Health inspection·May 10, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital records, facility policy review and interview the facility failed to ensure Resident #91 was free from a significant medication error when the facility administered Resident #91's diuretic (medication to increase the production of urine) when it should have been on hold. Residents Affected - Few Actual Harm occurred on 03/29/24 when the facility failed to hold Resident #91's diuretic medication resulting in a significant change in the resident's condition resulting in an unplanned hospitalization. On 03/29/24 Primary Care Physician (PCP) #615 ordered to hold Resident #91's Torsemide (diuretic medication) due to abnormal lab work including an increase in the resident's creatinine level (a test that measured how well the kidneys filter waste from the blood) to 3.3 mg/ deciliter (dl) indicating worsening of her kidney function, repeat the lab work on 04/01/24 and to notify Nephrologist #614 of the results. On 04/01/24 Resident #91's creatinine increased to 5.4 mg/dl; however, the facility restarted the Torsemide medication on this date without a physician order. The facility was unable to contact Nephrologist #614 regarding the increase in creatinine level until 04/03/24 without PCP #615 knowledge. The facility continued to administer Resident #91's Torsemide until 04/03/23 at 4:25 P.M. when the resident was sent to the hospital. Hospital Internal Medicine Physician #900 noted per his history and physical Resident #91 looked remarkedly dry and he suspected uremia (like threatening condition caused by kidney failure and waste build up in the blood). The note also revealed her labs were consistent with over diuresis (excessive production of urine usually caused by diuretics) and if no improvement the resident would require dialysis. This affected one resident (#91) of three residents reviewed for medication administration. The facility census was 87. Findings included: Review of closed medical record for Resident #91 revealed an admission date of 03/09/24. The resident was transferred to the hospital on [DATE] and she did not return to the facility. Resident #91 had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, osteomyelitis, and hypertension. Review of March 2024 physician orders revealed Resident #91 had an order dated 03/20/24 for the diuretic medication, Torsemide 20 milligram (mg) one tablet by mouth two times a day for edema. She also had an order to have weekly lab work, a Completed Blood Count (CBC), Basic Metabolic Panel (BMP) and Renal Function Panel (RFP) with the order indicating to fax the results to Nephrologist #614. Resident #91 was on a 1500 milliliter (ml) fluid restriction per day. Review of an After Visit Summary dated 03/09/24 revealed hospital discharge instructions included (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 6 Event ID: 366015 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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)