Inspection·June 21, 2021

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 record review, interview and policy review, the facility failed to ensure medications were transcribed to the resident's medical record from hospital paperwork for Resident #323 and failed to ensure medications were administered according to the physician's order for Resident #72. This affected two residents (Resident #72 and Resident #323) of seven (Resident's (#18, #42, #49, #62, #72, 173 and #323) reviewed for unnecessary medication. The facility census was 75. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #323 was admitted to the facility on [DATE]. Her admitting diagnoses included urinary tract infection, chronic obstructive pulmonary disease, enterocolitis due to clostridium difficile, atrial fibrillation, and secondary polycythemia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Functionally, she required extensive assistance of one staff for most activities of daily living including toilet use and personal hygiene. Review of the resident's admission orders to the facility from the hospital showed this resident was to receive: • Eliquis (a medication to reduce the risk of stroke and blood clots in people who have atrial fibrillation) 2.5 milligrams (mg) by mouth twice daily • Hydroxyurea (treats cancer by stopping the growth of cancer cells) 500 mg one capsule by mouth to be given two times a day. Review of the facility's physician orders in the facility, showed Eliquis 2.5 mg to be given two times a day but the Hydroxyurea order was not listed. Review of the residents Medication Administration Record (MAR) for the month of May 2021 revealed the resident did receive the Eliquis as ordered but did not receive her hydroxyurea. Further review of this MAR revealed this medication was not listed on the MAR. Interview on 06/16/21 at 1:50 P.M. with the Director of Nursing and Regional Clinical Services Manager #174 verified the MAR and stated that there was no policy stating that what a nurse should do (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: 366404 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 366404 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage of Hudson 1212 West Barlow Road Hudson, OH 44236 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)