Health inspection·October 2, 2023

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, review of physician orders, review of medication information from Medscape and interview, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer information. Four medication errors were identified out of 38 opportunities resulting in a 10.5% medication error rate. This affected three (Residents #11, #14, and #28) of three residents observed for medication administration. Residents Affected - Few Findings include: 1. On 10/02/23 at 8:46 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #14. Among the medications administered was hydralazine (a vasodilator) 25 milligrams (mg). Review of Resident #14's physician order sheet revealed an order dated 03/22/23 for hydralazine 25 mg with instructions to administer three tablets every eight hours for hypertension. On 10/02/23 at 10:17 A.M., LPN #100 verified she only gave one of the hydralazine but should have administered three. 2. On 10/02/23 at 9:03 A.M., Registered Nurse (RN) #101 was observed administering medication to Resident #28. Among the medications administered were enteric coated aspirin 81 mg and isosorbide mononitrate (anti-anginal) extended release (ER) 60 mg. The medications were crushed prior to administration. Review of Resident #28's physician order sheet revealed an order dated 12/18/22 that medications could be crushed unless contraindicated. On 12/18/22 an order was written for enteric coated aspirin 81 mg in the morning. On 12/18/22 an order was written for isosorbide mononitrate ER 60 mg in the morning. Review of medication information from Medscape revealed enteric coated aspirin should not be crushed because it could release all of the drug at once increasing the risk of side effects. Medscape revealed the extended release isosorbide mononitrate must not be crushed. On 10/02/23 at 9:08 A.M., RN #101 verified the enteric coated aspirin was crushed, stating Resident #28 did not like the taste of chewable aspirin. At 10:14 A.M., RN #101 verified she also crushed the enteric coated isosorbide mononitrate. 3. On 10/02/23 at 9:26 A.M., LPN #102 was observed administering medication to Resident #11. Among the medications administered was tetrahydrozoline HC 0.05% eye drops with one drop applied in both (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: 365862 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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)