Inspection·July 24, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews, resident interview, family interview, medical record reviews, and policy reviews, the facility failed to ensure residents were free from significant medication errors. This affected two (#85 and #14) of six residents reviewed for medication administration. The facility census was 86. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 12/05/23. Medical diagnoses included neurocognitive disorder with lewy bodies, dementia, hypertension, and bradycardia (low heart rate of less than 60 beats per minute). Review of Resident #85's Minimum Data Set (MDS) quarterly assessment, dated 06/13/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09 indicating moderately impaired cognition. Review of Resident #85's physicians orders revealed an order dated 07/19/24, for metoprolol tartrate (an antihypertensive medication used to lower blood pressure and/or heart rate) 25 milligrams (mg) by oral route twice daily. The order specified to hold the medication for a systolic blood pressure less than 100 and/or a heart rate less than 60. Review of Resident #85's Medication Administration Record (MAR) for July 2024 revealed the medication has been administered twice daily since it was ordered on 07/19/24. The MAR contained no corresponding blood pressure and heart rate levels recorded to reflect the resident's vital signs at the time of the metoprolol administration. An observation on 07/23/24 at 7:56 A.M. revealed Registered Nurse (RN) #200 prepared Resident #85's morning medications. RN #200 retrieved Resident # 85's medication out of the medication cart and checked the medications against the order's on the resident's MAR. RN #200 stated the resident's medication regimen included an order for one tablet of metoprolol tartrate 25 mg. RN #200, who was looking directly at Resident #85's MAR, stated the resident's metoprolol had no vital sign parameters or instructions on when to give or not give the medication. RN #200 retrieved the card of metoprolol 25 mg and identified the resident's metoprolol were in half-tablet doses (12.5 mg each). RN #200 removed two half-tablets of metoprolol and placed them in the cup with Resident #85's other morning medications. RN #200 then retrieved her automatic blood pressure cuff and stated she would check Resident #85's blood pressure as a good nursing practice prior to giving the resident all of his morning medications. RN #200 entered Resident #85's medications where the resident was lying in bed. RN #200 gently awakened the resident and informed him she was checking his blood pressure. RN #200 applied her automatic blood pressure cuff to the resident's right arm, and obtained a blood pressure of 99/57 (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 3 Event ID: 365408 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 365408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Delaware 2270 Warrensburg Road Delaware, OH 43015 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)