Health inspection·September 15, 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 Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders were followed and insulin administration was given timely for three of four residents reviewed (Residents R2 R3, and Resident R4). Residents Affected - Few Findings Include: Review of Resident R2's clinical record revealed diagnoses including but not limited to Diabetes Mellitus (impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood). Review of Resident R2's clinical record revealed a physician's order for Lantus (long acting insulin) SoloStar Solution Pen-Injector 100 UNIT/ML (mililiter) with instruction to Inject 10 unit subcutaneously (under the skin) one time a day for diabetic, give 8 am. Review of Resident R2's clinical record including the September 2023 MAR (Medication Administration Record) revealed the Lantus insulin was not administered within acceptable time parameter ten times from September 1, 2023 through September 15, 2023. Review of clinical record of Resident R3 revealed a diagnosis of Diabetes Mellitus. Further review of Resident R3's clinical record revealed a physician's order initiated on April 21, 2023 for NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) with instructions to Inject 8 unit subcutaneously four times a day for diabetic give 6a/12p/4p/8p. Additional review of Resident R3's clinical record including September 2023 MARs revealed the following: September 1, 2023 NovoLOG was to be administered at 4 p.m. but was not administered until 8:48 p.m. with the next administration scheduled for 8 p.m. which was administered at 8:50 p.m. On September 2, 2023, Novolog was to be administered at 4 p.m. but was not administered until 7:41 pm. with the next administration dose scheduled for 8 p.m. which was administered at 7:42 p.m. On september 3, 2023 the 4 p.m. scheduled dose was administered at 6:34 p.m. and the 8 p.m. NovoLOG dose was administered at 8:39 p.m. September 6, 2023 the NovoLOG 4 p.m. dose was administered at 6:35 p.m. and the 8 p.m. dose was administered at 7:09 p.m. Further review of Resident R3's September 2023 MARs revealed on September 12, 2023 the NovoLOG 6 a.m dose was not administered until 9:59 a.m. On September 13, 2023 the 4 p.m. Novolog dose was not administered until 8:46 p.m. and the 8 p.m. dose was adminstered at 9:01 p.m. Review of Resident R4's clinical record revealed a diagnosis of Diabetes Mellitus. (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 2 Event ID: 395436 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 395436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory House Nursing Home 3120 Horseshoe Pike Honey Brook, PA 19344 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)