Inspection·November 8, 2023

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 and resident and staff interview, the facility failed to administer medications to the residents as physician ordered. This affected two (Residents #34 and #61) of three residents reviewed for medication administration. The facility census was 60. Findings include: 1. Review of Resident #34's medical record revealed the resident was admitted to the facility on on 10/13/23. Diagnoses included urinary tract infection (UTI), type II diabetes mellitus, chronic heart failure, wound to left lower leg, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of the progress note dated 10/13/23 at 3:26 P.M. revealed Resident #34 was admitted to the facility. Review of the physician orders dated 10/13/23 revealed Resident #34 had physician orders to receive the following medications: cephalexin (antibiotic) 500 milligrams (mg) four times daily; carvedilol (to treat high blood pressure and heart failure) 25 mg twice daily; glipizide (anti-diabetic) 10 mg twice daily; Lyrica (anticonvulsant also used for diabetic peripheral neuropathy) 100 mg daily; Metformin (Insulin Response Enhancer) 500 mg twice daily; Omeprazole (Proton Pump Inhibitors) 40 mg daily; and Spironolactone (treat high blood pressure) 25 mg daily. Review of the medication administration record (MAR) revealed Resident #34 was not administered the following medications as physician ordered: cephalexin 500 mg on 10/13/23 (one missed dose) and on 10/14/23 (four doses); Coreg 25 mg the evening of 10/13/23 and 10/14/23, and the morning of 10/14/23; glipizide 10 mg the evening of 10/13/23 and the morning of 10/14/23; Lyrica 100 mg on 10/14/23, 10/15/23, 10/16/23, 10/17/23, and 10/18/23; Metformin 500 mg on 10/13/23; Omeprazole 40 mg on 10/14/23; and Spironolactone 25 mg on 10/14/23. The reason marked for each missed dose was drug/item unavailable. Lyrica's reason was marked awaiting pharmacy. Review of the Omnicell (automated medication dispensing unit) inventory log revealed cephalexin, carvedilol, glipizide, metformin, Omeprazole, and spironolactone were available to obtain from the automated medication dispensing unit within the facility. Interview on 11/08/23 at 9:32 A.M. with Resident #34 revealed some of her medications were not administered for several days when she was admitted to the facility. Resident #34 was told they needed orders for the medications. (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 4 Event ID: 365481 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 365481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Newark North Inc. 151 Price Road Newark, OH 43055 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)