Health inspection·January 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to ensure medications were administered as physician ordered. This affected two (#40 and #102) out of three residents reviewed for medication administration. The facility census was 89. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 04/12/18 with diagnoses of hypertensive heart disease without heart failure, paraplegia, and type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 was independent with bed mobility, required set-up assistance with eating, oral hygiene, and personal hygiene. Resident #40 required supervision with bathing, dressing, transfers, and wheelchair mobility, and required substantial assistance with toileting hygiene. Review of Resident #40's physician orders revealed an order dated 02/23/24 for Pregabalin Capsule 300 MG, give 300 milligrams (mg) by mouth two times a day for neuropathic pain. Review of Resident #40's progress notes revealed a progress note dated 12/25/24 at 8:50 A.M. documented Pregabalin capsule 300 mg by mouth two times a day for neuropathic pain, medication not available, resident and physician notified. A progress note dated 12/25/24 at 10:53 P.M. documented Pregabalin Capsule 300 mg by mouth two times a day for neuropathic pain, medication not available. A progress note dated 12/26/24 at 10:38 A.M. documented Pregabalin Capsule 300 mg by mouth two times a day for neuropathic pain, medication unavailable. A progress note dated 12/27/24 at 1:20 A.M. documented Pregabalin Capsule 300 mg by mouth two times a day for neuropathic pain, medication not available, pharmacy contacted. Review of Resident #40's medication administration record (MAR) for 12/2024 revealed on 12/25/24 the 7:00 A.M. dose and 7:00 PM. dose were not administered and on 12/26/24 the 7:00 A.M. dose and 7:00 PM. dose were not administered. 2. Review of the medical record for Resident #102 revealed an admission date of 01/03/25 and a discharge date of 01/17/25 with diagnoses of esophagitis, unspecified with bleeding, type 2 diabetes mellitus with diabetic chronic kidney disease and hypertensive chronic kidney disease. Review of the physician orders for Resident #102 revealed an order dated 01/06/25 for Pregabalin Page 1 of 3 365374 365374 01/23/2025 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

F 0755 Oral Capsule 200 mg give one capsule by mouth three times a day for nerve pain. Level of Harm - Minimal harm or potential for actual harm Review of the MAR for Resident #102 for 01/2025 revealed Pregabalin Oral Capsule 200 mg (Pregabalin)-give one capsule by mouth three times a day for nerve pain was not administered on 01/03/25 at 2:00 P.M. and 8:00 P.M.; on 01/04/25 at 8:30 A.M.; on 01/09/25 at 1:00 P.M.; on 01/10/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M.; on 01/11/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M.; on 01/12/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M.; and on 01/13/25 at 6:00 A.M. and 1:00 P.M. Residents Affected - Few Review of the progress notes for Resident #102 revealed a note date 01/09/25 at 1:48 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, pharmacy aware to send, physician aware. A progress note dated 01/10/25 at 5:52 A.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, waiting on pharmacy, physician aware. A progress note dated 01/10/25 at 4:54 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, on order. A progress note dated 01/10/25 at 11:11 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, waiting for pharmacy, physician aware. A progress noted 01/11/25 at 5:56 A.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, medication not available. A progress noted dated 01/11/25 at 12:10 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, medication not available. A progress noted dated 01/11/25 at 9:18 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, not in stock. A progress noted dated 01/12/25 at 5:52 A.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, not in stock, pending pharmacy delivery. A progress note dated 01/12/25 at 4:12 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, pending clarification. A progress noted dated 01/12/25 at 9:47 P.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, waiting for pharmacy delivery. A progress note dated 01/13/25 at 5:51 A.M. revealed Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain, pending pharmacy delivery. And a progress note dated 01/13/25 at 1:07 P.M. revealed Pregabalin Oral Capsule 200 mg give one capsule by mouth three times a day for nerve pain, pharmacy aware to send. Interview on 01/22/25 at 10:49 A.M. with Licensed Practical Nurse (LPN) #208 confirmed when she arrived to work on 12/25/24 and Resident #40 did not have any Pregabalin 300 mg available to administer and there was none available in the emergency box. Interview with LPN #208 also confirmed Resident #40 did not receive Pregabalin 300 mg tabs on 12/25/24 at 7:00 A.M. and 7:00 P.M. and did not receive his Pregabalin 300 mg on 12/26/24 at 7:00 A.M. and 7:00 P.M. Interview with LPN #208 confirmed the pharmacy was called and the physician was notified that Resident #40 needed a refill of Pregabalin 300 mg due to none being available. Interview with LPN #208 confirmed the refill of Pregabalin 300 mg was delivered on 12/27/24. Interview on 01/23/25 at 9:12 A.M. with Pharmacist #213 confirmed the pharmacy received a new prescription for Resident #40 for Pregabalin Capsule 300 mg, give 300 mg by mouth two times a day for neuropathic pain on 12/26/25, and it was sent to the facility on [DATE]. The interview with Pharmacist #213 also confirmed that Resident #102 was admitted on [DATE] with a five-day prescription for Pregabalin Oral Capsule 200 mg (Pregabalin), give one capsule by mouth three times a day for nerve pain which was delivered on 01/04/25. Interview with Pharmacist #213 also confirmed the pharmacy received a new prescription for Pregabalin Oral Capsule 200 mg, give one capsule by mouth three times a day for nerve pain on 01/13/25, and it was dispensed on 01/13/25. Interview with Pharmacist #213 confirmed the pharmacy did not received a prescription for a refill prior to 01/13/25 from the physician. 365374 Page 2 of 3 365374 01/23/2025 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Pharmacist #213 also confirmed the facility and the physician had been notified of the need for a new prescription on 01/06/25. Interview on 01/23/25 at 2:56 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) Regional Clinical Support #12 confirmed Resident #40's order for Pregabalin 300 mg on the MAR documented on 12/25/24 7:00 A.M. dose and 7:00 PM. the doses were not administered and on 12/26/24 7:00 A.M. and 7:00 PM. doses were not administered. Interview also confirmed the Pregabalin 300 mg tabs was filled on 12/26/24 and was delivered on 12/27/24. Interview also confirmed Resident #102 did not received Pregabalin Oral Capsule 200 mg (Pregabalin), give one capsule by mouth three times a day for nerve pain was not administered on 01/03/25 at 2:00 P.M. and 8:00 P.M., on 01/04/25 at 8:30 A.M., on 01/09/25 at 1:00 P.M., on 01/10/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M., on 01/11/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M., on 01/12/25 at 6:00 A.M., 1:00 P.M., and 7:00 P.M., and on 01/13/25 at 6:00 A.M. and 1:00 P.M. due to awaiting a new prescription from the physician. Review of the Administering Medication policy, dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. Review of the Medication and Treatment Orders policy, dated July 2016 revealed drugs and biological's that are required to be refilled must be reordered from the issuing pharmacy prior to the last dosage being administered to ensure that refills are readily available. This deficiency represents non-compliance investigated under Master Complaint Number OH00161492 and Complaint Number OH00161377. 365374 Page 3 of 3