Health inspection·April 25, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and facility policy review, the facility failed to ensure Resident #1 was free from a significant medication error in the area of antihypertensive (medications used to lower blood pressure) medications. This affected one of three residents review for use of antihypertensive medication use. The facility census was 61. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an initial admission date of 11/23/22 with a latest readmission date of 04/21/23. Diagnoses included but were not limited to congestive heart failure, myocarditis, and hyperlipidemia. Review of the plan of care, dated 11/25/22, revealed Resident #1 had an altered cardiovascular status related to congestive heart failure, hyperlipidemia, hypertension, history of myocarditis, and history of myocardial infarction. Interventions included administer medications as ordered, assess for chest pain every shift, and educate on the need to call for assistance if the pain starts, elevate head of bed as tolerated and as needed, monitor/document/report as needed any signs/symptoms of coronary artery disease, and oxygen as ordered. Review of the cardiology consult summary, dated 02/24/23, revealed Resident #1 was to stop taking Losartan (medication used to treat high blood pressure) 25 mg by mouth. Review of Resident #1's discontinued physician orders revealed an order dated 11/23/22 for Losartan 12.5 mg by mouth daily for hypertension. The order was discontinued on 04/21/23. Review of Resident #1's Medication Administration Record (MAR) for February 2023 revealed Resident #1's Losartan 25 milligrams (mg) with special instructions to give one half tablet (12.5 mg) by mouth daily for hypertension was not discontinued and was administered to Resident #1 on 02/25/23, 02/26/23, 02/27/23 and 02/28/23. Review of Resident #1's MAR for March 2023 revealed Resident #1's Losartan 25 milligrams (mg) with special instructions to give one half tablet (12.5 mg) by mouth daily for hypertension was not discontinued and Resident #1 was administered all scheduled doses except for 03/01/23, 03/04/23 and 03/08/23 due to Resident #1's blood pressure being too low to administer the medication. Review of Resident #1's MAR for April 2023 revealed Resident #1's Losartan 25 milligrams (mg) with special instructions to give one half tablet (12.5 mg) by mouth daily for hypertension was not discontinued and Resident #1 was administered all scheduled doses from 04/01/23 to 04/18/23. Page 1 of 3 366155 366155 04/25/2023 New Albany Care Center 5691 Thompson Road Columbus, OH 43230

F 0760 Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse #101 on 04/24/23 at 3:35 P.M., verified Resident #1's Losartan was not discontinued on 02/24/23 as physician ordered and Resident #1 continued to receive the medication. Review of the facility policy titled Medication Administration, undated, revealed all medications are administered in a safe manner that meets all regulatory guidelines and National Patient Safety Goals. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00142197 and OH00140741. 366155 Page 2 of 3 366155 04/25/2023 New Albany Care Center 5691 Thompson Road Columbus, OH 43230

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview, the facility failed ensure resident medical records were accurate. This affected one (Resident #1) out of three residents reviewed for accurate medical records. The census was 61. Findings include: Review of the medical record for Resident #1 revealed an initial admission date of 11/23/22 with the latest readmission date of 04/21/23. Diagnoses included cervical disc disorder with myelopathy, muscle wasting and atrophy, generalized muscle weakness, contact dermatitis, arthritis, asthma, congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, glaucoma, myocarditis, gastro-esophageal reflux disease, hyperlipidemia, history of malignant neoplasm of bronchus and lung, obstructive sleep apnea, insomnia, neuromuscular dysfunction of bladder and retention of urine. Review of the plan of care, dated 11/25/22, revealed Resident #1 was at risk for outcomes from potential hypo/hyperglycemic episodes related to diagnosis of diabetes mellitus. Interventions included administer oral hyperglycemic agents as ordered, lab results as ordered with results to physician, monitor for signs/symptoms of infection due to increased risk and notify physician of abnormal blood glucose monitoring results as ordered. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 04/12/23, revealed Resident #1 had clear speech, understood others, made himself understood, and his cognition was not assessed. The assessment did not indicate diabetes mellitus was a current diagnoses. Review of Resident #1's monthly physician orders for April 2023 revealed an order, dated 01/04/23, for Entresto (medication used for heart failure and diabetes mellitus) 24-26 mg tablet by mouth twice daily for congestive heart failure. Review of Resident #1's medical record revealed no documented evidence Resident #1's licensed physician documented diabetes mellitus as a current diagnoses for Resident #1. Interview with Certified Nurse Practitioner (CNP) #158 on 04/25/23 at 9:36 A.M., verified diabetes mellitus was not an accurate diagnoses for Resident #1. This deficiency represents non-compliance investigated under Complaint Number OH00141052. 366155 Page 3 of 3