Inspection·December 21, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, medical record review, and policy review, the facility failed to ensure a resident was assessed for self-administration of medication and ensure medications were not left unattended at the resident's bedside. This affected one resident (#277) of one observed for unattended medications. The facility census was 72. Residents Affected - Few Findings Include: Review of the medical record for Resident #277 revealed an admission date of 12/07/23 with diagnoses that included dependence on renal dialysis, end stage renal disease, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #277 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #277 required assistance with activities of daily living (ADL). Review of the care plan dated 12/14/23 revealed Resident #277 had an ADL self-care deficit with interventions that included assistance with ADLs as needed. Review of the medical record revealed no assessments for self-administration of medications or no physician orders for medications to be left at the bedside. Observation and interview on 12/19/23 at 9:30 A.M. revealed Resident #277 in bed in her room, with a medication cup that contained two white colored pills, one yellow pill, one maroon/burgundy color pill, and one peach colored pill. The five pills were located on Resident #277's bedside table. Resident #277 revealed she informed Registered Nurse (RN) #567 that she would take them after she finished her breakfast. Observation and interview on 12/19/23 at 9:40 A.M. with RN #567 verified the five pills left at Resident #277's bedside. RN #567 revealed Resident #277's medications were not to be left unattended at her bedside and Resident #277 should have taken them in her presence. Review of the facility document titled General Dose Preparation and Medication Administration revised 01/01/23, revealed staff were to ensure medications were not left unattended and to observe the consumption of the medications. 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: 366395 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 366395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141 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)