Inspection·December 7, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected one (#81) of three residents reviewed for narcotic medication administration. The census was 78. Findings include: Review of Resident #81 closed medical record revealed an admission date of 10/16/23. Diagnoses included pubic fracture, dorsalgia, osteoarthritis, and femur fracture. Resident #81 was discharged from the facility on 11/03/23. Review of an admission Minimum data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively intact and needed some help with activities of daily living (ADL's). Review of physician orders revealed an order dated 10/16/23 for take 0.5 to one Oxycodone hydrochloride five milligram (mg) tablet (narcotic pain medication) every six hours for pain up to seven days. Review of the facility's Controlled Drug Receipt/Record/Disposition Form revealed one tablet of Oxycodone hydrochloride five mg was documented as being withdrawn on 10/27/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being withdrawn on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. Review of medication administration records (MAR's) revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/17/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being administered on 10/17/23 at 6:25 A.M. Further review of MAR's revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. During an interview on 12/06/23 at 10:30 A.M. the Director of Nursing (DON) confirmed the missing and inaccurate documentation in Resident #9's MAR of the Oxycodone medication. The DON had spoken with the nurse responsible for the missing and inaccurate documentation and reported the nurse forgot to log the Oxycodone hydrochloride five mg in the MAR after administering to Resident #9. The DON confirmed all medications administered to residents should be documented in the MAR accurately. Review of the facility;s policy titled Administration of Oral Medications dated revised December (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: 366040 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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)