Health inspection·December 6, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 and resident interview, and policy review, the facility failed to ensure physician orders were followed correctly. This affected one (#17) out of three residents reviewed for medications. The facility census was 100. Residents Affected - Few Findings included: Review of the medical record for Resident #17 revealed an admission date of 05/19/23. Diagnoses included cerebrovascular attack (CVA/stroke) with hemiplegia affecting left dominant side, renal insufficiency, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17, revealed the resident was cognitively intact. Her functional status was impairment of her upper and lower extremities, and she was independent for activities of daily living (ADLs). Review of the physician's orders dated 10/13/23 for Resident #17 revealed the resident ordered to have Metro Vaginal Gel one tube applied intravaginally at bedtime for bacterial vaginitis times six days. Review of the Medication Administration Records (MARs) dated 10/13/23, 10/14/23, and 10/15/23 which had a number 9' indicating to see the nurse's progress notes. Review of the nurse's progress notes for Resident #17 revealed no documented evidence resident received her Metro Vaginal Gel on 10/13/23, 10/14/23 and 10/15/23. Interview with Resident #17 on 12/06/23 at 9:11 A.M., revealed the Metro Vaginal Gel was not administered to her as ordered for the six days. Interview with the Director of Nursing (DON) on 12/06/23 at 3:30 P.M., confirmed the staff were late in giving Metro Vaginal Gel to Resident #17 and verified it was not given as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00147673. Page 1 of 2 365178 365178 12/06/2023 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff and resident interviews, the facility failed to ensure their pharmacy services provided resident's medication in a timely manner. This affected one (#17) out of three residents reviewed for medication administration. The census was 100. Findings included: Review of the medical record for Resident #17 revealed an admission date of 05/19/23. Diagnoses included cerebrovascular attack (CVA/stroke) with hemiplegia affecting left dominant side, renal insufficiency, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17, revealed the resident was cognitively intact. Her functional status was impairment of her upper and lower extremities, and she was independent for activities of daily living (ADLs). Review of the physician's orders dated 10/13/23 for Resident #17 revealed the resident ordered to have Metro Vaginal Gel one tube applied intravaginally at bedtime for bacterial vaginitis times six days. Review of the Medication Administration Records (MARs) dated 10/13/23, 10/14/23, and 10/15/23 which had a number 9' indicating to see the nurse's progress notes. Review of the nurse's progress notes dated 10/13/23, 10/15/23 and 10/16/23 for Resident #17, revealed the nurses called the pharmacy to let them know the facility was waiting for Metro Vaginal Gel to be delivered to the facility. Interview with Resident #17 on 12/06/23 at 9:11 A.M. revealed the Metro Vaginal Gel was late getting to the facility from the pharmacy and missed doses. Interview with the Director of Nursing (DON) on 12/06/23 at 3:30 P.M. confirmed the pharmacy was late in filling the order for Resident #17's Metro Vaginal Gel. This deficiency represents non-compliance investigated under Complaint Number OH00147673. 365178 Page 2 of 2