Licensed Practical Nurse #140 kept Resident #97's unopened insulin aspart injection pen in the top drawer of a medication cart on the North Front unit. The insulin remained in its original pharmacy bag, which carried a label instructing staff to "refrigerate until opened."
The discovery occurred at 8:00 A.M. on September 23 when inspectors observed the medication cart during their investigation. Two minutes later, when questioned about the insulin's storage, LPN #140 confirmed the medication was unopened and had not been refrigerated.
Insulin aspart is a rapid-acting insulin that requires specific temperature control to maintain its effectiveness. Manufacturers specify that unopened insulin pens must be stored in refrigerated conditions to preserve the medication's potency and prevent deterioration.
The facility's own medication storage policy, dated September 1, 2021, explicitly addresses this requirement. The policy states that "each medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location."
The same policy mandates that the facility "shall not use discontinued, outdated, or deteriorated drugs or biologicals" and requires that "all drugs should be returned to the dispensing pharmacy or destroyed" if they become compromised.
Beyond refrigeration requirements, the policy establishes that the facility "shall store all drugs and biologicals in a safe, secure, and orderly manner." The insulin pen's placement in an unrefrigerated medication cart drawer violated multiple aspects of these storage protocols.
The violation occurred despite clear labeling from the dispensing pharmacy. The insulin flexpen arrived in a pharmacy bag that specifically instructed staff to refrigerate the medication until it was opened for use.
State inspectors classified the deficiency as causing "minimal harm or potential for actual harm" affecting "few" residents. However, improper insulin storage can render the medication less effective or completely ineffective, potentially leading to dangerous blood sugar fluctuations in diabetic patients.
The inspection was conducted in response to Complaint Number 1260763, suggesting someone reported concerns about medication handling practices at the facility. The specific nature of the original complaint was not detailed in the inspection report.
For Resident #97, the storage violation meant their prescribed diabetes medication may have been compromised. Insulin that loses potency due to improper storage can fail to adequately control blood glucose levels, creating risks for both immediate complications and long-term health consequences.
The facility operates under Medicare and Medicaid certification, which requires compliance with federal medication storage standards. These standards exist specifically to protect vulnerable nursing home residents who depend on staff to properly handle their medications.
New Lebanon Rehabilitation and Healthcare Center is located at 101 Mills Place in New Lebanon, a small community in southwestern Ohio. The facility serves residents requiring both rehabilitation services and long-term care.
The September 30 inspection report does not indicate whether other medications were improperly stored or if additional residents were affected by storage violations. The focus remained on the single insulin pen found in the unrefrigerated medication cart.
LPN #140's acknowledgment that the insulin was unopened and unrefrigerated suggests awareness of the medication's condition. However, the report does not detail whether the nurse understood the storage requirements or planned to refrigerate the insulin.
The violation represents a breakdown in the facility's medication management system. Proper storage requires coordination between pharmacy delivery, nursing staff recognition of storage requirements, and systematic placement of temperature-sensitive medications in appropriate locations.
State inspectors completed their investigation on September 30, 2025, documenting the deficiency under federal tag F 0761, which addresses pharmaceutical services and medication storage requirements.
The facility must submit a plan of correction addressing how it will prevent future medication storage violations and ensure proper handling of temperature-sensitive medications like insulin.
For Resident #97, the immediate concern was whether their diabetes management was compromised by the improperly stored insulin. The long-term question remains whether systematic problems in medication handling affected other residents' care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Lebanon Rehabilitation and Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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