Health inspection·May 31, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, policy review and interview, the facility failed to ensure Resident #1 was free from a significant medication error. This affected one (Resident #1) of three residents reviewed for infections. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 09/03/23 with diagnoses of Alzheimer's disease, staphylococcal arthritis right knee, anxiety disorder, delirium, mood disorder, and infection and inflammatory reaction due to internal right knee prothesis. Review of the communication with physician note dated 04/07/23, timed 10:21 A.M. revealed Physician #5 was updated to right knee being red and very warm in comparison to surrounding skin. Resident #1 complained of discomfort to the area. Physician #5 ordered labs and to start doxycycline (an antibiotic) 100 milligrams (mg) by mouth twice a day for 14 days. Review of the April 2023's physician orders revealed doxycycline hyclate 100 mg give one tablet by mouth two times a day for a possible infection right knee for 14 days. Review of the antibiotic therapy care plan, revised on 04/11/23 revealed Resident #1 was on antibiotic therapy related to possible right knee infection with an intervention to administer antibiotic medications as ordered by physician. Review of the April 2023 Medication Administration Record (MAR) revealed Resident #1 was administered doxycycline 100 mg beginning the evening of 04/07/23. Doxycycline 100 mg was administered during the morning and evening medication pass of 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, 04/13/23 and 04/14/23. There was a 9 on the morning and evening medication pass slots of 04/15/23 indicating to other/see progress notes signed with the initials of agency Licensed Practical Nurse (LPN) #6 in each slot. Review of the orders - administration note dated 04/15/23, timed 4:52 P.M., authored by agency LPN #6 revealed doxycycline hyclate tablet 100 mg give one tablet by mouth two times a day for possible infection right knee for 14 days. 04/14/23 was 14 days. Review of the orders - administration note dated 04/15/23, timed 4:53 P.M., authored by Agency LPN #6 revealed doxycycline hyclate tablet 100 mg give one tablet by mouth two times a day for possible infection right knee for 14 days. 04/14/23 was 14 days. Review of Physician #5's progress note dated 04/23/23 revealed Resident #1 had fatigue and joint (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: 366281 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 366281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483 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)