Health inspection·August 29, 2019

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation staff interview, and review of manufacturer guidelines, the facility failed to ensure a resident's insulin was administered according to manufacturer guidelines, resulting in a significant medication error. This affected one Resident (#5) of two residents observed for insulin administration. The facility identified three residents receiving insulin. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 07/26/18. Medical diagnoses included chronic kidney disease, diabetes mellitus, major depressive disorder, hypertension, malignant neoplasm of colon, and anxiety disorder. Review of the resident's physician's orders revealed an order dated 08/23/19 for Lantus insulin (long acting insulin) pen 33 units subcutaneous once daily. Observation of medication administration on 08/28/19 at 8:06 A.M. with Registered Nurse (RN) #200 revealed she prepared Resident #5's Lantus pen by turning the dial to 33 units. She then administered Lantus 33 units subcutaneous without priming the Lantus insulin pen. Interview with RN #200 on 08/28/19 at 8:10 A.M. verified she did not prime the resident's Lantus insulin pen prior to administration. Interview with Regional Nurse #210 on 08/28/19 at 9:19 A.M. revealed the facility did not have a policy regarding insulin administration. She stated the facility staff were to follow manufacturer guidelines. Review of Lantus Solostar Pen manufacturer guidelines dated 2017 revealed steps for injection included performing a safety test. Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. Always perform the safety test before each injection. 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 3 Event ID: 365405 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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)