Health inspection·December 1, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#15,#17,#18,#19,#21,#23,#26,#46, #28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Residents Affected - Some Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Page 1 of 6 365690 365690 12/01/2023 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0694 Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Residents Affected - Some Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she completed the resident IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy. This deficiency represents non-compliance investigated under Complaint Number OH00148183. 365690 Page 2 of 6 365690 12/01/2023 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#46,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60, #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 milliliter per hour 365690 Page 3 of 6 365690 12/01/2023 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0755 (ml/hr). Level of Harm - Minimal harm or potential for actual harm Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Residents Affected - Some Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she completed the resident IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy This deficiency represents non-compliance investigated under Complaint Number OH00148183. 365690 Page 4 of 6 365690 12/01/2023 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#46, #12,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 ml/hr. 365690 Page 5 of 6 365690 12/01/2023 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0837 Level of Harm - Minimal harm or potential for actual harm Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Residents Affected - Some Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she complemented resident the IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy This deficiency represents non-compliance investigated under Complaint Number OH00148183. 365690 Page 6 of 6