Health inspection·August 9, 2024

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 medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (Resident #40) of the three residents reviewed for medication administration. The facility census was 130. Findings include: Review of the medical record for Resident #40 revealed an admission date of 07/09/24 with medical diagnoses of local infection of skin, diabetes mellitus, morbid obesity, Chronic Obstructive Pulmonary Disease (COPD), hypothyroidism, and hyperlipidemia. Review of the medical record for Resident #40 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #40 was cognitively intact and was independent with eating and bed mobility, required partial/moderate staff assistance with toilet hygiene, and supervision with transfers. Review of the medical record for Resident #40 revealed physician orders dated 07/09/24 for apixaban 5 milligram (mg) one tablet by mouth two times per day and metformin 500 mg give 0.5 tablet by mouth two times per day, an order dated 07/16/24 for lactobacillus one tablet two times per day, an order dated 07/26/24 for metoprolol 25 mg one tablet by mouth two times per day, and an order dated 08/06/24 for Lasix 40 mg one tablet by mouth daily. Review of the medical record for Resident #40 revealed a Medication Administration Record (MAR) for August 2024 which revealed documentation to support Resident #40 had received the morning doses of apixaban, Lasix, lactobacillus, metformin and metoprolol on 08/09/24. Observation and interview on 08/09/24 at 9:56 A.M. of Resident #40 revealed Resident #40 sitting in a wheelchair with bedside table in front of his chair. The observation revealed a medication cup with five pills in the cup. Resident #40 stated the nurse had brought his morning medications in a while ago and he had not taken them yet. Interview on 08/09/24 at 10:10 A.M. with Registered Nurse (RN) #212 confirmed Resident #40 had a medication cup with medications in the cup sitting on his bedside table. RN #212 stated she had left Resident #40's morning medications sit at the bedside and had not watched Resident #40 consume the medications. (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 08/09/2024 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)