Florence Health Services: Insulin Order Missed on Admission - WI
The error surfaced during a complaint inspection on October 8, 2025. A surveyor reviewing the resident's medication administration record found only one daily blood sugar check. The hospital discharge summary, sitting in the facility's records, contained a sliding scale insulin order that had never been transcribed into the resident's active orders.
RN-G, interviewed that morning, said she was unsure why the MAR showed only a single daily check. She reviewed the discharge summary herself during the interview and confirmed the sliding scale order was there. "The sliding scale is an order," she told the surveyor, adding that she would have clarified it if she had been the nurse transcribing the orders on admission. She said discharge summaries should be read thoroughly and that any discrepancies should be taken back to the discharging hospitalist.
The pharmacist who reviewed the facility's medication orders had not caught it either. PH-F told the surveyor the pharmacy reviews orders that are faxed over, but does not check every medication to confirm it was entered correctly unless something appears off. The sliding scale, PH-F said, should be entered by the facility. PH-F also noted that best practice is to have blood sugar checks ordered before meals to confirm insulin is working as intended.
That wasn't happening for this resident.
The director of nursing, DON-B, acknowledged the sliding scale was missing from the medication orders and said it should have been clarified. When the surveyor pressed on whether blood sugar should have been monitored before meals, DON-B pointed to the fact that the resident saw a provider the day after admission, and said the facility's practice is to follow provider orders.
That answer raised its own questions. DON-B explained that the facility's provider does not use electronic health records. Verbal orders are given to nurses, who write them down and place them in the provider's mailbox to be signed. There is no second nurse assigned to review what the admitting nurse transcribed from a discharge summary.
"Staff are trusted to double check," DON-B said.
DON-B confirmed that staff could have contacted the discharging provider directly to verify the sliding scale order for this resident. They did not.
By the time the surveyor asked about it on October 8, DON-B said she was already working on a new admission process and would begin auditing blood sugar checks and insulin administration. That work started the same day inspectors were on site.
Sliding scale insulin protocols exist precisely because blood sugar does not behave predictably. The scale ties insulin doses to glucose readings taken before meals, so that a patient running high gets a corrective dose and one running low does not get insulin that could drop their levels further. Without the checks before meals, and without the scale entered as an active order, neither the nurses nor the system had the information needed to manage the resident's glucose between the single daily reading and the next.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents.
Florence Health Services is a small facility in Florence County, in Wisconsin's northernmost reaches. The inspection was a complaint survey, meaning someone had raised a concern before investigators arrived. The report does not identify who filed the complaint or what triggered it.
What it does show is a gap that ran from the moment the resident walked through the door. The discharge summary had the order. The admitting nurse did not transcribe it. The pharmacy did not flag it. The provider visit the next day did not produce a corrective order in the record. And the facility had no formal process, beyond individual nurses trusting themselves, to catch what was missed.
The resident's blood sugar went unchecked before meals for however long it took an outside complaint to bring surveyors to the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Florence Health Services from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
Florence Health Services in Florence, WI was cited for violations during a health inspection on October 8, 2025.
The error surfaced during a complaint inspection on October 8, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.