Health inspection·November 27, 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 medical record review, staff interview, and policy review, the facility failed to monitor blood sugar levels as ordered. This affected one (#60) out of three reviewed for monitoring of blood sugar levels. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record for Resident #60 revealed an admission date of 10/13/23 with medical diagnoses of hepatic encephalopathy, abdominal pain, diabetes mellitus (DM), hypertension (HTN), and chronic kidney disease (CKD). Review of the medical record for Resident #60 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #60 was cognitively intact and required partial/moderate staff assistance with bathing, supervision with toileting and bed mobility, and was independent with transfers. The MDS indicated Resident #60 received seven days of insulin injections. Review of the medical record for Resident #60 revealed a physician order dated 11/06/23 to complete accu checks (finger blood sugar level checks) daily before each meal and at bedtime. The order stated to call the physician if blood sugar levels were less than 74 or greater than 400. Review of medical record for Resident #60 revealed a medication administration record (MAR) for November 2023 which did not contain documentation of Resident #60's blood sugar level results from 11/06/23 to 11/24/23. Interview on 11/27/23 at 4:10 P.M. with Assistant Director of Nursing (ADON) #63 confirmed Resident #60's medical record did not contain documentation of blood sugar level results from 11/06/23 to 11/24/23 as ordered. Review of the policy titled, Insulin Administration, revised September 2014, stated the facility was to document the resident's blood sugar as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00148156. Page 1 of 4 366236 366236 11/27/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0759 Ensure medication error rates are not 5 percent or greater. 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, observations, staff interview, review of manufacturer's instructions and policy review, the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 25 opportunities or a 12 percent (%) medication error rate. This affected two (#54 and #68) out of the seven residents reviewed for medication administration. The facility census was 50. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #54 revealed an admission date of 01/14/21 with medical diagnoses of gastrointestinal bleed, emphysema, osteoporosis, anemia, gastric esophageal reflux disease (GERD), bipolar disorder, anxiety, and hypertension (HTN). Review of the medial record for Resident #54 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #54 was cognitively intact and required supervision with activities of daily living (ADL's). Review of the medical record for Resident #54 revealed physician orders dated 11/02/23 for acetaminophen 325 milligram (mg) two tablets by mouth every six hours for pain, clonazepam 0.5 mg one tab by mouth three times per day, oxycodone 5 mg PO one tab every six hours for osteoporosis, ferrous sulfate 325 mg one tab by mouth three times per day for anemia, dicyclomine 20 mg one tab by mouth three times per day for gastric spasm, gabapentin 800 mg one tab by mouth three times per day for neuropathy, Robaxin 750 mg one tab by mouth four times per day for leg pain, sucralfate 1 gram one tab by mouth four times per day for GERD, Lactaid Fast Act 9000 unit, give 0.5 tablet by mouth three times per day for lactose intolerance, Guaifenesin 600 mg one tab by mouth three times per day for chronic obstructive pulmonary disease, and requip 0.25 mg one tab by mouth three times per day for restless leg syndrome. Observation on 11/27/23 at 11:45 A.M. revealed Licensed Practical Nurse (LPN) #137 administered the following medication to Resident #54 as ordered: Acetaminophen, clonazepam, oxycodone, ferrous sulfate, dicyclomine, gabapentin, sucralfate, Guaifenesin, and requip. Observation revealed LPN #137 was not able to administer Resident #54's Robaxin or Lactaid due to the medications were not available. Interview on 11/27/23 at 11:50 A.M. with LPN #137 confirmed Resident #54's Robaxin and Lactaid were not administered as ordered due to the medications were not available. LPN #137 stated she would reorder the medications from the pharmacy. 2. Review of the medical record for Resident #68 revealed an admission date of 07/24/23 with medical diagnoses of diabetes mellitus (DM), severe protein calorie malnutrition, and anemia. Review of the medical record for Resident #68 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #68 was cognitively intact and was independent with activities of daily living (ADL's). The MDS indicated Resident #68 received seven days of insulin injections. Review of the medical record for Resident #68 revealed a physician order, dated 08/16/23, for Humalog Kwikpen subcutaneous (SQ) solution pen-injector 100 units per milliliter (ml), inject five units SQ with meals for monitoring. 366236 Page 2 of 4 366236 11/27/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

