Inspection·May 28, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record reviews, staff and resident interviews, review of a facility medication error report, and facility policy review, the facility failed to administer medications as ordered. This affected one( #15) resident out of three residents reviewed for medications administration. The facility census was 117. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/10/25 with medical diagnoses of pulmonary hypertension, disorder of the autonomic nervous system, left hemiplegia, and atrial fibrillation. Review of the medical record for Resident #15 revealed an admission MDS assessment, dated 04/16/25, which indicated Resident #15 was cognitively intact and required partial/moderate staff assistance for eating, was dependent upon staff for toilet hygiene, and bathing, and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #15 revealed a communication form, dated 05/16/25 at 12:00 A.M., which stated Resident #15 was administered Meclizine (antihistamine) via percutaneous endoscopic gastrostomy (peg) tube in error around 10:30 P.M. The form stated Resident #15 had no adverse reaction, vital signs were taken, and Nurse Practitioner (NP) and family were notified of the medication error. Orders were given to monitor Resident #15. Review of the medical record for Resident #15 revealed no documentation to support an order for Meclizine. Review of the facility Medication Error Report, dated 05/16/25, stated on 05/15/25 Resident #15's roommate, Resident #16, had requested his Meclizine. The report stated the nurse administered the Meclizine to Resident #15 instead of Resident #16 and that Resident #15 did not have an order for Meclizine. The report stated the NP was notified and an order to monitor Resident #15 was given. Interview on 05/28/25 at 1:44 P.M. with Resident #15 confirmed he was given Resident #16's Meclizine by mistakes a few weeks ago. Resident #15 stated he had some dizziness afterwards but no residual effects from the medication administration error. Interview on 05/28/25 at 2:21 P.M. with Administrator confirmed Resident #15 was given the wrong medication on 05/15/25 and that staff education was provided. Administrator stated Resident #15 did not have a negative outcome from medication error. (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: 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 05/28/2025 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)