Inspection·December 9, 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. Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure a medication was available for administration as ordered. This affected one (#51) resident out of the three residents reviewed for medications available from pharmacy for administration. The facility census was 62. Findings include: Review of the medical record for Resident #51 revealed an admission date of 08/14/24 with medical diagnoses of acquired absence of left below knee amputation (BKA), peripheral vascular disease, diabetes mellitus, and hypertension. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #51 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and transfers and partial/moderate staff assistance with bathing and bed mobility. Review of the medical record for Resident #51 a physician order dated 09/12/24 for Percocet 5-325 milligram (mg) give one tablet by mouth every four hours for pain. Review of the medical record for Resident #51 revealed the October 2024 Medication Administration Record (MAR) which did not have documentation to support Resident #51 received Percocet as ordered on 10/12/24, 10/13/24, 10/18/24, and 10/28/24. Review of Resident #51's December 2024 MAR revealed no documentation to support Resident #51 received Percocet as ordered on 12/04/24. Review of the medical record for Resident #51 revealed a nurses' note dated 10/18/24 at 12:46 P.M. with stated the nurse spoke with the pharmacy and per the representative the Percocet would be delivered in the evening. Review of Resident #51's nurses' note dated 10/19/24 at 12:03 A.M. stated Resident #51 was out of Percocet. The note stated the nurse contacted the pharmacy to get authorization to pull the medication from the Pyxis system, but the nurse did not have access to the Pyxis. The note continued to state the nurse contacted the on-call supervisor who stated she did not have access to the Pyxis system either. Review of the medical record for Resident #51 revealed a nurses' note dated 12/04/24 at 10:47 P.M. which stated Percocet was not given because the medication was not available in the medication cart and the medication was reordered. Interview on 12/04/24 at 11:38 A.M. with Resident #51 confirmed he does not receive his pain medication at times because the medication was not available at the time of administration. (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: 366178 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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)