Health inspection·July 3, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interviews and policy review, the facility failed to ensure medications were securely stored. This affected three (#56, #24 and #54) residents of three reviewed for medication storage. The facility census was 86. Findings include: Medical record review for Resident #56 revealed an admission date of 06/01/23 with diagnoses including but not limited to schizoaffective disorder, major depression, personality and behavioral disorder due to known physiological condition. Review of the quarterly MDS dated [DATE] revealed an intact cognition. Resident #56 requires supervision for eating, toileting, bed mobility and transfers. Review of the plan of care for Resident #56 dated 12/08/22 revealed resident uses psychotropic medication for diagnoses of schizophrenia. Interventions include aims testing, pharmacy consults, monitoring of adverse side effects, and consistent daily routines when possible. Review of the active physician orders for Resident #56 for July 2024 revealed an order dated 03/22/24 for Fluticasone Propionate (corticosteriod) 50 micrograms (mcg) suspension one spray in each nostril for allergies. Observation on 07/02/24 at 2:57 P.M. of unsecured pharmacy labeled Fluticasone Propionate in Resident #56 room sitting on his dresser. Interview on 07/02/24 at 2:59 P.M. with Licensed Practical Nurse (LPN) #301 verified the observation of the bottle of Fluticasone Propionate in Resident #56 room, stating that it should not have been left in the room. 2. Medical record review for Resident #24 revealed an admission on [DATE] with diagnoses including but not limited to hemiplegia, affecting left dominate side, hemiplegia and hemiparesis following a cerebral infarction, diabetes type two, acute kidney failure and bipolar disorder, wernicke's encephalopathy and anxiety. Review of the quarterly MDS assessment for Resident #24 dated 05/03/24 revealed resident had intact cognition. Resident #24 was independent with eating. Resident #24 required supervision for bed Page 1 of 3 365178 365178 07/03/2024 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0761 mobility, transfers and toileting. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care for Resident #24 revealed resident has history of Cerebral Vascular Accident (CVA) left side weakness limited range of motion in left hand with complaint of pain and hemiplegia. Interventions included administer medications as ordered, observe for adverse side effects and effectiveness. Residents Affected - Few Review of the physician orders for the Month of July 2024 for Resident #24 did not include orders for Gabapentin (anticonvulsant) or Hydroxyzine (antihistamine). Observation on 07/02/24 at 1:57 P.M. of three medication bottles (one Gabapentin bottle and two Hydroxyzine bottles) all with medication capsules/tablets visible sitting on the dresser in Resident #24's room with prescriptions dated 03/28/24. Interview on 07/02/24 at 1:57 P.M. with Resident #24 stated his psychologist prescribes the medication for him (Gabapentin 600 milligrams and Hydroxyzine (antihistamines) daily and he keeps them in his room so he can take them when he needs them. Interview on 07/02/24 at 2:04 P.M. with the Director of Nursing (DON) verified Resident #24 should not have any prescription medications in his room and did not have any order in the medical record for the prescribed medication. 3. Review of the medical record for Resident #54 revealed an admission on [DATE] with diagnoses including but not limited to disorders of the vein, non pressure chronic ulcer of right ankle with unspecified severity. Review of the comprehensive MDS dated [DATE] for Resident #54 revealed an intact cognition. Resident #54 required set up assistance for eating, supervision for bed mobility and toileting. Resident #54 required moderate assistance for transfers. Resident #54 was coded with five venous ulcers. Review of the plan of care dated 05/16/24 for Resident #54 revealed resident had impaired skin integrity and at risk for pressure ulcer development related to weakness, fatigue, venous insufficiency, obesity and lymphoid. Resident #54 has current skin impairments on the left inner foot, left heel, right lower leg, right great toe and right ankle. Interventions include administer treatments as ordered by medical provider, complete skin at risk assessment as ordered, weekly skin checks and encourage resident to turn and reposition or assist as needed as resident allows Review of the active physicians order for Resident #54 revealed an order dated 06/18/24 for left inner foot, cleanse with normal saline, apply betadine to base of wound, secure with rolled gauze and ace bandage change daily. Observation on 07/02/24 at 3:30 P.M. of Resident #54's in room sink revealed a large bottle of betadine unsecured with a warning label to notify poison control if ingested. Interview on 07/02/24 at 3:42 P.M. with Registered Nurse (RN) #302 verified the bottle should have not been left in the residents room. Review of the facility policy titled Storage of Medications, dated 09/2018 stated medications and biologicals are stored safety, securely and properly. Additionally stated medication supply is 365178 Page 2 of 3 365178 07/03/2024 Kenwood Terrace Healthcare Center 7450 Keller Road Cincinnati, OH 45243

F 0761 accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365178 Page 3 of 3