Health inspection·December 28, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, staff interview, and policy review, the facility failed to ensure medications were stored with accurate labeling for safe administration when staff prepped medications and took the medications out of their original packaging. This affected two (#57 and #59) out of four residents observed for medication administration. The facility census was 93. Findings included: 1. Review of the clinical record revealed Resident #59 readmitted to the facility on [DATE]. His diagnoses included but were not limited to paraplegia, urinary tract infection, overactive bladder, neuromuscular dysfunction of the bladder, constipation, anemia, bladder disorder, and chronic pain syndrome. Review of Resident #59's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Observation on 12/28/23 at 5:45 A.M. of Licensed Practical Nurse (LPN) #156 pulling medication for Resident #59 revealed the resident's medications were observed to be in a foam cup with no name or label. The medications stored in the cup included Baclofen 10 milligrams (mg), Baclofen 5 mg, and Gabapentin 300 mg. 2. Review of the clinical record revealed Resident #57 had an admission date of 02/13/12. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, age-related osteoporosis, major depressive disorder, heart failure, hypothyroidism, peripheral vascular disease, anxiety disorder, anemia, cognitive communication deficit, polyosteoarthritis, and chronic pain syndrome. Review of Resident #57's annual MDS assessment dated [DATE] revealed she had moderate cognitive impairment. Observation on 12/28/23 at 6:26 A.M. of LPN #56 pulling medication for Resident #57 revealed the resident's medications were observed to be in a foam cup with no name or label. The medication stored in the cup included Famotidine 20 mg, Amlodipine 5 mg, Levothyroxine 75 micrograms (mcg), Clopidogrel 75 mg, Benazepril 20 mg, and Venlafaxine Hydorchloride 25 mg. Interview on 12/28/23 at 5:45 A.M. with LPN #156 revealed she set up her medications for the 5:00 (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 2 Event ID: 365469 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 365469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Batavia Nursing Care Center 4000 Golden Age Drive Batavia, OH 45103 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)