Embassy of Woodview: Blood Sugar Monitoring Failures - OH
The resident, identified in inspection records only as Resident 150, was admitted July 14 and discharged July 16. She had type two diabetes, ischemic cardiomyopathy, and heart disease. Her physician had ordered blood glucose monitoring four times daily, with instructions to notify the doctor immediately if her blood sugar dropped below 60 milligrams per deciliter or climbed above 400. She was also prescribed Humulin R 500, a concentrated insulin more than five times the standard strength, injected twice daily, along with a weekly injectable diabetes medication called Trulicity. Her oxygen saturations were also supposed to be monitored. Neither was.
Inspectors reviewed the medication administration record and the treatment administration record for July 2025. The monitoring entries were blank. Not once during her stay had staff documented obtaining a blood glucose reading.
When inspectors interviewed a regional nurse on August 29, the explanation that emerged raised its own questions. Regional Nurse 185 confirmed the monitoring had not happened as ordered, but said the resident was wearing a FreeStyle continuous glucose monitor that sent readings to her personal phone. The readings existed. Nobody had entered them into the medical record.
The distinction matters. A continuous glucose monitor worn by a resident and tracked on her own phone is not a substitute for nursing staff obtaining, reviewing, and documenting readings in the clinical record, particularly for a patient on concentrated insulin where a dosing error or an undetected blood sugar crash carries serious consequences. The regional nurse confirmed this herself.
Resident 150 was cognitively intact. Inspection records note she had intact short-term memory and was independent in daily decision-making. She was not a resident who could not have communicated symptoms. Whether she did, and whether anyone acted on them, the inspection report does not say.
The facility census at the time of the inspection was 74 residents. Inspectors reviewed three residents for changes in condition. The monitoring failure was found in one.
The inspection was conducted September 3, 2025, and was triggered by a complaint, filed under complaint number 2572438. The level of harm was cited as minimal harm or potential for actual harm, the lower end of the federal harm scale, meaning inspectors did not find documented evidence that the monitoring failure caused injury. With a two-day stay and a resident tracking her own glucose on a personal device, that determination is plausible. It is also the best-case reading of what happened.
What is not in dispute is that a physician ordered four daily blood glucose checks for a patient on high-concentration insulin, and the facility produced no documentation that any of them occurred. The regional nurse did not dispute it. The facility's own records confirmed it.
Concentrated insulin like Humulin R 500 is used when patients require very large doses and carries a higher risk of hypoglycemia if doses are given without confirming current blood sugar levels first. The physician's order to notify staff if glucose fell below 60 or rose above 400 was not a formality. Those thresholds represent clinical boundaries where intervention becomes urgent.
Resident 150 was discharged after two days. Where she went, and in what condition, the inspection report does not say. The readings her monitor captured during her stay, the ones that went to her phone and nowhere else, are not part of the medical record at Embassy of Woodview. They never were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Embassy of Woodview from 2025-09-03 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
EMBASSY OF WOODVIEW in COLUMBUS, OH was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as Resident 150, was admitted July 14 and discharged July 16.
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.