Health inspection·January 16, 2025

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 and staff and Hospice Director Physician #100 interviews, the facility failed to ensure a resident's pain medication order was transcribed correctly resulting in medication errors. This affected one (Resident #64) of three residents reviewed for medications. The facility census was 63. Findings include: Record review of Resident #64 revealed an admission date of 10/27/24. Resident #64 passed away in the facility on hospice care on 12/17/24. The resident had pertinent diagnoses of cerebral palsy and reflux uropathy. Review of the 08/22/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and used a wheelchair to aid in mobility. The resident required substantial to maximum assistance for personal hygiene, rolling left to right, sit to lying, lying to sitting, and sit to stand. The resident had an indwelling catheter and was occasionally incontinent of bowel. Resident #64 was admitted to hospice services on 12/15/24 with a diagnosis of sepsis. Review of the 12/16/24 Hospice Client Medication Report revealed an order for Morphine concentrate (pain medication) 100 mg/5 milliliter (ml) (20 mg/1 ml) oral solution give 10 mg (0.5 ml) by mouth every hour as needed. Review of the 12/17/24 Hospice Client Medication Report revealed an order for Morphine concentrate 100 mg/5 ml (20 mg/1 ml) oral solution give 20 mg (1 ml) by mouth every two hours scheduled. Review of the 12/17/24 facility Physician Orders revealed Morphine Sulfate Oral Solution 20 mg/5 ml give 1 ml by mouth every 1 hours as needed for pain and shortness of breath and give 1 ml by mouth every two hours for restlessness. Review of the controlled drug receipt/record disposition on 01/14/25 revealed Morphine was dispensed as 20 mg/1 ml and on 12/17/24 it was given at 2:30 P.M., 4:30 P.M., 6:30 PM., 8:00 P.M., 9:00 P.M., and 10:00 P.M. All administrations were of 1 ml (20 mg) of Morphine concentrate. Interview with the Hospice Director Physician #100 on 01/15/25 at 12:23 P.M. revealed he did not believe the increased dose of Morphine concentrate of 20 mg twice would negatively affect the resident. He stated at times for breakthrough pain residents are given 20 mg Morphine concentrate every 20 Page 1 of 3 365694 365694 01/16/2025 Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601

F 0755 minutes for up to a three time dose. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 01/15/25 at 2:30 P.M. verified the order was transcribed incorrectly from the hospice order as the physician order in the facility states she was supposed to receive 4 mg every two hours and 2 mg every hour as needed. The DON verified at 5:30 P.M. and 9:00 P.M. the resident should of only received 10 mg for as needed administration but he received 20 mg at those times. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00190964 and OH00160922. 365694 Page 2 of 3 365694 01/16/2025 Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with a wound. This affected one (Resident #37) of three residents reviewed for wounds. The facility census was 63. Residents Affected - Few Findings include: Record review of Resident #37 revealed an admission date of 11/23/24 with a discharge 12/02/24 and readmission on [DATE]. The resident had pertinent diagnoses of cerebral infarction, hemiplegia and hemiparessis following cerebrovascular disease affecting right non dominant side, type two diabetes mellitus, anxiety disorder, hypertension, and hyperlipidemia. Review of the 11/27/24 Minimum Data Set (MDS) assessment revealed Resident #37 is cognitively intact. The resident has an unstageable pressure ulcer. Review of the 01/09/25 wound evaluation revealed the resident had a stage two pressure ulcer on his left heel. Observation of Resident #37 on 01/14/25 at 2:14 P.M. revealed Registered Nurse (RN) #20 performing wound care. RN #20 gathered her supplies and washed her hands and put on her gloves and performed the dressing change. RN #20 did not put on a gown and there was no sign stating Resident #37 was on EBP. Interview with RN #20 on 01/14/25 at 2:25 P.M. verified Resident #37 had a wound and should of been on EBP and there was no a sign for EBP. RN #20 verified she did not wear a gown while completing the dressing change and verified she should of since Resident #37 has a wound. Review of the 01/01/24 facility Enhanced Barrier Precautions policy revealed EBP refers to the use of gown and gloves during high contact care activities for residents with any of the following: chronic wounds. Chronic wounds include pressure ulcers/ diabetic ulcers/ non-healing surgical wounds/ venous stasis ulcer. The high contact resident care activities are typically bundled care activities and include: performing wound care. This was an incidental finding found during the course of the complaint investigation. 365694 Page 3 of 3