Health inspection·September 16, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, manufacturer medication information, and interview the facility failed to ensure Resident #69 was free from significant medication error. Actual harm occurred on 07/29/24 when Resident #69 required evaluation and treatment in the emergency room due to a significant medication error of the resident's Topiramate (anti-epileptic/seizure medication). The resident had been administered, per the nurse practitioner, greater than three times the recommended dose of the medication (ordered 100 mg twice a day and received 625 mg twice a day) from 07/24/24 until 07/29/24 when the error was discovered. This affected one resident (#69) of five residents reviewed for medication administration. Findings include: Review of Resident #69's admission orders provided by the family per the Director of Nursing (DON) revealed a hospital After Visit Summary report dated 09/25/23. The report indicated the resident was ordered Topiramate 25 milligrams (mg)/milliliter (ml) solution, four ml by mouth two times a day for seizures (100 mg of Topiramate twice daily). Review of Resident #69's admission Notice form dated 07/24/24 at 5:00 P.M. revealed the resident was a respite stay from home and was admitted with spastic cerebral palsy with epilepsy. Review of Resident #69's medical record revealed the resident was admitted on [DATE] and discharged on 07/30/24 with diagnoses including epilepsy, gastrostomy status and scoliosis. Review of Resident #69's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely/never understood. Review of Resident #69's physician orders revealed an order dated 07/24/24 (discontinued 07/29/24) for Topiramate oral solution 25 mg/ml give 25 ml via percutaneous endoscopic gastrostomy (PEG) tube (tube inserted through the abdominal wall and into the stomach for nutrition, fluids and medications to be delivered directly into the stomach) two times a day to prevent seizures (625 mg of Topiramate twice daily). Review of Resident #69's Physician/Nurse Practitioner (NP) Progress Note dated 07/27/24 at 12:04 P.M. authored by NP #889 revealed Resident #69 had severe developmental delay and was not alert and oriented. The resident was nonverbal and could not make his needs known. The resident appeared (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: 365753 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 365753 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Oak Nursing & Rehab Ctr 6973 Pearl Rd Middleburg Heights, OH 44130 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)