Health inspection·May 11, 2023

F 0727 Level of Harm - Potential for minimal harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules, staff interview, and review of the policy, the facility failed to ensure there was a Registered Nurse (RN) physically present in the facility for at least eight consecutive hours daily. This had the potential to affect 112 of 112 residents residing in the facility. The facility census was 112. Findings include: Review of facility staffing schedules revealed an RN was not scheduled on 04/15/23. Interview on 05/10/23 at 3:02 P.M., with the Administrator confirmed the facility did not have an RN working on 04/15/23. Review of the policy titled Nursing Staffing Protocol dated March 2013 revealed the facility would ensure sufficient staffing on a 24-hour basis and the facility would have an RN for at least eight consecutive hours a day seven days a week. This deficiency is based on incidental findings discovered during the course of this complaint investigation. Page 1 of 2 366080 366080 05/11/2023 Chesterwood Village 8073 Tylersville Road West Chester, OH 45069

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. Based on record review, observation, resident and staff interview, and review of policy, the facility failed to ensure resident medications were available for administered as ordered by the physician. This affected one (#104) of four residents observed for medications. The census was 112. Findings include: Review of the medical record for Resident #104 revealed an admission date of 12/09/22, with a diagnoses including chronic obstructive pulmonary disease (COPD), asthma, and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #104 dated 04/19/23 revealed resident's cognitive status was not assessed, and resident required extensive assistance with activities of daily living (ADLs). Review of the May 2023 monthly physician orders for Resident #104 revealed an order dated 03/03/23 for resident to receive Flonase nasal spray two sprays in each nostril once daily for nasal congestion. Observation of medication administration on 05/10/23 at 7:56 A.M., with Licensed Practical Nurse (LPN) #470 revealed Flonase was not available for administration as ordered for Resident #104. LPN #470 checked resident's room with resident's permission to see if the Flonase had been left in the room by mistake, but did not find the Flonase. Interview on 05/10/23 at 7:58 A.M., with Resident #104 confirmed she had not received the Flonase nasal spray for the past several days and she was unsure where it was, and she was not sure why she hadn't gotten it. Interview on 05/10/23 at 8:10 A.M., with LPN #470 confirmed according to Resident #104's electronic medical record (EMR) the only time resident's Flonase had been dispensed by the pharmacy was 03/03/23, and it had not been reordered. LPN #470 confirmed she would reorder the Flonase. Interview on 05/10/23 at 3:28 P.M., with LPN #470 confirmed Resident #104's Flonase had not arrived from the pharmacy, and she was not able to administer the medication as ordered for 05/10/23. Review of the policy titled Administration Oral Medications dated December 2021 revealed facility would ensure staff administered medications per physician's orders. This deficiency represents the noncompliance discovered during the investigation of Complaint Number OH00142323. 366080 Page 2 of 2