Health inspection·June 13, 2023

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 record review, staff interviews and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#11) of three residents reviewed reviewed for medication administration. The facility census was 101. Findings include: Review of medical record for Resident #11 revealed admission date of 05/04/23. Diagnoses included acute respiratory failure with hypoxia, chronic kidney disease stage three (of four) and acute on chronic congestive heart failure. The resident was hospitalized on [DATE] and did not return. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had a Brief Interview Mental Status (BIMS) score of six out of 15 indicating impaired cognition. Resident #11 required extensive two-person assistance for bed mobility, transfers, toileting supervision for eating. Resident #11 was documented as frequently incontinent of urine and bowel during the lookback period. A care plan relative revealed Resident #11 had potential for alteration in nutrition and hydration status as evidenced by therapeutic diet and fluid restriction initiated 05/15/23. Interventions included to accommodate food preferences as able, heart healthy, regular texture 2000 milliliter/day fluid restriction, monitor for signs and symptoms of dehydration, ad encourage consumption of fluids within the parameters of the fluid restriction. At risk for dehydration initiated 05/15/23 related to diuretics interventions included monitor for signs and symptoms of dehydration (poor skin integrity, new onset of confusion, abnormal lab values), offer water/ice chips every shift within the parameters of the fluid restrictions and monitor lab work. Review of Resident #11's physician order revealed the staff received orders for the resident to receive Molnupiravir (antiviral) Oral Capsule 200 milligrams twice a day for five days, with a start date of 05/10/23 to treat Coronavirus Disease 2019 (COVID-19). Further review of Resident #11's May 2023 Medication Administration Record (MAR) revealed the first dose on 05/10/23 for the 6:00 A.M. to 11:00 A.M. time had an H documented. The review revealed Resident #11 received nine doses of the Molnupiravir rather than the full 10 doses. Interview on 06/13/23 at 1:32 P.M. with the Director of Nursing (DON) revealed Resident #11's Molnupiravir was marked as held on 05/10/23 because the resident was sent to the emergency room. The DON confirmed Resident #11 did not receive the medication upon returning later in the day. The DON confirmed Resident #11's Molnupiravir end date was not extended; therefore, the resident did not receive the full five days of medication. (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: 365984 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 365984 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingston of Miamisburg 1120 South Dunaway Street Miamisburg, OH 45342 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)