Inspection·January 11, 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, observations, staff interview, policy review and review of the Standards of safe medication administration by a certified medication aide, the facility failed to ensure medications were administered by the staff member who prepared the medications. This affected one (#45) of four residents reviewed for medication administration. The facility census was 76. Finding include: Review of the medication record for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to hypoatremia, anemia, hypertensive orthostatic hypotension renal disease, dementia, and depression. Review of the quarterly Minimum Data Assessment (MDS) assessment dated [DATE] for Resident #45 revealed a brief interview for mental status revealing severe cognitive impairment. Resident #45 required moderate assistance with bed mobility, transfers, and toileting. Resident #45 required set up assistance for meals. Review of the plan of care for Resident #45 revealed the resident had impaired cognition and impaired decision making skills related to dementia. Interventions included administer medication as ordered, cue and reorient as needed and engage the resident is simple structured activities. Review of the physician orders for Resident #45 for the month of January 2024 revealed the resident was scheduled to receive Amlodipine five milligrams (mg) one tablet by mouth, fiber-lax 625 mg by mouth, vitamin B-12 micrograms (mcg) one tablet, digoxin 0.125 mg one tablet by mouth, omeprazole 20 mg tablet by mouth, vitamin D-3 1000 units one tablet by mouth, escitalopram 10 mg one tablet by mouth, sodium chloride one gram (gm) by mouth, questran four gm-one packet mixed with water and metoprolol tartrate 25 mg by mouth. Observation on 01/11/24 at 9:00 A.M. of Licensed Practical Nurse (LPN) #69 prepare the medications for Resident #45. LPN #69 prepared Amlodipine, fiber-lax, vitamin B-12, digoxin, omeprazole, vitamin D-3, escitalopram, sodium chloride, questran, and metoprolol tartrate and placed them in a medication administration cup. LPN #69 then handed the medication cup with medications to the Medication Aide (MA-C) #96 who was not present at the time of medication preparation. MA-C #96 then entered the room of Resident #45 and administered the medication to resident. Interview on 01/11/24 at 9:10 A.M. with LPN #69 verified that MA-C #96 did not prepare the medication for Resident #45. LPN #45 additionally verified she documented in the medical record that she (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 01/11/2024 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)