Inspection·March 21, 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** Based on medical record review, staff interview, review of the facility policy, and review of an online medication resource, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #10) of three residents reviewed for medication administration. The census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 05/31/23 with diagnoses including malignant neoplasm of endometrium, heart disease, chronic kidney disease, and anemia. Review of physician's orders for Resident #10 revealed an order dated 11/29/23 for Afinitor (an anti-cancer drug) 7.5 milligrams (mg) one tablet by mouth once daily for treatment of malignant neoplasm of the endometrium. Review of the complete blood count (CBC) laboratory test results for Resident #10 dated 02/01/24 revealed the resident's hemoglobin (a lab value which indicates the level of red blood cells in the body) level was 6.5 grams per deciliter (g/dL). A normal level was 12.1 to 15.1 g/dL for females. Per review of the progress note for Resident #10 dated 02/01/24 per Agency Nurse (AN) #110 revealed the resident's physician called an order to the facility to withhold Afinitor 7.5 mg until notified by the office to resume. The physician also gave an order to draw a CBC laboratory test on 02/05/24 and call the physician's office with the results so they could determine if it was appropriate to restart the Afinitor. Review of the CBC laboratory test results for Resident #10 dated 02/05/24 revealed the resident's hemoglobin level was 6.4 g/dL. Review of the Medication Administration Record (MAR) for Resident #10 dated February 2024 revealed the resident's Afinitor was withheld on the following dates: 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/06/24. The medication was signed off as administered on the following dates: 02/07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24. Review of the CBC laboratory test results for Resident #10 dated 02/13/24 revealed the resident's hemoglobin level was 5.6, and the resident was sent to the hospital for an evaluation due to the low hemoglobin level. Review of the hospital notes for Resident #10 revealed the resident was admitted to the hospital on [DATE] with a diagnosis of acute on chronic anemia and her hemoglobin level was 5.6 g/dL. The (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: 365864 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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)