Health inspection·February 27, 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 observation, medical record review, contingency medication box medication list review, staff interview, and review of a facility policy, the facility failed to ensure newly admitted residents had medications pulled from the contingency medication supply and administered the night of admission as ordered. This affected two (#11 and #67) of three residents reviewed for medications. The facility census was 63. Findings include: 1. Review of Resident #11's medical record revealed admission to the facility on [DATE] with medical diagnoses including morbid obesity, kidney failure, anxiety, and congestive heart failure (CHF). Review of Resident #11's hospital discharge medications list prior to admission included the muscle relaxant cyclobenzaprine five (5) milligrams and the pain medication Neurontin 600 mg were ordered for bedtime. Review of Resident #11's progress notes revealed the resident arrived to the facility on [DATE] at 6:45 P.M. Review of Resident #11's February 2024 medication administration record (MAR) revealed at bedtime on 02/02/24 the resident did not receive any of her ordered medications. Further review of the MAR identified the medications were not available. 2. Review of Resident #67's medical record revealed admission to the facility on [DATE] with diagnoses including respiratory failure, ventilator dependence, morbid obesity, and congestive heart failure (CHF). Review of Resident #67's hospital medication discharge list prior to admission included the diuretic Lasix 40 mg due at bedtime. The hospital records identified the last dose of Lasix given to Resident #67 occurred on 01/08/24 at 8:35 A.M. Review of Resident #67's January 2024 MAR revealed on 01/08/24 the Lasix 40 mg was not given at 8:00 P.M. as order as it was identified as not available. Observation of the facility's contingency medication box was completed on 02/27/24. The box was observed with a listing of all medications that were available to staff. Review of the medication list of what was available in the contingency medication box on 02/27/24 revealed the box contained cyclobenzaprine 5 mg, Neurontin 600 mg, and Lasix 40 mg which were available and could have been (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: 365681 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 365681 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Lane Healthcare Center 355 Windsor Lane Gibsonburg, OH 43431 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)