Health inspection·June 17, 2021

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a physician reviewed and responded to pharmacy reviews. This affected three (#47, #80 and #42), out of five residents reviewed for pharmacy reviews. The facility's census was 84. Findings included: 1. Medical record review for Resident #47 revealed an admission date of 08/21/19. Diagnoses included chronic obstructive pulmonary , bipolar disease, major depressive disorder, edema, cerebrovascular, chronic respiratory failure, obstructive sleep apnea, anxiety disorder, anemia, polyneuropathy, insomnia, and type II diabetes. Review of Resident #47's Minimum Data Set Assessment 3.0 (MDS) revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating Resident #47 was cognitively impaired. Review of Resident #47's pharmacy reviews revealed on 01/31/21, the pharmacist made a recommendation to evaluate the need for Trazodone and Wellbutrin. On 04/28/21, the pharmacist made a recommendation to evaluate the need for Abilify. The recommendations were blank showing no evidence the physician reviewed the medications. Interview on 06/16/21 at 3:47 P.M. the Administrator verified there was no evidence the physician reviewed the pharmacy recommendations for Resident #47. 3. Review of the medical record for Resident #42 revealed and admission date of 01/21/20. Diagnoses included anxiety disorder, altered mental status, major depressive disorder severe with psychotic symptoms, difficulty walking, long term drug therapy, urinary retention, unspecified dementia with behavioral disturbance, cognitive communication deficit, cerebral infarction, gait and mobility abnormalities, insomnia, hypertension, hyperlipidemia and muscle weakness. Review of the quarterly MDS for Resident #42 dated 04/08/21 revealed a Brief Interview for Mental Status (BIMS) of seven indicating severe cognitive impairment. Review of Resident #42's pharmacy recommendation dated 07/27/20 revealed the pharmacist requested a gradual dose reduction (GDR) for the prescribed Remeron (antidepressant) 15 milligrams (mg) orally at bedtime. The pharmacy recommendation contained no information for any physician acknowledgement and/or signature. The pharmacy recommendation dated 08/27/20 revealed the pharmacist requested a GDR for the prescribed Trazodone (antidepressant) 75 mg orally every day. The pharmacy recommendation was contained no information for any physician acknowledgement and/or signature. Continued review of the pharmacy recommendations revealed on 01/31/21 a GDR was requested for Remeron 15 mg orally every night. The pharmacy recommendation contained handwriting to decrease the Remeron to 7.5 mg orally at bedtime with a physician signature but was not dated by the physician. Review of the physician orders subsequently revealed the medication was not decreased until 03/04/21 which was 32 days after the pharmacist recommendation. On 02/24/21 the pharmacist recommended a GDR for Sertraline (antidepressant) 125 mg by mouth daily and Aripiprazole (antipsychotic) five mg orally daily. The physician declined and signed the recommendations on 04/15/21 which was 50 days after the medication review was completed by the pharmacist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 2 of 5 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/16/21 at 3:45 P.M. with the Administrator confirmed the monthly medication reviews contained no information for the physician addressing the dosage reductions and/or not being completed in a timely fashion from the date of the pharmacy review. The Administrator reported the pharmacy reviews should have been addressed by the prescribing physician for the identified medications. Review of the facility policy titled, Pharmaceutical Services dated 05/2017 revealed the pharmacist must report any irregularities to the attending Physician, the facility's Medical Director and the Director of Nursing. 2. Review of the medical record for Resident #80 revealed an admission date of 02/28/18. Diagnoses included hemiplegia and hemiparesis, mood disorder and anxiety disorder. Review of the MDS for Resident #80 dated 05/28/21 revealed the resident was assessed as being severely cognitively impaired. Review of the Consultant Pharmacist's Medication Regimen Review from dated 07/28/20 for Resident #80 revealed the resident currently has a as needed order for Hydroxyzine 25 milligrams (mg) by mouth twice daily for anxiety. If the medication is to continue, please provide the following documentation, which is required as part of the CMS Requirements of Participation Guidelines: 1. Specific duration of therapy: there was no response; 2. Rationale for the extended time period: there was no response. There was no signature or any kind of documentation the physician had reviewed this document. Further review date of 10/01/20 revealed per the guidelines for managing psychotropic drug therapy, the following medications are due for an evaluation for continued use: Buspar 15 mg by mouth three times a day and Zoloft 150 mg by mouth three times a day , please evaluate and consider a gradual dose reductions for the above medications and check the appropriate response. There was not a response from the physician. Interview on 06/16/21 at 3:47 P.M. the Administrator verified there was no evidence the physician reviewed the pharmacy recommendations for Resident #80. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 3 of 5 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and physician interview, review of the facility policy and review of medication information from Medscape, the facility failed to ensure all contraindicated medications were not crushed prior to administration resulting in a significant medication error. This affected one (#85) out of five residents reviewed for medication administration. The current census is 84. Residents Affected - Few Findings include: Review of Resident #85's medical record revealed the resident had been admitted to the facility on [DATE]. Diagnoses include hemiplegia, hyperlipidemia, occlusion of stenosis of right artery, chronic obstructive pulmonary disease, bipolar disorder, dysphagia, depression, and heart failure. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident did not have a cognitive score coded in the MDS. Review of Resident #85's physician orders revealed on 06/01/21 the resident was ordered to receive Potassium Chloride 20 milliequivalents, (meq), extended release tablets. Review of Resident #85's physician orders revealed the physician ordered on 05/30/21 it was ok to crush medications, unless contraindicated. Review of Resident #85's progress notes dated 06/14/21 revealed nurse took resident medications, applied nicotine patch to right arm, lidocaine patch to lower back, and Bio-freeze to rest of back with sister's assistance with resident. This nurse was informed pills needed to be in applesauce and potassium crushed, this was accommodated and resident had no difficulty. Observation on 06/15/21 at 8:10 A.M. of Licensed Practical Nurse (LPN) #133 administering medications to Resident #85 revealed the nurse separated the Potassium Chloride 20 meq tablet from the other oral medications. LPN #133 was observed crushing the Potassium Chloride tablet and putting it into applesauce. Interview on 06/15/21 at 8:15 A.M. with LPN #133 revealed the nurse explained Resident #85 will not take her Potassium Chloride unless the pill is crushed. LPN #133 stated there was a physician order to crush the Potassium Chloride tablet. Interview on 06/16/21 at 3:55 P.M. with the Primary Physician #9 stated Potassium Chloride extended release tablets are contraindicated to be crushed. Per the physician another form of potassium should be offered instead of crushing the potassium tablet. Interview on 06/16/21 at 11:40 A.M. with the Administrator and the Director of Nursing (DON) verified Resident #85 receives Potassium Chloride extended release tablet orally once a day. Per the DON the potassium tablet should not be crushed. DON verified the resident and her family requested the medication be crushed. The DON stated the facility pharmacy does have liquid potassium available. Review of the facility's policy/protocol titled, 'Skill Competency Check List', dated 04/2013 revealed all resident's receiving crushed medications will have a physician order. Review of medication information from Medscape revealed crushing extended-release tablets is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 4 of 5 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 recommended. This destroys their extended-release delivery mechanism and may result in potentially toxic peaks and low troughs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 5 of 5