Health inspection·June 18, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for 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, interview, review of the medication error report review, facility policy review, the facility failed to ensure the proper route of medication administration for Resident #51. This affected one resident (#51) of eight residents reviewed for proper medication administration. The facility census was 50. Findings include: Review of the medical records revealed Resident #51 was admitted to the facility on [DATE] and discharged on 05/20/24. Significant diagnoses included paraplegia, bacteremia, stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right and left buttocks, diabetes mellitus type II, and infection and inflammatory reaction due to cardiac valve prothesis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of the physician's orders revealed an order dated 04/18/24 through 05/17/24 for ceftriaxone sodium (an antibiotic) intravenous (IV) use 2000 milligrams (mg) IV two times a day and an order dated 04/18/24 through 05/17/24 ampicillin sodium injection solution (an antibiotic), use 2000 mg IV every four hours. On 05/17/24 a new order was obtained for ampicillin sodium injection solution use 2000 mg IV every four hours for two weeks. A review of a progress note dated 05/03/24 at 6:26 A.M. revealed LPN #177 misread the order for ampicillin and gave the 05/02/24, 8:00 P.M. dose intramuscularly (IM) instead of intravenously. The resident's wife was notified. The nurse practitioner was notified and stated the medication was okay to be given IM and no adverse reaction was expected. The nurse spoke with the pharmacist who said the medication was okay to be given IM. No redness or swelling was noted to the injection site. The resident stated he was not having pain. A review of the document titled, Country Club Retirement Center Medication and Treatment Errors and Omissions dated 05/03/24 signed by LPN #177 and the Director of Nursing (DON) revealed ampicillin 2000 mg was administered IM instead of IV as ordered on 05/02/24 at 8:00 P.M. by LPN #177. On 06/17/24 at 1:45 P.M. an interview with the DON verified that LPN #177 gave ampicillin 2000mg IM instead of IV as ordered and corrective actions were taken immediately. The nurse practitioner and (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: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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)