Health inspection·August 2, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, record review, and review of the facility policy the facility failed to ensure medication error rate was less than five percent. There were 30 medication errors out of 32 opportunities, resulting in a 93.75 percent medication error rate. This affected four residents (#26, #28, #31 and #37) out of four residents reviewed for medication administration. The facility census was 43. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 07/19/23 with diagnoses including malignant neoplasm of the upper lobe of the left lung, diabetes mellitus, and heart failure. Review of the physician's orders and Medication Administration Record (MAR) for August 2023 for Resident #37 revealed she had orders dated 07/19/23 for Amlodipine 5 milligrams (mg), one time a day at 8:00 A.M. for hypertension, Anastrozole (hormone based chemotherapy) 1 mg one time a day at 8:00 A.M., Aspirin one time a day at 8:00 A.M. for coronary artery disease, Vitamin D 250 micrograms (mcg) (supplement) one time a day at 8:00 A.M., Citalopram 40 mg one time a day at 8:00 A.M. for depression, Ferrous Sulfate 325 mg one time a day at 8:00 A.M. for anemia, Lasix 40 mg one time a day at 8:00 A.M. for edema, Losartan Potassium 100 mg one time a day at 8:00 A.M. for hypertension, and Toprol XL 200 mg one time a day at 8:00 A.M. for heart failure. She also had an order for blood glucose management to take blood sugar before meals and at night, timed at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 10:00 P.M. Observation on 08/02/23 at 6:49 A.M. of medication administration by Licensed Practical Nurse (LPN) #200 to Resident #37 revealed she obtained her blood sugar and then administered Amlodipine 5 mg, Anastrozole 1 mg, Aspirin, Vitamin D 250 mcg, Citalopram 40 mg, Ferrous Sulfate 325 mg, Lasix 40 mg, Losartan Potassium 100 mg, and Toprol XL 200 mg. Interview on 08/02/23 at 7:27 A.M. with LPN #200 verified she had not administered Resident #37's medications as ordered. She stated she administered the medications too early and should have administered them from 7:00 A.M. to 9:00 A.M. Review of the facility policy titled, Medication Administration, dated 07/24/23, revealed staff should administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician. 2. Review of the medical record for Resident #28 revealed an admission date of 02/25/21 with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, and hypertension. Page 1 of 4 366241 366241 08/02/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0759 Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders and MAR for August 2023 for Resident #28 revealed she had orders for Atenolol 50 mg one time a day at 8:30 A.M. for hypertension dated 12/08/22, Vitamin D 2,000 units one time a day at 8:30 A.M. dated 12/08/22, Prednisolone Acetate eye drops twice a day at 8:30 A.M. and 8:30 P.M. for dry eyes dated 12/08/22, and MiraLAX 17 grams one time a day at 8:00 A.M. for constipation dated 03/22/23. Residents Affected - Some Observation on 08/02/23 at 7:00 A.M. of medication administration by LPN #200 to Resident #28 revealed she had pre-poured (prepared the medications early and then placed them in a medication cup in the medication cart) the Atenolol 50 mg and Vitamin D 2,000 units. She had labeled the medication cup with Resident #28's name but was unable to provide this surveyor with proof of what medications were in the cup though stated it was the resident's Atenolol and Vitamin D3. She then administered the two medications in the cup as well as Prednisolone Acetate eye drops to Resident #28. Resident #28 refused her MiraLAX medication. Interview on 08/02/23 at 7:27 A.M. with LPN #200 verified she had not administered Resident #28's medications as ordered. She stated she administered the medications too early and should have administered them from 7:30 A.M. to 9:30 A.M. She also verified she should not have pre-poured the medications in a medication cup and stored them in the medication cart. Review of the facility policy titled, Medication Administration, dated 07/24/23, revealed staff should administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician. 3. Review of the medical record for Resident #31 revealed an admission date of 08/02/21 with diagnoses including dementia, depression, aphasia, and hypertension. Review of the physician's orders and MAR for August 2023 for Resident #31 revealed she had orders for Atorvastatin 20 mg one time a day at 8:30 A.M. for high cholesterol dated 08/02/21, Century multi-vitamin one time a day at 8:30 A.M. dated 08/02/21, Lisinopril-Hydrochlorothiazide 10-12.5 mg one time a day at 8:30 A.M. for hypertension dated 08/02/21, Celexa 10 mg one time a day at 8:30 A.M. for depression dated 03/04/22, Vitamin D3 25 mcg two times a day at 8:30 A.M. and 5:00 P.M. dated 12/08/22, Namenda 10 mg two times a day at 8:30 A.M. and 5:00 P.M. for Alzheimer's disease dated 02/25/23, and Cephalexin 500 mg. four times a day at 8:00 A.M., 12:00 P.M. 5:00 P.M. and 8:00 P.M. for urinary tract infection dated 08/01/23. Observation on 08/02/23 at 7:06 A.M. of medication administration by LPN #200 to Resident #31 revealed she administered Atorvastatin 20 mg, Celexa 10 mg, Century multi-vitamin, Lisinopril-Hydrochlorothiazide 10-12.5, Namenda 10 mg, Vitamin D3 25, and Cephalexin 500 mg. Interview on 08/02/23 at 7:27 A.M. with LPN #200 verified she had not administered Resident #31's medications as ordered except for the Cephalexin. She stated she administered the medications too early and should have administered them from 7:30 A.M. to 9:30 A.M. Review of the facility policy titled, Medication Administration, dated 07/24/23, revealed staff should administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician. 