Health inspection·November 13, 2024

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. Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide medications as ordered by physician. This affected one resident (Resident #11) of three residents reviewed for medication administration. The facility census was 94 residents. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/10/24 with diagnoses including osteoarthritis and attention deficit hyperactivity disorder (ADHD). Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 10/15/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #11 revealed an order dated 07/15/24 for Adderall five milligrams (mg) two tablets twice daily. Review of controlled drug administration records for Resident #11 revealed Adderall was not administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. Review of Medication Administration Records (MAR) for Resident #11 dated August 2024 and September 2024 revealed Adderall was documented as not administered on 08/28/24, 08/29/24, 09/02/24 evening dose only, 09/03/24, 09/07/24, 09/08/24, 09/13/24, 09/14/24, 09/16/24 to 09/23/24, and 09/25/24 morning dose only. Interview on 11/13/24 at 10:25 A.M. with Resident #11 confirmed she did not receive her Adderall for approximately two weeks a couple months ago. Interview on 11/13/24 at 1:45 P.M. with the Director of Nursing (DON) confirmed Resident #11's Adderall was not available to be administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. The DON confirmed staff were at times signing off medication as administered in the MAR when the medication was not available. Further interview with the DON confirmed she was unaware Resident #11 had missed numerous doses of Adderall in August and September 2024 until the Surveyor questioned her regarding the medications. Review of the facility policy titled Administering Medications dated December 2012 revealed medications must be administered in accordance with the orders, including any required time frame. Page 1 of 3 365186 365186 11/13/2024 Ayden Healthcare of Madeira 5970 Kenwood Road Cincinnati, OH 45243

F 0755 The deficiency represents noncompliance investigated under Complaint Number OH00159293. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365186 Page 2 of 3 365186 11/13/2024 Ayden Healthcare of Madeira 5970 Kenwood Road Cincinnati, OH 45243

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. Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to accurately document medication administration. This affected one (Resident #11) of three residents reviewed for medication administration. The facility census was 94 residents. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/10/24 with diagnoses including osteoarthritis and attention deficit hyperactivity disorder (ADHD). Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 10/15/24 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #11 revealed an order dated 07/15/24 for Adderall five milligrams (mg) two tablets twice daily. Review of controlled drug administration records for Resident #11 revealed Adderall was not administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. Review of Medication Administration Records (MAR) for Resident #11 dated August 2024 and September 2024 revealed Adderall was documented as administered on 08/27/24, 08/30/24, 08/31/24, 09/01/24, 09/02/24 morning dose only, 09/15/24, 09/17/24, 09/18/24, 09/19/24, 09/20/24, 09/21/24, 09/22/24, 09/24/24, 09/25/24 evening dose only. Interview on 11/13/24 at 10:25 A.M. with Resident #11 confirmed she did not receive her Adderall for approximately two weeks a couple months ago. Interview on 11/13/24 at 1:45 P.M. with the Director of Nursing (DON) confirmed Resident #11's Adderall was not available to be administered on the following dates: 08/27/24 to 09/03/24, 09/07/24, 09/08/24, and 9/13/24 to 09/25/24. The DON confirmed staff signed off medication in the resident's MAR as administered on the following dates/times: 08/27/24, 08/30/24, 08/31/24, 09/01/24, 09/02/24 morning dose only, 09/15/24, 09/17/24, 09/18/24, 09/19/24, 09/20/24, 09/21/24, 09/22/24, 09/24/24, 09/25/24 evening dose only. Further interview with the DON confirmed staff should not document medications as administered unless they were actually administered. Review of the facility policy titled Administering Medications dated December 2012 revealed the individual administering medications will record admininstration in the medical record. 365186 Page 3 of 3