Inspection·July 19, 2024

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of the facility incident log, staff interview, and policy review, the facility failed to ensure an intravenous (IV) medication was administered as ordered. This affected one (#31) resident out of the three residents reviewed for medication administration. The facility census was 36. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/19/2020 with medical diagnoses of anoxic brain injury, chronic respiratory failure, dependence on respirator, and persistent vegetative state. Review of the medical record revealed Resident #31 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical record for Resident #31 revealed an annual Minimum Data Set (MDS) assessment, dated 04/23/24, which indicated Resident #31 was noncommunicable due to persistent vegetative state. The MDS indicated Resident #31 was dependent upon all staff for activities of daily living (ADL). Review of the medical record for Resident #31 revealed hospital discharge orders dated 06/11/24 for Avycaz (antibiotic) 2.5 grams IV every eight hours with end of treatment on 06/14/24. Review of physician orders revealed the resident had Avycaz 2.5 grams IV every eight hours for six administrations dated 06/14/24. Review of Resident #31's Medication Administration Record (MAR) revealed documentation to support Resident #31 received Avycaz as ordered until 06/16/24. Review of the medical record for Resident #31 revealed an Interdisciplinary Team (IDT) note on 06/14/24 at 1:53 P.M. which stated Resident #31 readmitted from the hospital on [DATE] with a diagnosis of chronic respiratory failure, anoxic brain damage, pseudomonas, and Klebsiella pneumonia. The note stated Resident #31 was ordered Avycaz for eight doses and one dose was given at the hospital before discharge and per Nurse Practitioner (NP) the first dose of the antibiotic could be administered at 10:00 A.M. when arrived from the pharmacy to the facility on [DATE]. The note continued to stated Resident #31 was noted to have a decrease in oxygen saturation throughout the night and pulmonologist group was notified and an order was received to increase oxygen to keep pulse oxygen saturation above 89% with oxygen at eight liters per tracheostomy mask, elevate head of bed, and order to continue Avycaz for six doses with flush orders. The note stated the guardian was notified and stat complete metabolic panel and complete blood count labs were obtained. The note stated NP stated no x-rays were needed as the facility is aware Resident #31 had pneumonia and pseudomonas and felt that facility needed to complete the antibiotic as ordered. Further review of the medical record for Resident (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 3 Event ID: 365527 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 365527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Springfield 1600 Saint Paris Pike Springfield, OH 45504 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)