Inn at Ashland Woods The

Based on observation, staff interview, and review of facility policy and manufacturer guidance, the facility failed to ensure that an insulin pen was properly primed prior to administration. This deficient practice affected one (Resident #41) of one residents observed receiving insulin and had the potential to affect one additional resident Resident #46, who also received insulin from the facility. The facility census was 52.

Findings include:

During an observation on 07/09/25 at 11:00 A.M., Medical Technician (Med Tech) #249 was observed administering two units of Insulin Lispro to Resident #41 using a prefilled Insulin pen (KwikPen). The pen was not primed prior to the injection.

In an interview conducted at the time of the observation, Med Tech #249 confirmed the Insulin pen was not primed prior to administration. Med Tech #249 stated the pen had already been opened and was assumed to be ready for use without priming.

In a follow-up interview on 07/09/25 at 02:10 P.M., Director of Nursing (DON) confirmed that facility policy requires insulin pens to be primed prior to every injection and acknowledged the step was not followed during the observed administration of Resident #41.

Review of the manufacturer ' s Instructions for Use for the Insulin Lispro KwikPen, revised 07/2023, stated the pen must be primed before each injection to remove air from the needle and cartridge that may collect during normal use and to ensure accurate dosing. The instructions warn that failure to prime may result in too much or too little insulin being delivered.

Review of the facility ' s Medication Administration Policy, revised 03/2023, confirmed staff are required to follow manufacturer guidelines when administering medications, including priming insulin pens prior to each use.

Based on observation and interview, the facility failed to ensure expired food items were properly discarded. This had the potential to affect all residents residing at the facility. The facility census was 52.

Findings include:

Observation on 07/14/25 at 8:38 A.M. of the facility's kitchen revealed two loafs of bread dated to expire on 07/13/25, four bags of hamburger buns dated to expire 07/08/25, three bags of hot dog buns dated to expire 07/11/25.

Observation on 07/14/25 at 9:00 A.M. of the memory care kitchenette noted two loafs of wheat bread dated to expire 07/01/25.

Interview on 07/14/25 at 9:00 A.M. and Dietary Cook #233 verified she was unaware of expired bread. She reported that all residents in the facility are able to receive bread products.