Health inspection·November 1, 2023

F 0760 Ensure that residents are free from significant medication errors. 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, hospital documentation review, and staff interview, the facility failed to ensure medications were administered as ordered. This affected one (#13) of three residents reviewed for medication administration. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and discharged on 09/21/23. Diagnoses upon admission included chronic respiratory failure with hypercapnia and hypoxia, centrilobular emphysema, chronic obstructive pulmonary disease with exacerbation, congestive heart failure, chronic kidney disease, and urinary tract infection. Additional diagnoses on 09/13/23 included bacterial infection, altered mental status, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the nursing progress notes revealed Resident #13 discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the hospital documentation dated 09/13/23 revealed Resident #13 was diagnoses with a urinary tract infection, Extended Spectrum Beta-Lactamase (ESBL) infection, and aspiration pneumonia. The resident had discharge orders to receive the antibiotic meropenum in sodium chloride 100 milliliters, one gram by intravenous route every 12 hours for four days, and the antibiotic linezolid (Zyvox) 600 milligram (mg) by mouth two times per day for five days. Review of physician orders for Resident #13 revealed an order with a start date of 09/13/23 and an end date of 09/18/23 for Zyvox 600 mg with instructions to give one tablet by mouth every morning and at bedtime for ESBL infection of the urine for five days unsupervised self-administration. Review of Resident #13's medication administration record (MAR) for September 2023, revealed the code U-SA was documented on each occasion the Zyvox was to be administered. Review of the MAR code key revealed the code U-SA was an abbreviation for unsupervised self-administration. There was no indication the medication was administered to the resident. Interview on 11/01/23 at 12:03 P.M. with the Director of Nursing (DON), revealed Resident #13's physician order for Zyvox 600 mg was entered into the medical record incorrectly, as the resident did not self-administer any medications while residing in the facility. The DON stated, subsequently, the nursing staff were not notified or alerted to administer the medication to Resident #13 as ordered. (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: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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)