Health inspection·December 23, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, review of hospital records, staff, pharmacist, and physician interview, and review of the facility policy, the facility failed to ensure residents were administered medications indicated for their medical diagnosis and free from unnecessary medications. This affected one (#39) of three residents reviewed for unnecessary medications. The facility census was 65.Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/24/25 and a discharge date of 12/22/25. Admitting diagnosis included Type I diabetes mellitus (T1DM) (a form of diabetes known as juvenile diabetes where the pancreas does not function at all in the production of insulin to control blood sugar levels in the body).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and had a diagnosis of T1DM and required insulin injections.Review of the diagnosis list for Resident #39 revealed a diagnosis of Type I diabetes mellitus with other specified complications, Type I diabetes mellitus with diabetic autonomic (poly) neuropathy, chronic osteomyelitis, and acquired absence of right leg below the knee.Review of the hospital history and physical (H&P) (detailed history of the patient of past medical diagnosis and current problems during hospitalization) dated 11/13/25 revealed Resident #39 had a diagnosis of Type I diabetes mellitus.Review of the care plan, initiated 12/09/25, revealed Resident #39 had pain related to T1DM.Review of a written physician order dated 11/26/25 revealed Resident #39 was ordered Trulicity (a once weekly injectable medication used for Type II diabetes [T2DM]) 0.75 milligrams (mg) subcutaneously weekly. Further review of the physician orders located in the electronic medical record (EMR) revealed Resident #39 had an order dated 11/27/25 for Trulicity subcutaneous solution auto-injector 0.75 mg subcutaneously in the morning every Monday for diabetes, give 0.75 mg weekly. Additionally, Resident #39 was ordered Lantus SoloStar (long-acting insulin) subcutaneous solution pen-injector 100 unit/milliliter (u/ml), inject 32 units subcutaneously two times a day for diabetes and insulin lispro (rapid-acting insulin) subcutaneous solution pen-injector 100 u/ml, inject subcutaneously before meals and at bedtime for diabetes. Review of the Medication Administration Record (MAR) for December 2025 revealed Resident #39 was administered doses of Trulicity on 12/01/25, 12/08/25, and 12/15/25.Interview on 12/22/25 at 2:41 P.M. with Pharmacist #550 revealed Trulicity was not an approved medication for use in a patient with T1DM. Pharmacist #550 stated Trulicity was only approved for use in people who produced insulin as it triggered a hormone in the body to trigger insulin to work and do the job it was supposed to do. Pharmacist #550 further stated that anyone with a diagnosis of T1DM did not make insulin so Trulicity was useless for someone with T1DM and would be considered an ineffective treatment, and an unnecessary medication for that population of people.Interview on 12/22/25 at 3:00 P.M. with Nurse Practitioner (NP) #515 verified she prescribed Trulicity to Resident #39. NP #515 further stated she would use Trulicity to treat a resident with a diagnosis of T1DM and further stated she treated T1DM and T2DM the same. NP #515 verified she would give Trulicity to a resident with T1DM and Residents Affected - Few Page 1 of 2 366328 366328 12/23/2025 Divine Rehabilitation and Nursing at Toledo 1011 North Byrne Road Toledo, OH 43607

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, sure why not. NP #515 further stated she did not know Resident #39 very well as he was not in the facility for a long period of time.Interview on 12/22/25 at 4:41 P.M. with Physician #500 revealed Trulicity was not an appropriate medication for a resident diagnosed with T1DM and it was contraindicated. Physician #500 further stated when a medication list was reviewed and someone was on both long acting and short acting insulin, it was inferred that person had T1DM.Interview on 12/23/25 between 9:00 A.M. and 9:30 A.M. with Licensed Practical Nurse (LPN) #525 and Registered Nurse (RN) #520 verified Resident #39 had a diagnosis of T1DM and each denied knowledge that Trulicity was not approved for use in residents with a diagnosis of T1DM.Interview on 12/23/25 at 9:43 A.M. with Pharmacist #510 revealed Trulicity was not an approved medication for anyone diagnosed with T1DM due to the mechanism of how Trulicity worked, adding this would not be beneficial for anyone diagnosed with T1DM and would be an unnecessary treatment.Review of the facility policy titled, Unnecessary Drugs, undated, revealed it was the facility's policy that each resident's entire drug/medication regime was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs.This deficiency represents non-compliance investigated under Complaint Number 2686130. 366328 Page 2 of 2