Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/15/24, it was confirmed the facility failed to ensure a safe medication system for a resident who was evaluated as unable to self-administer his/her own insulin for 1 of 1 sampled resident (# 1). Resident 1 was unable to administer his/her own insulin and was hospitalized on 02/10/24 for high blood sugars.

Resident 1 was diagnosed with Type 1 diabetes and had experienced a decline in his/her vision. Resident 1 returned the facility on 02/07/24 from a skilled nursing facility.

On 02/09/24, Resident 1 was observed getting instruction from Staff 4 (RN) on insulin administration. Resident 1 was able to administer his/her own insulin with the instructions of the RN providing visual assistance.

An interim service plan, dated 02/07/24, indicated Resident 1  " Returned from skilled nursing today without [his/her] insulin pump and is unable to administer [his/her] own insulin safely. "

A self-medication administration evaluation, completed by the facility RN on 02/09/24, indicated Resident 1 was unable to safely administer his/her own insulin. Resident 1 continued to administer his/her own insulin after s/he had been evaluated as unable to do so.

The facility failed to follow up with the nursing evaluation and obtain an order for staff to administer his/her insulin.

On 02/10/24, at approximately 10:10 am, Resident 1 was found by Compliance Specialists in his/her wheelchair, slouched facing the wall. Resident 1 was unresponsive and difficult to rouse.

Compliance Specialists witnessed Resident 1 attempt unsuccessfully to check his/her own blood sugar. Compliance Specialists notified staff. Staff 7 (MT) was able to check Resident 1 ' s blood sugar level at approximately 10:47 am. Resident 1 ' s blood sugar was 537, above normal parameters.

Resident 1 was sent to the emergency department, admitted to the hospital, and had not returned to the facility as of 02/15/24.

On 02/14/24, at approximately 4:03 pm, 5:03 pm, and 6:54 pm, the Compliance Specialists requested an immediate plan of correction in the event Resident 1 returned to the facility.

On 02/14/24 at approximately 8:54 pm, Compliance Specialists received a plan of correction. The plan of correction related to Resident 1 ' s insulin administration was accepted at 9:17 pm.

It was determined the facility failed to ensure a safe medication system when Resident 1 was unable to self-administer his/her own insulin. Resident 1 was found unresponsive and hospitalized on 02/10/24 for high blood sugars.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Campus Director), Staff 2 (Memory Care Director), and Staff 3 (Regional Operations Director) on 02/15/24.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/15/24, it was confirmed the facility failed to ensure a safe medication system for a resident who was evaluated as unable to self-administer his/her own insulin for 1 of 1 sampled resident (# 1). Resident 1 was unable to administer his/her own insulin and was hospitalized on 02/10/24 for high blood sugars.

Resident 1 was diagnosed with Type 1 diabetes and had experienced a decline in his/her vision. Resident 1 returned the facility on 02/07/24 from a skilled nursing facility.

On 02/09/24, Resident 1 was observed getting instruction from Staff 4 (RN) on insulin administration. Resident 1 was able to administer his/her own insulin with the instructions of the RN providing visual assistance.

An interim service plan, dated 02/07/24, indicated Resident 1  " Returned from skilled nursing today without [his/her] insulin pump and is unable to administer [his/her] own insulin safely. "

A self-medication administration evaluation, completed by the facility RN on 02/09/24, indicated Resident 1 was unable to safely administer his/her own insulin. Resident 1 continued to administer his/her own insulin after s/he had been evaluated as unable to do so.

The facility failed to follow up with the nursing evaluation and obtain an order for staff to administer his/her insulin.

On 02/10/24, at approximately 10:10 am, Resident 1 was found by Compliance Specialists in his/her wheelchair, slouched facing the wall. Resident 1 was unresponsive and difficult to rouse.

Compliance Specialists witnessed Resident 1 attempt unsuccessfully to check his/her own blood sugar. Compliance Specialists notified staff. Staff 7 (MT) was able to check Resident 1 ' s blood sugar level at approximately 10:47 am. Resident 1 ' s blood sugar was 537, above normal parameters.

Resident 1 was sent to the emergency department, admitted to the hospital, and had not returned to the facility as of 02/15/24.

On 02/14/24, at approximately 4:03 pm, 5:03 pm, and 6:54 pm, the Compliance Specialists requested an immediate plan of correction in the event Resident 1 returned to the facility.

On 02/14/24 at approximately 8:54 pm, Compliance Specialists received a plan of correction. The plan of correction related to Resident 1 ' s insulin administration was accepted at 9:17 pm.

It was determined the facility failed to ensure a safe medication system when Resident 1 was unable to self-administer his/her own insulin. Resident 1 was found unresponsive and hospitalized on 02/10/24 for high blood sugars.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Campus Director), Staff 2 (Memory Care Director), and Staff 3 (Regional Operations Director) on 02/15/24.