Health inspection·May 2, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. 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, observation, staff interview, and review of facility policy, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 10.7% and included three medication errors out of 28 medication administration opportunities. This affected two residents (#27 and #29) out of two residents observed during medication administration. The census was 65. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including but not limited to heart failure, gastroesophageal reflux disease, and vitamin D deficiency. Review of Resident #29's April 2023 physician orders revealed Resident #29 had orders to receive omeprazole (proton pump inhibitor) 20 milligrams (mg) in the morning and multivitamin with minerals one daily. Observation on 05/01/23 at 9:20 A.M. revealed Registered Nurse (RN) #109 was administering medications to Resident #29. RN #109 removed omeprazole 20 mg from a bubble pack which included a message to take before eating and on an empty stomach, as well as a multivitamin (MVI) with minerals from a stock bottle which had a best by date of March 2023. When the medications were ready for administration, it was brought to the attention of RN #109 that the MVI with minerals were retrieved from a bottle which had a best by date of March 2023. Interview on 05/01/23 at 9:41 A.M. with State Tested Nurse Aide (STNA) #102 revealed Resident #29 received her breakfast tray around 7:50 A.M. Interview on 05/01/23 at 10:48 A.M. with RN #109 verified she was going to administer the multivitamin with mineral which was from a stock bottle that was past the best by date. The interview further verified the omeprazole 20 mg was administered to Resident #29 after breakfast and was not administered before eating and on an empty stomach as directed. 2. Review of Resident #27's medical record revealed an admission date of 05/01/22 and a readmission date of 04/07/23 with diagnoses including but not limited to end stage renal disease, type two diabetes, and gastroesophageal reflux disease. Review of Resident #27's April 2023 physician orders revealed Resident #27 had an order for omeprazole delayed release 20 milligrams (mg) in the morning. (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: 366104 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 366104 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem North Healthcare Center 250 Continental Drive Salem, OH 44460 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)