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. (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: 365849 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 365849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Toledo 4293 Monroe St Toledo, OH 43606 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)