Bath Creek Estates

to ensure a medication error rate of less than 5 percent (%).

Two errors were observed in 28

residents observed for medication administration.

The facility census was 94.Findings include:1.

Record review for Resident #36 revealed an admission date of 10/19/21.

Diagnosis included diabetes mellitus due to underlying conditions with other specified complications.

Review of the physician order dated 06/25/24 for Resident #36 revealed an order for insulin aspart units 100 insulin pen, 100 units per milliliter (ml) give 23 units subcutaneous (sq).

Give with meals at 8:00 A.M.,12:00 P.M. and 5:00 P.M.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was cognitively intact. Resident #36 had a diagnosis of diabetes mellitus and received insulin injections seven of seven days.

Review of the care plan dated 02/04/26 revealed Resident #36 received insulin related to diabetes mellitus.

Interventions included administering insulin per physician order.Observation on 03/25/26 at 11:48 A.M. of Licensed Practical Nurse (LPN) #249 administer insulin to Resident #36 revealed LPN #249 remove the aspart insulin pen from the medication cart drawer. LPN #249 dialed the insulin pen to 23 units, placed the needle on the pen then administered the insulin to Resident #36. LPN #249 never primed the insulin pen before setting the required number of units. LPN #249 confirmed she never primed the insulin pen and revealed normally she would prime the insulin pen then dial in the required number of units, then put the needle on the pen.2.

Record review for Resident #15 revealed an admission date of 10/20/23.

Diagnoses included Crohn's disease, diverticulosis and constipation.

Review of the physician orders for Resident #15 revealed an order for MiraLAX powder (laxative) 17 grams orally once per day dated 10/21/23.

Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and was frequently incontinent of bowel.Observation on 03/26/26 at 8:29 A.M. of LPN #280 administer medications to Resident #15 revealed LPN #280 filled the MiraLAX powder to right under the very bottom line inside the MiraLAX lid. LPN #280 then poured the MiraLAX powder into the water cup to be administered. LPN #280 confirmed the MiraLAX was measured appropriately and was ready for administration.

Requested LPN #280 to read the instructions on the MiraLAX container for administration of 17 grams.

The container read, The bottle cap is a measured cup designed to contain 17 grams of fiber when filled to the top rim. LPN #280 confirmed the error.

Review of the Manufacturer's Instructions for Use for KwikPen insulin administration, undated revealed Always use a new needle for each injection.

Push the capped needle straight onto the pen.

Priming your Pen: Prime before each injection, priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. To prime the pen, turn the dose knob to select two units.

Hold the pen with the needle pointing up.

Tap the cartridge holder gently to collect air bubbles at the top.

Continue holding the pen with needle pointing up.

Push the dose knob in until it stops and 0 is seen in the dose window.

Hold the dose knob in and count to five slowly.

You should see insulin at the tip of the needle. If you don't see insulin, repeat the priming steps.

Next turn the dose knob to the correct number of units you need to inject.The deficiency represents noncompliance investigated under Complaint Number 2738943.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE