Health inspection·January 20, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, observation, interview and review of facility policy, the facility failed to ensure medications were accurately documented as administered. This affected one resident (Resident #83) of three residents who were observed for medication administration. The facility census was 96.Findings include:Review of the medical record for Resident #83 revealed an admission date of 08/20/25. Pertinent diagnoses included sepsis with an unspecified organism, urinary tract infection, chronic obstructive pulmonary disease (COPD), metabolic encephalopathy, gastroesophageal reflux disease (GERD), unspecified atrial fibrillation, unspecified heart failure, diastolic congestive heart failure, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 12/05/25 revealed Resident #83 had intact cognition and no history of behaviors or rejection of care. High risk drugs included medications from the antidepressant, anticoagulant, and opioid categories. Review of the active medication orders revealed Resident #83 had an order for pantoprazole sodium 40 milligrams (mg) delayed release granule tablets, one tablet via PEG-tube (percutaneous endoscopic gastrostomy tube, a tube that is inserted into the abdominal wall into the stomach with the help of a thin, flexible camera, that can be used for tube feeding, medication administration, and/or fluid administration) in the morning for GERD. Orders for scheduled respiratory medication included umeclidinium bromide inhalation aerosol powder breath activated 62.5 micrograms per actuation (mcg/ACT), inhale one puff orally in the morning for COPD and fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/ACT, inhale one puff inhale orally two times a day for COPD. Both inhalers included instructions to rinse the mouth with water and spit after each use. Further review of the medications revealed an order for acetaminophen 325 mg oral tablet, give two tablets by mouth or PEG tube every six hours as needed for pain. Review of the care plan dates 08/21/25 through 01/16/26 revealed Resident #83 had COPD. Interventions included giving bronchodilators and aerosols as ordered and documenting the effectiveness of these medications and any noted side effects. Further review of the care plan revealed Resident #83 was on pain management therapy and that analgesics (pain medications) were to be administered as ordered and documented and monitored for effectiveness and for side effects. The care plan also revealed that Resident #83 had GERD. Interventions included giving medications as ordered and observing for side effects and effectiveness. Observation on 01/14/25 between 9:05 A.M. and 9:50 A.M. revealed Licensed Practical Nurse (LPN) #177 prepared and administered Resident #83's morning medications, which consisted of one topical medication, one intravenous medication, and placing tablets or capsules into individual clear medication cups, each consisting of a different medication type that needed crushed or opened and dissolved prior to administration. The total number of medicine cups was 13, which was confirmed by LPN #177 at the time of the observation. During this observation, LPN #177 confirmed that one of the 13 medicine cups contained two tablets of acetaminophen, which Resident #83 had ordered as needed for pain, and the other 12 medicine cups contained the following: one zenpep Page 1 of 2 366431 366431 01/20/2026 Avenue at Aurora 425 South Chillicothe Road Aurora, OH 44202

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3,000-10,000-14,000-unit delayed release capsule, one bupropion hydrochloride (HCL) 75 mg tablet, one 0.6 mg colchicine tablet, one 5 mg Eliquis tablet, one 1,000 mcg folic acid tablet, one 37.5 mg metoprolol tablet, one 10 mg paroxetine HCL tablet, one 20 milliequivalent( mEq) potassium chloride tablet, two one gram (gm) sodium chloride tablets, one 100 mg thiamine HCL tablet, one vitamin D3 tablet, and one 25 mg hydroxyzine pamoate tablet. The medicine cups did not include the ordered pantoprazole 40 mg tablet that was to be administered each morning. The medications observed being prepared and administered did not include the two inhalers (umeclidinium bromide 62.5 mcg/ACT and fluticasone-salmeterol100-50 mcg/ACT). Review of the Medication Administration Record (MAR) dated 01/14/25 at 11:31 A.M. revealed a checkmark with the initials of LPN #177 in the boxes indicating that the morning doses of the 40 mg pantoprazole via PEG tube, one puff of umeclidinium bromide 62.5 mcg/ACT, and one puff of fluticasone-salmeterol100-50 mcg/ACT had been administered as ordered. Further review of the MAR revealed no documentation that acetaminophen, two 325 mg tablets, were administered to Resident #83 during the morning medication pass or documentation that Resident #83 indicated she expressed or exhibited signs of pain. Review of the progress notes revealed a linked electronic medication administration record (eMAR) note dated 01/14/25 indicating that Resident #83 received hydroxyzine pamoate 25 mg for anxiety at 10:57 A.M. (which was observed as administered between 9:05 A.M. and 9:55 A.M.). Interview on 01/14/25 at 3:20 P.M. with Resident #83 confirmed she had received Tylenol with her morning medications and since she had received an additional aerosol treatment earlier that morning, she did not want the two inhalers that were prescribed to be taken with the morning medication pass. Interview on 01/14/25 at 3:32 P.M. with LPN #177 confirmed two acetaminophen tablets were administered to Resident #83 during the observed morning medication pass for discomfort, but he must have forgotten to document the administration and reason for administration. At the time of the interview, LPN #177 confirmed there was no documentation of Resident #83 receiving acetaminophen since 12:36 A.M., during the previous shift. LPN #177 further confirmed that the two ordered inhalers (umeclidinium bromide 62.5 mcg/ACT and fluticasone-salmeterol100-50 mcg/ACT) were not given because resident had a breathing treatment earlier and typically refused the inhalers afterward. During the interview, LPN #177 confirmed that the MAR reflected that pantoprazole, umeclidinium bromide, and fluticasone-salmeterol were administered. LPN #177 could not recall whether pantoprazole was administered or not, though was able to recall the number of medicine cups counted during the observation was 13, not the expected 14. Review of the policy titled Medication Administration - General Guidelines, dated December 2017, revealed that the person who administered the medications to the resident was to document administration on the MAR, directly after the medication administration. Further review of the policy revealed that when a PRN (as needed) medication was administered, the date, time, and reason for the medication administration was to be documented upon administration. The policy also stated that if a medication was refused, the MAR should reflect that the medication was not given and the medical record was to include an explanatory note indicating the reason. 366431 Page 2 of 2