Inspection·April 25, 2019

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and Medscape medication review, the facility failed to ensure a medication used to elevate blood pressure was necessary for a resident. This affected one resident (Resident #83) of six reviewed for unnecessary medications. The facility census was 86. Residents Affected - Few Findings include: Review of Resident #83's medical record revealed an admission date of 03/29/19 with diagnoses including acute respiratory failure and essential hypertension. Review of the minimum data set (MDS) dated [DATE] revealed resident required total assist for all activities of daily living, with one person assist. A brief interview mental status (BIMS) was unable to be completed. Review of the resident's plan of care dated 04/19/19 revealed interventions related to monitoring for side effects of anti-hypertensive and hypotensive medications. Review of Resident #83's physician's order dated 03/29/19 revealed an order for Midodrine five milligrams (mg.), give one tablet via gastric (G)-tube every six hours as needed for low blood pressure. The physician order did not identify any parameters for the administration of the medication. Review of Resident #83's medical record revealed no evidence of blood pressure documentation on 03/30/19, 03/31/19, 04/01/19, 04/02/19, 04/03/19, 04/08/19, 04/13/19, 04/14/19, 04/15/19, 04/16/19, 04/17/19, 04/18/19 and 04/23/19 to determine whether the medication, Midodrine was needed. Interview on 04/23/19 at 4:50 P.M. with Director of Nursing (DON) confirmed Midodrine was administered on 04/07/19 (blood pressure 80/50), 04/09/19 (blood pressure 83/51) and 04/11/19 (blood pressure 80/55) for low blood pressures. The DON confirmed the physician order for Midodrine was to be given for low blood pressure. The DON stated her expectation for residents receiving Midodrine was that blood pressures should be obtained on each shift. The DON confirmed Resident #83's blood pressure was not obtained on 03/30/19, 03/31/19, 04/01/19, 04/02/19, 04/03/19, 04/08/19, 04/13/19, 04/14/19, 04/15/19, 04/16/19, 04/17/19, 04/18/19 and 04/23/19 to determine whether the medication, Midodrine was needed for low blood pressure. Interview on 04/24/19 at 9:25 A.M. with Medical Doctor #200, the resident's physician, revealed his expectation was blood pressures should be obtained every shift or at minimum, daily when a resident is on Midodrine. Review of the pharmacy resource, Medscape, revealed a black box warning for Midodrine. Midodrine may cause elevation of supine blood pressure. Reserve use for patients whose lives are considerably impaired despite standard clinical care for orthostatic hypotension. It is essential to monitor supine (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: 365515 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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)