Homestead at Towne Center

Based on record review and staff interview, the facility failed to maintain the menus served for the previous three months. This had the potential to affect all 60 residents residing in the facility.

Findings include:

Review of facility documents revealed there was no evidence of menus being maintained for three months.

Interview on 10/06/25 at 10:45 A.M. with Dietary Manager #111 revealed she has been in the position for approximately three weeks and had no knowledge of any menus retained for three months.

Based on observation, staff interview, and review of the dishwasher sanitization log, the facility failed to ensure dishes were sanitized. This had the potential to affect all 60 residents residing in the facility. The facility census was 60.

Findings include:

Observation on 10/06/25 at 9:40 A.M. revealed the sanitization strips had no reaction when Dietary Aide (DA) #104 tested the rinse cycle of the dishwasher. DA #104 stated it must be empty. Observation of the five-gallon container for the hypochlorite solution revealed it to be empty. DA #104 stated she would let maintenance know.

Review of the dishwasher sanitization log revealed it was dated for September 2025 with the last entry indicated sanitization was checked on 09/10/25. The chart labeled for 04/25 had only 21 of the 60 slots completed, the chart for 05/25 had only 31 of the 62 slots documented, and the chart labeled for 06/25 had only eight of the 60 slots documented. The charts had a label which read the rinse reached 50 PPM (Parts m]per million) hypochlorite or +.

Interview on 10/06/25 at 10:40 A.M. with Dietary Manager #111 provided verification of the missing documentation on the facility dishwasher sanitization log.

Based on observation, staff interview and review of policy, the facility failed to ensure food was prepared in a manner that protects against potential contamination. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Findings included:

Observation on 07/15/25 at 8:50 A.M. revealed Activities Director #51 placed premade raw cookie dough on a cooking sheet using her bare hands before removing a second cooking sheet out of convection oven then placing it on counter top. Activities Director #51 then placed cooking sheet with raw dough in convection oven. Activities Director #51 removed the cooked cookies from the cooking sheet with a scraper using her bare hands onto a cooling rack. Activities Director #51 then walked to dining tables and began to change the center piece cards on the dining tables without performing hand hygiene.

Interview on 07/15/25 at 8:55 A.M. with Activities Director #51 verified she handled the cookie dough with her bare hands and did not perform hand hygiene before changing the center piece cards on the dining room tables. The facility confirmed all 61 residents residing in the facility receive meals from the kitchen.

Review of facility policy titled Dietary Employee Person Hygiene, dated 12/01/20, revealed employees should never use bare hand contact with any food, ready-to-eat or otherwise.

This violation is on incidental findings discovered during the course of this complaint investigation.

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Based on record reviews, observation, review of a Self-Reported Incident (SRI), and staff interviews, the facility failed to ensure medications were administered per physician order. This affected six residents (#11, #23, #27, #39, #42, and #44) of eight residents reviewed for medication administration. The facility census was 65.

Findings include:

Review of the SRI dated 04/10/25 revealed the facility discovered Licensed Practical Nurse (LPN) #75 had not administered medications to five residents but signed off in the electronic medical charts the medications had been administered. Per the investigation the facility substantiated the neglect and terminated LPN #75. This affected Residents #11, #23, #39, #42, and #44.

1. Record review for Resident #11 revealed the resident was admitted to the facility on 12/09/21. Diagnoses included chronic heart failure and mild cognitive impairment.

Review of Resident #11's service plan dated 12/2021 revealed the resident required staff at the facility to administer medications.

Review of Resident #11's medication orders revealed on 10/25/24 the resident was ordered to receive Acetaminophen 500 milligrams (mg) one tablet orally as needed.

Review of Resident #11's Medication Administration Record (MAR) dated 04/2025 revealed LPN #75 documented the resident received Acetaminophen (treats mild pain) 500 mg tablet in the evening on 04/10/25.

Review of the facility's SRI investigation dated 04/10/25 revealed Resident #11's Acetaminophen tablet was found in the trash in the medication cart and was documented by LPN #75 as administered. Per the investigation, Resident #11 did not report any knowledge of receiving his medications and denied any adverse effects from missing the Acetaminophen tablet.

2. Record review for Resident #23 revealed the resident was admitted to the facility on 12/20/21. Diagnoses included general anxiety disorder, hypertension (HTN), hypothyroidism, and insomnia.

Review of Resident #23's service plan dated 12/10/24 revealed the resident requires staff assistance for administering medications up to three times a day with four or more medications per pass.

