Inspection·March 12, 2025

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, review of hospital documentation, staff interview, nurse practitioner interview, and facility policy review, the facility failed to ensure residents received medications as ordered which resulted in a significant medication error. This affected one (#72) of three residents reviewed for medication administration. The facility census was 69. Residents Affected - Few Findings Included: Review of the medical record for Resident #72 revealed an admission dated of 12/13/24. Diagnoses included displaced intertrochanteric fracture of the left femur, hemiplegia, hemiparesis following cerebral infarction affecting the left dominant side, hypertensive chronic kidney disease, tachycardia, and personal history of transient ischemic attack. The resident was discharged on 12/27/24. Review of a hospital Discharge summary dated [DATE] revealed Resident #72 was admitted to the hospital on [DATE] for a fracture to the left hip after suffering a fall. Resident #72 had surgery and a post open reduction and internal fixation (ORIF) with transfemoral nails. Resident #72's active problems included systemic lupus erythematosus, chronic kidney disease, transient ischemic attack, nonrheumatic aortic valve insufficiency, carotid stenosis bilateral, anti-phospholipid syndrome, tachycardia, palpitations, hypertension, intertrochanteric fracture of the left femur, and valvular heart disease. Further review revealed the resident was discharged with orders for the anticoagulant medication warfarin (Coumadin) five (5) milligrams (mg) with instructions to take one tablet by mouth for two days. It was indicated Resident #72 required 7.5 mg of warfarin. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, required set up help for meals, supervision for oral care, toileting hygiene, dressing the upper body, and personal hygiene, and required partial to moderate assistance for putting on and off footwear, bathing, and dressing the lower body. Review of physician orders dated 12/26/24 revealed Resident #72 had an order for a one time dose of warfarin 7.5 mg at 1:30 P.M. Review of the December 2024 medication administration record (MAR) revealed Resident #72 only received a one time dose of warfarin 7.5 mg on 12/26/24 at 1:30 P.M. for the resident's entire stay at the facility. Review of a progress note dated 12/27/24, written by Licensed Practical Nurse (LPN) #229, revealed the indication for Resident #72 to use warfarin was a prior to history of transient ischemic attack (TIA). (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: 366245 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 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 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)