Health inspection·January 6, 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 observation, staff interview, medical record review, manufacture's guidelines, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#47) of one resident reviewing for insulin pen priming. The facility identified two residents (#47 and #55) in House #1 who received insulin. The facility census was 55. Residents Affected - Few Findings include: Review of the medical record for Resident #47 revealed an admission date of 08/05/21 with diagnoses of transient cerebral ischemic attack, type two diabetes mellitus without complications, anemia, adult failure to thrive, hypertension and dementia. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment. Review of physician orders dated 01/29/24 for Resident #47 revealed the resident was prescribed Insulin Glargine Solution 100 units, with instructions to inject 8 units subcutaneously each morning before breakfast to manage Diabetes Mellitus. Observation of medication administration on 12/18/24 at 8:41 A.M. for Resident #47 indicated the resident was scheduled to receive 8 units of insulin Glargine solution 100 units/ml. Registered Nurse (RN) #113 prepared the medication at the medication cart, first cleansing the tip of the insulin pen, attaching a needle, and placing the pen on a clean tissue. The nurse then grabbed an alcohol wipe, locked the medication, and entered the resident's room. Upon entering, the nurse performed hand hygiene, donned clean gloves, and approached the resident. The nurse wiped the right side of the resident's arm with the alcohol wipe, twisted the insulin pen to prepare 8 units, but failed to prime the insulin pen prior to administration. The nurse quickly showed the pen to the surveyor with 8 units dosed and then administered the medication. Interview on 12/18/24 at 8:46 A.M. with RN #113 confirmed she did not prime the insulin pen before administering the medication. RN #113 was unaware of the required procedure or the proper amount of insulin to use for priming the insulin pen. Review of policy entitled Insulin Pen Quick Reference Guide dated 2021 revealed Lantus insulin pens require two units to be used for priming the needle before an injection is administered, ensuring accurate dosing. Review of the manufacturer's guidelines entitled Drop Safe Safety Pen Needle not dated revealed a (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 4 Event ID: 366430 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 366430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230 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)