Health inspection·May 3, 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, staff interview, and review of the facility policy, the facility failed to ensure a medication error rate below five percent (%). There were three medication errors out of 27 opportunities, resulting in a medication error rate of 11.11%. This affected three residents (#6, #39, and #93) of three residents observed during the medication pass observation. The facility census was 114. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #93 revealed an admission date of 03/17/23 and the diagnoses of chronic kidney disease stage three, protein calorie malnutrition, and iron deficiency anemia. Review of the physician orders revealed Resident #93 was ordered Vitamin D (Cholecalciferol) 50 micrograms (mcg) (2,000 units (iu)) with instructions to give one tablet by mouth daily for vitamin deficiencies. Observation and interview on 05/03/23 at 7:50 A.M. with Licensed Practical Nurse (LPN) #212 revealed she prepared Resident #93's medications, including the resident's Cholecalciferol. She placed one tablet of Cholecalciferol 400 iu into the pill cup, she confirmed she had 13 medications to administer, and she administered the medications. Interview on 05/03/23 at 10:22 A.M. with LPN #212 confirmed she only placed one Cholecalciferol 400 iu tablet into the pill cup, which was less than the dosage ordered. 2. Review of the medical record for Resident #39 revealed an admission date of 06/04/19 and the diagnosis of seasonal allergies. Review of the physician orders for Resident #39 revealed orders for Fluticasone Propionate Suspension 50 micrograms per actuation (mcg/act) with instructions to administer two sprays in both nostrils daily for allergies. Review of the care plan dated 03/16/23 revealed Resident #39 had the potential for difficulty breathing and she was at risk for respiratory complications related to asthma, smoking and seasonal allergies with interventions to administer medications and treatments as ordered. Observation and interview on 05/03/23 at 8:10 A.M. with Licensed Practical Nurse (LPN) #213 revealed she administered Resident #39's by mouth medications and her insulin. After the administration of medications, LPN #213 arrived back at her mediation cart, she placed the Fluticasone medication into (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: 365222 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 365222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Norworth The 6830 North High Street Worthington, OH 43085 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)