Health inspection·April 11, 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 medical record reviews, observations, staff interviews, and policy and procedure review, the facility failed to ensure a medication error rate of less than five percent (%). After 32 opportunities, three errors were identified to equal an error rate of 9.3%. This affected two residents (#30 and #32) of four residents observed during the medication pass observation. The census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 02/22/23 and the diagnoses of congestive heart failure, atrial fibrillation, dysphagia, urine retention, high blood pressure, and obesity. Review of Resident #30's physician orders revealed an order for Potassium Chloride Crys Extended Release (ER) tablet 20 milliequivalent (mEq) daily for hypokalemia. Observation on 04/10/23 at 9:21 A.M., with Registered Nurse (RN) #108 and Resident #30 revealed the resident didn't want the Potassium unless it was crushed as she had a hard time swallowing it. RN #108 then crushed and administered Resident #30's Potassium ER 20 mEq. Interview on 04/10/23 at 9:33 A.M., with RN #108 confirmed that specific Potassium was an extended-release tablet and should not have been crushed. She stated she was not sure if the physician had been notified that the resident only liked that Potassium crushed in an attempt to obtain an order for a different kind of Potassium supplement. 2. Review of the medical record for Resident #32 revealed an admission date of 07/15/22 and the diagnoses of cerebral palsy, parkinson's disease, high blood pressure, depression, post-traumatic stress disorder, and schizophrenia. Review of Resident #32's physician orders revealed she was to receive Xifaxan 550 milligrams (mg) twice daily (due at 9:00 A.M. and 9:00 P.M.) and Depakote Extended Release (ER) 24 hour tablet 500 mg daily for behaviors. Observation and interview on 04/10/23 at 9:34 A.M., with Registered Nurse (RN) #108 revealed she prepared Resident #32's medications including Depakote ER 500 mg which she crushed, along with her other medications. RN #108 also did not have the resident's Xifaxan 550 mg medication. She confirmed the shipment for the Xifaxan medication was received on 04/08/23 and it was supposedly on hand, but she didn't have it on hand. The resident's medications were administered on 04/10/23 at 9:48 A.M. Interview on 04/10/23 at 9:48 A.M., with RN #108 confirmed she crushed the Depakote ER medication (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: 365426 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 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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)