Inspection·July 17, 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, interview, record review and facility policy review, the facility failed to ensure a medication error rate of less than 5%. There were a total of 29 opportunities for error and a total of two errors resulting in a medication error rate of 6.8%. This affected one resident (#50) of three residents observed for medication administration. The facility census was 83. Residents Affected - Few Findings included: Review of Resident #50's medical record revealed an admission date of 07/14/23 with diagnoses including anemia, unspecified, type two diabetes mellitus without complications, peripheral vascular disease and essential hypertension. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment revealed it was not completed due to the recent admission. Review of Resident #50's Skilled Daily - Medically Complex form, dated 07/15/23, revealed the resident was oriented to person, place, date, and time and was a diabetic. Review of Resident #50's physician order, dated 07/15/23, identified he was to receive ferrous sulfate (iron) extended release oral tablet 140 milligrams (mg) by mouth one time a day related to anemia and Insulin Glargine Solostar subcutaneous solution pen-injector 100 units/ml, 30 units subcutaneously in the morning related to type two diabetes mellitus without complications. Observation on 07/17/23 at 8:15 A.M. of Licensed Practical Nurse (LPN) #101 administering medications to Resident #50 revealed Resident #50 was provided one iron tablet 325 mg with his other oral medications. Additional observation revealed LPN #101 dialed Resident #50's Glargine Solostar insulin pen and placed a new needle tip on the pen. She did not prime the pen with two units. Interview following administration of the Resident #50's medications, LPN #101 verified she did not prime the Glargine Solostar insulin pen with two units of insulin resulting in Resident #50 only getting 28 units of insulin and not 30 units. Interview on 07/17/23 at 9:36 A.M. with LPN #101 verified Resident #50 did not receive his Ferrous Sulfate (iron) medication as ordered. She verified she administered 325 mg of ferrous sulfate, and he should have received ferrous sulfate extended release 140 mg. Review of facility policy titled, Medication Administration, dated revised 01/01/22, revealed the licensed nurse or other staff who are legally authorized to administer medications was to review the Medication Administration Record (MAR) to identify medication to be administered. The staff are to (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 4 Event ID: 365474 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 365474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112 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)