Health inspection·June 28, 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** Based on observation, record review, interviews, review of the manufacturer's instructions, and review of the facility policy the facility failed to ensure medications were given per physician's orders. This effected one resident (#39) of five residents reviewed for medication administration. The facility census was 66. Residents Affected - Few Findings include: Record review for Resident #39 revealed an admission date of 06/09/23. Diagnosis included cystitis, hypertension, type II diabetes mellitus, and depression. Review of Resident #39's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He required extensive assistance by two staff members for transfers and toileting. He required an extensive assist by one staff member for wheelchair mobility, dressing, bathing, and was independent with eating. Review of Resident #39's physician's orders dated for June 2023 revealed orders for Lantus (insulin) 15 units (u) subcutaneously twice a day for diabetes mellitus. Observation made on 06/28/23 at 8:30 A.M. of medication administration with Licensed Practical Nurse (LPN) #806 for five residents with 27 opportunities revealed for Resident #39 she did not prime the Lantus insulin needle with two units prior to setting the pen to the ordered dose of 15 units. Interview on 06/28/23 at 9:30 A.M. with LPN #806 revealed she verified she did not prime Resident #39's insulin pen with two units prior to administering 15 units of Lantus as per the manufacturer's instructions. Review of the Manufacturer's instructions for Lantus insulin pen as stated in step three, nursing to test dose of two units daily, hold pen with needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle, press the injection button all the way in, and check to see if insulin comes out of the needle. If no insulin comes out, repeat the test two more times. Step four states to dial up ordered amount of insulin and administer. Review of the facility policy titled Medication Administration Safety and Medication Error Policy, dated November 2015, revealed all medications are to be given per physician's orders and as directed by manufacturer's instructions. This deficiency represents non-compliance investigated under Master Complaint Number OH00144036. Page 1 of 2 366460 366460 06/28/2023 Canfield Acres LLC Dba Windsor House at Canfield 6445 State Route 446 Canfield, OH 44406

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and employee personnel file review the facility failed to maintain accurate medical records for Resident #67. This effected one resident (#67) of six residents reviewed for accurate medical records. The facility census was 66. Findings include: Review of the closed medical record for the Resident #67 revealed an admission date of 06/15/23 and a discharge date of 06/26/23. Diagnosis included aftercare following joint replacement of right knee, impaired glucose tolerance, osteoarthritis, hypertension, depression, and the presence of right knee artificial joint. Review of Resident #67's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she required limited assist by one staff member for bed mobility, transfers, walking, bathing, wheelchair mobility, dressing, toileting, and personal hygiene. She required set-up help only with eating. Review of the physician's orders for Resident #67 dated June 2023 revealed treatment orders for blisters to residents' right knee at incision site to be cleansed with Betadine (antiseptic), apply Xeroform (Vaseline) gauze pad with abdominal dressing and secure with Ace wrap twice a day and as needed. Review of Resident #67's Treatment Administration Record (TAR) for June 2023, revealed all treatments were initialed and signed off as being completed by nursing staff as ordered. Review of progress notes for Resident #67 revealed there were not any progress notes regarding treatments being signed off in error as completed. Interview on 06/27/23 at 1:35 P.M. with the Corporate Quality Assurance Nurse Registered Nurse (RN) # 801 revealed Licensed Practical Nurse (LPN) #802 was disciplined and issued a write-up for falsification of documentation for signing off treatments for Resident #67 as if they were completed; LPN #802 did not complete the treatments on 06/17/23. Interview on 06/28/23 at 3:30 P.M. with LPN #802 revealed she confirmed she signed of the treatment record for Resident #67 as if she had completed all treatments as ordered; however, she did not complete any of the treatments for the resident. She confirmed the facility administration issued her a write-up for falsification of documentation and instructed her to put in a progress note stating the treatment was signed off in error and was not completed. Review of LPN #802's employee file revealed a disciplinary action for falsification of documentation regarding Resident #67's treatments for 06/17/23. This deficiency represents non-compliance investigated under Master Complaint Number OH00144036. 366460 Page 2 of 2