Health 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. Page 1 of 2 365065 365065 06/22/2023 Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211

F 0759 This deficiency represents non-compliance investigated under Complaint Number OH00142819. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365065 Page 2 of 2