Health inspection·September 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, staff interview, and review of the facility policy, the facility failed to report an allegation of misappropriation of resident funds to the Ohio Department of Health (ODH.) This affected one (Resident #33) of three residents reviewed for misappropriation. The facility census was 47 residents. Findings include: Review of the medical record for Resident #33 revealed an admission date of 01/26/24 with diagnoses including chronic obstructive pulmonary disease (COPD), traumatic compartment syndrome of left lower extremity, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #33 dated 07/06/24 revealed the resident had intact cognition and required supervision with activities of daily living (ADLs.) Review of the progress note for Resident #33 dated 09/01/24 timed at 4:03 P.M. per Licensed Practical Nurse (LPN) #20 revealed Resident #33 reported he had two hundred dollars in his room, and someone had stolen it. LPN #20 documented Resident #33's allegation of misappropriation of money would be reported to administration. Review of the facility Self-Reported Incidents (SRIs) dated 08/31/24 to 09/19/24 revealed the facility did not complete an SRI regarding Resident #33's allegation of misappropriation of money. Interview on 09/19/24 at 10:10 A.M. with the Director of Nursing (DON) confirmed the facility should have completed an SRI regarding Resident #33's allegation of stolen money made to staff on 09/01/24. The DON confirmed the Assistant Director of Nursing (ADON) was not available for interview. Interview on 09/19/24 at 10:58 A.M. with the Administrator confirmed the staff reported Resident #33 had made an allegation of missing money, but the facility did not report the allegation to ODH via an SRI. Interview on 09/19/24 at 11:12 A.M. with LPN #20 confirmed a staff member reported that Resident #33 alleged on 08/31/24 or 09/01/24 that someone had stolen two hundred dollars from him. LPN #20 further confirmed she reported the allegation to the Administrator and the ADON on 08/31/24 or 09/01/24. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 revealed residents had the right to be free from misappropriation of Page 1 of 4 365529 365529 09/19/2024 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0609 Level of Harm - Minimal harm or potential for actual harm resident property. Staff should investigate and report allegations of misappropriation within timeframes required by federal regulations. This deficiency represents noncompliance investigated under Complaint Number OH00157751. Residents Affected - Few 365529 Page 2 of 4 365529 09/19/2024 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, interview, review of manufacturer's guidelines, and review of the facility policy, the facility failed to ensure medication error rates below five percent (%). This affected three (Residents #21, #26, and #27) of three reviewed for medication administration. The medication error rate was 11.1 % based on 36 medication opportunities and four observed errors. The facility census was 47 residents. Residents Affected - Few Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 12/20/22 diagnoses including bipolar disorder, congestive heart failure (CHF), and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 07/09/24 revealed the resident had moderate cognitive impairment and required setup with activities of daily living (ADLs.) Review of the physician's orders for Resident #21 revealed an order dated 08/09/24 for Lantus insulin inject 10 units subcutaneously two times a day for diabetes management and an order dated 09/06/24 for loratadine 10 milligrams (mg) one tablet by mouth one time a day for allergies. Observation on 09/18/24 at 8:57 A.M. revealed loratadine was not available for administration. Observation on 09/18/24 at 8:59 A.M. revealed LPN #20 did not prime the Lantus insulin pen with two units prior to administering 10 units of insulin to Resident #21. Interview on 09/18/24 at 9:01 A.M. with LPN #20 confirmed she did not administer loratadine to Resident #21 because it was unavailable. LPN #20 also verified she did not prime the insulin pen with two units of insulin prior to administration. Review of the manufacturer's instructions for Lantus insulin pens dated 06/12/24 revealed the insulin pen should be primed before each use. This should be done to remove any bubbles, to ensure that the pen is working properly, and that the device can administer the dose of insulin required. 2. Review of the medical record for Resident #26 revealed an admission date of 07/10/23 with diagnoses including type two diabetes mellitus, chronic kidney disease, depression, and anxiety disorder. Review of the MDS assessment for Resident #26 dated 07/16/24 revealed the resident had moderate cognitive impairment and required setup with ADLs. Review of the physician's orders for Resident #26 revealed an order dated 09/29/23 for amiodarone 200 mg give one tablet by mouth in the morning for antiarrhythmic. Observation on 09/18/24 at 8:41 A.M amiodarone was not available for administration. Interview on 09/18/24 at 8:43 A.M. with LPN #20 verified she did not administer amiodarone to Resident #26 to because it was unavailable. 3.Review of the medical record for Resident #27 revealed an admission date of 06/05/24 with diagnoses including emphysema, and generalized anxiety disorder. 365529 Page 3 of 4 365529 09/19/2024 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0759 Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment for Resident #27 dated 07/05/24 revealed the resident had intact cognition required setup and assistance with ADLs. Review of the physician's orders for Resident #27 revealed an order dated 06/05/24 for Claritin capsule 10 mg give one capsule by mouth one time a day for allergies. Residents Affected - Few Observation on 09/18/24 at 8:30 A.M. revealed Claritin was not available for administration. Interview on 09/18/24 at 8:33 A.M. with LPN #20 confirmed she did not administer Claritin 10 mg to Resident #27 because it was unavailable. Review of the facility policy titled Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner, and as prescribed. Medications were administered in accordance with prescriber orders, including any required time frame. This deficiency represents noncompliance investigated under Complaint Number OH00157751. 365529 Page 4 of 4