Health inspection·October 27, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to store medications properly for Residents #5, #20, #22, and #55 in the medication cart on the South and Speret units. This affected four residents (#5, #20, #22, and #55) of 12 residents (#4, #5, #8, #20, #22, #23, #24, #26, #32, #55, #64, and #69) the South and Speret units who receive narcotic medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 03/16/20. Diagnoses included Alzheimer's disease, antisocial behavior, and major depressive disorder. Review of care plan for Resident #5 dated 06/14/22 revealed he had aggressive behaviors. Interventions included administering medications as ordered and redirecting Resident #5 from unsafe situations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment with a memory problem. Resident #5 required extensive one-person assistance for bed mobility, dressing, transfers, toilet use, and personal hygiene; and supervision with set-up help only for eating. Review of a physician's order dated 10/26/23 revealed an order for Ativan (controlled antianxiety medication) 0.5 milligram (mg) every two hours as needed for behaviors. 2. Review of the medical record for Resident #20 revealed an admission date of 03/14/23. Diagnoses included dementia, hypothyroidism, and hypertension. Review of physician's order dated 03/29/23 revealed an order for Resident #20 for Ativan 0.5 mg three times daily. Review of the care plan dated 03/30/23 for Resident #20 revealed she had anxiety. Interventions included administering medications as ordered and encouraging her to participate in activities. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required cueing assistance for activities of daily living. Page 1 of 2 365402 365402 10/27/2023 Altercare of Alliance Ctr for Rehab & NC Inc 11750 Klinger Avenue NE Alliance, OH 44601

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of the medical record for Resident #22 revealed an admission date of 10/22/10. Diagnoses included Alzheimer's disease, anxiety disorder, and osteoarthritis. Review of the care plan dated 08/09/19 revealed Resident #22 had a potential for an alteration in comfort. Interventions included administering medications as ordered and offering nonpharmacological interventions as needed. Review of the physician's order dated 09/01/22 for Resident #22 revealed an order for tramadol (controlled pain medication) 25 mg twice daily. Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had moderate cognitive impairment. Resident #22 required supervision with set up help only for bed mobility and eating; supervision with one-person assistance for transfers; and extensive one-person assistance for dressing, toileting, and personal hygiene. 4. Review of the medical record for Resident #55 revealed an admission date of 10/02/23. Diagnoses included hypertension, anxiety disorder, and anemia. Review of physician's order dated 10/02/23 revealed an order for Exelon (memory medication) 3 mg twice daily. Review of the care plan dated 10/02/23 revealed Resident #55 had impaired cognition. Interventions included administering mediations as ordered and reporting any changes in his status to the physician. Review of admission MDS assessment dated [DATE] revealed Resident #55 had severe cognitive impairment. Functional abilities were not documented at the time of the assessment. Observation on 10/27/23 at 8:15 A.M. during medication pass of the narcotic drug book on the medication cart for the South and Speret units revealed Resident #22 was to have 26 tablets in her blister pack of tramadol medication. When Licensed Practical Nurse (LPN) #502 removed the pack from the narcotic drawer there were only 25 tablets in it. LPN #502 confirmed the discrepancy and popped a pill out leaving 24 tablets in the pack and administered the medication to Resident #22. When LPN #502 returned to the cart she reported she had prefilled the medication at the beginning of her shift. LPN #502 then reached into her narcotic drawer and removed four medication cups with pills in them for four different residents. LPN #502 confirmed the pills were the tramadol for Resident #22, Exelon for Resident #55, Ativan for Resident #20, and Ativan for Resident #5. Comparisons with the pills in the cups matched the medications inside with packs for each resident. LPN #502 confirmed the medication cups were not listed with pill identification or the resident names listed on them, and she had prefilled them at the beginning of her shift. Review of the facility-controlled medication storage, dated May 2020, revealed controlled medication accountability sheets are maintained in the designated book. All medications received must state the name of the resident, prescription number, drug name, strength and dosage form of medication, and quantity received. Review of the undated facility policy guidelines for medication administration undated revealed medications are administered at the time they are prepared. Medications are not pre-poured. 365402 Page 2 of 2