Review of Resident #23's medication orders for April 2025 revealed there were orders for clonidine (treats HTN) 0.2 milligrams (mg) twice a day, in the morning and evening; montelukast (treats asthma and allergies) 10 mg in the evening; nitrofurantoin (prevents urinary tract infections) 50 mg orally at bedtime; and Seroquel (antipsychotic) 50 mg at bedtime.

Review of Resident #23's Medication Administration Record (MAR) dated 04/2025 revealed LPN #75 documented the resident received clonidine, montelukast, nitrofurantoin, and Seroquel on 04/10/25 in the evening.

Review of the facility's SRI investigation dated 04/10/25 revealed Resident #23 did not receive the evening scheduled dose of clonidine, montelukast, nitrofurantion, and Seroquel on 04/10/25. The medications were found in the medication cart in the packets unopened. LPN #75 had documented administering the medications to Resident #23 in the electronic medical record.

3. Record review for Resident #39 revealed the resident was admitted to the facility on 08/19/23. Diagnoses included atrial fibrillation and dementia.

Review of Resident #39's service plan dated 03/31/25 revealed the resident required assistance from the facility to administer medications.

Review of Resident #39's medication orders for April 2025 revealed there were orders to administer donepezil (treats dementia) 10 milligrams (mg) at bedtime and quetiapine (antipsychotic) 25 mg at bedtime.

Review of Resident #39's Medication Administration Record (MAR) dated 04/2025 revealed LPN #75 documented the resident received donepezil and quetiapine on 04/10/25 in the evening.

Review of the facility's SRI investigation dated 04/10/25 revealed Resident #39 did not receive the evening scheduled dose of donepezil and quetiapine on 04/10/25. The medications were found in the medication cart in the packets unopened. LPN #75 had documented administering the medications to Resident #39 in the electronic medical record.

4. Record review for Resident #42 revealed the resident was admitted to the facility on 11/04/22. Diagnoses included mitral valve prolapse, anxiety, urinary tract infections, and asthma.

Review of Resident #42's service plan dated 02/21/25 revealed the resident required assistance from the facility to administer medications.

Review of Resident #42's medication orders for April 2025 revealed there were orders to administer Nebivolol (treats high blood pressure) five milligrams (mg) and calcium carbonate (antacid) 600 mg at bedtime.

Review of Resident #42's Medication Administration Record (MAR) dated 04/2025 revealed LPN #75 documented the resident received Nebivolol and the calcium on 04/10/25 in the evening.

Review of the facility's SRI investigation dated 04/10/25 revealed Resident #42 did not receive the evening scheduled dose of Nebivolol and the calcium carbonate on 04/10/25. The medications were found in the medication cart in the packets unopened. LPN #75 had documented administering the medications to Resident #42's in the electronic medical record.

5. Record review for Resident #44 revealed the resident was admitted to the facility on 05/28/24 and discharged home on 05/15/25. Diagnoses included Alzheimer's disease, dementia, and agitation.

Review of Resident #44's service plan dated 03/20/25 revealed the resident required assistance from the facility to administer medications.

Review of Resident #44's medication orders for April 2025 revealed there were orders to administer the following medications at bedtime: acetaminophen (treats mild pain)650 milligrams (mg) two tablets; quetiapine (antipsychotic) 25 mg; divaloprex (treats seizures and bipolar disorder) 125 mg; and sertraline (treats depression) 50 mg.

Review of Resident #4's Medication Administration Record (MAR) dated 04/2025 revealed LPN #75 documented the resident received divaloprex, quetiapine, sertraline, and acetaminophen.

Review of the facility's SRI investigation dated 04/10/25 revealed Resident #44 did not receive the evening scheduled doses of divaloprex, quetiapine, sertraline, and acetaminophen on 04/10/25. The medications were found in the medication cart in the packets unopened. LPN #75 had documented administering the medications to Resident #44 in the electronic medical record.

6. Record review for Resident #27 revealed the resident was admitted to the facility on 06/27/23. Diagnoses included dementia, hypertension, hyperparathyroidism, and atrial fibrillation.

Review of Resident #27's service plan dated 04/14/25 reveled the resident required the facility to administer medications.

Review of Resident #27's medication orders revealed on 05/25/25 the resident was ordered to receive acetaminophen 650 milligrams (mg) one tablet as needed every eight hours.

