Health inspection·May 23, 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. Based on review of the medical record, review of controlled substance administration records, review of medication administration records, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders and failed to ensure an accurate system of dispensing and administering controlled substances. This affected three (#77, #26, #18) of three residents reviewed for medication administration. The facility census was 76. Finding include: 1. Review of the medical record for Resident #77 revealed an admission date on 06/21/23, a readmission date of 10/06/23, and a discharge date of 04/20/24. Diagnoses included acute on chronic respiratory failure with hypoxia, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, dysphagia, obstructive sleep apnea, hypertension, and chronic pain syndrome. Review of the physician's orders dated 04/13/24 revealed the resident had orders for lorazepam tablet 0.5 milligrams (mg) by mouth every four hours as needed. Review of a physician order dated 04/14/24, revealed orders for morphine sulfate solution 20 mg/milliliter (ml), give two mg by mouth every two hours as needed for pain, and a physician order dated 04/11/24, for hydrocodone/acetaminophen 5/325 mg every four hours as needed for pain. Review of the controlled substance administration record (CSAR) revealed five doses of lorazepam were removed as follows: on 04/13/24 at 3:35 P.M. and 10:30 P.M.; on 04/14/24 at 11:00 A.M., on 04/17/24 at 4:00 P.M.; and on 04/18/24 at 2:45 P.M.; however, the medications were not documented as administered on the medication administration record (MAR). Further review of the CSAR revealed 0.1 ml of morphine was removed as follows: on 04/13/24 at 7:43 A.M.; on 04/14/24 at 10:00 A.M. and 3:35 P.M.; on 04/15/24 at 8:53 P.M.; and on 04/18/24 at 8:00 P.M.; however, not documented as administered on the MAR. Further review of the MAR revealed one dose of morphine was administered on 04/14/24 but was never documented on the CSAR. Continued review of the CSAR revealed 16 doses of hydrocodone/acetaminophen 5/325 mg were removed as follows: on 04/01/24 at 1:00 P.M., 8:00 P.M.; on 04/02/24 at 1:00 A.M.; on 04/04/24 at 9:00 A.M., and 3:36 P.M.; on 04/05/24 at 12:00 A.M.; on 04/06/24 at 3:42 P.M.; on 04/07/24 at 7:00 P.M.; on 04/08/24 at 6:00 P.M.; on 04/09/24 at 4:00 A.M., 9:00 A.M., and 7:00 P.M.; on 04/10/24 at 4:00 P.M. and 10:00 P.M.; on 04/11/24 at 8:00 P.M.; and on 04/12/24 at 4:00 P.M. These medications were never documented as administered on the MAR. 2. Review of the medical record for Resident #26 revealed an admission date of 04/19/19. Diagnoses Page 1 of 3 365737 365737 05/23/2024 Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614

F 0755 included chronic obstructive pulmonary disease, hypertension, and peripheral vascular disease. Level of Harm - Minimal harm or potential for actual harm Review of the monthly physician orders for April 2024 revealed an order for lorazepam 0.5 mg every fours as needed for agitation until 07/31/24; morphine sulfate 20 mg/ml, give two mg every two hours as needed for pain or shortness of breath; and tramadol 50 mg, one tablet by mouth every six hours for pain. Residents Affected - Few Review of the CSAR for tramadol 50 mg revealed doses were removed from the card as follows: on 04/01/24 at 4:30 P.M. and 04/09/24, 04/10/24, and 04/11/24, and the medications were not documented as administered on the MAR. Additional review of the MAR revealed there was documentation that 20 doses of tramadol were administered: on 04/14/24 at 12:00 P.M.; on 04/21/24 at 6:00 P.M.; on 05/03/24 at 12:00 A.M. and 6:00 A.M.; on 05/04/24 at 12:00 A.M., on 6:00 A.M. and 6:00 P.M.; on 05/06/24 at 6:00 P.M.; on 05/07/24 at 12:00 A.M. and 12:00 P.M.; on 05/09/24 at 12:00 P.M.; on 05/12/24 at 12:00 A.M., 6:00 A.M., 12:00 P.M.; on 05/14/24 at 12:00 P.M.; on 05/15/24 at 6:00 P.M.; on 05/16/24 at 12:00 P.M.; on 05/17/24 at 12:00 P.M.; and on 05/20/24 at 12:00 A.M. and 6:00 P.M. The 20 medication doses were not documented on the CSAR to be administered. Review of the CSAR revealed one dose of morphine sulfate 100 mg/5 ml was removed on 05/06/24 at 9:00 P.M., and the medication was never documented as administered on the MAR. Review of the CSAR revealed 11 doses of lorazepam 0.5 mg was removed to be administered as follows: on 04/18/24 at 4:00 P.M.; on 04/22/24 at 12:00 P.M.; on 04/23/24 at 7:00 P.M.; on 04/26/24 at 4:00 P.M. and 7:00 P.M.; on 05/02/24 at 6:00 P.M.; on 05/04/24 at 6:00 P.M.; on 05/06/24 at 4:00 A.M.; on 05/07/24 at 8:00 A.M.; and on 05/13/24 at 6:00 P.M. The medications were not documented as administered on the MAR. 3. Review of the medical record for Resident #18 revealed an admission date of 05/16/24. Diagnoses included type two diabetes mellitus, hypertension, stage four pressure ulcer of the right hip, and chronic pain. Review of the admission physician orders for Resident #18 revealed an order for morphine sulfate oral solution 20 mg/ml, give 0.25 ml by mouth every one hour as needed for pain. Review of a physician order dated 05/19/24 revealed an order for lorazepam tablet one (1) mg every four hours as needed for restlessness and anxiety. Review of the CSAR revealed there were five doses of morphine sulfate solution 100 milligrams (mg)/five milliliters (ml) removed and only two of the doses had a nurse signature. The doses signed out on 05/18/24 and 05/19/24 were not recorded as administered on the MAR. Review of the CSAR for lorazepam tablet one milligram revealed on 05/17/24 one dose was signed out on the CSAR but not documented as administered on the MAR. Interview on 05/22/24 at 12:03 P.M., with Licensed Practical Nurse (LPN) #109 revealed when giving a narcotic medication: the count should be verified, then pull the medication from the drawer and sign out the medication on both the MAR and the CSAR. LPN #109 revealed she was recently in-service on correct procedures for pulling and administering controlled substances along with proper documentation in the MAR and CSAR. Interview on 05/23/24 beginning at 9:50 A.M., with the Director of Nursing (DON) verified nine 365737 Page 2 of 3 365737 05/23/2024 Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses had not documented narcotic medications as administered on the MAR and/or had documented narcotic medications as administered but were never removed from the CSAR to be administered for Resident #77, Resident #26, and Resident #18. Review of the policy titled, Medication Administration, dated 06/21/17, revealed medication would be administered by legally authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. Further review of the policy revealed after administering medications, return to the medication cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering medication to each resident. This deficiency represents non-compliance investigation under Master Complaint Number OH00153619, Complaint Number OH00153565, and Complaint Number OH00153605. 365737 Page 3 of 3