Health inspection·May 1, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, and staff interview, the facility failed to residents were free from significant medication errors. This affected two (Resident #23 and Resident #34) out of three residents reviewed for medications. The facility census was 72. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed admission date of 02/16/23 with diagnoses including but not limited to malignant neoplasm of rectum, chronic kidney disease stage two, congestive heart failure, and celiac disease. Review of the Minimum Data Set (MDS) assessment, dated 04/22/24, revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders revealed an order for capecitabine (medication used to treat cancer) 500 milligrams (mg) by mouth, give three tablets one time a day seven days on and seven days off for cancer treatment, and give two tablets by mouth at bedtime seven days on and seven days off for cancer treatment. The order had a start date of 02/24/24. Review of Resident #23's Medication Administration Record (MAR) for March 2024 revealed capecitabine 500 mg was documented as not available on 03/28/24 evening shift and 03/29/24 evening shift. Review of the nurse's note, dated 03/29/24, revealed the nurse spoke with the pharmacy about Resident #23's capecitabine. The pharmacy stated the medication will be out on the next run. The nurse stressed the importance of the medication. The pharmacy stated he would have to wait until after 7:00 A.M. to request a refill when the pharmacist comes in but he would call with any questions. Review of Resident #23's nurse's notes revealed there were no nurses notes regarding notification of the physician that the capecitabine was unavailable. Interview with Resident #23 on 05/01/24 at 11:36 A.M. revealed the facility ran out of her medication on one occasion. Interview on 05/01/24 at 2:49 P.M. with Registered Nurse (RN) #705 verified Resident #23's capecitabine was documented as not available on 03/28/24 evening shift and 03/29/24 evening shift. RN #705 verified there was no documentation the physician was notified. Interview on 05/01/24 at 3:55 P.M. with the Director of Nursing (DON) revealed Resident #23 had a pharmacy supply and home supply of cancer medication and it should not have run out. The DON stated (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 2 Event ID: 365374 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 365374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432 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)