Shurmer Place at Altenheim

Based on observations, staff interviews, record reviews, and review of the facility policy, the facility failed to administer medications to the residents according to the physician's order. This affected two (Residents #1 and #83) of five residents reviewed for medication administration. The facility census was 87.

Findings include:

1. Record review for Resident #1 revealed an admission date of 08/26/25. Diagnosis included type two diabetes mellitus (DM).

Review of the physician order dated 08/28/25 revealed Resident #1 had an order for insulin lisper subcutaneous (SQ) solution pen-injector 100 units per milliliter (ml) inject 11 units SQ before meals for DM.

Observation and interview on 10/16/25 at 8:55 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #202 removed Resident #1's Lispro insulin pen-injector from the medication cart. LPN #202 applied a new needle then dialed 11 units on the pen. LPN #202 did not prime the insulin pen injector. LPN #202 then administered the insulin SQ to Resident #1. LPN #202 confirmed she did not prime the insulin pen injector prior to administering the medication. LPN #202 asked what prime meant and stated, We don't do that.

2. Record review for Resident #83 revealed an admission date of 06/05/25. Diagnosis included type two diabetes mellitus (DM) with diabetic chronic kidney disease.

Review of the physician orders dated 10/14/25 revealed Resident #83 had an order for Novolog 70/30 flex pen subcutaneous (SQ) (insulin aspart) 30 units SQ one time a day related to DM with diabetic chronic kidney disease.

Observation and interview on 10/16/25 at 9:35 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #203 removed Resident #83' s aspart insulin pen-injector from the medication cart. LPN #203 applied a new needle then dialed 30 units on the pen. LPN #203 did not prime the insulin pen injector. LPN #203 then administered the insulin SQ to Resident #83. LPN #203 confirmed she did not prime the insulin pen injector prior to administering the medication. LPN # 203 stated sometimes she does prime it and sometimes she doesn't.

Review of the facility policy titled Insulin Pen Usage In Service dated 06/01/23 revealed instructions for preparing your pen include: Attach a new pen needle to the insulin pen. Prime the insulin pen. Priming means removing the air bubbles from the needle. It ensures that the needle is open and working. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the two units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears.

Based on staff interviews and record review, the facility failed to ensure the residents were evacuated in at least two fire drills a year on each shift. This had the potential to affect all 87 residents residing at the facility.

Findings include:

Review of the facility's monthly Fire Alarm/Drill forms from 10/01/24 through 09/30/25 revealed no residents were evacuated during any of the 12 consecutive monthly fire drills reviewed with the exception of the drill completed 07/25/25 at 9:00 P.M. two residents were documented as evacuated.

Interview on 10/15/25 at 1:45 P.M. with Director of Maintenance (DOM) #201 confirmed he completed each of the 12 fire drills reviewed. DOM #201 revealed during each fire drill, staff present participated but residents did not. DOM #201 confirmed they never involve residents in any fire drills stating the only reason there were two residents marked for 07/25/25 was because they happened to be standing in the hall at that time where the drill was conducted. DOM #201 confirmed they have done fire drills in residential rooms but never evacuated any residents in the area.

Interview on 10/15/25 at 2:27 P.M. with Resident Director #500 revealed residents' should be part of fire drills and evacuated if they reside in the room on either side of the fire or above the room, including on either side where the fire was located.

Based on observation and interview, the facility failed to ensure trash cans in the laundry rooms shared by residents and staff were fireproof. This had the potential to affect all 87 residents residing at the facility.

Findings include:

Observation and interview on 10/15/25 at 2:25 P.M. with Resident Director #500 revealed there were four laundry areas on each floor of the two-story facility, totaling eight laundry areas in the facility. The laundry area on the first floor had a small plastic trash can next to the washer/dryer. Resident Director #500 confirmed the trash can was plastic and was not fireproof. Resident Director #500 stated the facility used the same type of plastic non-fireproof trash cans in all eight of the facility laundry areas utilized by residents and staff. Resident Director #500 confirmed after reviewing the facility regulations, the trash cans were required to be fireproof.