Inspection·April 12, 2023

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 medical record review, observation, staff interview, and review of the manufacturers recommendations, the facility failed to ensure residents were free from significant medication errors when an insulin pen was not primed prior to administration. This affected one resident (#43) out of 10 residents observed for medication administration. The facility identified 12 residents who received insulin pens in the facility. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/18/20. Diagnoses included type two diabetes mellitus, major depressive disorder, atrial fibrillation, and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the care plan dated 08/02/22 revealed Resident #43 had a diagnosis of diabetes mellitus. Interventions included diabetes medication as ordered by the physician and observe for side effects and effectiveness. Staff to monitor fasting serum blood sugar as ordered by the physician. Review of the physician order dated 11/16/22 revealed Resident #43 was ordered Humalog KwikPen Solution Pen-injector 100 unit/milliliter (ml). Inject as per sliding scale: If blood sugar was 181 milligram per deciliter (mg/dL) to 200 mg/dL give one unit If blood sugar was 201 mg/dL to 250 mg/dL give two units If blood sugar was 251 mg/dL to 300 mg/dL give four units If blood sugar was 301 mg/dL to 350 mg/dL give six units (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 4 Event ID: 365277 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 365277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013 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)