Inspection·July 31, 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. Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were stored in a safe manner. This directly affected one (#137) of one random resident observed. The facility census was 138. Findings include: Observation on 07/30/24 at 11:05 A.M., revealed two medications in a small, plastic medication cup, sitting on the overbed table of Resident #137. Resident #137's roommate was observed in the room but was not independently mobile. No other residents were observed in the area. Interview at the time of the observation, with Licensed Practical Nurse (LPN) #241, verified the findings and identified the two pills as a Flomax 0.4 milligram (mg) capsule, and a gemfibrozil 600 mg tablet. LPN #137 removed the pills from the room and discarded them. Review of the medical record of Resident #137 revealed an admission date of 06/04/24. Diagnoses include hyperlipidemia and benign prostatic hyperplasia without lower urinary tract symptoms. Review of the physician orders dated 06/04/24 revealed Flomax 0.4 milligrams (mg) to be administered by mouth at bedtime. An order dated 06/18/24 for gemfibrozil 600 mg to be administered by mouth twice daily. Review of the medication administration record for Resident #137 revealed the medications were signed off as having been administered on 07/29/24 at 7:00 P.M. to 11:00 P.M., by LPN #210. Review of the undated policy titled Storage of Medications, revealed the facility shall store all drugs in a safe, secure, and orderly manner. This deficiency represents non-compliance investigated under Complaint Number OH00155990. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365278 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)