F 0759 Level of Harm - Minimal harm or potential for actual harm Observation on 11/27/23 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #137 set the dose to Resident #68's Humalog Kwikpen to five units. LPN #137 cleansed Resident #68's abdomen with alcohol swab, allowed skin to dry, and administered Humalog Kwikpen five units SQ in Resident #68's abdomen. Observation revealed LPN #137 did not prime the Kwikpen prior to administration of insulin to Resident #68. Residents Affected - Few Interview on 11/27/23 at 11:33 A.M. with LPN #137 confirmed the Resident #68 was given five units of insulin SQ and that she did not prime the Kwikpen prior to administration. LPN 3137 stated she was not aware that the Kwikpen needed to be primed prior to administration of insulin. Review of the manufacturer's instruction for the Humalog Flexpen (also known as Kwikpen), provided by the Director of Nursing (DON), stated the staff were to select a dose of two units, take off the outer and inner cap, and with the pen pointing up, tap the insulin to move the air bubbles to the top. Then press the button all the way in and make sure the insulin comes out of the needle. Repeat if needed. Check that the dose counter shows zero after the safety test and turn the dose counter to the number of Flexpen units that equal the dose to be given. Review of the facility policy titled, Insulin Administration, revised September 2014, stated nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Review of the facility policy titled, Administering Oral Medications, revised October 2010, stated staff are to verify there is a physician order for the medication, confirm the identity of the resident, and remain with the resident until all medications have been taken. This deficiency represents non-compliance investigated under Complaint Number OH00148156. 366236 Page 3 of 4 366236 11/27/2023 Good Shepherd Village 422 North Burnett Road Springfield, OH 45503

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, observations, staff interviews, review of manufacturer's instructions and policy review, the facility failed to ensure an insulin pen was primed per manufacturer's instructions prior to insulin administration resulting in a significant medication error. This affected one (#68) out of three residents reviewed for insulin administration. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record for Resident #68 revealed an admission date of 07/24/23 with medical diagnoses of diabetes mellitus (DM), severe protein calorie malnutrition, and anemia. Review of the medical record for Resident #68 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #68 was cognitively intact and was independent with activities of daily living (ADL's). The MDS indicated Resident #68 received seven days of insulin injections. Review of the medical record for Resident #68 revealed a physician order, dated 08/16/23, for Humalog Kwikpen subcutaneous (SQ) solution pen-injector 100 units per milliliter (ml), inject five units SQ with meals for monitoring. Review of the medication administration record (MAR) for November 2023 revealed Resident #68 was administered Humalog Kwikpen five units SQ three times per day. Observation on 11/27/23 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #137 set the dose to Resident #68's Humalog Kwikpen to five units. LPN #137 cleansed Resident #68's abdomen with alcohol swab, allowed skin to dry, and administered Humalog Kwikpen five units SQ in Resident #68's abdomen. Observation revealed LPN #137 did not prime the Kwikpen prior to administration of insulin to Resident #68. Interview on 11/27/23 at 11:33 A.M. with LPN #137 confirmed the Resident #68 was given five units of insulin SQ and that she did not prime the Kwikpen prior to administration. LPN #137 stated she was not aware the Kwikpen needed to be primed prior to administration of insulin. Review of the manufacturer's instruction for the Humalog Flexpen (also known as Kwikpen), provided by the Director of Nursing (DON), stated the staff were to select a dose of two units, take off the outer and inner cap, and with the pen pointing up, tap the insulin to move the air bubbles to the top. Then press the button all the way in and make sure the insulin comes out of the needle. Repeat if needed. Check that the dose counter shows zero after the safety test and turn the dose counter to the number of Flexpen units that equal the dose to be given. Review of the facility policy titled, Insulin Administration, revised September 2014, stated nursing staff would have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. This deficiency represents non-compliance investigated under Complaint Number OH00148156. 366236 Page 4 of 4