Inspection·December 18, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of hospital records, staff interviews and policy review, the facility failed to ensure a therapeutic medication interchange was reconciled timely resulting in a significant medication error for the resident's diabetic medication (insulin). This resulted in Actual Harm when Resident #102 did not receive her insulin as ordered on 11/20/22 which resulted in Resident #102 being admitted to the hospital with a high blood sugar reading of 964 milligrams (mg)/ deciliter (dL). This affected one (#102) out of the three residents reviewed for medications administration. The facility census was 85. Findings included: Review of the medical record for Resident #102 revealed an admission date of 11/17/22 with medical diagnoses of protein calorie malnutrition, diabetic mellitus with ketoacidosis, dysphagia, and senile degeneration of the brain. Review of the medical record revealed Resident #102 was discharged to the hospital on [DATE] with altered mental status. Review of the medical record for Resident #102 revealed a discharge Minimum Data Set (MDS), dated [DATE], which indicated Resident #102 had short term memory loss and had modified independence with decision making. The MDS stated Resident #102 required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the medical record for Resident #102 revealed a physician order, dated 11/18/22 for Humalog solution (insulin) 100 units per milliliter (ml) per sliding scale, to inject insulin subcutaneous (SQ) before meals and every evening for diabetes mellitus. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call medical director (MD). Review of the medical record revealed a physician order, dated 11/20/22 for Humalog Kwikpen 100 units/ml solution pen-injector. The order stated to inject before meals and every evening for diabetes mellitus per sliding scale. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call MD. Review of the medical record for Resident #102 revealed the November 2022 Medication Administration Record (MAR) which indicated Resident #102 received her insulin as ordered on 11/19/22 but did not contain documentation to support the facility checked Resident #102's blood sugar levels or that Resident #102 was administered insulin on 11/20/22. (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: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue Hamilton, OH 45011 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)