Inspection·August 18, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, and facility policy review the facility did not ensure insulin was dated after it was opened and/or failed to ensure the insulin was labeled with the resident's name after it was pulled from the contingency box. This affected three residents (#44, #45 and #59) out of nine residents who had orders for insulin on the C North medication cart. This had the potential to affect 20 residents (#6, #9, #14, #16, #27, #29, #30, #32, #35, #44, #45, #47, #50, #52, #55, #59, #60, #74, #80, and #85) who had orders for insulin at the facility. Findings included: 1. Review of the medical record for Resident #44 revealed an admission date of 04/14/23 with diagnoses including diabetes, chronic obstructive pulmonary disease, and heart failure. Review of the August 2023 physician orders revealed Resident #44's orders included: Novolog FlexPen 100 units per milliliter (ml) inject 35 units subcutaneously (SQ) before meals and Ozempic pen-injector 2 milligram (mg) per 1.5 ml inject 0.25 mg SQ every seven days in the morning. Observation on 08/18/23 at 9:06 A.M. revealed Licensed Practical Nurse (LPN) #602 opened a new Novolog insulin FlexPen and administered Resident #44's 35 units SQ to his right upper arm per his order. She placed the new insulin FlexPen back into the medication cart without labeling with the date that she had opened. Observation of the C North medication cart with LPN #602 on 08/18/23 at 10:06 A.M. revealed Resident #44's Novolog continued to be not dated. Observation revealed there was an opened Ozempic insulin pen that was undated as to when it was opened and without a name to who the insulin pen belonged to. Interview on 08/18/23 at 10:06 P.M. with LPN #602 verified she had forgot to date the Novolog insulin for Resident #44 when she opened it. She also verified the Ozempic insulin pen was unlabeled with name of resident and/ or date when opened. She revealed she did not know who the Ozempic pen belonged to. Interview on 08/18/23 at 10:08 A.M. with the Director of Nursing (DON) as she walked by the C North medication cart verified the Ozempic pen was unlabeled as there was no identification of a resident's name on the pen and/ or a date of when the pen was opened. She revealed the pen was pulled from the contingency box and should have been labeled with the resident name and dated when opened. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365129 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365129 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)