Health inspection·November 21, 2023

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 review, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#134) out of the three residents reviewed for medications. The facility census was 129. Findings included: Review of the medical record for Resident #134 revealed an admission date of 03/16/22 with medical diagnoses of hypothyroidism, end stage renal disease, dependence on dialysis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/17/23 which indicated Resident #134 was cognitively intact. The MDS indicated Resident #134 required limited staff assistance with bed mobility and extensive staff assistance with transfers, toileting, dressing, and bathing. Review of the medical record for Resident #134 revealed a physician order, dated 08/16/23, for ipratropium-albuterol inhalation aerosol 20-100 microgram (mcg) per actuation (act), one inhalation by mouth three times per day on Monday, Wednesday, and Fridays for COPD. Review of the medical record for Resident #134 revealed a Medication Administration Record (MAR) for October 2023 which did not contain documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/23/23, and 10/27/23. Review of the MAR for November 2023 revealed no documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23. Interview on 11/20/23 at 11:05 A.M. with Resident #134 confirmed the nursing staff administer her medications and that she had not received her ipratropium-albuterol inhalation medication as ordered. Resident #134 stated she was told by the nursing staff that the medication had not been delivered by the pharmacy. Resident #134 denied any medical concerns related to not receiving the ipratropium-albuterol inhalation medication as ordered. Interview on 11/20/23 at 3:00 P.M. with Director of Nursing (DON) confirmed Resident #134 had the ipratropium-albuterol aerosols ordered Monday, Wednesday and Friday routinely and an as needed medication for use other days/times. The DON confirmed Resident #134 did not receive the ipratropium-albuterol aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23. DON stated the pharmacy changed the medication from an inhaler administration to nebulizer (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 11/21/2023 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)