Inspection·June 22, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, and staff interview, the facility failed to ensure medications were administered as ordered by the physician. A total of three medication errors were observed out of 25 opportunities for a medication error rate of 12 percent (%). This affected two (#60 and #61) of four residents observed during medication administration. The facility census was 82. Residents Affected - Few Findings include: 1. Review of Resident #60's medical record revealed an admission date of 01/06/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, and hypertension. Review of a physician order dated 02/16/23 revealed Resident #60 was ordered supplement vitamin D2 50,000 units one capsule by mouth once daily on Monday and Thursday for vitamin D deficiency. Observation on Thursday, 06/22/23 at 8:10 A.M., revealed Registered Nurse (RN) #125 administered medications to Resident #60 including one capsule of supplemental cholecalciferol (Vitamin D3) 1,000 units. Interview with RN #125 on 06/22/23 at 10:09 A.M. verified Resident #60 had orders to receive vitamin D2 50,000 units, but was administered vitamin D3 1,000 units in error. 2. Review of Resident #61's medical record revealed an admission date of 05/05/22 with diagnoses including chronic obstructive pulmonary disease, schizophrenia, depression, and type two diabetes mellitus. Review of a physician order dated 11/21/22 revealed Resident #61 was ordered an anti-seizure medication Depakote 500 milligrams (mg) by mouth once daily for seizures. Review of a physician order dated 11/21/22 revealed an order for cholecalciferol (Vitamin D3) 4,000 units once daily. Observation on 06/22/23 at 8:16 A.M. revealed RN #125 administered medications to Resident #61 including one tablet of Depakote 250 mg and two tablets of vitamin D3 1,000 units. Interview with RN #125 on 06/22/23 at 10:10 A.M. verified Resident #61 had orders for Depakote 500 mg and vitamin D3 4,000 units, but was administered one tablet of Depakote 250 mg and two tablets of vitamin D3 1,000 units. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365065 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)