Inspection·September 24, 2024

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 of medication pass, staff interview, medical record review, review of manufacturer's instructions, review of medication card instructions and review of facility policy, the facility failed to maintain a medication error rate of less than five percent. The facility medication error rate was calculated to be 10.34 percent (%) and included three medication errors of 29 observed medication opportunities. This affected two residents (#58 and #75) of four residents observed for medication pass. The facility census was 96. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #58 revealed an admission date of 01/04/22. Diagnoses included cerebral infarction (stroke), dementia, syncope (fainting), type II diabetes, chronic kidney disease and depression. Review of the September 2024 physician orders revealed an order for potassium chloride extended release (ER) 20 milliequivalent (meq) by mouth, vitamin C 50 milligram (mg), ferrous sulfate 325 mg, losartan 25 mg and a multivitamin. Observation on 09/18/24 at 8:40 A.M. of medication pass with Licensed Practical Nurse (LPN) #250 revealed LPN #250 prepared Resident #58's morning medications, including the potassium chloride ER. Resident #58 requested LPN #250 cut the pill in half due to difficulty swallowing. Resident #58 was unable to swallow the potassium chloride ER. LPN #250 then crushed the potassium chloride ER, mixed the crushed medication in pudding and administered the crushed potassium chloride ER to Resident #58. Interview on 12/08/20 at 8:51 A.M. with LPN #250 verified she crushed the potassium chloride ER and administered the crushed medication to Resident #58. LPN #250 stated the pill was scored and able to be crushed. LPN #250 stated she called the pharmacy about crushing potassium for another resident and was told potassium could be crushed. Review of the manufacture's prescribing instructions for potassium chloride ER revealed the formulation was intended to slow the release of potassium so the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract is reduced. Potassium chloride ER tablets are to be swallowed whole without crushing, chewing or sucking the tablets. 2. Review of the medical record for Resident #75 revealed an admission date of 01/04/24. Diagnoses included chronic kidney disease, heart failure, anxiety disorder, peripheral vascular disease, hypothyroidism and constipation. Review of the September 2024 physician orders revealed morning medications included levothyroxine (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: 365811 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 365811 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwestern Healthcare Center 570 North Rocky River Drive Berea, OH 44017 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)