Health inspection·December 29, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on review of time sheets, staff interviews and policy review, the facility failed to ensure staff completed medication counts at shift change and failed to ensure narcotic lock box keys were securely locked when not in possession of the designated nurse. This had the potential to affect 17 (#29, #23, #25, #24, #39, #28, #27, #41, #31, #42, #37, #32, #40, #30, #45, #35, and #34) residents who had narcotics stored on the medication cart and 32 (#29, #3, #20, #46, #23, #37, #36, #32, #22, #33, #13, #1, #38, #47, #8, #21, #44, #5, #16, #25, #24, #39, #15, #28, #10, #43, #27, #26, #12, #19, #4, and #17) residents who were ambulatory or could self-propel with mobility assistive devices and that could access the medication cart. The census was 45. Findings include: 1. Review of time sheets dated 12/12/23 revealed Licensed Practical Nurse (LPN) #127 clocked in at 7:15 A.M. and clocked out at 11:15 P.M. LPN #123 clocked in at 12:00 A.M. and clocked out at 6:30 A.M. Interview on 12/29/23 at 10:05 A.M. LPN #127 stated she worked overtime on 12/12/23 because there had been some confusion with the schedule. LPN #127 stated she had to leave to pick up her kids. LPN #127 stated there was a second nurse in the facility. LPN #127 had passed the evening medications and the other nurse would not complete the medication cart count and would not take possession of the medication cart keys. LPN #127 stated she counted the medications and recorded it with her cell phone. LPN #127 then secured the keys and texted the oncoming nurse the location. LPN #127 stated the keys were secured where no one would find them. LPN #127 was only out of the facility for 15 minutes. LPN #127 had returned to the facility after she picked up her kids, the oncoming nurse was in the facility, had located the keys and completed the medication cart count with no discrepancy. Interview on 12/29/23 at 10:37 A.M. the Administrator stated she was aware of the schedule confusion and to her understanding, LPN #127 had agreed to stay until LPN #123 arrived. The three of them had been in contact with each other. The Administrator was not sure why LPN #127 did not stay that last 15 minutes. The Administrator stated there was a 15 minute gap between the nurses leaving and arriving in the facility. At 12:04 P.M. the Administrator reported the keys were placed in the bottom right hand drawer, behind and under everything, in a binder at the nurses station. There was no lock on the drawer. The Administrator verified the keys should have been in a locked location. The Administrator verified the nurses had not completed the medication count together. There had been no medication errors and no count discrepancies. The facility confirmed there were 17 (#29, #23, #25, #24, #39, #28, #27, #41, #31, #42, #37, #32, #40, #30, #45, #35, and #34) residents who had narcotics stored on the medication cart and 32 (#29, #3, #20, #46, #23, #37, #36, #32, #22, #33, #13, #1, #38, #47, Page 1 of 2 365218 365218 12/29/2023 Blue Ash Care Center 4900 Cooper Road Cincinnati, OH 45242

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #8, #21, #44, #5, #16, #25, #24, #39, #15, #28, #10, #43, #27, #26, #12, #19, #4, and #17) residents who were ambulatory or could self-propel with mobility assistive devices and that could access the medication cart. Review of facility policy titled Medication Storage in the Facility, dated 07/01/23, revealed only licensed nursing and pharmacy personnel have access to controlled substances. Scheduled II-V medications and other medication subject to abuse of diversion are stored in a permanently affixed, double-locked compartment separate from all medication or per state regulation. Alternatively, in a unit dose system, medications may be kept with other medications in the cart if the supply of medications is minimal and a shortage is readily detectable. The access system to controlled medications is not the same as the system giving access to other medications (the key that opens the is different for the key that opens the medication cart). If a key system is used, the keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing or designee. Review of facility policy titled Medication Storage in the Facility, dated 07/01/23, revealed at each shift change, or when keys are transferred, a physical inventory or all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. This deficiency represents non-compliance investigated under Complaint Number OH00148827. 365218 Page 2 of 2