Health inspection·May 5, 2025

Greenhills Manor Recertification Survey Event ID Y9GW11 Exit Date 4/4/2025 State Citation B was written. F759 §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater. From 4/1/25 to 4/4/25, an unannounced recertification survey was conducted at the facility. The facility had a medication error rate of 25.93% when 7 medication errors occurred out of 27 opportunities during medication administrations for four out of six patients (5, 6, 14, and 146). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in patients not receiving the full therapeutic effects of the medications. 1. During a medication pass observation on 4/1/25, at 10:29 a.m. with Licensed Vocational Nurse C (LVN C), LVN C stated he did not have gabapentin (pain reliever) 100 milligrams (mg, a metric unit of mass) and tamsulosin (helps increase the flow of urine) 0.4 mg on hand to give to Patient 146. During a concurrent medication pass observation LVN C also crushed levetiracetam (helps control seizures) one 500mg tablet and Klor-Con (used to treat and prevent low potassium) M10 Extended Release (ER) one 20 milliequivalent (mEq, a unit of measure that expresses the combining power of a substance) tablet, mixed with apple sauce, and administered to Patient 146. During a medication pass observation on the labels of levetiracetam 500 mg and Klor-Con 20 mEq bubble pads and interview with LVN C on 4/1/25, at 11:21 a.m., LVN C confirmed that he crushed levetiracetam 500 mg and Klor-Con 20 mEq, but their labels stated, "Do Not Chew or Crush." Review of Patient 146's physician orders indicated Patient 146 was to receive gabapentin 100 mg, started on 4/1/25; tamsulosin 0.4 mg, started on 3/29/25; levetiracetam 500 mg, started 3/29/25; and Klor-Con 20 mEq, started on 3/29/25, at 9 a.m. Review of the facility's policy, "Medication Administration - General Guidelines," dated 2007, indicated " ... 5. ... b. Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought." Review of the facility's undated job description, "Registered Nurse," indicated "Job Functions: ... Obtains medications, supplies, and medical records needed to provide safe, efficient, and therapeutic care to patients on a continuing basis." 2. During a medication pass observation on 4/1/25, at 4:07 p.m. with LVN D, LVN D administered calcium carbonate (used to treat low calcium conditions) 500 mg crushed through Patient 14's nasogastric tube (NG-tube, a thin, flexible tube inserted through the nose, down the throat, and into the stomach, used for delivering fluids, crushed medications, or nutrition, or removing substances from the stomach). Review of Patient 14's physician order, dated 1/29/25, indicated he was to receive calcium carbonate 1250 mg one tablet enterally two times a day at 8 a.m. and 5 p.m. During an interview with LVN D on 4/1/25, at 5:32 p.m., he reviewed Patient 14's physician orders and confirmed that the physician ordered calcium carbonate 1250 mg for Patient 14, but he administered calcium carbonate 500 mg to him. 3. During a medication pass observation on 4/1/25, at 4:46 p.m. with LVN D, LVN D gave Symbicort inhaler (helps reducing inflammation in the lungs and keeping airways open) to Patient 6 to administer herself two puff inhales orally without instructing her to shake the Symbicort inhaler well and rinse mouth after use. During a medication pass observation on the label of Symbicort inhaler and interview with LVN D on 4/1/25, at 5:03 p.m., LVN D confirmed that the label stated, "Shake well before using; rinse mouth after each use," and he did not instruct Patient 6 to do that. 4. During a medication pass observation on 4/3/25, at 10:24 a.m. with registered nurse E (RN E), RN E administered one tablet of Multiple Vitamin to Patient 5. Review of Patient 5's physician order, dated 2/11/25, indicated she was to receive one tablet of Multiple Vitamin with 400 micrograms (ug, a metric unit of mass) of folic acid (helps the body make new cells) one time a day at 8 a.m. During an observation on the ingredients of Multiple Vitamin bottle and interview with RN E on 4/3/25, at 11:48 a.m., RN E confirmed that the Multiple Vitamin tablet that she administered to Patient 5 did not have folic acid ingredient in it. Review of the facility's policy, "Administering Medications," dated 4/2019, indicated " ... 4. Medications are administered in accordance with prescriber orders ... 8. If a dosage is believed to be inappropriate or excessive for a patient, or a medication has been identified as having potential adverse consequence for the patient or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the patient's attending physician or the facility's medical director to discuss the concerns." In violation of the above cited standards, the facility failed to ensure medication error rates are not 5 percent or greater. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.