Inspection·March 14, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to ensure medications were obtained and administered as ordered by the physician resulting in significant medication errors. This affected one (#13) of six sampled residents reviewed for medication administration. The facility census was 65. Residents Affected - Few Findings include: Resident #13 readmitted from the hospital on [DATE] with the diagnosis including, chronic respiratory failure, dependence on respirator, chronic obstructive pulmonary disease, gastrostomy tube, and tracheostomy. According to the minimum data set assessment dated [DATE] Resident #13 was assessed with moderately impaired cognition, dependent on staff for the completion of activities of daily living, experienced constant pain with pain medication administration including opioid administration. Review of Resident #13's physician orders noted the following medications ordered on 02/16/24; Metoprolol Tartrate Tablet 25 milligrams (mg) give one tablet via gastrostomy tube (G-Tube) two times a day for hypertension, MagOx 400 Oral Tablet give 400 mg via G-Tube two times a day for supplement, Seroquel Oral Tablet give 50 mg via G-Tube one time a day for anxiety, Trazodone Oral Tablet 50 mg via G-Tube one time a day for insomnia, Donepezil Oral Tablet give 10 mg via G-Tube one time a day for anxiety, Lasix Oral Tablet give 20 mg via G-Tube one time a day for congestive heart failure, Apixaban Oral Tablet give 5 mg via G-Tube two times a day for venous thromboembolism (VTE) prophylaxis, Lipitor Oral Tablet give 10 mg via G-Tube one time a day for hyperlipidemia. On 02/21/24 Sertraline 50 mg via G-Tube once daily for major depression was ordered. Review of the medication administration record (MAR) from February 2024 noted the following medications documented as being omitted and not given as ordered; Metoprolol Tartrate Tablet 25 milligrams (mg) MAR scheduled to be given at bedtime omitted dose 02/18/24. MagOx 400 mg MAR scheduled to be given at morning upon rising and at bedtime missed morning dose on 02/18/24 and bedtime dose on 02/22/24. Seroquel 50 mg MAR scheduled to be given at bedtime missed doses on 02/17/24, 02/18/24, 02/19/24, 02/20/24. Trazodone 50 mg MAR scheduled to be given at bedtime missed doses on 02/18/24, 02/19/24, 02/20/24. Donepezil 10 mg MAR scheduled to be given at bedtime missed doses on 02/18/24, 02/19/24, 02/20/24. Lasix 20 mg MAR scheduled to be given at morning upon rising missed 02/19/24 dose. Apixaban Oral Tablet 5 mg MAR scheduled to be given at morning upon rising and at bedtime missed bedtime doses on 02/18/24, 02/20/24, 02/21/24 and missed morning doses on 02/21/24, 02/22/22. Lipitor Oral Tablet 10 mg MAR scheduled to be given at bedtime missed doses on 02/17/24, 02/18/24, 02/19/24, 02/20/24. Sertraline 50 mg ordered on 02/21/24 MAR scheduled to be given in morning upon rising missed dose on 02/22/24. Further review of the medical record lacked documentation indicating the physician was notified of the medications being omitted (missed) or a second pharmacy being contacted in an attempt to obtain the medications. On 03/13/24 at 8:55 A.M. interview with the Director of Nursing (DON) during a review of Resident #13's medical record revealed the facility had difficulty obtaining certain medications for the resident on the listed dates. The DON stated the pharmacy reported lack of supply leading to the medications not being obtained. The DON further verified the physician was not notified of the medications not being obtained or administered and lack of a secondary pharmacy being contacted in an attempt to obtain Resident #13 medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 If continuation sheet Page 2 of 3 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Review of the medication administration policy revised 08/22/22 revealed staff should review the Medication Administration Record (MAR) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify medication name, form, dose, route and time. Administer medications as ordered. Sign MAR after administered. Report and document any adverse side effects of refusals. Residents Affected - Few Review of medication reordering policy dated revised 01/01/2024 revealed the facility will utilize a systematic approach to provide or obtain routine and emergency medications and biological's in order to meet the needs of each resident. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. If a medication is not available to be administered and not in the emergency kit the nurse will notify the pharmacy, physician, resident and or responsible party. This deficiency represents non-compliance investigated under Complaint Number OH00151380. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366073 If continuation sheet Page 3 of 3