Health inspection·October 3, 2024

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 observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 24 medications were observed with two errors for a medication error rate of 8.33%. This finding affected two (Resident #39 and #41) of three residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of medical record for Resident #39 revealed an admission date of 03/26/20. Diagnoses included type two diabetes with diabetic neuropathy, unspecified, major depressive disorder, recurrent and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of physician order dated 01/24/24 revealed orders for Novolin 70-30 via flexpen, administer 45 units one time a day. Observation on 10/03/24 8:43 A.M. revealed Licensed Practical Nurse (LPN) #836 administered 45 units of Novolin to Resident #39. LPN #836 retrieved the injector pen, sanitized the tip, twisted the injector needle and turned to the dosage dial to 45 units before injecting the insulin. LPN #836 did not prime the insulin pen. Interview during observation with LPN #836 revealed they did not know they were supposed to prime the insulin pen before administering insulin. 2. Review of medical record for Resident #41 revealed an admission date of 03/30/23. Diagnoses included type two diabetes with foot ulcer. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of physician order dated 09/25/24 revealed orders for insulin Glargine-yfgn, administer 14 units one time a day. Observation on 10/03/24 8:11 A.M. revealed LPN #840 administered 14 units of Glargine to Resident #41. LPN #840 retrieved the injector pen, sanitized the tip, twisted on the injector needle and turned to the dosage dial to 14 units before injecting the insulin. LPN #840 did not prime the insulin Page 1 of 5 366441 366441 10/03/2024 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0759 pen. Level of Harm - Minimal harm or potential for actual harm Interview during observation with LPN #836 revealed they were not aware of the need to prime the insulin pen. Residents Affected - Few Review of the facility policy titled, Using Insulin Pen Delivery Systems, dated 2023 indicated to attach new safety pen needle, hold upright and prime the pen to remove air bubbles and to ensure the needle is open and working properly, dial to prescribed dosage, and inject fully by depressing push button. 366441 Page 2 of 5 366441 10/03/2024 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observations and interviews the facility failed to ensure insulin was dated, labeled, and discarded properly. This affected six residents (#11, #12, #16, #30, #41 and Resident #53) of 12 residents reviewed for insulin storage. Findings include: Review of medical record for Resident #11 revealed an admission date of 05/22/21. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #11 dated 08/14/24 revealed the resident had impaired cognition. Review of medical record for Resident #12 revealed an admission date of 11/28/23. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 09/26/24 revealed the resident had intact cognition. Resident #12 was ordered insulin. Review of medical record for Resident #16 revealed an admission date of 09/28/23. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #16 dated 09/30/24 revealed the resident had intact cognition. Resident #16 was ordered insulin. Review of medical record for Resident #30 revealed an admission date of 05/02/24. Diagnoses included type two diabetes, alcoholic cirrhosis of the liver and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #30 dated 08/07/24 revealed the resident had intact cognition. Resident #30 was ordered insulin. Review of medical record for Resident #41 revealed an admission date of 03/30/23. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #41 dated 07/30/24 revealed the resident had intact cognition. Resident #41 was ordered insulin. Review of medical record for Resident #53 revealed an admission date of 04/08/24. Diagnosis included type two diabetes and hypoglycemia unspecified. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #53 dated 08/02/24 revealed the resident had impaired cognition. Resident #53 was ordered insulin. Observation of a medication cart on 10/03/24 at 8:30 A.M. revealed insulin injector pens with no date or name documented. Observations included one injector pen with no name or date, an injector pen of Aspart for Resident #11 dated 08/18/24, two injector pens of Lispro for Resident #12 not dated, and an injector pen of Lispro for Resident #41 that was not dated. Interview during observation with Licensed Practical Nurse (LPN) #840 verified the findings and stated all insulin must be labeled with names and dates. LPN #840 revealed insulin should be discarded after 28 days of the open date. Observations of a medication cart on 10/03/24 at 8:50 A.M. revealed insulin injector pens with no date or name documented. Observations included one injector pen with no name or date, an injector pen 366441 Page 3 of 5 366441 10/03/2024 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0761 Level of Harm - Minimal harm or potential for actual harm Lispro for Resident #16 not dated, an injector pen of Lispro and B insulin for Resident #30 not dated, and an injector pen of Glargine for Resident #53 not dated. Interview during observations with LPN #836 verified the findings and stated all insulin must be labeled with names and dates when opened. Residents Affected - Some Review of the facility policy titled Pharmacy Services and Procedure Manual, dated 2022 noted staff should document the date opened on the label of medications with shortened expiration dates including insulin's and irrigation solutions. 366441 Page 4 of 5 366441 10/03/2024 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and policy review the facility failed to maintain infection control standards when administering medications. This affected one (Resident #30) of three residents reviewed for infection control during medication administration. Residents Affected - Few Findings include: Review of medical record for Resident #30 revealed an admission date of 05/02/24. Diagnoses included type two diabetes, alcoholic cirrhosis of the liver and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #1 dated 08/07/24 revealed the resident had intact cognition. Observations on 10/02/24 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #836 administering medications for Resident #30. LPN #836 placed nine medications into her bare hand before placing them in the medication cup. Interview during the observation with LPN #836 revealed she should not have put the medication in my hand, they should go in the cup. Review of the facility policy titled, Pharmacy Services and Procedure Manual, dated 2022 revealed staff should not touch the medication when opening a bottle or unit dose package. 366441 Page 5 of 5