Health inspection·May 16, 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 observation, interview, record review, and facility policy review the facility failed to ensure Resident #51's medications were administered properly. This affected one resident (#51) of the 24 residents (#3, #4, #5, #6, #7, #13, #16, #18, #22, #23, #24, #25, #26, #27, #29, #34, #36, #37, #39, #47, #48, #51, #55, and #56) who reside on the 400 unit. The facility census is 58. Residents Affected - Few Findings include: Review of the medical record for Resident #51 revealed an admission date of 01/20/23. Diagnoses included atrial fibrillation, insomnia, osteoarthritis, peripheral vascular disease, and hypertension. Review of physician's orders dated 01/21/23 for Resident #51 revealed an order for Eliquis (anticoagulant) 5 milligrams (mg) two times a day; an order for Verapamil HCL ER (blood pressure medication) 180 mg daily; Tylenol 325 mg give two tablets every six hours as needed for pain; and Metoprolol (blood pressure medication) 12.5 mg twice a day. Review of the care plan dated 04/24/23 for Resident #51 revealed she had impaired cognition. Interventions included administering medications as ordered and observing a decline in cognition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had moderate cognitive impairment. Resident #51 required extensive two-person physical assistance for bed mobility and toilet use; extensive one-person physical assistance for transfers, dressing, and personal hygiene; and supervision with set-up help only for eating. Review of the facility Medication Administration Record (MAR) for Resident #51 revealed she was administered Tylenol, Metoprolol, Eliquis, and Verapamil on 05/15/23 at 8:00 A.M. Observation on 05/15/23 at 11:39 A.M. of Resident #51 revealed her lying in bed sleeping. Her bedside tray was halfway across the bed and on the edge closest to her was a pill cup with five pills inside. Interview during the observation with Resident #51 revealed she did not know what they were and why they were there. Interview on 05/15/23 at 11:42 A.M. with Registered Nurse (RN) #502 confirmed she gave those pills to Resident #51 on 05/15/23 at 8:00 A.M. RN #502 was unsure of what medication was in the cup. RN #502 discarded the medications and then administered the 8:00 A.M. pills to Resident #51. RN #502 could not confirm that Resident #51 had even taken any medications that morning. RN #502 reported she did not stay with Resident #51 to ensure she had taken the medications before she documented them as administered. Page 1 of 2 365642 365642 05/16/2023 Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/15/23 at 12:00 P.M. with the Director of Nursing (DON) confirmed nurses must make sure the residents swallow all their pills or refuse them before they document that the pills were administered. Review of the facility policy titled Administration Procedures for all Medications, effective 07/01/21, revealed all medication storage areas are locked at all times unless in use and under direct observation of the medication nurse/aide. Once medications are removed from the package or container, unused or partial doses should be disposed of in accordance with the medication destruction policy. 365642 Page 2 of 2