Inspection·April 10, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN EXAMPLE OF PAST NONCOMPLIANCE SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, emergency room documentation review, review of the facility investigation, interview, review of the Lantus (glargine) Insulin prescribing information, review of www.insulins.lilly.com the facility failed to ensure medications were administered per physician orders resulting in a significant medication error. This affected one resident (Resident #73) of three residents reviewed for medications. Actual harm occurred on 03/14/25 at 10:30 P.M. when Resident #73, a diabetic resident who received insulin with meals and at bedtime, was administered the incorrect type of insulin (short acting instead of long-acting insulin) resulting in the resident having a headache, upset stomach and a blood sugar in low range. The physician was notified and ordered an emergency department transfer. Resident #73 was treated for hypoglycemia with intravenous fluids and concentrated intravenous dextrose before returning to the facility. Findings include: Review of Resident #73's medical record revealed an admission date of 03/06/25 with diagnoses that included diabetes mellitus, urinary tract infection with sepsis and hypertension. Upon admission Resident #73 was ordered Humalog (rapid acting, mealtime insulin) six units subcutaneously (SQ) with meals and insulin glargine (long-acting insulin) 54 units SQ at bedtime. On 03/14/25 at 10:30 P.M. a progress note revealed Resident #73 was having a headache, upset stomach and blood sugar in low range. The physician was updated on patient status and ordered to end to the emergency department for evaluation. Resident #73 returned from the emergency department on 03/15/25 at 5:10 A.M. with no new orders. Review of the facility transfer out of facility form completed on 03/14/25 revealed the indication for transfer out was due to receiving the wrong medication. Review of the emergency department Discharge summary dated [DATE] revealed Resident #73 was diagnosed with hypoglycemia (low blood sugar) due to insulin and administered intravenous (IV) dextrose 5% in water one liter and dextrose 25 grams per 50 milliliters by IV twice. A physician's progress note dated 03/15/25 indicated Resident #73 had an emergency department evaluation after administered the incorrect dosage of Humalog. (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: 366214 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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)