Health inspection·March 21, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a controlled substance medication was administered per physician orders. This affected one resident (#21) out of three residents reviewed for medication administration. This had the potential to affect fifteen residents (#1, #4, #8, #10, #11, #13, #17, #21, #26, #29, #31, #33, #37, #45, and #47) who were ordered controlled substance medication. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/03/24. Diagnosis included acute respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, depression, history of transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, asthma, anxiety disorder, and atrial fibrillation. Review of the 5-day Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the physician orders dated February 2024 revealed an order for Alprazolam (brand name Xanax) 0.25 milligram (mg) (anti-anxiety medication) give one tablet every twelve hours as needed for anxiety for fourteen days. Resident #21 did not have an order for Ambien (controlled medication, sedative). Review of the Resident #21's Medication Administration Records (MAR) for February 2024 revealed on 02/19/24 Xanax 0.25 mg had a blank spot. Review of the late entry progress note dated 02/19/24 revealed Resident #21 received Zolpidem (Ambien) 5 mg after stating she needed an as needed (PRN) medication. Interview on 03/12/24 at 6:49 A.M. with Licensed Practical Nurse (LPN) #172 (night nurse) revealed on 02/19/24 she discovered Resident #21 received the wrong medication. LPN #172 reported the resident received Ambien instead of Alprazolam. LPN #172 reported she notified the physician and Resident #21's daughter (who is a nurse at the facility - LPN #158). LPN #172 reported LPN #158 (daughter) helped pull the wrong medication from the starter kit with a second nurse, LPN #164, who administered the Ambien instead of the ordered Alprazolam. Interview on 03/12/24 at 8:17 A.M. with LPN #158 revealed Resident #21 was administered Ambien instead of Alprazolam for anxiety on 02/19/24. (LPN #158 is also the daughter of Resident #21). LPN #158 reported LPN #164 pulled the wrong medication and she witnessed it. LPN #158 thought Alprazolam was (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 3 Event ID: 365825 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 365825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Oaks 24579 Broadway Ave Oakwood Village, OH 44146 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)