Health inspection·December 24, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, policy review, review of manufacturer instructions, observation, and staff interview, the facility failed to ensure appropriate needles were used during intramuscular medication administration. This affected one (Resident #81) of two residents observed for injectable medications. The facility census was 97. Residents Affected - Few Findings include: Review of the medical record for Resident #81 revealed an admission date of 03/06/20. Resident #81 had a new diagnoses added on 11/25/24 of urinary tract infection (UTI) and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired. Review of the care plan dated 11/17/24 revealed Resident #81 had a UTI. Interventions included to administer antibiotic therapy as ordered and monitor/document for side effects and effectiveness. Review of the physician orders dated 12/12/24 for Resident #81 revealed Ertapenem Sodium intramuscular injection solution reconstituted (antibiotic) one gram every 24 hours for infection for 10 days Observation of medication administration on 12/16/24 at 2:03 P.M. revealed Registered Nurse (RN) #104 was preparing to administer the antibiotic to Resident #81. RN #104 grabbed a BD blunt fill needle-filter to draw up the lidocaine solution and place it into Ertapenem sodium injection powder. The appropriate amount of lidocaine was placed into the Ertapenem injection powder, the blunt needle was removed, and the nurse discarded it in the trash. After a thorough mixing, RN #104 opened up the cart looking for another needle. He was unable to find one, so he went to the storage room and grabbed four more BD blunt fill needle-filters. He said he wanted to use a fresh needle because the previous one would be dull. The nurse then placed a new blunt fill needle-filter onto the syringe and drew up the medication with a five milliliter (ml) syringe, taking 3.2 ml of the solution. The nurse capped off the needle, grabbed an alcohol pad to clean the resident's skin, and locked the cart. RN #104 walked into Resident #81's room where the nurse introduced himself and informed Resident #81 that he would be administering the antibiotic. RN #104 walked up to Resident #81 with the syringe in hand, and was approaching the resident to administer the medication. At that point, surveyor intervened prior to administration of the medication. RN #104 confirmed he was going to administer the antibiotic with a BD blunt needle-filter, and explained this was the needle he used for injections. RN #104 was unable to answer what type of needle was used for intramuscular injections. RN #104 proceeded to go through the cart for additional needles and found a 22 gauge, one-inch beveled end needle. This appropriate needle was then used 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: 365618 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 365618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Presidential Post-Acute 524 James Way Marion, OH 43302 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)