Health inspection·March 22, 2024

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 Based on record review, observations staff and resident interviews and policy review the facility failed to ensure a residents dressing changes were completed per physician orders. This affected one (#20) out of three residents reviewed for skin breakdown. The facility census was 70. Residents Affected - Few Findings include: Record review of Resident #20 revealed an admission date of 12/20/23. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Further review of Resident #20's medical record revealed the resident had an order for the left 2nd toe to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wound care; an order for the right hip to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wounds; an order for the left foot to cleanse with saline, apply xeroform and foam dressing every day shift for wound care, an order for the left ischium to cleanse with saline, apply medihoney, calcium alginate, cover with foam every day shift for wound; and order for the right ishium to cleanse with saline, apply medihoney, calcium algnate, cover with foam every day shift. Review of Resident #20's treatment administration record (TAR) for March 2024 revealed the treatments for the right ischium, left ischium, left foot, right hip and left 2nd toe dressing were not done and not initialed off as being completed on 03/21/24. Observation and interview on 03/22/24 at 10:27 A.M. with Resident #20 revealed multiple dressings were dated 03/20/24. Resident #20 stated her dressing changes were to be changed daily. The observations revealed dressings on right ischium dated 03/20/24, left ischium dated 03/20/24, left foot dated 03/20/24, right hip dated 03/20/24, and left 2nd toe dated 03/20/24. Interview on 03/22/24 at 10:32 A.M. with the Assisted Director of Nursing (ADON) #9 confirmed dressings on Resident #20 were last changed on 03/20/24 and the treatment record did not reflect the dressing were changed on 03/21/24. Interview with ADON #9 also confirmed she would ensure the dressings Page 1 of 4 365202 365202 03/22/2024 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

F 0684 get changed at this time. Level of Harm - Minimal harm or potential for actual harm Interview on 03/22/24 at 1:35 P.M. with the Director of Nursing (DON) confirmed Resident #20 did not have her dressings to her L-2nd toe, R-hip, L-foot, L-ischium, and R-ishium changed on 03/21/24 and that the resident had asked the nurse to come back later due to having company and the nurse reported she forgot to go back and change the resident's dressings. Interview also confirmed the DON contacted the nurse responsible today, 03/22/24 and she was going to have the nurse initial a refusal for Resident #20 dressing changes on 03/21/24. When questioned why the nurse would initial that the resident refused when the DON confirmed the resident asked her to come back, and the nurse reported she forgot, the DON stated there isn't another choice to choose. DON advised there is an option for 5 Hold / See Nurses Notes. Residents Affected - Few Review of the Wound Care procedure, dated October 2010 revealed the staff are to verify there is a physician's order for this procedure. Document any problems or complaints, signature and title of the person recording the data. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 365202 Page 2 of 4 365202 03/22/2024 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

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 record review, review of a medication error report, staff interview and policy review, the facility failed to ensure medications were transcribed and administered per the physician's order. This affected one (#20) out of three residents reviewed for medication administration. The facility census was 70. Findings include: Record review of Resident #20 revealed an admission date of 12/20/23. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Review of Resident #20's medication administration record (MAR) revealed the resident has a current order for Tylenol Oral Tablet 325 milligrams (mg) (Acetaminophen) give two tablet by mouth three times a day for pain and had another entry for Tylenol Oral Tablet 325 mg (Acetaminophen) give three tablet by mouth three times a day for pain that was discontinued on 03/03/24. Review of the MAR revealed Resident #20 received one of the Tylenol Oral Tablet 325 mg (Acetaminophen) Give three tablet by mouth three times a day was discontinued. Resident #20 received duplicate doses of Tylenol Oral Tablet 325 MG (Acetaminophen) give three tablet by mouth three times a day from 02/26/24 through 03/03/24 morning dose. Review of the medication error report revealed on 02/26/24 Resident #20 an order was received for Tylenol and the order was written in as a duplicate order on the MAR. Interview on 03/22/24 at 11:39 A.M. with the Nurse Practitioner (NP) #12 confirmed Resident #20 recently received additional Tylenol due to a transcription error. NP #12 further stated the nursing staff entered a duplicate Tylenol order on Resident #20's MAR. Review of the Administering Medications policy, revised April 2019 revealed medications are administered in a safe and timely manner, as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00151876. 365202 Page 3 of 4 365202 03/22/2024 Carecore at Lima 599 South Shawnee Street Lima, OH 45804

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview and policy review, the facility failed to ensure residents received medication per the physician's orders resulting in three medication errors out of 25 opportunities or a 12 percent (%) medication error rate. This affected one (#32) out of two residents observed for medication administration. The facility census was 70. Residents Affected - Few Findings include: Record review of Resident #32 revealed an admission date of 02/29/24. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, coronary artery disease, major depressive disorder, personal history of transient ischemic attack (TIA), cerebral infarction, anxiety disorder, history of other venous thrombosis and embolism, history of traumatic brain injury, chronic pain syndrome, seizures, dementia and mood disturbance Observation on 03/22/24 at 8:54 A.M. of medication administration pass with Licensed Practical Nurse (LPN) #210 revealed Resident #32 was administered the following medications: Lacosamide 100 milligram (mg) one tablet (tab), Aripiprazole 2 mg one tab, Atorvastatin 40 mg one tab, Clonidine HcL 0.1 mg one tab, Eliquis 5 mg one tab, Hydrochlorothiazide 25 mg one tab, Levetiracetam 500 mg one tab, Famotidine 10 mg one tab, Metoprolol Succ 50 mg one tab, Potassium Chloride 10 milliequivalent (mEq) ER on e tab and Zoloft 100 mg give two tabs was not administered. Further review of Resident #32's physician orders revealed medication orders were Lacosamide 100 mg one tab every day, Aripiprazole 1 mg daily, Atorvastatin 40 mg one tab, Clonidine HcL 0.1 mg one tab, Eliquis 5 mg one tab, Hydrochlorothiazide 25 mg one tab, Levetiracetam 500 mg one tab, Famotidine 20 mg one tab, Metoprolol Succ 50 mg one tab, Potassium Chloride 10 mEq ER on e tab and Zoloft 100 mg give two tabs. Interview on 03/20/24 at 9:15 A.M. with LPN #210 confirmed she administered Resident #32 Aripiprazole 2 mg one tab instead of the ordered amount of Aripiprazole 1 mg. Interview with LPN #210 also confirmed she administered Famotidine 10 mg one tab instead of the ordered amount of Famotidine 20 mg one tab. Interview with LPN #210 also confirmed she did not administer Resident #32 Zoloft 100 mg two tabs and that it was not available in the cart to give, but she had initialed on the Medication Administration Record (MAR) that it was given. Review of the Administering Medications policy, revised April 2019 revealed medications are administered in a safe and timely manner, as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00151876. 365202 Page 4 of 4