Inspection·December 5, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital discharge orders, staff interview and review of medication information from Medscape, the facility failed to ensure a resident received anticoagulant medications as physician ordered resulting in significant medication errors. This affected one (#10) of three residents reviewed for medication administration. Facility census was 65. Residents Affected - Few Findings include: Review of medical record for Resident #10 revealed admission date of 10/30/23. Diagnoses include atherosclerosis of native arteries of extremities with intermittent claudication in bilateral legs, peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Resident #10 was discharged on 11/02/23 to the emergency room, and then discharged home. Review of Resident #10's five-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. He was independent for eating, bed mobility, clean up assistance for toileting, partial to moderate assistance for transfers. Review of the hospital admitting orders revealed an order for Enoxaparin Sodium (anticoagulant) inject 0.7 milliliters (ml) under the skin every 12 hours. Warfarin (anticoagulant) five mg tablet, take one and a half tablets on Monday, Wednesday and Friday. Warfarin five mg tablet, take one tablet on Sunday, Tuesday, Thursday and Saturday. Review of the physician orders revealed no order for Enoxaparin. An order with a start date of 11/01/23 for Warfarin five mg one and half tablets every Monday, Wednesday and Friday. An order 11/02/23 on for Warfarin five mg in the evening of Tuesday, Thursday, Saturday and Sunday. Review of the November 2023 Medication Administration Record (MAR) revealed no documentation Warfarin had been given. Additionally, there was no documentation regarding the administration of Enoxaparin. Interview on 12/05/23 at 1:51 P.M. with the Director of Nursing (DON) revealed it was reported to her Resident #10 had been upset with staff regarding his medications. The DON stated upon review it was discovered Resident #10's medications had not been ordered properly upon his admission. The DON verified Resident #10's admission medications were not initiated upon as prescribed, and he did not receive Enoxaparin Sodium or Warfarin as ordered. Review of medication information from Medscape (at (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: 365426 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 365426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors West 375 West Main Street West Jefferson, OH 43162 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)