On 05/27/25 at 8:23 A.M. during an observation of medication administration with Registered Nurse (RN) #70 was observed taking two tablets of acetaminophen 650 mg tablets out of the bottle and placing them into a medication cup for Resident #27. RN #70 verified the bottle was labeled with Resident #27's name and the dosage of the tablets were 650 mg, RN #70 verified the label on the bottle read, 'one tablet every eight hours.' RN #70 stated the new order for Resident #27 was to receive two tablets of acetaminophen. RN #70 verified she had placed two tablets of the 650 mg acetaminophen into the medication cup. RN #70 was observed taking the medication to Resident #27 and explaining the medications to be administered. Resident #27 refused the medications and the nurse returned the pills to the locked medication cart. RN #70 verified she was going to administer the medications she had prepared.

Interview and observation on 05/27/25 at 9:45 A.M. with Executive Director (ED) verified the medication cup in the locked medication cart. ED #71 identified there were two tablets of the acetaminophen in the medication cup. The ED reviewed the current medication orders and stated there was a new order for acetaminophen 325 mg two tablets for a total of 650 mg in the resident's medication orders. The ED verified RN #70 had prepared to administer the wrong dosage of the acetaminophen for Resident #27. The ED was observed removing and wasting the medications from the medication cart.

Interview on 05/27/25 at 3:15 P.M. with the ED stated the order for Resident #27 had been verified and corrected in the records. ED #71 stated there has been no further medications errors from 04/10/25 to 05/27/25. The ED stated after the discovery of the medication errors from LPN #75 for Residents #11, #23, #39, #42, and #44, the ED investigated all residents' records to audit for medication errors. The ED verified there had been no specific education for medication administration after 04/10/25. The ED verified the facility staff had not conducted any audits for medication errors outside of the ED's own review after 04/10/25. The ED verified there had been no adverse effects of any of the missed medications for the residents who missed medications.

This violation represents non-compliance discovered during the SRI investigation for Control Number OH00165502.

Based on observation and staff interview, the facility failed to maintain self-closing doors to resident rooms in a safe manner in the event of a fire. This directly affected 15 (#03, #05, #24, #31, #35, #36, #38, #43, #50, #52, #54, #55, #57, #59, and #60) of 63 residents and had the potential to affect all 63 residents residing in the facility. The census was 63.

Findings include:

Observation on 04/15/25 between 8:50 A.M. to 9:00 A.M. revealed the self-closing doors leading into the rooms of 14 (#03, #05, #24, #31, #35, #36, #38, #43, #50, #52, #55, #57, #59, and #60) resident's rooms were propped open using a wedge, and the door to Resident #54's room was propped open using a chair.

Observations and interview with the Administrator on 04/15/25 at 9:25 A.M. verified the self-closing doors for 15 (#03, #05, #24, #31, #35, #36, #38, #43, #50, #52, #54, #55, #57, #59, and #60) residents were inappropriately propped open with unapproved devices.

Based on record review, staff interview, review of the facility incident log, and review of the policy, the facility failed to ensure fall interventions were in place to prevent a fall. This affected one (#15) of three residents reviewed for falls. Additionally, the facility failed to document and investigate a fall resulting in injury. This affected one (#14) of three residents reviewed for falls. The facility census was 61.

Findings include:

1. Review of the medical record for Resident #15 revealed an admission date of 01/11/22, with diagnoses of hypertension and shortness of breath.

Review of the Resident Evaluation dated 01/31/24 revealed Resident #15 was oriented to person, place and time. Further review revealed Resident #15 required two staff to assist with transfers.

Review of a nurse's progress note dated 06/16/24 revealed Resident #15 was transferring using a walker and gait belt in bedroom after breakfast to recliner. Resident #15 lost his balance and slid down the Resident Assistant's (RA) leg and sat down onto the floor of the bedroom. Resident #15 complained of neck and right shoulder pain. Resident #15 was sent to the hospital for x-rays.

Review of an x-ray dated 06/16/24 revealed Resident #15 had no acute abnormality.

Review of the Resident Evaluation dated 06/20/24 revealed Resident #15 was oriented to person, place and time. Further review revealed Resident #15 had more than one fall in the last three months and staff were educated to always have two people present when transferring Resident #15.

Interview on 08/27/24 at 1:40 P.M., with the Executive Director (ED) confirmed Resident #15 always required two staff for transfers.

Interview on 08/28/24 at 11:45 A.M., with the ED stated she contacted the nurse who completed the incident report for Resident #15's fall on 06/16/24 and confirmed only one Resident Assistant was present during Resident #15's transfer instead of two staff as required by Resident #15's assessment.

