Inspection·October 19, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and review of a policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#10) of one residents observed for medications. The census was 130. Findings include: Review of the medical record of Resident #10 revealed an admission date of 07/27/23. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side, anxiety, and depressive disorder. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #10 was assessed with severely impaired cognition. Review of the October 2023 medication administration record (MAR) revealed Resident #10 was ordered the pain medication aspirin 81 milligrams (mg) one tablet, the supplement levothyroxine 137 micrograms (mcg) one tablet, the supplement selenium 200 mcg one tablet, the supplement vitamin D3 125 mcg one tablet, the antianxiety medication alprazolam 0.25 mg one tablet, the supplement magnesium 500 mg two tablets, the blood pressure medication metoprolol succinate 50 mg one capsule, the supplement sodium chloride one (1) gram one tablet, and the antidepressant venlafaxine 25 mg one tablet. Observation on 10/18/23 at 9:15 A.M. revealed a small plastic medication cup with 10 unidentified tablets and capsules sitting on Resident #10's breakfast tray. Further observation revealed Resident #10 was eating in her room. Interview on 10/18/23 at 9:15 A.M. with Resident #10 revealed the resident could not identify any of the medications in the medication cup on her breakfast tray, but stated she thought she was supposed to take them. Observation and interview on 10/18/23 at approximately 9:30 A.M. with Registered Nurse (RN) #200 verify the medications that were left at Resident #10's bedside. Review of the facility policy titled, Administration Oral Medications, dated December 2021, revealed the nurse administering the medication must remain with the resident until the medicine was swallowed. (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: 366388 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 366388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonespring of Vandalia 4000 Singing Hills Bvld Dayton, OH 45414 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)