Inspection·December 28, 2019

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy and procedure review the facility failed to ensure blood pressures and/or pulse were obtained for two residents (#2 and #15) prior to receiving antihypertensive medications as physician ordered. This affected one of four residents observed for medication administration and one of five residents reviewed for unnecessary medications. Residents Affected - Few Findings include: 1. Review of Resident #15's medical record revealed an admission date of 06/07/19 with the admitting diagnoses of hypertension, non-rheumatic mitral valve insufficiency and anxiety. Review of the plan of care dated 06/23/19 revealed he was at risk for complications related to the diagnoses of hypertension and the use of antihypertensive medications. Interventions included to administer antihypertensive medications as ordered and obtain blood pressure (BP) readings before administration of the antihypertensive medications and daily. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. Review of the resident's monthly physician's orders for December 2019 revealed an order dated 06/07/19 for Lopressor (a medication used to lower BP) 25 milligrams by mouth twice a day with the special instructions to hold the medication if his pulse was less than 60 and/or systolic BP was less than 110 and/or diastolic BP was less than 60. Review of the November and December 2019 Medication Administration Record (MAR) revealed no documented pulse or BP prior to administering the medication Lopressor. On 12/28/19 at 9:06 A.M. observation of Licensed Practical Nurse (LPN) #150 administer Resident #15's morning medication revealed the LPN did not obtain a blood pressure or pulse for the resident prior to administering the medication Lopressor. On 12/28/19 at 10:48 A.M. interview with LPN #150 verified the resident's BP and pulse was not obtained prior to administering the residents medication Lopressor. 2. Review of Resident #2's medical record revealed an admission date of 10/26/16 with the admitting diagnoses of hypertension, Parkinson's disease and anxiety. (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: 366107 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 366107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home 2274 McDermott Pond Creek Road McDermott, OH 45652 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)