Continuing Healthcare of Cuyahoga Falls: Insulin Error - OH
The error happened on the morning of August 6, inside Continuing Healthcare of Cuyahoga Falls, a 50-bed facility. Federal inspectors were watching when it occurred.
The resident, identified in inspection records only as Resident 112, is a woman in her seventies or eighties with a list of serious diagnoses: chronic kidney disease, heart failure, type two diabetes, and protein calorie malnutrition. She has lived at the facility since February 2021. Her cognition is fully intact, inspectors noted, meaning she was aware of everything happening around her.
Her physician had written a specific order on June 18: give three units of Novolog insulin twice daily. And hold the dose entirely if her blood sugar dropped below 110.
At 11:42 in the morning, Licensed Practical Nurse 231 came to check the resident's blood sugar. She cleaned her hands and the glucometer, swabbed the resident's finger with alcohol, pricked it with a lancet, wiped away the first drop of blood, and placed the test strip over the second drop. The glucometer read 93.
Ninety-three. Seventeen points below the threshold the doctor had set.
The nurse then walked to the medication cart, pulled out the resident's multidose vial of Novolog, wiped the top with an alcohol swab, and drew up four units into an insulin syringe. Not three units, the ordered dose. Four.
She returned to the room, injected the insulin into the resident's right upper arm, and performed hand hygiene afterward.
Two errors had just occurred at once. The dose should have been held because the blood sugar was 93. And when the nurse drew it up anyway, she drew up the wrong amount.
The Director of Nursing confirmed both errors during an interview with inspectors that afternoon. The DON went to assess Resident 112 for signs of hypoglycemia, the dangerous drop in blood sugar that insulin can trigger when given to someone whose levels are already low. Shakiness, confusion, sweating, loss of consciousness. The resident showed none of those signs. She had not been visibly harmed.
The DON documented the error in the electronic medical record and told both the resident and her physician what had happened. No new orders came back from the physician.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, the lower tier of the two-tier scale used in federal nursing home enforcement. The finding came through a complaint investigation, complaint number 2581097, rather than a routine annual survey.
The facility's own medication policy, last revised in June 2019, instructs nurses to review physician orders and follow the eight rights of medication administration before giving any drug. One of those rights is the right dose. Another is confirming the patient's condition warrants the medication at all.
What inspectors documented that morning was a nurse who did neither.
The error itself may not have left Resident 112 in the hospital. Her blood sugar stayed stable. But she has chronic kidney disease and heart failure, two conditions that complicate how the body handles blood sugar swings. Her care plan, updated back in August 2021, flagged her as specifically at risk for hypoglycemic episodes. The order to hold insulin below 110 existed precisely because of that risk.
She was sitting in her room, cognitively intact, aware of what was happening, when a nurse gave her a drug she wasn't supposed to receive at a dose she was never prescribed.
The physician was notified. No new orders were written. The record was updated.
Resident 112 went on with her day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Healthcare of Cuyahoga Falls from 2025-08-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
CONTINUING HEALTHCARE OF CUYAHOGA FALLS in CUYAHOGA FALLS, OH was cited for violations during a health inspection on August 20, 2025.
The error happened on the morning of August 6, inside Continuing Healthcare of Cuyahoga Falls, a 50-bed facility.
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.