Health inspection·April 9, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in three medication errors out of 29 opportunities or a 10.3 percent (%) medication error rate. This affected one (#37) out of the two residents observed for medication administration. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/02/25 with medical diagnoses of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia. Review of the medical record for Resident #37 revealed an admission Minimum Data Set (MDS) assessment, dated 01/08/25, which indicated Resident #37 had moderate cognitive impairment and was dependent for toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #37 revealed physician orders dated 01/03/25 for tamsulosin (Flomax) 0.4 milligram (mg) one tablet by mouth daily, aspirin-dipyridamole (Aggrenox- an antiplatelet) 12 hour 25-100 mg one tablet by mouth two times per day, and Colace 100 mg one tablet by mouth daily. Review of the physician orders revealed no documentation to support an order for aspirin 81 mg one tablet daily. Review of the medical record for Resident #37 revealed an April 2025 Medication Administration Record (MAR) which indicated staff administered Colace, tamsulosin, and aspirin-dipyridamole as ordered from 04/01/25 through 04/07/25. Review of the medical record for Resident #37 revealed a pharmacy recommendation, dated 03/28/25, which recommended discontinuation of Colace and tamsulosin. The pharmacy recommendation revealed documentation to support the physician agreed with the pharmacy recommendation and an order to discontinue the medications was signed on 03/31/25. Observation on 04/08/25 at 8:05 A.M. revealed Registered Nurse (RN) #114 prepared Resident #37's medications for administration. The observation revealed RN #114 prepared one Colace 100 mg tablet, one aspirin 81 mg tablet, and one tamsulosin 0.4 mg tablet for administration. The observation revealed RN #114 administered the Colace, aspirin, and tamsulosin tablets to Resident #37. Interview on 04/08/25 at 8:26 A.M. with RN #114 confirmed she administered aspirin 81 mg tablet to Resident #37 and not the aspirin-dipyridamole 25-100 mg tablet as ordered by physician. RN #114 also confirmed she also administered Colace and tamsulosin to Resident #37. Page 1 of 3 366263 366263 04/09/2025 Grace Brethren Village 1010 Taywood Road Englewood, OH 45322

F 0759 Level of Harm - Minimal harm or potential for actual harm Interview on 04/09/25 at 1:00 P.M. with Chief Clinical Officer (CCO) #112 confirmed Resident #37's pharmacy recommendation dated 03/28/25 indicated a recommendation to discontinue Colace and tamsulosin medications. The pharmacy recommendation revealed documentation the physician discontinued the orders for Colace and tamsulosin on 03/31/25. Interview with CCO #112 confirmed the medications were not discontinued and staff administered medications from 04/01/25 through 04/08/25. Residents Affected - Few Review of the facility policy titled, Administering Oral Medications, revised October 2010 stated staff are to verify there is a physician's medication order, check label of the medication, and confirmed the medication name and dose with Medication Administration Record (MAR), check medication dose, and re-check to confirm proper dose. The deficiency was based on incidental findings discovered during the course of this complaint investigation. 366263 Page 2 of 3 366263 04/09/2025 Grace Brethren Village 1010 Taywood Road Englewood, OH 45322

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record reviews, observations, staff interviews, review of medication information from Medscape, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (#37) out of two residents reviewed for medication administration. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/02/25 with medical diagnoses of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia. Review of the medical record for Resident #37 revealed an admission Minimum Data Set (MDS) assessment, dated 01/08/25, which indicated Resident #37 had moderate cognitive impairment and was dependent for toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #37 revealed a physician order dated 01/03/25 aspirin-dipyridamole (Aggrenox- an antiplatelet medication) 12 hour 25-100 milligram (mg) one tablet by mouth two times per day. Review of the physician orders revealed no documentation to support an order for aspirin 81 mg one tablet daily. Observation on 04/08/25 at 8:05 A.M. revealed Registered Nurse (RN) #114 prepared Resident #37's medications for administration. The observation revealed RN #114 prepared one aspirin 81 mg for administration and administered the aspirin tablet to Resident #37. Interview on 04/08/25 at 8:26 A.M. with RN #114 confirmed she administered aspirin 81 mg tablet to Resident #37 and not the aspirin-dipyridamole 25-100 mg tablet as ordered by physician. Review of the facility policy titled, Administering Oral Medications, revised October 2010 stated staff are to verify there is a physician's medication order, check label of the medication, and confirmed the medication name and dose with Medication Administration Record (MAR), check medication dose, and re-check to confirm proper dose. Review of medication information from Medscape at https://reference.medscape.com/drug/aggrenox-aspirin-dipyridamole-342148?_gl=1*19qd2zd*_gcl_au*MTEwNzM0NDc3O revealed aspirin/dipyridamole is a antiplatelet medication used to treat stroke secondary prophylaxis of transient ischemic attack (TIA) or cerebrovascular accident (CVA). The deficiency was based on incidental findings discovered during the course of this complaint investigation. 366263 Page 3 of 3