Health inspection·August 16, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review and interview, the facility failed to ensure medications were administered timely according to physician orders. This affected one resident (#75) out of three residents reviewed for medication administration. The facility census was 72. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date of 06/28/23 and a discharge date of 07/05/23. Diagnoses included seizures, bipolar disorder, asthma, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), acute pyelonephritis, anxiety disorder, old myocardial infarction, history of transient ischemic attack (TIA), and tobacco use. Review of Resident #75's physician orders revealed an order for Atorvastatin 40 milligram (mg) (statin to treat high cholesterol) once a day at 7:00 P.M. to 11:00 P.M., Diphenoxylate-Atropine tablet 2.5 - 0.025 mg (medication to treat diarrhea) give two tablets four times a day (QID) at 7:00 A.M. to 11:00 A.M., 12:00 P.M., 2:30 P.M. and 4:00 P.M. to 6:30 P.M., and Meclizine 12.5 mg (medication to treat motion sickness) at 7:00 P.M. to 11:00 P.M. Review of Resident #75's medication administration records (MAR) for June 2023 revealed Atorvastatin 40 mg once a day at 7:00 P.M. to 11:00 P.M. Diphenoxylate-atropine tablet 2.5 - 0.025 mg between 4:00 P.M. to 6:30 P.M. and between 7:00 P.M. to 11:00 P.M., and Meclizine 12.5 mg tablet, and Meclizine 12.5 mg between 7:00 P.M. to 11:00 P.M. were not administered on 06/28/23 as ordered by the physician. Review of the documents titled, Prescription Order, revealed the orders were entered into the system on 06/28/23 at 11:25 A.M. by Registered Nurse (RN) #193. Review of Resident #75's progress notes dated 06/28/23 at 3:34 P.M. revealed RN #193 entered the mediation and vital signs orders in the matrix. Review of Resident #75's progress note dated 06/29/23 at 11:58 A.M. revealed the Director of Nursing (DON) contacted the physician to notify no medications were administered on 06/28/23 as ordered by the physician. (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 6 Event ID: 366434 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 366434 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224 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)