Health inspection·October 11, 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 policy review, the facility failed ensure medications as ordered by a physician. A total of two medications were administered in error out of 36 opportunities for a medication error rate of 5.55 percent (%). This affected two (#3 and #22) of four residents observed for medication administration. The facility census was 56. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 05/17/23 with a diagnosis of nicotine dependence. Review of the most current physician orders dated October 2023 for Resident #3 revealed a nicotine transdermal patch, seven (7) milligrams per 24 hours was ordered. Observation of medication administration on 10/11/23 at 7:40 A.M. with Registered Nurse (RN) #367 revealed RN #367 pulled and administered a nicotine transdermal patch, 14 milligrams per 24 hours to Resident #3. Interview on 10/11/23 at 10:31 A.M., with RN #367 verified Resident #3 was ordered a nicotine transdermal patch, 7 milligrams per 24 hours, and confirmed RN #367 administered a nicotine transdermal patch, 14 milligrams per 24 hours to Resident #3. 2. Review of the medical record for Resident #22 revealed an admission date of 09/22/23 with a diagnosis of diabetes mellitus type II. Review of most current physician orders dated October 2023 for Resident #22 revealed the anti-diabetic medication metformin 500 milligrams (mg), give two tablets to equal 1000 mg was ordered. Observation of medication administration on 10/11/23 at 8:32 A.M., with RN #348 revealed RN #348 pulled and administered metformin 500 mg to Resident #22. Interview on 10/11/23 at 10:24 A.M., with RN #348 verified Resident #22 was ordered metformin 500 mg to give two tablets to equal 1000 mg, and and RN #348 confirmed she only administered Resident #22 metformin 500 mg. Review of a facility policy titled, Medication Administration, revised January 2022, revealed medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff are to compare medication source with Page 1 of 2 365523 365523 10/11/2023 Arbors at Oregon 904 Isaac Streets Drive Oregon, OH 43616

F 0759 Level of Harm - Minimal harm or potential for actual harm medication administration record to very resident name, medication name, form, dose, route, and time of the administration. This deficiency represents non-compliance investigated under Complaint Number OH00146566. Residents Affected - Few 365523 Page 2 of 2