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 (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: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 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)