Health inspection·October 12, 2023

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MAR for September 2023 revealed an entry dated 09/09/23 at 8:00 A.M., for Lispro Insulin (short acting) inject per sliding scale: with blood glucose 0 - 200 give 0 units, 201- 250 give 8 units, 251 300 give 12 units and with a parameter if over 300 give 16 units, with meals for diabetes. The insulin was discontinued on 09/09/23 at 1:22 P.M. per therapeutic exchange. Review of a pharmacy therapeutic exchange dated 09/09/23 revealed Pharmacy Note: Therapeutic interchange/substitution - a modification of product to preferred product choice. Humalog for Lispro. Review of the MAR for September 2023 revealed an entry dated 09/12/23 at 2:00 P.M., for Humalog Insulin inject per sliding scale: with blood glucose 0 - 200 give 0 units, 201- 250 give 8 units, 251 - 300 give 12 units and with a parameter if over 300 give 16 units, with meals for diabetes. Review of Resident #2's vital signs revealed only two results for the blood glucoses were documented on 09/09/23 at 7:24 A.M. of 167, and at 12:02 P.M. of 300. No other blood glucose results were documented in the record. Review of Resident #2's Medication Administration Record (MAR) dated 09/09/23 to 09/13/23 revealed the resident received 12 units of insulin Lispro per sliding scale for a blood glucose of 300 on 09/09/23 at 12:00 P.M. No other doses of Humalog insulin were documented as given per order. Review of Resident #2's progress notes dated 09/12/23 at 4:00 P.M., revealed the nurse documented the resident refused to have her blood glucose monitored. No other refusals were documented in the progress notes or MAR for the insulin or blood glucose monitoring. No notification to the physician of resident refusals of insulin were noted in the records. Interview on 10/05/23 at 11:18 A.M., with Licensed Practical Nurse (LPN) #200 revealed the nurse could not recall specifics regarding Resident #2's care. LPN #200 did state any refused medications, including blood glucose monitoring is to be documented in the computer immediately after the resident refused. LPN #200 stated if Resident #2 had an order to monitor the blood glucose or administer insulin during her shift and refused, the nurse would have documented the refusal in the progress notes. Interview on 10/05/23 at 11:25 A.M., with the Director of Nursing (DON) verified there were admission orders dated 09/09/23 for Resident #2's blood glucose monitoring and insulin medications. The DON verified the resident received the Lantus insulin on 09/11/23 and 09/12/23 per order. Per the DON, the insulin was on the admission order for coverage of blood sugars with Lispro and to receive daily Glargine insulin. The DON stated the pharmacy completed two therapeutic exchanges for the Lispro and the Glargine on 09/09/23. The new therapeutic exchanged insulins were mistakenly not added to the MAR until 09/11/23 for the long acting and 09/12/23 for the short acting insulins. The DON verified the first dose of the long acting was not administered until 09/11/23 and had missed the 09/09/23 and 09/10/23 dose. The DON also verified the resident was not having the blood sugars monitored per the physician orders due to the Lispro being stopped on 09/09/23 and the Humalog being added until 09/12/23. So, the resident was not receiving any insulin due to no blood sugars being checked. The DON stated an offsite corporate nurse enters all physician orders into the medical profiles for the residents and they are to be verified by the unit nurses when residents are admitted . The DON stated the resident did have a behavior of refusing treatments and medications during her short stay at the facility and stated it was procedure to document all refusals in the progress notes. Review of the policy titled Medication Administration, with review date of 05/29/19, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 2 of 3 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm medications would be administered as ordered. Medications that are refused or withheld or not given will be documented. Critical medications, such as insulin, that are refused shall be followed up with physician notification. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 3 of 3