Inspection·December 11, 2023

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. Based on medical record review, review of controlled drug administration records, staff interview, and review of facility policy, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected three residents (Residents #07, #17, and #92) of three residents reviewed for controlled medications. The facility census was 91. Findings include: 1. Review of the medical record for Resident #07 revealed an admission date of 10/05/2023. Diagnoses included paraplegia, chronic pain, muscle weakness, and morbid obesity. Review of Resident #07's plan of care, revised 10/18/23, revealed Resident #07 to be at risk for pain related to diagnoses of chronic pain, low back pain, discitis and polyneuropathy. Interventions included to provide non-pharmacological interventions, follow physician's orders for complaint of pain, and observe for pain every shift. Additionally, the plan of care stated to provide medications per orders, monitor for signs and symptoms of side effects and evaluate the effectiveness of the medication. Review of Resident #07's physician's orders revealed an order dated 12/01/23 for oxycodone (an opioid analgesic medication used for pain relief) five milligrams (mg) give two tablets by mouth every six hours as needed (PRN) for pain. Reconciliation of Resident #07's Controlled Drug Administration Record (CDAR) and Medication Administration Record (MAR) for December 2023 revealed the following discrepancy related to oxycodone: • 12/10/23 - four doses signed out on the CDAR, three doses recorded on the MAR 2. Review of the medical record for Resident #17 revealed an admission date of 10/02/23. Diagnoses included fractures of the left tibia, right fibula, left humerus, and the lumbar vertebrae, an injury to the external genitals, muscle weakness, and depression. Review of Resident #17's plan of care, revised 10/16/23, revealed Resident #17 was at risk for pain related to multiple fractures. Interventions included to provide non-pharmacological interventions, follow physician's orders for complaint of pain, and observe for pain every shift. Additionally, the plan of care stated to provide medications per orders, monitor for signs and symptoms of side (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 3 Event ID: 365623 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 365623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Health Care 3364 Kolbe Rd Lorain, OH 44053 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)