Health inspection·November 1, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure medications were not prepared prior to administration. This affected three (#03, #04, and #13) out of three residents reviewed for medication administration. The facility census was 54. Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 10/26/24 with medical diagnoses of anemia, thrombocytopenia, morbid obesity, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the medical record for Resident #03 revealed an admission assessment dated [DATE] which indicated Resident #03 was cognitively intact. Review of the medical record for Resident #03 revealed a Functional Abilities assessment, dated 10/28/24, which revealed Resident #03 required set-up assistance with eating, toilet hygiene, bathing, bed mobility, and transfers. 2. Review of the medical record for Resident #04 revealed an admission date of 06/14/24 with medical diagnoses of Alzheimer's disease, atrial fibrillation, hypertension, and depression. Review of the medical record for Resident #04 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/01/24, which indicated Resident #04 had severe cognitive impairment and required partial/moderate staff assistance with bathing, bed mobility, and transfers, and supervision with toilet hygiene. 3. Review of the medical record for Resident #13 revealed an admission date of 06/29/21 with medical diagnoses of chronic respiratory failure, spinal bifida, depression, anxiety, and bipolar disorder. Review of the medical record for Resident #13 revealed a quarterly MDS assessment, dated 08/08/24, which indicated Resident #13 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene, bathing, bed mobility and transfers. Observation with interview on 11/01/24 at 9:03 A.M. revealed Licensed Practical Nurse (LPN) #200 was standing at the medication cart on 400 Hall with three medication pill cups filled with medications sitting on top of her cart. The observation revealed each medication cup was labeled with Resident #03, #04, and #13 names. Interview with LPN #200 confirmed she had prepared the medications for Page 1 of 2 366464 366464 11/01/2024 Springs of Lima The 370 North Eastown Road Lima, OH 45807

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #03, #04, and #13 while standing at the nurse's station and stated she was going to bring the medications to the resident's rooms. Review of the facility policy titled, Medication Administration, revised November 2018 stated medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. The policy stated when mediations are administered by mobile cart and taken to the resident's location (room, dining room, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 366464 Page 2 of 2