Health inspection·June 12, 2024

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minute. Resident #11 was placed on a non-breather oxygen mask and 10 Liters Per Minute (LPM) of oxygen was administered. The pulse oxygen saturation increased to 85 percent (%) (normal 95-100 %). Nine-one-one (911) was called to transfer the resident to the hospital. The Medical Director (MD) and Power-of-Attorney (POA) were notified. Review of a Nursing Policy/Procedure Manual Medication Incident Report, dated 06/02/24, revealed Resident #11 had medications that were not implemented from a hospital discharge on [DATE]. Review of Employee Progressive Disciplinary Report, dated 06/03/24 ,revealed LPN #24 was terminated for substandard work including failing to audit hospital paperwork that resulted in a medication error. Interview on 06/11/24 at 10:57 A.M. with the Director of Nursing (DON) verified former LPN #42 did not check the physician orders for Resident #11 when he returned from the hospital on [DATE] and the resident's ferrous sulfate 325 mg, metoprolol ER 25 mg, and Ticagrelor 90mg was never started. The DON stated the LPN #42 was disciplined and ultimately terminated due to failure to do a proper readmission for Resident #11 that resulted in the significant medication error. Interview on 06/12/24 at 10:15 A.M. Medical Director (MD) #35 reported he was never informed of the medication error involving Resident #11 because he was on vacation when it happened. MD #35 stated Resident #11 was declining in health due to strokes, non-compliance with care and had suffered cognitive decline causing him to be on the memory care locked unit. MD #35 indicated that he was not aware that Resident #11 had been re-admitted to the hospital on [DATE] because he was still on vacation. An additional interview on 06/12/24 at 10:30 A.M. with the DON, reveled the Assisted Director of Nursing (ADON) #34 called her on 06/02/24 to inform her that Registered Nurse (RN) #31 and LPN #32 received a call from the hospital to reconcile the resident's current medications and to question why ferrous sulfate 325 mg, metoprolol ER 25 mg, and Ticagrelor were not listed on the transfer list of medications. The DON stated that is when the facility discovered the medication error had occurred. Interview on 06/12/24 at 10:38 A.M. with ADON #34, revealed she received a phone call on 06/02/24 from RN #31 stating the hospital called her to reconcile the resident's medications when she discovered orders for Resident #11 were never transcribed upon being re-admitted on [DATE]. ADON #34 stated she informed the DON, and an investigation was initiated. Interview on 06/12/24 at 10:45 A.M. with LPN #32, revealed after Resident #11 was admitted to the hospital, an unknown staff member called the facility to find out if Resident #11 was taking the Ticagrelor, metoprolol and ferrous sulfate which was ordered when he was discharged on 05/21/24 since it was not listed on his current medication list sent with the resident to the hospital. LPN #32 stated she pulled Resident #11's chart and there were no hospital discharge orders or physician orders for the Ticagrelor, metoprolol 25 mg, and iron and no pharmacy records which showed the medications had been ordered. LPN #32 stated she and RN #31 looked around the nurse's station for the 05/21/24 discharge orders and they were found between a bunch of folders and paperwork on the nurse's desk. Interview on 06/12/24 at 11:20 A.M. with RN #31, revealed the hospital called when Resident #11 was admitted reconciling the resident's medications. RN #31 stated the Ticagrelor, metoprolol and ferrous sulfate were not on the physician order sheet. RN #31 stated the nurse never transcribed the new orders from the hospital discharge when Resident #11 was readmitted to the facility on [DATE]. RN #31 stated after learning of the medications not being started, she started searching the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365293 If continuation sheet Page 2 of 3 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 365293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Airy Gardens Rehabilitation and Nursing Center 2250 Banning Road Cincinnati, OH 45239 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm station and found the envelope with the orders between folders and other paperwork where no one would have thought to look. Review of the undated facility policy titled Administering Medications, revealed medications must be administered in accordance with the physician orders, including any required time frames. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00154602. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365293 If continuation sheet Page 3 of 3