Health inspection·September 23, 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, staff, and resident interviews the facility failed to ensure medications were administered as per physician order. This affected one Resident (#10) of three reviewed. The facility census was 92. Findings include: Review of medical record for Resident #10 revealed admission date of 05/19/22. The resident was admitted with diagnoses including type two diabetes mellitus, Diabetic retinopathy, bipolar disease and peripheral vascular disease. The resident remained in the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He required extensive one person assistance for bed mobility, transfers, toileting and supervision for eating. Review of the physician orders revealed the following active orders: Combigan Ophthalmic (used to lower raised pressure in the eye) 0.2 Percent (%) - 0.5% into both eyes, two times a day for Glaucoma. The order had a start date of 12/26/23. Rocklatan Ophthalmic (used to lower raised pressure in the eye) 0.02 Percent (%) - 0.005% into both eyes, at bedtime related to cataract extraction. The order had a start date of 08/14/23. Review of the September 2024 Medication Administration Record (MAR) revealed the resident did not receive the morning or evening dose of Combigan Ophthalmic Solution on 09/01/24 and did not receive Rocklatan Ophthalmic on 09/03/24 at 8:30 P.M. as per physician order. The MAR documented OT for these doses, review of the MAR key revealed OT was other. Review of progress notes dated 09/01/24 at the 10:17 A.M. revealed Combigan Ophthalmic solution was not available from the pharmacy. Review of progress note dated 09/01/24 at 6:24 P.M. revealed Combigan Ophthalmic solution was not available from the pharmacy and the pharmacy was contacted. Review of progress note dated 09/03/24 at 9:44 P.M. revealed Rocklatan Ophthalmic solution was not available and was reordered. Interview on 09/19/24 at 10:31 A.M. with Resident #10 revealed he had a concern he did not always (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: 365616 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 365616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kettering Heights Post Acute 3313 Wilmington Pike Kettering, OH 45429 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)