Health inspection·December 28, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interviews, photographic evidence and review of policy and procedures, the facility failed to ensure correct medications were provided upon discharge. This affected one (#272) of six residents(#273, #274, #275, #276 and #277) reviewed for discharge planning. Residents Affected - Few Findings include: Review of the closed medical record review for Resident #272 revealed an admission date of 11/17/23 and a discharge to home date of 12/02/23. Diagnoses included but were not limited to osteoarthritis, cognitive communication deficit, glaucoma, dysphagia, type II diabetes mellitus, hypertension, and depression. Review of the 11/24/23 admission Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview of Mental Status (BIMS) score of 12 which suggested Resident #272 had moderate cognitive impairment. Review of the physicians' orders dated 12/02/23 for Resident #272 revealed she was receiving the following medications upon discharge: Acetaminophen 325 milligram (mg) every six hours as needed give two tablets Amlodipine (used to treat high blood pressure and chest pain) 10 mg once a day Aspirin 81 mg once a day Bupropion HCl (antidepressant) 300 mg tablet once a day Cholecalciferol 25 (vitamin D3) microgram (mcg) twice daily Coenzyme Q10 (antioxidant) 200 mg once a day Cyanocobalamin (vitamin B12) 1000 mcg once a day Diclofenac sodium gel (nonsteroidal anti-inflammatory) one percent (%) 2 grams apply to lower back every six hours as needed. Docusate sodium (for constipation) 100 mg once a day Doxazosin (used to treat high blood pressure) 2 mg once a day Page 1 of 3 365287 365287 12/28/2023 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0624 Hydroxyzine HCl (used to treat anxiety) 25 mg every six hours as needed both eyes once a day. Level of Harm - Minimal harm or potential for actual harm Lantanoprost drops (used to treat glaucoma) 0.005%; apply one drop to both eyes once daily. Levothyroxine (thyroid medication) 137 mcg once a day Residents Affected - Few Loratadine (antihistamine) 10 mg once a day Lumigan drops (used to treat glaucoma) 0.01% administer one drop once a day. Maxzide tablet (diuretic) 75-50 mg administer half a tablet once a day. Metformin (anti-diabetic medication) 500 mg twice a day Metoprolol tartrate 50 mg tablet twice a day Nystatin powder (antifungal) 100,000 unit/gram three times a day as needed topically. Pantoprazole delayed release tablet (used to treat gastric reflux) 40 mg twice a day. PreserVision AREDS-2 capsule 250-90-40-1 mg one tablet once daily. Refresh Optive drops 0.5-0.9% administer one drop to both eyes every 12 hours as needed. Saline Nasal Mist aerosol spray 0.65% one spray every 12 hours as needed. Systane gel drops 0.4-0.3% administer one strip once a day. Valsartan (used to treat high blood pressure) 320 mg once a day Phone interview on 12/27/23 at 11:46 A.M. with Registered Nurse (RN) #508 revealed he had completed the discharge assessment and discharge instructions with Resident #272 and was unaware any wrong medications had been sent home with her. Phone interview on 12/27/23 at 11:54 A.M. with Resident #272's son revealed his mother had contacted him related to other residents' medications being sent home with her at discharge. Resident #272's son stated he had photographic evidence of medications belonging to other residents that were sent home with Resident #272. Observation of the four photographs (jpeg numbers: #163932, #163942, #163947 and #163926) revealed medication punch cards containing a 30-day supply of medications which belonged to Residents #275, #276 and #277 which were sent home with Resident #272. These medications included Gabapentin (anticonvulsant and nerve medication) 100 mg, Gabapentin 300 mg, Gabapentin 600 mg and Methocarbamol (muscle relaxant) 500 mg. Review of the October 2016 facility policy called Discharge Planning revealed the facility would determine the resident's preferred pharmacy. Nursing was to review the medication and treatment list with the physician prior to discharge. Nursing was to arrange for resident medication or prescription to be provided upon discharge. The policy stated to refer to Medication Provided to Discharge 365287 Page 2 of 3 365287 12/28/2023 Altercare of Cuyahoga Falls Ctr for Rehab & Nursin 2728 Bailey Rd Cuyahoga Falls, OH 44221

F 0624 Resident in the Nursing Policies. Level of Harm - Minimal harm or potential for actual harm Interview on 12/27/23 at 12:40 P.M. with the Director of Nursing (DON) and Regional Nurse Consultant #502 confirmed the facility policy titled Discharge Planning indicated to refer to Medication Provided to Discharge Resident in Nursing Policies; however, the facility did not have a specific policy for medications at discharge. When a skilled resident was sent home, they were sent with their medications and could be in the original bubble medication card packaging obtained from the facility pharmacy. Residents Affected - Few Phone interview on 12/27/23 at 1:15 P.M. with former Resident #272 revealed she was alert to person, place, time, and situation. Further interview revealed Resident #272 received medications for three facility residents in addition to her own medications. Resident #272 said she did not take the medications and alerted the home health nurse of her concern. Three attempts to contact the home health nurse were unsuccessful. Interview on 12/28/23 at 10:07 A.M. with the DON revealed she was unsure how the additional medications were sent home with Resident #272 at discharge. Observation of the medication cart, at the time of the interview, revealed all drugs were stored in locked compartments and were labeled in accordance with professional standards including the resident's name, medication name, dosage, and directions. This deficiency represents non-compliance investigated under Complaint Number OH00148961. 365287 Page 3 of 3