Health inspection·February 5, 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 record review and staff and Pharmacist interviews, the facility failed to administer medications as physician ordered. This affected two (#100 and #60) of three residents reviewed for medication administration. Facility census was 101. Findings include: 1. Review of medical record for Resident #100 revealed admission date of 01/17/24. Diagnoses include cellulitis of left toe, type two Diabetes Mellitus, acute osteomyelitis left ankle and foot, Methicillin Susceptible Staphylococcus Areus (MRSA). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident remains in the facility. He was independent for eating, toileting, supervision for bed mobility and transfers. Review of the physician orders revealed an order for 12 Grams (gm) Nafcillin (antibiotic) to be given intravenously (IV) every 24 hours with a start date of 01/18/24. Record review of 01/18/24 progress note revealed Nafcillin was not available and was pending pharmacy delivery. Record review of the 01/19/24 progress note revealed the Nafcillin had not been delivered by the pharmacy. The physician was contacted, and orders were received to send Resident #100 to the hospital to receive the needed medication. A joint interview on 02/05/24 at 3:31 P.M. with the Director of Nursing and the Assistant Director of Nursing (ADON) #102 revealed medications cannot be ordered from the pharmacy until after a resident arrives at the facility. The DON acknowledged Resident #100 was admitted to the facility on [DATE]. The DON stated the specific dose for the Nafcillin needed clarification by the pharmacy. The physician was contacted on 01/18/24, and the order was for the Nafcillin to be sent in a one Liter bag to be run continuously over 24 hours. ADON #102 revealed he called the pharmacy on 01/18/24 right before 9:00 P.M. and was told the Nafcillin was being mixed and would be sent on the 11:00 P.M. run and would be at the facility between 2:00 A.M. and 3:00 A.M. on 01/19/24. On the morning of 01/19/24, ADON #102 stated as soon as he got to the facility, he checked with staff to ensure the antibiotic was administered to Resident #100. Once learning it had not, he called he called to inform the physician. ADON #102 received an order to send Resident #100 to the hospital to receive the medication. Page 1 of 4 365616 365616 02/05/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/05/24 at 4:07 P.M. interview with Pharmacist #103 revealed the pharmacy received the order for 12 grams of Nafcillin at 1:13 P.M. on 01/18/23, and requested clarification of the order was received at 3:00 P.M. Pharmacist #103 stated the Nafcillin order was prepared and left the pharmacy on the 11:00 P.M. delivery run and was delivered to the facility at 2:00 A.M. on 01/19/24. 2. Review of medical record for Resident #60 revealed admission date of 05/19/22. Diagnoses include peripheral vascular disease, hypertension, and diabetes mellitus type two. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #60 required supervision for activities of daily living. Review of the physician orders for Resident #60 revealed an order for 400 mg Acyclovir (antiviral) three times daily for five days with a start date of 01/20/24 at 8:30 A.M. Record review of the January Medication Administration Record (MAR) revealed Acyclovir was documented to be administered for five days at 8:30 A.M., 12:30 P.M. and 4:30 P.M. starting on 01/20/24. There was no documentation on 01/20/24 for the 8:30 A.M., or 12:30 P.M. dose. The 4:30 P.M. dose was documented as not available. The medication was documented to have been administered as ordered on 01/21/24, 01/22/24, 01/23/24 and 01/24/24. Interview on 02/05/24 at 3:31 P.M. with the DON verified the Acyclovir ordered for Resident #60 was given for four days instead of the ordered five days. This deficiency represents non-compliance investigated under Complaint Numbers OH00150313 and OH00149954. 365616 Page 2 of 4 365616 02/05/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

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 observation, staff interview, record review, the facility failed to ensure the medication were administered as ordered resulting in three medications errors out of 30 opportunities or a ten percent (%) medication error rate. This affected one (#64) out three residents observed for medication administration. The facility census was 101. Residents Affected - Few Findings include: Review of medical record for Resident #64 revealed admission date of 11/11/23. Diagnoses include Metabolic Encephalopathy, stroke, anxiety and hypertension. The resident remains in the facility. Medication observation on 02/05/24 of Licensed Practical Nurse (LPN) #100 for Resident #64 revealed Amlodipine (hypertension) five milligrams (mg), two Budesonide (steroid) three mg tablets, Buspar (antianxiety) 10 mg, Imodium (antidiarrheal) two mg, Vitamin D3 (supplement) 25 micrograms (mcg), Cholestyramine (cholesterol) four Grams, three Duloxetine (depression) 30 mg tablets, Plavix (anti platelet) 75 mg, Hydralazine (blood pressure) 10 mg, Nebivolol (hypertension) 10 mg, Potassium (supplement) 10 milliequivalents (mEq), Valsartan (hypertension) 320 mg, Nucynta (pain) 50 mg were given as ordered. LPN #100 searched the medication cart and stated the ordered Calcium-Magnesium-Zinc (supplement) tablet, Fosfomycin Tromethamine (Urinary Tract Infection prevention) three gram packet, and [NAME] Colon Health Capsule (probiotic) were unavailable for administration. Further review of the physician orders and Medication Administration Record (MAR) for Resident #64 revealed an order for the resident to receive Fosfomycin Tromethamine three-gram packet daily with a start date of 11/13/23, [NAME] Colon Health capsule daily with a start date of 11/12/23 and Calcium-Magnesium-Zinc tablet daily with a start date of 11/12/23. This deficiency represents non-compliance investigated under Complaint Numbers OH00150313 and OH00149954. 365616 Page 3 of 4 365616 02/05/2024 Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff and staff interviews and policy review, the facility failed to ensure proper medication storage. This affected one (#65) out of three residents observed for medication storage. The facility census was 101. Findings include: Review of medical record for Resident #67 revealed admission date of 09/27/23. Diagnoses include orthopedic aftercare, spinal stenosis and cardiomegaly. The resident remained in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #67 required extensive two-person assistance for bed mobility, transfers, one person assistance for toileting and independent for eating. Further review of Resident #67's medical record revealed there was no documentation to support the resident was permitted to self-administer medications. During an interview on 02/05/24 at 12:47 P.M. with Resident #67, State Tested Nursing Assistant (STNA) #106 entered the room to deliver his lunch tray. While removing the breakfast tray, STNA #106 picked up a medication cup, and held it in the air in the direction of Resident #67. STNA #106 asked if he forgot to take his medications this morning. Resident #76 answered he asked the nurse to leave the pills and he would take them later, but he forgot to. Observation of the medication cup revealed it contained eight unidentified tablets, which were verified with STNA #106. Interview on 02/05/24 at 2:30 P.M. with Licensed Practical Nurse (LPN) #106 verified when she handed Resident #67 his morning pills, she did not stay to ensure he took them. Review of the facility policy titled Preparation and General Guidelines dated 11/2021 revealed the resident would be observed after the administration of medication to ensure the medication was completely ingested. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 365616 Page 4 of 4