Inspection·October 11, 2023

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, facility policy and procedure review, and staff interview, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #51) of three residents reviewed for medications. The facility census was 139. Findings include: Review of Resident #51's medical record revealed an admission date of 08/03/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, respiratory failure, hypertensive heart disease, and type two diabetes mellitus without complications. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of a Medication Error Report dated 09/09/23 revealed Resident #51 received the following medications in error, that were prescribed for Resident #141: Metoprolol (anti-hypertensive) 25 milligrams (mg), Duloxetine (diabetic peripheral neuropathy) 60 mg, Diflucan (antibiotic) 200 mg, Jardiance (diabetes management) 25 mg, Magnesium Oxide (supplement) 400 mg, and Aspirin 81 mg. The incident occurred on 09/09/23 at 9:40 A.M., and the physician, the family, and the Director of Nursing (DON) were notified at 9:45 A.M. by Licensed Practical Nurse (LPN) #337. The medication error type included wrong medication and wrong resident. Review of Resident #51's nursing progress notes dated 09/09/23 at 10:36 A.M. revealed LPN #337 documented at 9:40 A.M. this morning, this writer prepared medications for Resident #51. However, the medication list that was pulled was for another resident's medication (Resident #141). Vitals were checked at the time of administration and checked roughly every thirty minutes later as well. The DON and doctor were notified. The physician ordered to administer Resident #51 Apixaban (anticoagulant) 5.0 mg, Lisinopril (anti-hypertensive) 40 mg, Sotalol (atrial fibrillation) 120 mg and continue to monitor throughout the shift. Resident #51 at this time with no complaints. On 10/10/23 at 12:10 P.M., during an interview Resident #51 confirmed he was notified by the nurse he had been given the wrong medications in September and was not certain of the date. Resident #51 stated he was assessed several times that day and had no adverse effects of the medications. On 10/11/23 at 12:17 P.M., during an interview LPN #337 revealed on 09/09/23, she administered medications to Resident #51 and when she pulled up the next residents Medication Administration Record (MAR), (Resident #141). The medications had been initialed as administered. LPN #337 stated she (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: 366120 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 366120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Cedar Village. 5467 Cedar Village Drive Mason, OH 45040 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)