Heritagespring Healthcare Center Of West Chester

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

During an interview on 09/17/25 at 2:31 P.M., Registered Nurse (RN) #5 stated the pharmacy notified the facility if a medication was missing, when an order required clarification, or a new prescription was needed.

RN #5 stated the facility communicated the needs as soon as possible or had pharmacy contact the physician for a prescription. RN #5 further stated it was critical for medications to be delivered timely, particularly when they were not available in the Pyxis. On 09/17/25 at 3:15 P.M., Unit Manager (UM) #3 stated that upon admission, medication orders were sent to the pharmacy, and pharmacy usually delivered

the medications the same night. UM #3 stated that if the medication was not in the Pyxis, the nurse must call the pharmacy, and delivery typically occurred within two hours. He stated for Resident #149, the prescribed hypnotic was not available, and the nurse documented the pharmacy was notified. During an

interview on 09/17/25 at 3:57 P.M., the Director of Nursing (DON) stated the best practice was to have signed prescriptions available on admission so staff could fax them to the pharmacy and have medications delivered that evening. The DON stated that she was not aware that Resident #149's medication had not been available. The DON stated the facility contacted an on-call nurse practitioner (NP) who called the pharmacy and gave an order for three zolpidem; however, neither staff nor pharmacy called to get another prescription. She stated it was not the facility's standard not to administer medications. The DON stated that

she expected staff to call the physician and get a prescription or reach out to her to assist so they could give the resident their medication.During a telephone interview on 09/19/25 at 10:06 A.M., Pharmacist #25 stated that when prescriptions were needed, the pharmacy contacted the provider. Per Pharmacist #25, on 05/25/25, they contacted the physician and received an electronic prescription from the on-call provider for

a three-day supply. Pharmacist #25 further stated she did not see evidence of follow-up with the provider until a fascimilie (fax) was sent on 05/27/25. Pharmacist #25 stated they received a valid prescription on 06/02/25 and 10 pills were delivered to the facility. On 09/18/25 at 8:13 A.M., the Administrator stated that regarding Resident #149's medication, they expected the pharmacy to either send the medication or notify

the facility if assistance was needed to obtain a prescription.Review of a facility policy titled, Ordering of Drugs (i.e. [id est, that is] Receiving Drug Orders from the Pharmacy, dated 01/2023, indicated, the purpose of exercising control in the ordering of drugs is to assure that the pharmacist dispenses and labels medications properly, assure correct financial responsibility and prompt delivery of drugs. Any shortage or irregularity with the order is documented and made known to the pharmacist on call by telephone.This deficiency represents non-compliance investigated under Complaint Number OH00166335 (1394611).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Heritagespring Healthcare Center of West Chester

7235 Heritagespring Drive West Chester, OH 45069

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)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

treatment options and opted for no cardiopulmonary resuscitation (CPR), no intubation, and conservative management. During an interview on [DATE REDACTED] at 11:33 A.M., the Lead Administrator stated the facility was notified that Resident #148 expired. During an interview on [DATE REDACTED] at 12:43 P.M., RN #16 stated she was

the nurse who made the mistake with Resident #148's medication orders on admission to the facility. She stated for resident admissions they reviewed orders uploaded into PCC. However, RN #16 stated that there was an old medication list uploaded for Resident #148 and since the resident was going to be admitted soon, she called the transferring facility and asked them to fax a medication list. She stated she entered the medication orders from the fax but did not notice that pages were missing. When the resident arrived at the facility, the resident's family brought a packet that contained a copy of the same orders that had been faxed.

She stated that she documented that the orders were verified with NP #360. RN #16 also stated that within 24 hours a unit manager double-checked the order. During an interview on [DATE REDACTED] at 9:39 A.M., NP #360 stated that upon admission, medications were reviewed and verified within 24 hours. NP #360 stated she reviewed Resident #148's medication orders and conducted a chart review but did not notice the missing fax. Resident #148's diagnosis of atrial fibrillation would not have triggered her to think the resident should be on Eliquis or any kind of anticoagulant due to the resident's age and other co-morbidities. NP #360 stated she recalled that after the resident was sent to the hospital, they discovered the resident was not receiving a blood thinner. Resident #148 had multiple co-morbidities that contributed to the development of pulmonary emboli on [DATE REDACTED], and not receiving Eliquis did not help but it was hard to say definitively that it caused the resident's death. During an interview on [DATE REDACTED] at 11:13 A.M., the ADON stated the admission nurses were responsible for transcribing orders, ensuring all pages and orders were received, and verifying orders with Medical Director (MD) #550. There were transcription errors regarding Resident #148 but he could not provide additional details. During an interview on [DATE REDACTED] at 1:03 P.M., the DON stated the facility did not receive the complete admitting orders for Resident #148, and there was a transcription error because there were missing pages in the fax. Her expectation was that nurses verify all pages were received. During an interview on [DATE REDACTED] at 1:57 P.M., MD #550 stated he was familiar with Resident #148 and the incident. MD #550 confirmed the resident did not receive Eliquis while at the facility. He stated that

he could not say with 100 percent certainty that not getting Eliquis caused the resident's pulmonary embolism. During an interview on [DATE REDACTED] at 11:29 A.M., the Administrator stated the hospital notified the facility of the medication error. They found that the even pages of the fax were missing. The Administrator stated that two nurses reviewed Resident #148's orders as required per protocol and the supervisor reviewed the resident's medical record the next day and no one caught the error. During a follow-up

interview on [DATE REDACTED] at 1:18 P.M., the Administrator stated that Resident #148 had a missing medication order. The Administrator stated he expected staff to review orders, ensuring all pages were received at the time of admission. Review of a facility policy titled, Practitioner Order Transcribing/Posting, revised 03/2025, indicated for Admitting Orders staff should review hospital transfer forms/paperwork and enter admit medication/ancillary orders in the EMR. Medication orders include medication name, dose, route of administration, and frequency. Staff should also verify the admission orders with the attending physician/NP/physician assistant and print an order recapitulation report after orders are verified and place copy in chart. Review of a facility policy titled, Administration Oral Medications, revised 11/2024, revealed

the facility will ensure patients are given medication per the physician orders. If there are any issues with physician orders, the nurse will contact the physician for clarification. This deficiency represents non-compliance investigated under Complaint Number OH00165685 (1394609).

Event ID:

Facility ID:

If continuation sheet