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. (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: 366263 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 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 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)