Health inspection·December 7, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Some Based on staff interview, record review, website review, and document review, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous Intravenous (IV) fluid medications to residents. This affected three (Residents #42, #43, and #46) of three reviewed for pharmacy services. The facility identified 36 (Residents #9, #10, #11, #15, #18, #20, #21, #23, #25, #26, #27, #28, #33, #34, #39, #41, #42, #43, #46, #48, #51, #52, #53, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71 ) who received IV fluids through the company. The facility census was 56. Findings include: 1. Record review of Resident #42 revealed an admission date of 06/13/22 with pertinent diagnoses of congestive heart failure, chronic pain syndrome, type one diabetes mellitus with diabetic neuropathy, xerosis cutis, chronic venous hypertension, localized edema, mild intellectual disabilities, anxiety disorder, cellulitis of left lower limb, cognitive communication deficit, morbid obesity, anemia, atherosclerotic heart disease of native coronary, cardiac arrhythmia, heart failure, hyperlipidemia, hypertension, presence of prosthetic heart valve, and peripheral venous insufficiency. Review of the 07/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Review of a physician order dated 03/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 milliliters (ml) 0.9% normal saline at 1000 ml per (/) hour (hr) additive formula: ascorbic acid 5 gram (gm) b complex - b5 250 milligrams (mg), b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. Review of a physician order dated 04/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 2. Record review of Resident #43 revealed an admission date of 11/21/22 with pertinent diagnoses of: parapelegia, radiculopathy cervical and thoracic region, muscle wasting and atrophy, colostomy status, morbid obesity, nutritional deficiency, xerosis cutis, neurogenic bladder, acute ischemic heart (continued on next page) 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 10 Event ID: 365336 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 365336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Locust Ridge Healthcare LLC 12745 Elm Corner Road Williamsburg, OH 45176 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)