4. Review of the medical record for Resident #26 revealed an admission date of 01/23/13 with diagnoses including dementia and hypertension. 366241 Page 2 of 4 366241 08/02/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician's orders and MAR for August 2023 for Resident #26 revealed she had orders for Claritin 10 mg one time a day at 8:30 A.M. for allergic rhinitis dated 02/07/18, Vitamin D3 5,000 units one time a day at 8:30 A.M. dated 02/07/18, Amiodarone 200 mg one time a day at 8:30 A.M. for arrhythmia dated 03/24/22, Lisinopril 5 mg one time a day at 8:30 A.M. for hypertension dated 03/24/22, Lactulose 20 gram/30 milliliters, give 15 milliliters two times a day at 8:30 A.M. and 8:30 P.M. for elevated ammonia dated 03/29/22, Fenofibrate 54 mg one time a day at 8:30 A.M. for hyperlipidemia dated 03/29/22, Breo Ellipta 100-25 mcg one time a day at 8:30 A.M. for chronic obstructive pulmonary disease dated 12/08/22, Pantoprazole 40 mg one time a day at 8:30 A.M. for diverticulosis dated 12/08/22, Exelon capsule 6 mg two times a day at 8:30 A.M. and 8:30 P.M. for dementia dated 12/08/22, Namenda 10 mg two times a day at 8:30 A.M. and 8:30 P.M. for dementia dated 12/08/22, Azelastine HCL 0.15% nasal spray two times a day at 8:30 A.M. and 8:30 P.M. for allergic rhinitis dated 12/23/22 and Dicyclomine 10 mg two times a day at 8:30 A.M. and 8:30 P.M. for diverticulosis dated 12/23/22. Observation on 08/02/23 at 7:21 A.M. of medication administration by LPN #200 to Resident #26 revealed she had pre-poured the Claritin 10 mg, Vitamin D3 5,000, Amiodarone 200 mg, Lisinopril 5 mg, Fenofibrate 54 mg, Pantoprazole 40, Exelon 6 mg, Namenda 10, and Dicyclomine 10 mg. She had labeled the medication cup with Resident #26's name and the original packaging was laying in the medication cart by the medication cup. LPN #200 then administered the pre-poured medications as well as Lactulose 15 milliliters and Breo Ellipta 100-25 mcg to Resident #26. Interview on 08/02/23 at 7:27 A.M. with LPN #200 verified she had not administered Resident #26's medications as ordered. She stated she administered the medications too early and should have administered them from 7:30 A.M. to 9:30 A.M. She verified she had not administered the Azelastine nasal spray to Resident #26. She also verified she should not have pre-poured the medications in a medication cup and stored them in the medication cart. Review of the facility policy titled, Medication Administration, dated 07/24/23, revealed staff should administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by a physician. 366241 Page 3 of 4 366241 08/02/2023 Steubenville Country Club Manor 575 Lovers Lane Steubenville, OH 43953

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, record review, and review of the facility policy the facility failed to maintain adequate infection control practices during administration of medications to residents. This affected four residents (#26, #28, #31 and #37) of four residents observed during medication administration. This also had the potential to affect two residents (#32 and #33) of two residents who received glucometer checks. The facility census was 43. Residents Affected - Some Findings include: Medication administration observations were made on 08/02/23. At 6:49 A.M. Licensed Practical Nurse (LPN) #200 was observed to prepare Resident #37's medications, enter Resident #37's room, lay the glucometer on her tray table without a barrier underneath. LPN #200 put on gloves and obtained Resident #37's blood sugar reading and then administered her medications. Upon leaving the room, LPN #200 took off her gloves and went to the medication cart and laid the glucometer on top of the medication cart. She threw away used supplies and then put the glucometer into the medication cart without cleaning it. She did not perform hand hygiene. At 7:00 A.M., LPN #200 then prepared Resident #28's medications without performing hand hygiene, went into her room, put on gloves, administered the eye drops and then administered the oral medications. LPN #200 took her gloves off and went to the medication cart and did not perform hand hygiene. At 7:06 A.M., LPN #200 prepared Resident #31's medications without performing hand hygiene, went to the resident who was in the common area and administered the medications to Resident #31. LPN #200 then went to the medication cart and did not perform hand hygiene. At 7:21 A.M., LPN #200 prepared Resident #26's medications without performing hand hygiene, went to the resident who was in the dining room and administered her medications. LPN #200 then went back to the medication cart and did not perform hand hygiene. Interview on 08/02/23 at 7:27 A.M. with LPN #200 verified she had not performed hand hygiene during the medication administrations of Residents #26, #28, #31 and #37 (before or after administering medications). LPN #200 also verified she had not cleaned the glucometer after using it to obtain Resident #37's blood sugar. She stated two other residents (#32 and #33) utilized the glucometer on that medication cart. Review of facility the policy titled, Glucometer Machine, dated March 2022, revealed staff should cleanse and sanitize glucometer with disinfecting/sanitizing wipes that is available to nursing staff (follow instructions on wipes) if the glucometer wasn't placed on a barrier and if resident's blood glucose was obtained by a back-up glucometer and resident did not have their own glucometer. Review of the facility policy titled, Medication Administration, dated 07/24/23, revealed staff should wash hands prior to administering medications and after. 366241 Page 4 of 4