Inspection·August 22, 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, medical record review, staff interview and review of policies, the facility failed to ensure medications were administered according to physician's order, resulting in a medication error rate which exceeded 5 percent (%). Thirty-five opportunities were observed with four medications errors, resulting in 11.42% error rate. This affected three (#1, #33, #43) of three residents observed during medications administration. The census was 61. Residents Affected - Few Findings included: 1. Review of the medical chart for Resident #1 revealed an admission date of 09/02/15, with diagnosis included hyperlipidemia. Review of the physician's order dated 06/20/23, for Resident #1, revealed an order for Fish Oil 500 milligrams (mg) tablet to give two tablets, one time a day for supplement. Observation of medication administration with Licensed Practical Nurse (LPN) #151 on 08/22/23 at 7:15 A.M., to Resident #1, revealed LPN #151 gave Fish Oil 1000 mg 2 tablets by mouth. Interview with LPN #151 on 08/22/23 at 8:52 A.M., verified she gave Resident #1 Fish Oil 1000 mg two tablets by mouth. Interview with Director of Nursing (DON) on 08/22/23 at 8:23 A.M., verified Resident #1 was to be given Fish Oil 1000 mg total with two tablets of 500 mg, which was not given per physician's order. 2. Review of the medical record for Resident #33 revealed an admission date of 08/14/21, with diagnosis included diabetes mellitus. Review of physician orders for Resident #33 revealed an order for Novolog Flex Pen 100 unit per milliliters (ml), to give six units with meals for diabetes mellitus. Observation of insulin injection on 08/22/23 at 7:40 A.M., revealed LPN #151 took out the Novolog Flex Pen, placed a new needle on and dialed up six units of insulin. She injected Resident #33 in the left abdomen. This surveyor did not observe the nurse prime the Flex Pen prior to dialing up the dosage amount. Interview on 08/22/23 at 7:40 A.M., with LPN #151 verified she did not prime the Flex Pen with two unit prior to dialing up the dosage of six unit for Resident #33. Interview with Unit Manager #107 verified the Flex Pen needle needs to be primed with two units (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 3 Event ID: 365483 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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)