Health inspection·January 18, 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 medical record review, observations and staff interview the facility failed to ensure residents were administered as ordered resulting in two medication errors out of 25 opportunities or an eight percent (%) medication error rate. This affected two (#18 and #19) out of of four residents observed for medication administration. The facility census was 88. Residents Affected - Few Findings include: 1. Review of medical record for Resident #18 revealed admission date of 04/18/23. Diagnoses include alcoholic hepatic failure without coma, traumatic subdural hemorrhage, bipolar disorder, chronic obstructive pulmonary disorder, depression and chronic respiratory failure. The resident remained in the facility. Observation of medication pass on 01/18/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #118 for Resident #18 revealed she was given Amlodipine (blood pressure) 10 milligrams (mg), Keppra (seizures) 750 mg, Lisinopril (blood pressure) 20 mg, Metformin (diabetes) 500 mg, Senna (laxative) 8.6 mg and Zyprexa (antipsychotic) 2.5 mg. Further review of Resident #18's physician orders revealed an order for each of the medication administered except Zyprexa. Review revealed an order for Zyprexa 2.5 mg daily with a start date of 06/21/23 and an end date of 08/21/23. Interview and observation on 01/18/24 at 12:58 P.M. with LPN #18 verified Resident #19's Zyprexa was not a current order. Observation of the pharmacy supplied medication revealed Zyprexa was listed on and present in the provided medication bag. 2. Review of medical record for Resident #19 revealed admission date of 01/05/24. Diagnoses include right femur fracture, and chronic obstructive pulmonary disease. Observation of medication pass on 01/18/24 at 8:19 A.M. with LPN #118 for Resident #19 revealed she was administered Breo Ellipta (fluticasone furoate and vilanterol) (corticosteroid) 100 micrograms (mcg)/ 25 mcg. Further review of Resident #19's physician orders revealed no order for Breo. There was an order for Trelegy Ellipta (flucosone- Umecliidinium-Vilanterol) (COPD) 200-62.5-25 mcg. Interview on 01/18/24 at 1:00 P.M. with LPN #118 verified Breo was administered to Resident #19 and Page 1 of 4 365821 365821 01/18/2024 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0759 not the prescribed Trelegy. Level of Harm - Minimal harm or potential for actual harm Interview on 01/18/24 at with the Director of Nursing (DON) revealed Resident #19 had Trelegy present in the medication cart and the Breo would be removed. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149480. 365821 Page 2 of 4 365821 01/18/2024 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, observations, staff interview and review of medication information from Medscape, the facility failed to ensure antipsychotic and/or blood pressure medications were administered as physician ordered resulting in significant medication errors. This affected three (#15, #13, #18) of four residents reviewed for medication administration. The facility census was 88. Residents Affected - Few Findings include: 1. Review of medical record for Resident #18 revealed admission date of 04/18/23. Diagnoses include alcoholic hepatic failure without coma, traumatic subdural hemorrhage, bipolar disorder, chronic obstructive pulmonary disorder, depression and chronic respiratory failure. Observation of medication pass on 01/18/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #118 for Resident #18 revealed she was given Amlodipine (blood pressure) 10 milligrams (mg), Keppra (seizures) 750 mg, Lisinopril (blood pressure) 20 mg, Metformin (diabetes) 500 mg, Senna (laxative) 8.6 mg and Zyprexa (antipsychotic) 2.5 mg. Further review of Resident #18's physician orders revealed an order for each of the medication administered except Zyprexa. Review revealed an order for Zyprexa 2.5 mg daily with a start date of 06/21/23 and an end date of 08/21/23. Interview and observation on 01/18/24 at 12:58 P.M. with LPN #18 verified Resident #19's Zyprexa was not a current order. Observation of the pharmacy supplied medication revealed Zyprexa was listed on and present in the provided medication bag. Review of medication information from Medscape at https://reference.medscape.com/drug/zyprexa-relprevv-olanzapine-342979 revealed Zyprexa is an antipsychotic medication used to treat schizophrenia and bipolar. Zyprexa should be taken as physician ordered. 2. Review of medical record for Resident #13 revealed admission date of 05/15/23 Diagnoses include stroke, Alzheimer's Disease and dementia. The resident remains in the facility. Review of Resident #13's physician orders revealed an order for Metoprolol Tartrate (beta blocker) 50 milligrams (mg) two times a day. Hold for Systolic Blood Pressure (SBP) of less than 120 millimeter of mercury (mm Hg) with a start date of 12/05/23. Review of Resident #13's December 2023 Medication Administration Record (MAR) revealed the Metoprolol Tartrate was given outside of the ordered parameters at 6:00 A.M. on 12/06/23 with a SBP of 116, on 12/09/23 with SBP of 118, on 12/18/23 with SBP of 118, on 12/31/23 with SBP 118 and at 6:00 P.M. on 12/08/23 with SBP of 118, on 12/17/23 with SBP of 118 and on 12/26/23 with SBP 85. Review of Resident #13's January 2023 MAR's revealed the Metoprolol Tartrate was given outside of the ordered parameters at 6:00 A.M. on 01/03/24 with SBP of 113, at 6:00 P.M. on 01/02/24 with SBP of 109 and on 01/07/24 with SBP of 110. On 01/18/24 at 1:07 P.M. with Corporate Registered Nurse #117 confirmed Resident #13's Metoprolol 365821 Page 3 of 4 365821 01/18/2024 Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439

F 0760 Level of Harm - Minimal harm or potential for actual harm Tartrate which is used to treat hypertension was administered outside the parameters on the identified dates. 3. Review of medical record for Resident #15 revealed admission date of 09/16/22. Diagnoses include atrial fibrillation, diabetes mellitus type two and hypertension. Residents Affected - Few Review of Resident #15's physician orders revealed and order for Metoprolol Tartrate (beta blocker) 25 mg two times daily, hold for SBP less than 110 mmHg and Pulse (P) less than 60. Review of Resident #15's December 2023 MAR's revealed the Metoprolol Tartrate was given outside of the parameters at 9:00 A.M. on 12/09/23 with SBP of 108, P of 58; at 9:00 P.M. on 12/17/23 with SBP of 96, on 12/22/23 with SBP of 94, and on 12/26/23 with SBP of 95. Review of Resident #15's January 2024 MAR's revealed the Metoprolol Tartrate was given outside of the parameters at 9:00 A.M. on 01/05/24 with SBP of 94, on 01/10/24 with SBP of 92, at 9:00 P.M. on 12/08/24 with SBP of 102, on 01/13/24 with SBP of 98 and 01/15/24 with SBP of 96. On 01/18/24 at 1:07 P.M. with Corporate Registered Nurse #117 confirmed Resident #15's Metoprolol Tartrate which is used to treat hypertension was administered outside the parameters on the identified dates. Review of medication information from Medscape at https://reference.medscape.com/drug/lopressor-toprol-xl-metoprolol-342360 revealed Metoprolol is a beta-blocker used to treat conditions such as hypertension, acute myocardial infarction, congested heart failure and angina. Metoprolol should be taken as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00149480. 365821 Page 4 of 4