Health inspection·January 15, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of manufacturer's instructions, the facility failed to ensure staff prime an insulin pen prior to administration. This affected one (#11) out of three reviewed for medication administration. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 08/31/24. Diagnoses included type two diabetes mellitus (DM II), chronic pulmonary edema, and congestive heart failure (CHF). Review of the care plan dated 08/31/24 revealed Resident #11 had diabetes mellitus. Interventions included administering diabetes medication as ordered. Review of the physician order dated 08/31/24, revealed Resident #11 was ordered Humalog (quick acting insulin) Kwik Pen 100 unit per milliliter (ml) solution pen-injector, inject subcutaneously with meals for DM II per a sliding scale. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, partial assistance with toileting, dressing, and transfers, and supervision with bathing. Observation on 01/14/25 at 9:40 A.M. revealed Licensed Practical Nurse (LPN) #22 administered two units of Humalog Kwik Pen to Resident #11. LPN #22 did not prime the insulin pen prior to administering the insulin to Resident #11. LPN #22 dialed insulin pen to two units per sliding scale related to blood sugar of 202. Interview on 01/15/25 at 9:45 A.M. with LPN #22 verified she did not prime insulin prior to administering insulin. Review of the manufacturer instructions for Humalog Kwik Pen revealed the following: 1) Pull the pen cap straight off. 2) Check the liquid in the pen. 3) Select a new needle. (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: 366380 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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)