Inspection·August 28, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure an medication error rate of 5% or less when medication that was noted to be delayed release was crushed, or capsule were opened during administration. Medication error rate was 9%. This affected two residents (Resident #6, and #32) of the four residents reviewed for medication administration. The facility census was 74. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #32 revealed an admission date of 04/23/21. Diagnoses included dementia, depression, and osteoarthritis. Review of Resident #32's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of the plan of care dated 06/26/23 revealed Resident #32 uses antidepressant medication related to depression and weight loss. Resident is at risk for complications related to antidepressant medication including, dry mucosa, constipation, urinary retention, suicidal ideation, and increased signs/symptoms of depression. Interventions include to give antidepressant medications as ordered by physician. Review of physician orders for Resident #32 revealed the following: -Duloxetine Hydrochloride (HCL) capsule, delayed release particles, 30 milligrams (MG), give one capsule by mouth daily for depression. Ordered 07/25/2024. -May crush appropriate medications, ordered 08/28/24. -Regular diet, with regular texture, regular/thin consistency liquids. Ordered 04/26/21. Observation completed on 08/28/24 at 8:39 A.M. of Licensed Practical Nurse (LPN) #160 administer morning medication revealed after pulling the capsule Duloxetine HCL from the medication cart, LPN #160 proceeded to open the capsule up and release the sprinkles into a medication cup with pudding along with other medication that had been crushed for this resident. Also during this time, LPN #160 was noted to need medication from the medication stock room which this nurse was noted to walk away from her medication cart on two different occasions while leaving her medication cart unlocked while out of view. (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 5 Event ID: 365421 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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)