Health inspection·June 24, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed medical record review, the facility failed to ensure blood draw orders were obtained for Resident #110 who was receiving Vancomycin (strong antibiotic) intravenously per standards of care. This affected one (Resident #110) of three residents reviewed for intravenous medication administration. The facility census was 97. Residents Affected - Few Findings include: Review of the closed medical record for Resident #110 revealed an admission date of 03/20/25, discharged to hospital on [DATE], returned to facility on 05/07/25 and discharged home on [DATE]. Diagnoses included acute osteomyelitis of right ankle and foot, peripheral vascular disease, diabetes mellitus type two, abscess tendon sheath of right ankle and foot. Upon return from hospital stay resident was diagnosed with metabolic encephalopathy and altered mental status. Review of the physician orders upon admission revealed Resident #110 was ordered Vancomycin hydrochloride intravenous solution 1250 milligrams/250 milliliters, use 250 milliliters (ml) once daily for osteomyelitis. The start date was 03/21/25 and was discontinued on 4/11/25. There were no orders for Vancomycin peak and or trough levels. Review of the nursing progress notes for Resident #110 revealed no documentation related to Vancomycin trough levels being completed. Review of the admissions Minimum Data Set (MDS) dated [DATE] revealed Resident #110 was cognitively intact with no behaviors. Resident #110 required maximum assistance from staff to complete activities of daily living. Resident #110 received intravenous medications, antibiotics, insulin and antiplatelet medications. Review of the 48 hour baseline plan of care and comprehensive plan of care revealed Resident #110 received intravenous antibiotics related to osteomyelitis of right foot and ankle. However, no laboratory interventions related to Vancomycin. Interview on 06/23/25 at 11:46 A.M. with Licensed Practical Nurse (LPN) #170 revealed Vancomycin antibiotic intravenous should have labs drawn often for peak and trough. The results would be called to the physician and pharmacy, as pharmacy helped with dosing. LPN #170 stated Resident #110 did not have any peak or trough levels drawn for three weeks in March 2025. Interview on 06/24/25 at 12:44 P.M. with Physician Assistant (PA) #410, who had provided care for Resident #110, revealed the expectation for residents admitted on the medication Vancomycin would be Page 1 of 2 365250 365250 06/24/2025 Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to have trough levels drawn regularly or as ordered by physician. The PA stated he expected the nursing staff to notify the physician if no lab orders upon admission or with any start of intravenous Vancomycin. PA #410 stated he was not aware Resident #110 had went three weeks without labs. PA #410 stated Resident #110 hospitalization did not have anything to do with not having lab values for Vancomycin. Interview on 06/24/25 at 12:51 P.M. with Consult Pharmacist #411 revealed residents receiving Vancomycin intravenously should have peak and trough levels regularly based on physician orders. Pharmacist #411 stated he reviewed Resident #110 medication the day after he was admitted and there were not any labs to review at that time. Pharmacist #411 stated there were orders from the hospital that stated to draw a trough every Monday and he reviewed Resident #110 medications on Friday. Therefore, he did not make a recommendation for labs to be drawn. Pharmacist #411 stated the level of the trough varied per the diagnosis. Interview on 06/24/25 at 2:12 P.M. with the Director of Nursing (DON) confirmed Resident #110 did not have Vancomycin trough levels drawn for three weeks prior to rehospitalization. Upon return from hospital, Resident #110 received weekly trough levels as ordered and as needed per the physician. The facility did not have a policy pertaining to lab draws and values for antibiotics. This deficiency represents non-compliance investigated under Complaint Number OH00166429. 365250 Page 2 of 2