Health inspection·July 6, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews, and review of facility policy, the facility failed to ensure medications were not left at a residents beside. This affected one (#63) on three observed for medication storage. The census was 46. Findings include: Review of Resident #63's medical record revealed an admission date of 09/01/22. Diagnoses listed included multiple sclerosis, hyperlipidemia, neuralgia, and major depressive disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact with a brief interview for mental status (BIMS) score of 15 and required extensive assistance with activities of daily living (ADL's). Observation on 07/05/23 at 9:36 A.M. revealed a medication cup containing multiple pills/tablets/capsules sitting on Resident #63's beside tray. Resident #63 reported those were her morning medications. During interview and observation on 07/05/23 at 9:40 A.M. Licensed Practical Nurse (LPN) #32 confirmed she had left medications with Resident #63 and had not watched her take the medications. LPN #32 stated she will leave medications at the bedside with Resident #63 because she does not like to take until she has food. LPN #63 stated the medication cup would have contained all Resident #63 morning pills/tablets/capsules she documented as being administered. Further review of medication administration records (MAR's) revealed 21 medications were documented as being administered to Resident #63 by LPN #32 on 07/05/23 at 8:00 A. M. These medications were Amantadine Hydrochloride (HCL) 100 milligrams (mg), Aspirin enteric coated 81 mg, Ferrous Gluconate 240 mg, Folic Acid one mg, Lisinopril five mg, Nitrofurantoin Macrocrystal 100 mg, Norvasc 10 mg, Oxybutynin HCL 15 mg, Potassium Chloride 20 milliequivalent's (mEq), Sertraline HCL 100 mg, Sertraline HCL 50 mg, Vitamin B-12 1000 micrograms (mcg), Acidophilus one tablet, Baclofen 10 mg, Buspirone HCL 7.5 mg, Carbamazepine 100 mg, Docusate Sodium 100 mg, Oxycarbazepine 600 mg, Sodium Chloride one gram, Gabapentin 400 mg, and Hydralazine HCL 50 mg. Review of Resident #63's medical record revealed there was no documentation (i.e. assessment, care plan, physician orders, etc.) regarding allowing the self-administration of medications. Review of the facility's policy titled Administering Oral Medications date revised October 2010 Page 1 of 2 365936 365936 07/06/2023 Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805

F 0761 revealed staff should remain with the resident until all medications have been taken. Level of Harm - Minimal harm or potential for actual harm This deficiency is based on incidental findings discovered during the course of this complaint investigation. Residents Affected - Few 365936 Page 2 of 2