Review of the policy titled, Accidents and Supervision

Based on review of employee files, medical record review, policy review, and staff interview, the facility failed to ensure new employees received the required training upon hire, to care with residents displaying behaviors in the specialized unit. This affected three employees (Tested Nursing Assistant #117, and Resident Care Assistants #118 and #120) of three staff reviewed received the required training, upon hire, to care for residents with behavioral needs. This affected two residents (#51 and #57) who exhibited aggressive behaviors and had the potential to affect all 16 residents (#45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, and #60) residing in the memory care unit. The facility census was 59.

Findings include:

Review of the employee files revealed State Tested Nursing Assistant (STNA) #117 was hired on 08/02/23. The file revealed STNA #117 had not received the required two hours of training on caring for residents with behavioral needs.

Review of the employee files revealed Resident Care Assistant (RCA) #118 was hired on 08/17/23. The file revealed RCA #118 had not received the required two hours of training on caring for residents with behavioral needs.

Review of the employee files revealed Resident Care Assistant (RCA) #120 was hired on 09/08/23. The file revealed RCA #120 had not received the required two hours of training on caring for residents with behavioral needs.

Review of the medical record of Resident #51 revealed an admission date of 05/28/24. Diagnoses include depression, Alzheimer's, dementia with anxiety, agitation and mood disturbance. Review of the nurses' notes revealed numerous entries of Resident #51 displaying aggressive behaviors.

Review of the medical record of Resident #57 revealed an admission date of 02/07/24. Diagnoses include Parkinson's disease, cognitive communication disorder, and insomnia. Review of the nurses' notes revealed numerous entries of Resident #57 displaying aggressive behaviors.

Review of the undated policy titled Memory Care Unit Policies revealed staff receive specialized training for the Memory Care Unit.

Interview on 06/04/24 at 3:30 P.M., with Director of Nursing (DON) provided verification the staff members had not received the training to care for residents with behavioral needs. DON added four employees have recently filed workers complaints related to Resident #57 causing injuries.

Based on review of employee files, medical record review, policy review, and staff interview, the facility failed to ensure staff (State Tested Nursing Assistant #113) of one staff reviewed for training, had received the required annual training to care for residents with behavioral needs. This affected two residents (#51 and #57) who exhibited aggressive behaviors and had the potential to affect all 16 residents (#45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, and #60) residing in the memory care unit. The facility census was 59.

Findings include:

Review of the employee file of STNA #113 revealed a hire date of 04/11/23. The file was absent for the required four hours of annual training to care for residents with behavioral needs.

Review of the medical record of Resident #51 revealed an admission date of 05/28/24. Diagnoses include depression, Alzheimer's, dementia with anxiety, agitation and mood disturbance. Review of the nurses' notes revealed numerous entries of Resident #51 displaying aggressive behaviors.

Review of the medical record of Resident #57 revealed an admission date of 02/07/24. Diagnoses include Parkinson's disease, cognitive communication disorder, and insomnia. Review of the nurses' notes revealed numerous entries of Resident #57 displaying aggressive behaviors.

Review of the undated policy titled Memory Care Unit Policies revealed staff receive specialized training for the Memory Care Unit.

Interview on 06/04/24 at 3:30 P.M., with Director of Nursing (DON) provided verification the staff member had not received the annual training to care for residents with behavioral needs. DON added four employees have recently filed workers complaints related to Resident #57 causing injuries.

Based on review of employee files, medical record review, policy review, and staff interview, the facility failed to ensure staff (State Tested Nursing Assistant #113) of one staff member reviewed for training, had received the required annual training to care for residents with severe mental illness needs. This affected two residents (#51 and #57) who exhibited aggressive behaviors and had the potential to affect all 16 residents (#45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, and #60) residing in the memory care unit. The facility census was 59.

Findings include:

Review of the employee file of STNA #113 revealed a hire date of 04/11/23. The file was absent for the required four hours of annual training for caring for residents with significant mental illness.

Review of the medical record of Resident #51 revealed an admission date of 05/28/24. Diagnoses include depression, Alzheimer's, dementia with anxiety, agitation and mood disturbance. Review of the nurses' notes revealed numerous entries of Resident #51 displaying aggressive behaviors.

Review of the medical record of Resident #57 revealed an admission date of 02/07/24. Diagnoses include Parkinson's disease, cognitive communication disorder, and insomnia. Review of the nurses' notes revealed numerous entries of Resident #57 displaying aggressive behaviors.

Review of the undated policy titled Memory Care Unit Policies revealed staff receive specialized training for the Memory Care Unit.

