Health inspection·January 24, 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 and staff interview, the facility failed to ensure residents received ordered medications upon admission. This affected two residents (#15 and #71) of three residents reviewed for admission medications. The facility census was 70. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/28/23 and discharge date of 01/19/24 with diagnoses including but not limited to metabolic encephalopathy, altered mental status, acute respiratory failure with hypoxia, fluid overload, congestive heart failure, type two diabetes, unspecified convulsions, chronic kidney disease stage three, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of five which indicated Resident #71 had severely impaired cognition. Resident #71 required extensive assistance for Activities of Daily Living (ADLs). Review of physician orders dated 12/28/23 revealed divalproex (Depakote - used to treat seizures) 500 milligrams (mg) twice daily, gabapentin (pain medication) 300 mg three times daily, carvedilol (used heart failure) 25 mg twice daily, and voltaren gel (pain gel) one percent three times daily. Review of the December Medication Administration Record (MAR) revealed resident did not receive Depakote 500 mg in the evening, gabapentin 300 mg at 2:00 P.M. and 9:00 P.M., carvedilol 25 mg at 4:00 P.M. and voltaren gel to knee at 5:00 P.M. on 12/28/23 upon admission. Further review of the medical record revealed no documentation that the medication missed was on hold. Interview on 01/24/24 at 2:40 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #622 verified Resident #71 did not receive medications upon admission due to medications not being available from the pharmacy. LPN #622 stated the Nurse Practitioner (NP) was in the facility that day and stated it was okay to hold the medication until received by the pharmacy. It was further verified there was no documentation available regarding the NP approving medications to be held. 2. Review of medical record for Resident #15 revealed an admission date of 11/27/23 with diagnoses including but not limited to metabolic encephalopathy, altered mental status, Alzheimer's disease, dementia, epilepsy, and hypertension. Page 1 of 2 365849 365849 01/24/2024 Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #15 was dependent for ADLs. Review of physician orders dated 11/27/23 revealed orders for latanoprost ophthalmic solution (eye drops) 0.005 percent (%), lacosamide (used for seizures) 10 mg/milliliters (ml): 10 ml every 12 hours, levetiracetam oral solution (antiepileptic) 100 mg/ml: 15 ml at bedtime. Review of the MAR for November revealed the resident did not receive latanoprost ophthalmic solution, lacosamide 10 ml, and levetiracetam 15 ml at bedtime on 11/27/23. Interview on 01/24/24 at 2:40 P.M. with the Director of Nursing (DON) verified that Resident #15 did not receive medications due to waiting on the pharmacy to deliver. Review of policy titled, Administering Medications, revised December 2012 revealed medications must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00149677. 365849 Page 2 of 2