Inspection·October 16, 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 resident and staff interviews, and record review, the facility failed to ensure medications were supplied by the pharmacy to be administered per physician order. This affected one (Resident #1) of three residents reviewed for medications. The facility census was 67. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included intervertebral disc disorder, arthritis, asthma, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of Resident #1's care plans dated 07/2023 revealed a focus for resident exhibiting a verbal difficulty with compliance of medication administration. Interventions included assessing for unmet needs, assist the resident with comprehension of policies and regulations, determine cause for behaviors, and observe for triggers to behaviors. Review of the physician orders revealed on 06/30/23, Resident #1 was ordered to receive Humira (immunosuppressive) 40 milligrams (mg) per 0.8 milliliter (ml) subcutaneous injection once a day every two weeks on Friday. Review of the Medication Administration Records (MAR) dated 06/2023 revealed Resident #1 received the Humira shot on 06/30/23 per physician order. On 07/14/23, Resident #1 received one dose of the Humira shot. On 07/28/23, Resident #1 did not receive the Humira shot for the reason charted as 'drug item unavailable, pharmacy to send'. On the 08/11/23, Resident #1 did not receive the Humira shot for the reason documented as 'drug unavailable, pharmacy notified of need to supply-resident to supply'. On 8/25/23, the Humira shot was not administered for the reason documented 'drug unavailable'. On 09/08/23, Resident #1 received the Humira shot per physician order. On 09/22/23, Resident #1 did not receive the Humira shot scheduled for the reason documented 'drug unavailable'. On 10/06/23, Resident #1 did not receive the Humira shot scheduled for the reason documented as 'drug unavailable'. Resident #1 received Humira three times out of eight opportunities. Interview on 10/11/23 at 2:30 P.M. with Resident #1 revealed the resident admitted to having medications from her personal pharmacy brought into the facility. Resident #1 stated she was upset because every time her Humira shot was due, the nurses would tell her it was unavailable. Resident #1 stated she did have her family bring her a Humira shot to her, and she was caught by the nurse with the medication. Resident #1 stated she only was taking the medication herself because she did not believe (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: 366384 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 366384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322 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)