Inspection·May 1, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, and policy review, the facility failed to ensure a resident consumed his medications at the time of administration resulting in unattended medications at a resident's bedside. This affected one (#172) resident out of four residents reviewed for medication administration. Facility census was 94. Findings include: Review of the medical record for Resident #172 revealed an admission date of 04/13/23 with medical diagnoses of disorder of the brain, peripheral vascular disease, diabetes mellitus, and benign prostate hypertrophy. Review of the medical record for Resident #172 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #172 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting, and dressing. Review of the medical record for Resident #172 revealed no documentation to support a medication self-administration assessment was completed. Review of the medical record for Resident #172's physician orders revealed no order for medication self-administration. Observation with interview on 05/01/23 at 9:27 A.M. of Resident #172 revealed Resident #172 sitting in his recliner with bedside table in front of the recliner. A medication pill cup with four medications was observed sitting on Resident #172's bedside table. Resident #172 stated the nurse left the pills on his bedside table while she went to get more water for him. Resident #172 stated the nurse had left to get water a while ago but must have gotten busy with other residents and forgot to bring him water. Interview on 05/01/23 at 9:35 A.M. with Licensed Practical Nurse (LPN) #130 confirmed Resident #172 had a medication pill cup with four medications sitting on his bedside table and that she had left the medications in Resident #172's room while she went to get a large cup of water for Resident #172. LPN #130 confirmed she was passing medications to other residents on the unit at the time of the interview and had forgotten to get the water for Resident #172 to take his medications. Review of the policy titled, Administering Oral Medications, revised October 2010, stated the staff (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: 365714 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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)