Interview on 06/04/24 at 3:30 P.M., with Director of Nursing (DON) provided verification the staff member had not received the annual training to care for residents with significant mental illness. DON added four employees have recently filed workers complaints related to Resident #57 causing injuries.

Based on review of employee files and staff interview, the facility failed to complete the required background checks for four new staff members. This affected four (State Tested Nursing Assistants #113 and #117, Resident Care Assistants #112 and #120) of four staff reviewed upon hire when the facility did not run the nurse aide registry check. This had the potential to affect all 59 residents residing in the facility.

Findings include:

Review of the employee files revealed State Tested Nursing Assistant (STNA) #117 was hired on 08/02/23. The file was absent for any nurse aide registry check.

Review of the employee files revealed Resident Care Assistant (RCA) #118 was hired on 08/17/23. The file was absent for any nurse aide registry check.

Review of the employee files revealed Resident Care Assistant (RCA) #120 was hired on 09/08/23. The file was absent for any nurse aide registry check.

Review of the employee file of STNA #113 revealed a hire date of 04/11/23. The file was absent for any nurse aide registry check.

Interview on 06/04/24 at 3:30 P.M., with Director of Nursing (DON) verified there was no documentation of the nurse aide registry checks being completed for the four staff.

Based on medical record review, staff interview, and policy review, the facility failed to ensure physician ordered were followed timely. This affected one (#57) of three residents reviewed for physician orders. The facility census was 59.

Findings include:

Review of the medical record of Resident #57 revealed an admission date of 02/07/24. Diagnoses include Parkinson's disease, cognitive communication disorder, and insomnia.

Review of a physician order dated 05/16/24 revealed an order for a complete blood count with differential (CBC with diff); cyanocobalamin (B12) level; thyroid stimulating hormone (TSH) with reflux T4; and a complete metabolic panel (CMP); change divalproex to 500 milligrams (mg) every morning and keep 500 mg at bedtime; discontinue escitalopram; and ziprasidone 20 mg by mouth every evening. The order was sent to the doctor for clarification of the ziprasidone with a note unable to read. The order was re-faxed to the facility on 05/17/24, with a note from the doctor hopefully you 'activated' the other orders. The Director of Nursing initialed the orders on 05/21/24.

Review of the laboratory results revealed the CBC with diff, TSH with reflux T4, B12, and CMP were collected on 05/22/24.

Review of the physician orders revealed the divalproex changes, laboratory test and ziprasidone orders were not entered until 05/21/24.

Interview on 06/04/24 at 3:30 P.M., with Director of Nursing provided verification the orders were not followed timely. She added she discovered the lapse upon her return from vacation.

Review of the policy titled, Provision of Physician Ordered Services

Based on review of the veterinary records of the resident pets and staff interview, the facility failed to ensure the pets received annual examinations from a veterinarian. This directly affected two (#22 and #28's cats) of five pets reviewed. This had the potential to affect all 59 residents residing in the facility. The facility census was 59.

Findings include:

Review of the pet file for Resident #22's cat revealed the last veterinary visit had been completed on 09/29/22.

Review of the pet file to Resident #28's cat revealed the last veterinary visit had been completed on 02/07/22.

Interview on 06/04/24 at 3:30 P.M., with Administrator provided verification the pets had not been seen by a veterinarian annually.

Based on review of facility fire drills and staff interview, the facility failed to complete 12 fire drills annually. This had the potential to affect all 59 residents residing in the facility. The facility census was 59.

Findings include:

Review of the facility fire drills revealed no documentation of fire drills having been conducted July 2023, August 2023, September 2023, October 2023, or November 2023.

Interview on 06/05/24 at 10:20 A.M., with Environmental Director #128 revealed he had been hired in December 2023 and knew the fire drills had not been conducted as required prior to that.

This violation is an example of the continued noncompliance from the annual survey completed on 03/22/23.

Based on medical record review, staff interview, and review of the policy, the facility failed to ensure physician orders were followed timely. This affected one (Resident #62) of one resident reviewed for physician orders. The facility census was 58.

Findings include:

Review of the medical record of Resident #62 revealed an admission date of 01/31/24. The resident discharged to a geriatric-psych facility on 02/22/24 and returned on 03/04/24 and died 03/30/24. The record indicated Resident #62 was on hospice upon admission. Diagnoses included vascular dementia with agitation, type II diabetes mellitus with neuropathy, psychotic disorder with hallucinations, Alzheimer's disease, and obstructive sleep apnea.

