Health inspection·May 1, 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, interview, and policy review, the facility failed to administer pain medication as scheduled to Resident #5. This affected one resident (#5) out of three residents reviewed for pain medication administration. The facility census was 77. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses including Alzheimer's disease, delusional disorder, anxiety disorder, insomnia, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Review of the quarterly pain assessment dated [DATE] revealed Resident #5 received scheduled pain medication. Resident #5 revealed they had frequent pain and rated the pain a four on a scale of zero to ten with ten as the worst pain imaginable. Review of the plan of care dated 04/15/23 revealed Resident #5 had complaints of pain. Interventions included to administer pain medication as ordered and notify physician of unrelieved pain. Review of physician orders for April and May 2023 included but not limited to tramadol (narcotic for moderate to severe pain) 50 milligram (mg) three times a day, acetaminophen (analgesic for minor aches and pains) 650 mg every six hours as needed, and pain management scale every shift. Review of the controlled drug receipt proof-of-use/disposition form revealed Resident #5 was administered the last tablet in the card of tramadol 50 mg on 04/20/23 at 9:30 P.M. Review of medication administration records (MAR) for April 2023 revealed Resident #5 did not receive tramadol 50 mg on 04/21/23 scheduled for 6:00 A.M. to 10:00 A.M. A reason for not administering the scheduled tramadol was listed as Not administered: Drug/item not available. Resident #5 did not receive tramadol 50 mg on 04/21/23 scheduled for 1:00 P.M. to 4:00 P.M. A reason for not administering the scheduled tramadol was listed as Not administered: Drug/item not available. Review of the MAR revealed Resident #5 was administered acetaminophen 650 mg on 04/21/23 at 4:46 P.M. for eight out of ten on the pain scale. An authorization to pull controlled substance from Omnicell (medication dispensing system) dated 04/21/23 at 8:20 P.M. revealed tramadol 50 mg was pulled for Resident #5. Review of the progress note dated 04/22/23 at 2:13 A.M. revealed tramadol 50 mg was pulled with authorization on 04/21/23 at (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: 366152 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 366152 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West View Healthy Living 1715 Mechanicsburg Road Wooster, OH 44691 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)