Health inspection·June 26, 2025

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, record review, medication information review, policy review and interview, the facility failed to administer medication as ordered and/or in accordance with acceptable standards of practice. Three errors out of 28 opportunities were identified resulting in a 10.7% medication error rate. This affected one (Resident #5) of five residents observed for medication administration. Residents Affected - Few Findings include: On 06/26/25 at 8:01 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #5. Medications administered included two tablets of Potassium Chloride extended release (ER) 10 milliequivalents (meq) and one tablet of verapamil ER 240 milligrams (mg) (calcium channel blocker used to treat high blood pressure and angina). The tablets were crushed and added to other crushed medications. Review of Resident #5's physician orders revealed in addition to medication administered, Resident #5 had an order for PreserVision AREDS (multivitamin with minerals) one tablet in the morning. On 06/26/25 at 8:03 A.M., LPN #100 verified she crushed extended release tablets of potassium chloride and verapamil, stating Resident #5 could not consume the pills whole. LPN #100 stated her understanding was Resident #5 crushed the pills for consumption at home also. LPN #100 was unaware if anybody had inquired of the physician if alternate forms of the drugs were available or if alternates would be more appropriate. At 8:38 A.M., LPN #100 stated after speaking to Resident #5 she was willing to try to take the extended release tablets without crushing them. At 11:34 A.M., LPN #100 verified she had not administered the PreserVision AREDS tablet as ordered, stating she had none available on the medication cart. At that time, she inquired of LPN #110 if she had any on her medication cart. On 06/26/25 at 1:25 P.M., Registered Nurse (RN) #120 verified extended release tablets were not generally supposed to be crushed. RN #120 provided a hospital inpatient swallowing discharge summary for service provided to Resident #5 on 01/03/25 which indicated Resident #5 was taking pills crushed in applesauce/pudding (if crushable). Review of medication information from Medscape revealed consideration should be given to use liquid potassium if a resident had difficulty swallowing. Review of the verapamil extended release manufacturer guideline revealed tablets should be swallowed whole and not chewed, broken, or crushed. (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 5 Event ID: 365696 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 365696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Continuing Healthcare at Forest Hill 100 Reservoir Road St Clairsville, OH 43950 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)