Health inspection·August 7, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, facility policy review, and review of manufacturer instructions, the facility failed to ensure insulin was administered as ordered. This affected one (#31) of seven residents observed for medication administration. The facility census was 38. Residents Affected - Few Findings include: Review of the medical record for Resident #31 revealed an admission date of 07/24/23. Diagnoses included type II diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, obstructive sleep apnea, peripheral vascular disease, encephalopathy, major depressive disorder, and insomnia. Review of the current physician orders for Resident #31 revealed an order dated 04/05/23 for blood glucose levels to be obtained prior to meals with Novolog insulin administered subcutaneously (SQ) per sliding scale via a Flex Touch pen. The order for insulin to be given per sliding scale was for blood glucose levels between 140 milligrams per deciliter (mg/dL) and 199 mg/dL, inject two units of insulin; for blood glucose levels between 200 mg/dL and 249 mg/dL, inject four units of insulin; for blood glucose levels between 250 mg/dL and 299 mg/dL, inject six units of insulin; for blood glucose levels between 300 mg/dL and 349 mg/dL, inject eight units of insulin; for blood glucose levels between 350 mg/dL and 399 mg/dL, inject 10 units of insulin; and for blood glucose levels greater than 400 mg/dL the physician was to be notified. Observation on 08/07/23 at 11:59 A.M. revealed Licensed Practical Nurse (LPN) #500 obtained Resident #31's blood glucose level and determined the level to be 171 mg/dL. Continued observation of LPN #500 revealed the nurse returned to the medication administration cart, and at 12:00 P.M., LPN #500 removed a clear plastic bag that contained the insulin pen (Novolog Flex Touch) for Resident #31 from the medication cart. LPN #500 then removed a needle and two alcohol swabs from the medication cart. The insulin pen was then removed from the bag, the cap was removed from the pen and laid on the plastic bag from which the Novolog Flex Touch pen was removed. LPN #500 proceeded to open an alcohol wipe, swabbed the top of the insulin pen, attached the needle, and dialed pen to two units of insulin. While holding the insulin pen in the left hand, LPN #500 used the right hand to return the plastic bag and the cap to the pen back into the medication cart. LPN #500 then locked the medication cart, picked up the second alcohol swab, and entered Resident #31's room. LPN #500 approached Resident #31 and injected the insulin into Resident #31's left arm. Interview with LPN #500 on 08/07/23 at 12:02 P.M. confirmed the insulin pen was not primed when the needle was applied and before administering insulin to Resident #31. LPN #500 stated insulin pens (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: 365571 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 365571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450 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)