Health inspection·January 26, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to report an allegation of misappropriation to the State Survey Agency. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95. Findings include: Record review of Resident #100 revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident was receiving hospice services. Diagnoses for Resident #100 include diabetes, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required extensive assistant of two staff for activities of daily living. Review of physician orders revealed Resident #100 was ordered the antianxiety medication Ativan every four hours as needed starting on [DATE]. Review of Resident #100's nursing progress note dated [DATE] at 12:30 A.M. revealed a verbal emergency order from the physician for Ativan intensol 0.25 milligrams by mouth every four hours as needed for anxiety. Review of the pharmacy delivery document dated [DATE] revealed Ativan and the narcotic pain medication morphine for Resident #100 was delivered on [DATE] at 3:41 A.M and Licensed Practical Nurse (LPN) #60 signed the receipt of the delivery document. Review of Resident #100's [DATE] medication administration record (MAR) revealed the resident did not receive doses of Ativan until [DATE] and subsequently received doses on [DATE], [DATE] and [DATE]. Review of LPN's #60 written statement, provided to the Director of Nursing (DON), revealed LPN #60 received a delivery package from the pharmacy on [DATE]. The delivery package had a black bag and a silver bag. LPN #60 stated she verified the morphine was in the black bag and LPN #60 disposed of the silver bag assuming it to be freezer packing. Review of facility self-reported incidents (SRIs) revealed no incident of Resident #100's missing Page 1 of 4 365081 365081 01/26/2024 Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248

F 0609 Ativan was reported to the State Survey Agency. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 3:50 P.M., with LPN #60 verified she signed for Resident #100's medication on [DATE]. LPN #60 stated she did not look at the medications she signed for, and did not verify or look for the Ativan in the pharmacy delivery package. LPN #60 verified the medication she opened was morphine, and threw away some silver wrapping that must have had the Ativan. LPN #60 stated she did not report missing Ativan because she did not know it was delivered or was missing. Residents Affected - Few Interview on [DATE] at 9:09 A.M., the Director of Nursing (DON) stated she was notified on [DATE] from Unit Manager (UM) #80 of the delivery and missing Ativan medication for Resident #100. On [DATE], the DON stated she reported the missing medication to the Administrator and to Regional Clinical Nurse (RCN) #100. The DON verified LPN #60 stated she had thrown out the pharmacy delivery packaging on [DATE]. The DON stated she counseled the LPN #60 regarding accepting medications from the pharmacy. The DON stated the process for investigation a missing item would include suspending the potential perpetrator, interviewing other staff, reviewing the effect on other residents and contacting the police. The DON stated a self-reported incident (SRI) would be filed for an unfound missing item. The DON denied LPN #60 was suspended. The DON verified she had not interviewed other staff regarding the missing medication, and had not conducted any part of an investigation of the missing medication. Interview on [DATE] at 9:28 A.M., the Administrator stated she had not been notified on [DATE] of Resident #100's missing Ativan. The Administrator stated she first heard of the missing medication on [DATE] when it was discussed with during the survey. The Administrator stated an SRI was not reported of the missing medication because she had no knowledge of the missing medication. The Administrator verified a missing medication would have been investigated and reported as an SRI. Interview on [DATE] at 5:00 P.M., RCN #100 verified there was no further documented investigation of Resident #100's missing medication other than the DON discussion with LPN #60. RCN #100 stated since LPN #60 stated the medication was unintentionally disposed of it was determined there was no need for further investigative procedures. Review of facility policy titled, Abuse, Neglect and Misappropriation, dated [DATE], revealed the facility will accurately and timely identify any event which would place residents at risk. Investigations are conducted timely. The facility is obligated to report any reasonable suspicion of a crime against a resident. This deficiency represents non-compliance investigated under Complaint Number OH00149590. 365081 Page 2 of 4 365081 01/26/2024 Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of self-reported incidents, review of pharmacy documents, review of written statements, and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#100) of two residents reviewed for misappropriation. The facility census was 95. Residents Affected - Few Findings include: Record review of Resident #100 revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident was receiving hospice services. Diagnoses for Resident #100 include diabetes, anxiety disorder, and dementia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and required extensive assistant of two staff for activities of daily living. Review of physician orders revealed Resident #100 was ordered the antianxiety medication Ativan every four hours as needed starting on [DATE]. Review of Resident #100's nursing progress note dated [DATE] at 12:30 A.M. revealed a verbal emergency order from the physician for Ativan intensol 0.25 milligrams by mouth every four hours as needed for anxiety. Review of the pharmacy delivery document dated [DATE] revealed Ativan and the narcotic pain medication morphine for Resident #100 was delivered on [DATE] at 3:41 A.M and Licensed Practical Nurse (LPN) #60 signed the receipt of the delivery document. Review of Resident #100's [DATE] medication administration record (MAR) revealed the resident did not receive doses of Ativan until [DATE] and subsequently received doses on [DATE], [DATE] and [DATE]. Review of LPN's #60 written statement, provided to the Director of Nursing (DON), revealed LPN #60 received a delivery package from the pharmacy on [DATE]. The delivery package had a black bag and a silver bag. LPN #60 stated she verified the morphine was in the black bag and LPN #60 disposed of the silver bag assuming it to be freezer packing. Review of facility self-reported incidents (SRIs) revealed no incident of Resident #100's missing Ativan was reported to the State Survey Agency. Interview on [DATE] at 3:50 P.M., with LPN #60 verified she signed for Resident #100's medication on [DATE]. LPN #60 stated she did not look at the medications she signed for, and did not verify or look for the Ativan in the pharmacy delivery package. LPN #60 verified the medication she opened was morphine, and threw away some silver wrapping that must have had the Ativan. LPN #60 stated she did not report missing Ativan because she did not know it was delivered or was missing. Interview on [DATE] at 9:09 A.M., the Director of Nursing (DON) stated she was notified on [DATE] from Unit Manager (UM) #80 of the delivery and missing Ativan medication for Resident #100. On 365081 Page 3 of 4 365081 01/26/2024 Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE], the DON stated she reported the missing medication to the Administrator and to Regional Clinical Nurse (RCN) #100. The DON verified LPN #60 stated she had thrown out the pharmacy delivery packaging on [DATE]. The DON stated she counseled the LPN #60 regarding accepting medications from the pharmacy. The DON stated the process for investigation a missing item would include suspending the potential perpetrator, interviewing other staff, reviewing the effect on other residents and contacting the police. The DON stated a self-reported incident (SRI) would be filed for an unfound missing item. The DON denied LPN #60 was suspended. The DON verified she had not interviewed other staff regarding the missing medication, and had not conducted any part of an investigation of the missing medication. Interview on [DATE] at 9:28 A.M., the Administrator stated she had not been notified on [DATE] of Resident #100's missing Ativan. The Administrator stated she first heard of the missing medication on [DATE] when it was discussed with during the survey. The Administrator stated an SRI was not reported of the missing medication because she had no knowledge of the missing medication. The Administrator verified a missing medication would have been investigated and reported as an SRI. Interview on [DATE] at 5:00 P.M., RCN #100 verified there was no further documented investigation of Resident #100's missing medication other than the DON discussion with LPN #60. RCN #100 stated since LPN #60 stated the medication was unintentionally disposed of it was determined there was no need for further investigative procedures. Review of facility policy titled, Abuse, Neglect and Misappropriation, dated [DATE], revealed the facility will accurately and timely identify any event which would place residents at risk. Investigations are conducted timely. The facility is obligated to report any reasonable suspicion of a crime against a resident. This deficiency represents non-compliance investigated under Complaint Number OH00149590. 365081 Page 4 of 4