Health inspection·July 11, 2024

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 medical record review, review of controlled substance records, review of pharmacy receipts, resident and staff interview, and policy review, the facility failed to timely obtain pharmacy services when resident medication was needed for administration. This affected one (#73) of three residents review for medications. The facility census was 70. Findings include: Review of the medical record for Resident #73 revealed an admission date of 06/13/24 and a discharge date of 07/08/24. Diagnoses included type two diabetes mellitus, osteoarthritis of the knee, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition. Review of the hospital discharge medication orders revealed Resident #73 was ordered the narcotic pain medication oxycodone-acetaminophen 5-325 milligrams (mg) per tablet with instructions to take one tablet by mouth every eight hours as needed for pain for two days. Review of a pharmacy receipt dated 06/14/24 revealed the facility received five oxycodone-acetaminophen 5-325 mg. On 06/19/24, the facility received one card of 56 tablets of oxycodone-acetaminophen 5-325 mg and one card of 29 tablets of oxycodone-acetaminophen. Review of a control drug record revealed on 06/14/24 Resident #73 had 20 oxycodone-acetaminophen tablets brought in from home. Further review of the control drug record revealed the resident was given ten doses of the medication from 06/14/24 through 06/19/24 before the medication was sent home with the resident's family member. Review of a physician order dated 06/14/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every eight hours as needed for pain for two days. Review of a physician order dated 06/15/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every six hours as needed for pain for two days. Review of a physician order dated 06/18/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every eight hours as needed for pain. Page 1 of 3 365453 365453 07/11/2024 Ayden Healthcare of Oregon 3953 Navarre Ave Oregon, OH 43616

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated 06/19/24 revealed an order for oxycodone-acetaminophen oral tablet 5-325 mg one tablet by mouth every six hours as needed for pain. Review of the active inventory of medications on hand at the facility revealed oxycodone-acetaminophen 5-235 mg was available for administration. Residents Affected - Few Interview on 07/10/24 at 1:26 P.M., the Director of Nursing (DON) stated nursing staff pulled Resident #73's oxycodone-acetaminophen 5-325 mg from her own stock of medications brought from home, and stated the nursing staff should have pulled the oxycodone-acetaminophen from the facility's contingent stock. Interview on 07/10/24 at 2:09 P.M., Resident #73 stated she had her home medications with her when she admitted to the facility. Resident #73 revealed the facility took her medications including her oxycodone-acetaminophen and used the medication without her permission. Resident #73 revealed the nurse told her the facility had no oxycodone-acetaminophen and had to use the medication the resident brought from home. Interview on 07/11/24 at 10:31 A.M., Unit Manager Registered Nurse (UMRN) #215 revealed Resident #73 brought medications from home and was educated she could not have the medications in her room. UMRN #215 revealed she never instructed the nursing staff to use the resident's home medications. Review of the policy titled, Emergency Medication Kit, dated 2022, revealed a specialized code could be obtained by the nurse from the pharmacist upon verification of receipt of a valid prescription before gaining access to controlled substances. This deficiency represents non-compliance investigated under Complaint Number OH00155011. 365453 Page 2 of 3 365453 07/11/2024 Ayden Healthcare of Oregon 3953 Navarre Ave Oregon, OH 43616

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and policy review, the facility failed to maintain the North and South shower rooms in a clean and sanitary manner. This had the potential to affect all residents except 24 (#3, #8, #9, #10, #15, #17, #18, #19, #20, #26, #27, #31, #33, #44, #47, #51, #52, #55, #56, #57, #58, #59, #62, and #70) residents identified as not using the shower rooms. The facility census was 70. Findings include: Observation on 07/10/24 beginning at 9:07 A.M., revealed there was a debris and a buildup of a dark colored substance around the perimeter of the shower floor tiles in both the North and South shower rooms. Interview on 07/10/24 at 9:11 A.M., with Housekeeping and Laundry Supervisor (HLS) #250 verified the dark colored substance on the floor tiles in both the North and South shower rooms. Review of the policy titled, Floors, last revised 2009, revealed floors would be maintained in a clean, safe, and sanitary manner. Review of the policy titled, Quality of Life-Homelike Environment, last revised 05/2017, revealed the facility would maintain a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00154998. 365453 Page 3 of 3