise it would be a wrong dose. Review of the facility's Instruction for Use, "BD Auto Shield Duo," indicated "... 1.3 Check if the pen needle is attached correctly - dial 2 units, point the pen up and press the thumb button." 4. During a medication pass observation with RN A on 8/26/25, at 4:43 p.m., RN A stated she did not have glycopyrrolate (used to treat open sores in the digestive tract) 1 milligram (mg, a metric unit of mass)/5 milliliters (ml, a metric unit of volume) on hand to give to Resident 2. During a concurrent medication pass observation, RN A crushed one midodrine (used to treat low blood pressure) 10 mg tablet, mixed it with 10 ml of sucralfate (used to treat open sores in the digestive tract) 1 gram (gm, a metric unit of mass)/10 ml, mixed them with water, and then administered them to Resident 2 through his jejunostomy tube (J-tube, a medical device that is surgically placed through the abdominal wall directly into the middle part of the small intestine to deliver liquid nutrition, fluids, and medications directly to the small intestine). During an interview with RN A on 8/26/25, at 5:12 p.m., she acknowledged that she should have administered midodrine and sucralfate to Resident 2 separately through his J-tube. Review of Resident 2's physician order, dated 8/18/25, indicated he was to receive 5 ml of glycopyrrolate 1 mg/5 ml three times a day for excessive secretion. Review of the facility's policy, "Administering Medication through an Enteral Tube," dated 11/2018, indicated "... General Guidelines: ... 3. Administer each medication separately and flush between medications." As stated, the facility had a medication error rate of 22.22% when 6 medication errors occurred out of 27 opportunities during medication administrations for four out of 8 residents (2, 3, 6, and 54). These failures resulted in medications not given in accordance with the prescriber's orders which resulted in several residents not receiving the therapeutic effects of the medications. These violations had a direct or immediate relationship to the health, safety, or security of the residents.