Health inspection·December 18, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. 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, observations, staff interview, and policy review, the facility failed to administer medications per physician orders resulting in four medication errors out of 41 opportunities or a 9.75 percent (%) medication error rate. This affected three (#4, #5, and #17) out of five residents observed for medication administration. The facility census was 46. Findings include: Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: left ventricular failure, muscle weakness, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require supervision or touching assistance for eating, oral hygiene, and toileting. Partial/moderate assistance for dressing and personal hygiene. Resident is always continent of bladder and occasionally incontinent of bowels. Record Review for Resident #4 revealed an order for Potassium 10 milliequivalents (meq) two capsules orally daily for hypokalemia and Buprenorphine eight milligrams (mg) one tablet sublingual for opioid dependence. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: localization-related (focal)(partial) symptomatic epilepsy and epileptic syndrome with complex partial seizures, intractable, without status epilepticus, chronic obstructive pulmonary disease, and anxiety disorder, and other manic episodes. Review of the MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a BIMS score of 13. This resident was assessed to require setup or cleanup assistance for eating, set up or clean up assistance for oral hygiene, setup or cleanup assistance for toileting, setup or cleanup assistance for shower/bathing, setup or cleanup assistance for dressing, and setup or cleanup assistance for personal hygiene. This resident is occasionally incontinent of urine and always continent of bowels. Record Review for Resident #5 revealed an order for Zoloft Oral Tablet 25 mg dated on 02/08/24 and to be given daily. Record review for Resident #17 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: atherosclerotic heart disease, diabetes mellitus type II, and convulsions. Review of the MDS assessment dated [DATE] revealed this resident had severe cognitive impairment evidenced by a BIMS score of five. This resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, dependent on staff for toileting, dependent for shower/bathing, dependent for dressing, and dependent for personal hygiene. Resident is always incontinent of bowel and bladder. Record for Resident #17 revealed an order for Levetiracetam oral tablet 1000 mg dated on 06/05/2024 to be given two times a day for seizures. Observation on 12/18/25 at 9:03 A.M. of medication pass with Licensed Practical Nurse (LPN) #104 revealed Resident #5's Zoloft was omitted from the morning medication administration due to not having the medication. Interview on 12/18/25 at 9:04 A.M with LPN #104 confirmed Resident #5's Zoloft was omitted from the morning medication administration due to not having the medication. Observation on 12/18/25 at 9:44 A.M. Residents Affected - Few Page 1 of 2 365529 365529 12/18/2025 Garden Park Health Care Center 3536 Washington Ave Cincinnati, OH 45229

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of medication pass with LPN #104 revealed Resident #17's levetiracetam was omitted from the morning medication administration due to not having the medication. Interview on 12/18/25 at 9:45 A.M with LPN #104 confirmed Resident #17's levetiracetam was omitted from the morning administration due to not having the medication. Observation on 12/18/25 at 10:16 A.M. of medication pass with LPN #104 revealed Resident #4's Potassium and Buprenorphine HCL was omitted from the morning administration due to not having the medication. Interview on 12/18/25 at 10:18 A.M with LPN #104 confirmed Resident #4's Potassium and Buprenorphine HCL was omitted from the morning administration due to not having the medication. Review of the facility policy titled, Medication and Treatment Orders revealed medications must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available. This deficiency represents non-compliance investigated under Complaint Number 2586417. 365529 Page 2 of 2