Health inspection·May 30, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of four medications errors were observed out of 39 opportunities for a medication administration error rate of 10.26%. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; on 05/19/24, Advair Diskus Aerosol Powder Breath Activated 250-50 micrograms (mcg) per(/) dose (Fluticasone-Salmeterol) one inhale orally every 12 hours related to chronic obstructive pulmonary disease (COPD) with acute exacerbation of shortness of breath with prescribed times 8:00 A.M. and 8:00 P.M.; on 03/08/24, Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3.0 milliliter (ml) inhale orally every four hours for COPD prescribed times 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M.; on 10/17/23, Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401 or greater than 400 give, 12 units and call physician, subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus; on 05/22/24, Polyvinyl Alcohol 1.4 % solution administer one drop in each eye three times daily for dry eyes. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's room. Medications included the following: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3.0 ml Lispro Insulin Pen 100 unit per (/) ml. LPN #400 stated she was unable to find Polyvinyl Alcohol 1.4 % Solution eye drops and would not administer due to unavailable. On 05/30/24 at 9:21 A.M., Dietary Aide (DA) #500 exited Resident #1 room carrying Resident #1's breakfast tray. Observation with LPN #400 noted the resident had consumed 75% of the meal. On 05/30/24 at 9:27 A.M., LPN #400 entered Resident #1's room with the medications. At 9:29 A.M., LPN #400 dialed two units to the indicator window of insulin the Lispro insulin pen. No prime of the pen was initiated. LPN #400 proceeded to administer an injection of the pen to the resident's right lower abdominal quadrant. LPN #400 proceeded to administer the Advair Diskus Aerosol. At 9:32 A.M., LPN #400 placed the contents of Ipratropium-Albuterol Solution into an aerosol machine chamber and placed the aerosol mask connected to the chamber on the resident. (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 3 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 05/30/2024 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)