Health inspection·July 14, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and facility policy review, the facility failed to ensure one resident's (#24) scheduled narcotic analgesic medication (Oxycodone) was available for administration. This affected one ( Resident #24) of three residents reviewed for scheduled narcotic analgesic medication. The facility identified five residents receiving scheduled narcotic analgesic medication. The facility census was 43. Findings Included: Review of the medical record for Resident #24 revealed an initial admission date of 03/15/22 with the admitting diagnoses including anorexia, severe protein-calorie malnutrition, hypothyroidism, hyperlipidemia, depression, psychosis, anemia, hypertension, adult failure to thrive, chronic pain, essential tremor, spinal stenosis lumbar region, unilateral post-traumatic osteoarthritis left him and generalized muscle weakness. Review of the plan of care dated 03/28/23 revealed the resident had a diagnoses of arthritis and was at risk for pain. Interventions included administer medications as ordered, evaluate/record effectiveness, evaluate/report adverse side effects, notify physician as needed, observe for and record any non-verbal signs of pain, observe and record verbal and non-verbal signs and symptoms of pain, offer rest periods as needed, position for comfort with physical support as necessary and provide assistance with activities of daily living (ADL) as needed. Review for the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident did not receive scheduled, as needed or non-medication interventions for pain. The assessment indicated the resident has almost constant pain that interfered with sleep and day to day activities. The assessment indicated the resident rated her pain at an eight with zero being no pain and 10 being the worst pain. Review of the monthly physician orders for July 2023 identified orders dated 05/20/22 for Meloxin 15 milligrams (mg) by mouth daily, 07/06/22 Oxycodone 5 mg by mouth every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the resident's progress notes revealed on 05/25/23 at 7:32 P.M. a call was placed to the on call Nurse Practitioner (NP) for a new script for the medication Oxycodone and requested to be sent to the pharmacy. Review of the progress note dated 05/27/23 at 7:39 A.M. revealed the nurse has explained to the Page 1 of 3 366480 366480 07/14/2023 Taylor Springs Health Campus 748 Taylor Road Gahanna, OH 43230

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident she would not be able to receive the scheduled 12:00 A.M. dose of the medication Oxycodone. The nurse explained to the resident the pharmacy was drop shipping the medication and would not authorize her to pull from the medication from emergency box. The resident insisted she could not miss the does and would like to speak to the Director of Nursing (DON). The nurse explained she was unable to do anything about the situation and the medication would arrive early in the morning. She received the scheduled 6:00 A.M. dose of Oxycodone 5 mg at 5:05 A.M. more than 11 hours following the last dose of Oxycodone 5 mg by mouth. Review of the May 2023 Medication Administration Record (MAR) revealed on 05/27/23 at 12:00 A.M. the medication Oxycodone 5 mg was charted as being unavailable. On 07/14/23 at 12:28 P.M., interview with the Director of Nursing (DON) confirmed Resident #24 missed the 12:00 A.M. dose of Oxycodone 5 mg on 05/27/23 due to unavailability. Review of the facility policy titled, Specific Medication Administration Procedures, dated 11/18 revealed administer medications in a safe and effective manner. This deficiency represents non-compliance investigated under C#OH00143434. 366480 Page 2 of 3 366480 07/14/2023 Taylor Springs Health Campus 748 Taylor Road Gahanna, OH 43230

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection when a staff nurse prepared two residents (#3 and #5) morning medications using bare hands and administered the medications to the residents. This affected two ( Resident #3 and #5) of four residents observed for medication administration. The facility census was 43. Residents Affected - Few Findings Included: On 07/14/23 at 8:51 P.M., observation of Licensed Practical Nurse (LPN) #199 prepare Resident #3's morning medication revealed the LPN popped the medications Atrovastatin 40 milligrams (mg), Cefdinir 300 mg, Clindamycin 300 mg, Lisinopril/HCTZ 20-12.5 mg and Metoprolol 25 mg from the blister packet into her hand and placed them into a clear plastic medication cup. The LPN then administered the medications to Resident #3. On 07/14/23 at 9:12 A.M., observation of LPN #199 prepare Resident #5's morning medication revealed the LPN popped the medications Alphalipoic 300 mg, Lipitor 40 mg, Cephalexin 500 mg, Coenzyme 200 mg, Eliquis 5 mg po, Entresta 24-26 mg, Farxiga 10 mg, Lopressor 100 mg, Pamelor 10 mg, Zoloft 25 mg and Lyrica 150 mg from the blister packet into her hand and placed them into a clear plastic medication cup. The LPN them administered the medication to Resident #5. On 07/14/23 at 9:20 A.M., interview with LPN #199 confirmed the medications were touched with bare hands and administered to Resident #3 and #5. Review of the facility policy titled, Specific Medication Administration Procedures, dated 11/18 revealed administer medications in a safe and effective manner. 366480 Page 3 of 3