Health inspection·October 9, 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, record review and staff interview the facility failed to ensure medication error rates were less than 5% when they gave Resident #39 the wrong medication and Resident #38 blood pressure medication was not held for low blood pressure. This affected two (Resident #38 and #39) of four residents observed for medication administration. There were two errors out of 25 opportunities for a medication error rate of 8 %. The facility census was 58. Residents Affected - Few Findings include: 1 Record review of Resident #38 revealed an admission date of 01/19/21 with pertinent diagnoses of: hypertension, cognitive communication deficit, hyperlipidemia, and dementia. Review of the 07/26/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and used a wheelchair to aid in mobility. Review of the Physician Order dated 03/26/24 revealed Norvasc (a blood pressure medication) five milligrams by mouth one time a day for hypertension. Hold for systolic pressure under 110. Observation of a medication administration pass for Resident #38 on 10/08/24 at 8:50 A.M. revealed he had a blood pressure of 107 systolic /63 diastolic millimeters of mercury (mmHg). Licensed Practical Nurse (LPN) #12 charted in the electronic record she was holding the Norvasc medication due to low blood pressure. LPN #12 then popped the Norvasc out of the pill pack and placed it in the medicine cup to administer. LPN #12 locked the med cart and was asked if she was going to give the medications and she replied she was. Interview with LPN #12 on 10/08/24 at 8:55 A.M. verified the Norvasc five milligram tab was in the pill cup to be administered to Resident #38 and that she should of held the medication. 2. Record review of Resident #39 revealed an admission date of 02/19/21 with pertinent diagnosis of: acute respiratory failure with hypoxia, hypertension, major depressive disorder, ischemic cardiomyopathy, and type two diabetes mellitus. Review of the 09/04/24 significant change Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and does not use any devices to aid in mobility. Review of the Physician Order dated 06/17/24 revealed an order for Senna (laxative medication) give two tablets by mouth two times a day for constipation. Observation of a medication administration pass for Resident #39 on 10/08/24 at 8:36 A.M. revealed (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: 365920 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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)