Inspection·August 14, 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, staff and resident interview, and policy review, the facility failed to ensure residents were free of any significant medication errors. This affected one resident (#12) of three residents reviewed for medication administration. The facility census was 57. Residents Affected - Few Findings included: Review of the medical record for Resident #12, revealed the resident was admitted on [DATE]. Medical diagnoses included cerebral infarction (stroke), cancer, neurogenic bladder, diabetes, and psychotic disorder. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 05/08/23 for Resident #12, revealed the resident was cognitively intact. Review of the active physician orders for Resident #12, revealed the resident was ordered to receive the following 6:00 A.M. medications: Aspirin 81 (over the counter pain relief) milligram (mg) daily in the morning, Furosemide (diuretic) 20 mg daily in the morning, Gabapentin (nerve pain) 300 mg every eight hours, and Tizanidine (muscle relaxer) 4 mg every hours Lactobacillus (probiotic) one capsule daily, Loratadine (anti-histamine)10 mg daily, Multiple Vitamin daily, Potassium Chloride (supplement) 10 milliequivalents daily in the morning, Vitamin-C 1000 mg daily, Metformin (treatment for diabetes) 1000 mg twice daily, Review of the Medication Administration Record (MAR) dated 07/14/23 at 6:00 A.M. for Resident #12, revealed LPN #117 administered Aspirin 81 mg, Furosemide 20 mg, Lactobacillus, Loratadine 10 mg, Multiple Vitamin, Potassium Chloride 10 milliequivalents, Vitamin C 1000 mg, Metformin 1000 mg, Gabapentin capsule 300 mg, and Tizanidine 4 mg. Review of the nurse's progress note entered as a late entry for 07/14/23 at 10:43 A.M. for Resident #12 authored by LPN #117, revealed the resident was given her 6:00 A.M. medications twice. Two nurses worked the shift and shared the B hall on the second floor. The first-floor nurse (LPN #58) came up and passed medications to the entire hall and LPN #117 was not aware. Note indicated the two nurses were believed to be splitting the hallway as they had previously done. All parties were notified. Resident #12's vital signs were blood pressure 98/56, pulse 70 and oxygen saturation was 92 to 94 percent. Review of the nurse's progress note dated 07/14/23 at 11:09 A.M. for Resident #12 and authored by LPN #73, revealed the resident's brother (guardian) was notified and asked for the resident to be sent to the hospital. Resident #12 refused to go to the hospital and stated she felt fine. Physician (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: 365738 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 365738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Fairfield 3801 Woodridge Boulevard Fairfield, OH 45014 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)