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 (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: 365737 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 365737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614 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)