Health inspection·July 29, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review the facility failed to ensure medications were fully ingested and not left at the bedside. This affected one resident (#21) and had the potential to affect eight residents (#65, #20, #45, #6, #31, #68, #57, and #60) the facility identified as independently mobile and cognitively impaired residing on the memory care unit. The facility census was 68. Findings include: Review of the medical record for Resident #21 revealed an admission date of 01/15/24 with diagnoses of Alzheimer and dementia with behavior disturbance. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she is cognitively impaired. Review of the care plan revised 07/24 for Resident #21 revealed she had impaired cognitive function and impaired thought process related to dementia. Review of the current physician orders for 07/24 for Resident #21 revealed for the morning medications she was to receive Actos (thiazolidinediones)15 milligram (mg), Vitamin B-complex (vitamin), magnesium oxide (supplement) 400 mg, Trajenta (DPP-4 inhibitor) five mg, Vitamin D-3 (vitamin) 25 microgram (mcg), Coreg (beta blocker) 6.25 mg, Depakote (antiseizure) tablet 125 mg, Colace (stool softener) 100 mg, Ferrous Sulfate (supplement) 325 mg, Memantine (NMDA receptor antagonist) 10 mg, Oyster Shell Calcium (mineral) 500 mg, and Quetiapine Fumarate (antipsychotic)150 mg. Observation on 07/24/24 at 11:25 A.M. revealed a plastic medication cup with Resident #21's name written on the plastic medication cup, with four partially dissolved pills on the overbed table for Resident #21. Interview on 07/24/24 at 11:30 A.M. with State Tested Nursing Assistant (STNA) #313 verified four partially dissolved pills in a plastic medication cup on the overbed table for Resident #21. STNA #313 further stated this is not uncommon. Interview on 07/24/24 at 11:36 A.M. with Licensed Practical Nurse (LPN) #338 stated there were not any medications left at the bedside this morning when she administered Resident #21 her medication. Follow-up interview on 07/25/24 at 10:39 A.M. with LPN #338 verified the medications at the bedside (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: 365619 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 365619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unger Park Post Acute 1170 W Mansfield Street Bucyrus, OH 44820 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)