Health inspection·May 29, 2024

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 medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were available to administer as ordered. This affected one (Resident #80) of five patients reviewed for medication administration. The facility census was 65. Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #80 had diagnoses including unspecified neoplasm of digestive organ, essential hypertension, gastroesophageal reflux disease, absence epileptic syndrome, oropharyngeal phase dysphagia, chronic ulcerative pancreatitis, unspecified lymphedema, sciatica, and unspecified anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated [DATE] revealed Resident #80 received Hospice services related to a diagnosis of protein calorie malnutrition. Interventions included to collaborate with Hospice to provide care services, to observe for non-verbal symptoms of pain (facial grimacing, crying, increased respirations), to observe for shortness of breath/secretions, to obtain orders as needed as symptoms occurred, to administer comfort medications as ordered, to monitor for effectiveness of medications, to notify Hospice of any change in condition, and to report any changes to Hospice and physician. Review of the medical record revealed Resident #80 had physician orders dated [DATE] for Morphine Sulfate 100 milligrams (mg) per 20 milliliters (ml) solution, 0.25 ml (5 mg) by mouth every four hours as needed for moderate pain or shortness of breath. This order was discontinued on [DATE] and a new order was placed for morphine sulfate 20 mg per 5 ml solution, give 0.5 ml (2 mg) by mouth every two hours for shortness of breath and pain for 14 days. This order was changed on [DATE] from as needed to be administered routinely every hour. Review of the Medication Reconciliation Sheet revealed on [DATE], the facility received a 30 ml bottle of Morphine Sulfate solution 100 mg/5 ml for Resident #80. The last dose from this bottle was administered on [DATE] at 9:00 A.M. Review of the Medication Reconciliation Sheet revealed on [DATE], the facility received a 15 ml bottle of Morphine Sulfate Concentrate, no strength, dosage, or frequency indicated. The first dose was administered on [DATE] at 9:42 A.M. Page 1 of 3 365603 365603 05/29/2024 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) dated [DATE] revealed Resident #80 received hourly administrations from [DATE] at 10:00 A.M. until 5:00 P.M., even though the morphine supply had run out. Hourly administrations were held from [DATE] at 6:00 P.M. to [DATE] at 8:00 A.M. Review of the progress notes revealed an unidentified agency nurse documented on [DATE] at 10:30 A.M. Resident #80's Morphine Sulfate 20 mg per 5 ml solution was unavailable due to awaiting med from pharmacy. LPN #33 documented on [DATE] at 5:35 P.M. and 11:32 P.M. that Resident #80's morphine sulfate was held due to the medication was on order. LPN #33 documented on [DATE] at 1:38 A.M., 3:16 A.M., and 6:43 A.M., the medication was held due to needing a prescription. On [DATE] at 9:12 A.M., LPN #44 documented Resident #80's routine morphine sulfate was held due to still waiting for the pharmacy to deliver. There was no additional documentation provided regarding the resident's condition between [DATE] at 9:00 A.M. to [DATE] at 9:42 A.M. while the morphine sulfate medication was held. During an interview on [DATE] at 11:00 A.M., the Director of Nursing (DON) verified the Medication Reconciliation Sheets showed Resident #80 did not receive Morphine Sulfate hourly as ordered from [DATE] at 9:00 A.M. until [DATE] at 9:42 A.M. The DON verified Resident #80's Morphine Sulfate was documented on the MAR as given at times when the reconciliation sheets showed there was no morphine sulfate available to administer. Review of policy titled Administering Medications dated 08/2022 revealed medications were administered as prescribed in a safe and timely manner. This deficiency represents noncompliance investigated under Complaint Number OH00154174. 365603 Page 2 of 3 365603 05/29/2024 Aventura at West Park 2950 West Park Drive Cincinnati, OH 45238

F 0760 Ensure that residents are free from significant medication errors. 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 review of facility policy, the facility failed to ensure residents were free from significant medication errors when they gave double the dose of Morphine to a resident. This affected one (Resident #80) of five residents sampled for medication administration. The facility census was 65. Residents Affected - Few Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #80 had diagnoses including unspecified neoplasm of digestive organ, essential hypertension, gastroesophageal reflux disease, absence epileptic syndrome, oropharyngeal phase dysphagia, chronic ulcerative pancreatitis, unspecified lymphedema, sciatica, and unspecified anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of care plan dated [DATE] revealed Resident #80 received Hospice services related to a diagnosis of protein calorie malnutrition. Interventions included to collaborate with Hospice to provide care services, to observe for non-verbal symptoms of pain (facial grimacing, crying, increased respirations), to observe for shortness of breath/secretions, to obtain orders as needed as symptoms occurred, to administer comfort medications as ordered, to monitor for effectiveness of medications, to notify Hospice of any change in condition, and to report any changes to Hospice and physician. Review of the medical record revealed Resident #80 had physician orders dated [DATE] for Morphine Sulfate 100 milligrams (mg) per 20 milliliters (ml) solution, 0.25 ml (5 mg) by mouth every four hours as needed for moderate pain or shortness of breath. This order was discontinued on [DATE] and a new order was placed for morphine sulfate 20 mg per 5 ml solution, give 0.5 ml (2 mg) by mouth every two hours for pain or shortness of breath for 14 days. This order was changed on [DATE] from as needed to be administered routinely every hour. Review of the Narcotic Reconciliation Sheet revealed the facility documented administered 75 doses of Morphine Sulfate 100 mg per 20 ml, 0.5 ml per dose, from [DATE] at 6:20 A.M. to [DATE] at 9:00 A.M. The facility gave double the dose that was ordered. During an interview on [DATE] at 12:26 P.M., Licensed Practical Nurse (LPN) #75 verified Resident #80 had a physician's order for Morphine Sulfate 20 mg per 5 ml solution give 0.5 ml (2 mg) every hour for pain and was administered multiple 0.5 ml (10 mg) doses of Morphine Sulfate 100 mg/5 ml from [DATE] to [DATE]. Review of the facility policy titled Administering Medications dated 08/2022 revealed the person administering medications checked three times prior to administering to ensure the nurse was giving the right medication in the right dose. This deficiency represents noncompliance investigated under Complaint Number OH00154174. 365603 Page 3 of 3