Health 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 Page 1 of 4 365474 365474 07/17/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0759 Level of Harm - Minimal harm or potential for actual harm compare medication source with the MAR to verify resident name, medication name, form, dose, route, and time of administration. Further review revealed, administer medication as ordered in accordance with manufacturer specifications. This deficiency represents non-compliance investigated under Complaint Number OH00144291. Residents Affected - Few 365474 Page 2 of 4 365474 07/17/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure insulin pens were dated when opened. This affected nine residents ( #6, #23, #25, #26, #30, #43, #44, #45, and #67) of 83 residents residing in the facility. The facility census was 83. Findings included: Observation on 07/17/23 at 8:30 A.M. of the North Short medication cart revealed the following open insulin pens which had been used and were not dated: Resident #6 an Insulin Glargine Solostar with 120 units remaining out of 260 units, Resident #30 a Lantus Solostar with 180 units remaining out of 260 units Resident #43 an Insulin Glargine Solostar with 140 units remaining out of 260 units and an Insulin Aspart Flex pen with 135 units remaining out of 250 units, Resident #67 an Insulin Glargine Solostar with 245 units remaining out of 260 units. An interview at the time with Licensed Practical Nurse (LPN) #101 verified all insulin pens should be dated when opened. Observation on 07/17/23 at 9:15 A.M. of the South Short medication cart revealed the following open insulin pens which had been used and were not dated: Resident #23 a Tresiba FlexTouch with 230 units remaining out of 250 units, Resident #25 a Lantus Solostar with 180 units remaining out of 260 units, Resident #26 an Insulin Lispro with 200 units remaining out of 220 units and a Lantus Solostar with 120 units remaining out of 260 units, and Resident #45 a Levemir FlexTouch with 140 units remaining out of 250 units. Also observed in the South Short medication cart was a bag labeled for Resident #44 dated 05/19/23 with a Levemir FlexTouch with 190 units remaining out of 250 units. An interview at the time with LPN #103 verified all insulin should be dated when they are opened. She also reported, insulin should be discarded after being open for 28 to 30 days depending on the manufacturer and that Resident #44's insulin pen was definitely over the 30 days. LPN #101 verified that without an open date documented on the pen, a nurse wouldn't know when to dispose of it when it reached to 28 or 30 day time frame. Review of the facility policy titled, Medication Storage, revised 01/01/22, revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure 365474 Page 3 of 4 365474 07/17/2023 Arbors at Carroll 3680 Dolson Court NW Carroll, OH 43112

F 0761 proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Level of Harm - Minimal harm or potential for actual harm This deficiency represents an incidental finding investigated under Complaint Number OH00144291. Residents Affected - Some 365474 Page 4 of 4