Inspection·September 24, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medications that were multi-use should be dated when first accessed/ opened. She confirmed you would not know when to discard the medication, after it had been opened, in accordance with the instructions included on the medication labels. 1 b.) On 09/23/24 at 10:35 A.M., an observation of the 300 hall medication administration cart with Registered Nurse (RN) #500 present revealed there were three bottles of liquid medicine found in the medication administration cart that was not dated when opened. One bottle was a stock bottle of Maalox 12 fluid ounce (355 ml) that was in the bottom drawer of the medication cart and had been opened. There was no date on the outside of the bottle to indicate when it had been opened. There was also a bottle of Lactulose solution 10 Grams (Gms)/ 15 ml for Resident #55 that had been opened and not dated. A third bottle of [NAME]/ PSE/ DM syrup 2/30/10 for Resident #30 that was found in one of the lower pull out drawers that had been opened. It was not dated after it had been opened. Findings were verified by RN #50 at the time of the observation. On 09/23/24 at 10:39 A.M., an interview with RN #500 revealed bottles containing liquid medication should be dated when first opened. She was not able to determine when the three bottles found in the medication administration cart had been opened. 1 c.) On 09/23/24 at 10:55 A.M., an observation of the medication administration cart for the 200 hall with RN #100 present revealed there was a Lantus 100 unit/ ml flexpen that was found in the top drawer of the medication cart that belonged to Resident #63. The flexpen had been used, but was not dated to reflect when it was first used. The label on the bag the flexpen was stored in included a high alert that indicated once opened it could be stored at room temperature for 26 days. There was a place on the label for them to indicate the date it was opened but no date was added. Findings were confirmed with RN #100 at the time of the observation. She confirmed flexpens should be dated when first used, so the nurses knew when to discard them by. There was a Novolog 100 unit/ ml flexpen for Resident #54 found in the top drawer of the 200 hall medication cart that was being used. There was no date written on the flexpen or on the label on the bag the flexpen was stored in that indicated when it had first been used. The label included a high alert that directed the nurses the flexpen could be stored at room temperature for up to 28 days. There was also two Tresiba (insulin) 100 units/ ml flexpens for Resident #50 that were found in the top drawer of the medication cart. One of the flexpens was dated 09/12/24 to show when it was first used. The other flexpen was not dated and could not be determined if it had been used or not. The label on the bag it came in had a high alert that instructed the staff to refrigerate and once opened it could be stored at room temperature for up to 65 days. RN #100 confirmed Resident #50 should not have two Tresiba flexpens stored in the medication cart at the same time. She stated the flexpen that was not in use should have been stored in the refrigerator, as the label indicated, until it was put in use. She further acknowledged all multi-use flexpens should be dated when first used, so the nursing staff would know the date the flexpens should be discarded by. She confirmed none of the insulin flexpens mentioned above had a date on the flexpen or on the bag they came in to show when they were first used. Review of the facility's policy on Storage of Medications (revised 04/2007) revealed the facility should store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals should be stored in the packaging, containers or other dispensing systems in which they were received. Only the issuing pharmacy was authorized to transfer medications between containers. The facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 2 of 3 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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)

F 0761 should not use discontinued, outdated, or deteriorated drugs or biologicals. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00157490. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 3 of 3