Health inspection·October 17, 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, interview, and record review, the facility failed to ensure a medication error rate of five percent (%) or less. Five medication errors out of 27 observed opportunities for error, created a medication error rate of 18.5%. This affected two of three residents reviewed for medication administration (Resident #5 and #4). The total census was 48. Residents Affected - Few Findings include: 1. Observation of a medication administration procedure for Resident #5 by Licensed Practical Nurse (LPN) #118 on 10/15/24 at 9:03 A.M. revealed the nurse prepared medications including a 2000 unit tabled of vitamin D-3, and polyethylene glycol (a laxative) powder, of which she measured 15 milliliters (ml) into a 30 ml medicine cup. She also prepared two eye drop medications (Brimonidine Tartrate and Ketorolac Tromethamine), which both included pharmacist instructions on their storage bags to wait five minutes between medications administered in the same eye. The nurse administered the above-noted medications and gave the eye drops in the right eye one immediately after the other at 9:19 A.M. Record review of Resident #5 revealed the only active order for vitamin D-3 was for one 5000 unit tablet once per day, and the only active order for polyethylene glycol was for 17 grams once per day. Interviews with LPN #118 on 10/15/24 at 9:42 A.M. and 10/16/24 at 8:35 A.M. confirmed these findings. 2. Observation of a medication administration procedure for Resident #4 by LPN #118 on 10/15/24 at 9:26 A.M. revealed the nurse administered one tablet of vitamin B-12 1000 micrograms (mcg). The nurse also administered one puff of a Fluticasone-Salmeterol 100-50 mcg inhaler, which included pharmacy instructions on the storage bag to rinse the mouth after use. The nurse administered the inhaler, then gave the resident their medications to swallow with a nutrition shake without offering to rinse their mouth first. Record review of Resident #4 revealed the only active order for vitamin B-12 was for one 100 mcg pill to be given daily. Interviews with LPN #118 on 10/15/24 at 9:42 A.M. and 10/16/24 at 8:35 A.M. confirmed these findings. Record review of the facility's medication administration policy dated 09/2018 revealed medication rights including the right dose were to be reviewed by the administering nurse when preparing the (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: 366021 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 366021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shaker Gardens Nursing and Rehabilitation Center 3550 Northfield Road Shaker Heights, OH 44122 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)