Health inspection·December 30, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of list of medications available in emergency box, staff interview, and policy review, the facility failed to administer a medication as per resident request and physician order. The affected one (#65) out of the three residents reviewed for medications administered as ordered. The facility census was 59. Findings include: Review of the medical record for Resident #65 revealed an admission date of 12/04/24 with medical diagnoses of Coronavirus Disease 2019 (COVID-19), acute respiratory failure, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, and congestive heart failure. The medical record indicated Resident #65 discharged to a hospital on [DATE]. Review of the medical record for Resident #65 revealed a discharge Minimum Data Set (MDS) assessment, dated 12/05/24, which indicated Resident #65 was dependent upon staff for toilet hygiene, bathing, and transfers, and required partial/moderate staff assistance for bed mobility and set-up assistance for eating. The MDS indicated Resident #65 had oxygen and had shortness of breath with exertion. No respiratory therapy was indicated on the MDS. Review of the medical record for Resident #65 revealed a physician order dated 12/04/24 for ipratropium-albuterol inhalation solution 0.5-2.5 (3) milligram (mg) per 3 milliliters (ml) to give one application inhale orally every six hours as needed for shortness of breath. Review of the medical record for Resident #65 revealed a nurse progress note, dated 12/04/24 at 7:29 P.M., which stated Resident #65 requested a breathing treatment. The note stated the nurse contacted the on-call Nurse Practitioner (NP) who ordered Duonebs (ipratropium-albuterol inhalation solution) every six hours for seven days and the orders were updated. Review of the medical record for Resident #65 revealed the Medication Administration Record (MAR) for December 2024 revealed no documentation to support Resident #65 received a breathing treatment on 12/04/24. Review of the MAR revealed Resident #65 received ipratropium-albuterol inhalation solution as ordered on 12/05/24 at 12:00 A.M. Review of the medical record for Resident #65 revealed hospital documentation, dated 12/05/24, which stated Resident #65 was admitted to the hospital for acute hypoxic respiratory and was treated for myocardial infarction and pulmonary edema. (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: 365773 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 365773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Laurels of Kettering 694 Isaac Prugh Way Kettering, OH 45429 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)