Health inspection·March 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 observation, medical record review, policy review and interview, the facility failed to ensure a medication error rate of not 5 percent or greater. This affected four (Resident #67, #111, #113 and #131) of six residents observed for medication administration. Five errors were observed out of 35 opportunities resulting in a medication error rate of 14.2%. The census was 111. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #67 was admitted on [DATE] with diagnoses including depression, high blood pressure and pain. Review of the Order Summary dated March 2024 revealed medications to administer included Tylenol Extra Strength 500 milligrams (mg) twice a day for osteoarthritis and Sertraline HCL 50 mg give 1.5 tablet by mouth in the morning for depression. On 03/28/24 at 8:13 A.M., observation of Resident #67's medication administration revealed Licensed Practical Nurse (LPN) #2 administered medications including acetaminophen 500 mg with diphenhydramine 25 mg and Sertraline 50 mg. LPN #2 stated the pharmacy sends Sertraline 25 mg and a Sertraline 50 mg tablet but the resident only gets the 50 mg tablet so she send the Sertraline 25 mg tablet back. 2. Medical record review revealed Resident #111 was admitted on [DATE] with diagnoses including disorder of bone density and structure, hypertension and anxiety. Review of the Order Summary dated March 2024 revealed medications to administer included calcium 600 mg in the morning. On 03/28/24 at 8:31 A.M., observation of Resident #111's medication administration revealed LPN #4 administered Calcium Plus D 600 mg/10 micrograms. 3. Medical record review revealed Resident #113 was admitted on [DATE] with diagnoses including cerebral infarction and osteoarthritis. Review of the Order Summary dated March 2024 revealed medications to administer included a topical 4% lidocaine patch. On 03/28/24 at 8:50 A.M., observation of Resident #113's medication administration revealed LPN #6 entered the resident's room and placed the sealed 4% lidocaine patch on Resident #113's overbed (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: 365436 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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)