Health inspection·April 15, 2024

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 the facility policy, the facility failed to maintain a medication error rate of less than five percent (%). The medication error was 12.00% due to three observed medication errors for 25 medication administration opportunities. This affected two (Residents #9 and #42) of four residents observed for medication administration. The facility census was 94 residents. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of [DATE] with diagnoses including dysphagia, hemiplegia, aphasia, anxiety disorder and reflux disease. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #9 dated [DATE] revealed the resident had impaired cognition and required staff assistance with bed mobility, transfers, and personal hygiene. Review of the [DATE] physician's orders for Resident #9 revealed the resident had an order for Aspirin 81 milligram (mg) enteric coated, delayed release tablet by mouth daily. Observation on [DATE] at 8:32 A.M. revealed Licensed Practical Nurse (LPN) #204 prepared Resident #9's morning medications which included a chewable Aspirin 81 mg tablet. The aspirin tablet was administered whole, and the resident swallowed the tablet with water. Interview on [DATE] at 8:44 A.M. with LPN #204 confirmed she administered a chewable aspirin tablet to Resident #9, but the resident's order was for an enteric coated, delayed release tablet. 2. Review of the medical record for Resident #42 revealed an admission date of [DATE] with diagnoses including bipolar disorder, depression, chronic obstructive pulmonary disease, and coronary artery disease. Review of the comprehensive MDS assessment for Resident #42 dated [DATE] revealed the resident had impaired cognition and required staff assistance with bed mobility, transfers, and personal hygiene. Review of the [DATE] physician's orders for Resident #42 revealed an order for Mucinex 600 mg by mouth every 12 hours and an order to give an iron tablet extend release by mouth every morning and evening for iron deficiency. The order did not indicate how many mg of iron was needed. (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 3 Event ID: 366111 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 366111 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falling Water Healthcare Center 18840 Falling Water Strongsville, OH 44136 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)