Review of the physician order dated 02/16/24, written by Doctor #149, revealed Resident #62 was to have a fasting glucose monitored before breakfast and at bedtime for one week and the log was to be faxed to the doctor's office. Resident #62 was further ordered to have Glargine insulin 15 units injected subcutaneously every morning.

Review of the Medication Administration Record (MAR) dated 02/24 revealed the first glucose level was obtained on 02/18/24 before breakfast and resulted as 208. The Glargine insulin was documented as not given with a note as unavailable. The 02/19/24 blood sugars were recorded as directed but the insulin was marked as unavailable. The 02/20/24 blood sugar before breakfast was recorded but not the bedtime one which was marked as refused. No insulin was administered as it was unavailable. The 02/21/24 morning blood sugar was documented as refused and no insulin was given and was documented as unavailable.

Interview on 04/22/24 at 4:25 P.M. with the Director of Nursing (DON) revealed she was unsure of the reason the Glargine insulin was unavailable, could have been a supply issue or the order was not faxed to pharmacy. The DON verified the resident did not have insulin administered as ordered.

Review of the policy titled, Provision of Physician Ordered Services

Based on review of personnel records, review of the facility Bureau of Criminal Investigation (BCI) log, and staff interview, the facility failed to ensure staff member backgrounds checks were completed timely. This affected one (#110) of six personnel records reviewed and had the potential to affect all 41 residents residing in the facility. The census was 41.

Findings include:

Review of Resident Care Assistant (RCA) #110's personnel record revealed a hired dated of 03/23/22.

Review of the facility's BCI log revealed RCA #110's BCI background check was submitted on 06/01/22 and results were received 06/02/22.

During an interview on 03/20/23 at 12:45 P.M. Business Office Manager (BOM) #180 confirmed RCA #110 did not have a BCI background check completed within 30 days of hired. BOM #180 confirmed RCA #110 was hired on 03/23/22 and BCI background check results received were not received until 06/02/22.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure insulin pens (injection device) were primed before administration. This affected one (#28) of two residents observed during medication administration. The census was 41.

Findings include:

Review of Resident #28's medical record revealed an admission date of 10/30/22. Diagnoses listed included hypothyroidism, hypertension, cardiac pacemaker, and insulin dependent diabetes.

Review of physician orders revealed an order dated 03/14/23 for Humalog Kwikpen insulin pen 100 units per milliliter (100 units/ml) per sliding scale subcutaneously (SQ). If blood sugar (BS) is between 100 to 200 give zero units, if BS is between 201 to 250 give one units, if BS is between 251 to 300 give two units, if BS is between 301 to 350 give three units, if BS is between 351 to 400 give four units, and if BS is greater than 400 call physician (MD).

During an observation on 03/20/23 at 11:07 A.M. Licensed Practical Nurse (LPN) #130 administered Humalog Kwikpen 100 unit/ml to Resident #28 for a BS reading of 291. LPN #130 attached the needle to the Humalog Kwikpen and then dialed it to five units. LPN #130 did not prime the pen needle. LPN #130 then administered the Humalog Kwikpen to Resident #28 in her abdomen.

During an interview on 03/20/23 at 11:10 A.M., LPN #130 confirmed she did not prime Resident #28's Humalog Kwikpen needle. Resident #28 sated she was unaware that insulin pen needles needed to be primed.

Review of the facility's policy titled Insulin Pen dated revised 01/01/23 revealed insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. To prime the insulin pen, dial two units by turning the dose selector clockwise with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears.

This violation represents non-compliance investigated under Complaint Number OH00140571.

Based on review of facility fire drills and staff interview, the facility failed to complete 12 fire drills annually. This has the potential to affect all 41 residents residing in the facility. The census was 41.

Findings include:

Review of facility fire drills revealed since January 2022 a total of five fire drills had been completed. A total of three fire drills were completed in 2022. Fire drills were documented as being completed on 10/06/22, 01/28/22, 02/24/22, 03/01/23, and 03/16/23.

During an interview on 03/20/23 at 10:20 A.M. the Administrator confirmed 12 fired drills were not completed annually.

Based on review of facility disaster preparedness documentation and staff interview, the facility failed to complete two disaster drills annually. This has the potential to affect all 41 residents residing in the facility. The census was 41.

Findings include:

Review of facility facility disaster preparedness documentation revealed no disaster drills were completed in 2022.

During an interview on 03/20/23 at 10:20 A.M. the Administrator confirmed no disaster drills had been completed in 2022.