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. (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 3 Event ID: 365453 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 365453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Oregon 3953 Navarre Ave Oregon, OH 43616 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)