Inspection·October 21, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility's policy, and record review, the facility failed to accurately assess a resident on an anticoagulant for bruising. This affected one (#100) of four residents reviewed for skin integrity. The facility census was 110. Residents Affected - Few Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, and anemia in chronic kidney disease. Review of Resident #100's annual Minimum Data Set (MDS) assessment, dated 08/29/21, revealed the resident to be cognitively intact and the resident was on an anticoagulant. Review of Resident #100 physician orders revealed Resident #100 was ordered Apixaban (used to prevent serious blood clots) 2.5 milligrams (mg) one tablet by mouth two times a day related to paroxysmal atrial fibrillation on 06/30/21. Review of the resident's care plan, dated 08/31/21, revealed Resident #100 was at risk for bleeding due to Apixaban (Eliquis) related to atrial fibrillation. Interventions included to monitor signs and symptoms of bleeding including bruising. Review of Resident #100's bleeding potential assessments dated 10/18/21, 10/19/21, 10/20/21 and 10/21/21 revealed Resident #100 had no bruising. Review of Resident #100's progress note, dated 10/21/21 at 10:13 A.M., revealed Resident #100 had a bruise to her left wrist, five small areas on her left hand, right wrist and forearm and three on her right first finger. Resident #100 stated she had bruising all the time and has old scars on both forearms and hands. Resident #100 stated she bumps into things periodically. Resident #100 was on dialysis and received heparin during dialysis treatments. Observation and interview with Resident #100 on 10/18/21 at 11:26 A.M. revealed Resident #100 had multiple scattered bruises on her right and left arms and a large bruise approximately two inches long by one inch wide on her left arm near her wrist. Resident #100 stated she was on a blood thinner and that she had multiple bruises including the bruise to her left arm. Interview with the Director of Nursing (DON) on 10/21/21 at 12:15 P.M. verified Resident #100 had bruising on her left harm. The DON also verified Resident #100's bruising was not identified on 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 4 Event ID: 366185 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 366185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillspring Health Care & Rehab 325 East Central Avenue Springboro, OH 45066 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)