Inspection·August 13, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to administered medications to residents as ordered. The medication administration observation identified four medication errors out of 39 medications administered for a medication error rate of 10.26 percent. This affected three (#19, #26, and #27) of four residents reviewed for medication administration. The facility census was 70. Residents Affected - Few Findings include: 1. Review of medical records for Resident #19 revealed an admission dated 02/04/23. Diagnoses included multiple sclerosis, peripheral vascular disease, age related cataract bilateral, dry eye syndrome of bilateral lacrimal glands, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed as moderately cognitively impaired. Review of a physician order dated 07/25/24 revealed Resident #19 was ordered Refresh Liquigel Ophthalmic Gel one (1) percent (%) eye drops to instill one drop in both eyes two times a day for dry eyes. 2. Review of medical records for Resident #26 revealed an admission date of 07/13/24. Diagnoses included acute kidney failure, heart failure, elevation of levels of liver transaminase levels, and cardiac pacemaker. Review of the MDS assessment dated [DATE] revealed Resident #26 was assessed as cognitively intact. Review of a physician order dated 07/14/24 revealed Resident #26 was ordered the combination medication for treatment of hepatitis C, sofosbuvir and velpatasvir 400-100 milligrams (mg) by mouth once daily. 3. Review of medical records for Resident #27 revealed an admission dated of 10/03/21. Diagnoses included epilepsy, agoraphobia with panic disorder, type two diabetes, schizophrenia, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #27 was assessed as cognitively intact. Review of a physician order dated 08/23/22 revealed Resident #27 was ordered Biotene [NAME] Mouth (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: 365690 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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)