Inspection·April 14, 2023

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 record review, interview, and facility policy review the facility failed to administer rapid-acting insulin in a timely manner. This affected two Residents (#5 and #6) of 15 residents who required insulin daily. The facility census was 104. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 09/11/21. Diagnoses included type two diabetes mellitus and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of physician order for Resident #5 revealed an order for 18 units of Humalog solution (paid acting insulin) (dated 08/04/23) subcutaneously before meals for glucose control. The time of administration ordered by the physician was 6:30 A.M. Review of breakfast service revealed Resident #5 was not expected to receive breakfast until 8:20 A.M. Review of the medication administration records (MAR) for April 2023 revealed Resident #5 received18 units of Humalog insulin at 6:13 A.M. on 04/07/23, 5:50 A.M. on 04/08/23, 5:49 A.M. on 04/11/23, and 5:45 A.M. on 04/14/23. 2. Review of the medical record for Resident #6 revealed an admission date of 03/03/23. Diagnoses included type two diabetes mellitus with hypo/hyperglycemia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had intact cognition. Review of physician order for Resident #6 revealed an order for Humalog solution (dated 03/14/23) subcutaneously before meals (sliding scale) for glucose control. The time of administration ordered by the physician was 6:30 A.M. Review of the MAR for April 2023 revealed Resident #6 received eight units of Humalog at 6:19 A.M. on 04/01/23, six units at 6:36 A.M. on 04/03/23, two units at 6:00 A.M. on 04/07/23, and eight units at 6:22 A.M. on 04/14/23. Review of breakfast service revealed Resident #6 was not expected to receive breakfast unit 7:50 (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 2 Event ID: 365392 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 365392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rocky River Gardens Rehab and Nursing Ctr 4102 Rocky River Dr Cleveland, OH 44135 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)