Inspection·June 6, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure transfer/discharge notice was given to residents failed to ensure the ombudsman was notified for hospital admissions. This affected two (Resident #86 and Resident #71) of two residents reviewed for hospitalization during the annual survey. The census was 93. Findings include: 1. Medical record review for Resident #86 revealed an admission date of 01/04/19. Medical diagnoses included septicemia, diabetes, renal insufficiency, and cancer. Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #86 revealed he was cognitively intact. His functional status revealed he required extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of Resident #86's progress note dated 02/07/19 revealed Resident #86 was on a leave of absence. Further review of notes dated 02/22/19 revealed a re-admission to the facility from the hospital. The notes were silent for a transfer/discharge notice given to the resident. The record was also silent for notification to the ombudsman as well. Review of progress note dated 03/07/19 for Resident #86 revealed he was sent out to the hospital. Further review of note revealed no documented evidence of a transfer/discharge notification to the resident or notification to the ombudsman. Interview with the Administrator on 06/06/19 at 4:59 P.M., confirmed he did not give notification of transfer/discharge to Resident #86 or inform the ombudsman of the hospital admissions for the resident. 2. Review of Resident #71's medical record revealed an admission date of 04/30/14. The resident was admitted with diagnoses including [NAME] Disease, anxiety and depression. She was alert and oriented to self only. Review of Resident #71's MDS assessment revealed she was totally dependent on staff for activities of daily living. A care plan relative to her medical and psychological needs revealed individualized interventions with measurable goals. Review of resident #71's medical record revealed she was transported to the hospital on [DATE] and was admitted . She was a Medicaid bed hold. Interview on 06/05/19 at 11:00 A.M., with the Business Office Manager (BOM) #110 revealed a letter of discharge with appeal rights was not given to the resident or the residents representative. Review of the Discharge Planning Policy (no date) revealed procedures for residents returning to the community. The policy and procedures did not address the procedures for transferring a resident to another facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 2 of 7 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASSR) was completed timely. This affected one (Resident #72) of one Resident reviewed for preadmission screening. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #72's medical record revealed an admission date of 08/14/18 with pertinent diagnoses including epilepsy, developmental disorder of speech and language, difficulty in walking, unspecified lack of coordination, dysphagia, expressive language disorder, cough unsteadiness on feet, abnormal posture, disorder of bladder, fatty liver, and downs syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and required extensive assistance for bed mobility, transfer, walking in corridor dressing, and personal hygiene. Review of the medical record on 06/04/19 at 10:25 A.M. revealed Resident #72 had a notice of PASSR determination dated 08/14/18 indicating she was an emergency admission to the facility for a seven day period. The form indicated the nursing facility and county board shall assist the resident with alternative placement options, services, and resources prior to the completion of her nursing facility stay. Interview with the Social Services Designee (SSD) #305 on 06/04/19 at 1:05 P.M., verified Resident #72's nursing facility placement was only supposed to be for seven days and that she was still residing in the facility. She stated it was an oversight on the facility's part and they should have sent in a new PASSR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 3 of 7 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure the physician responded to a recommendation by the pharmacist for Resident #55 and #69. This affected two (Resident #55 and #69) of five residents reviewed for unnecessary medications during the annual survey, The facility census was 93. Findings include: 1. Medical record review for Resident #55 revealed an admission date of 10/22/17. Medical diagnoses included dementia and Parkinson's. Review of care plan dated 04/06/18 for Resident #55 revealed the resident used psychotic medications. The intervention was for the physician to consider a dosage reduction when clinically appropriate at least quarterly. Review of physician orders dated 11/07/18 revealed Resident #55 was prescribed Nuplazid 34 milligram (mg) (atypical anti-psychotic) medication. Review of note to the attending physician/prescriber (pharmacy recommendations) dated 03/20/19 revealed Resident #55 had been taking Nuplazid since 11/08/18. The document further indicated to please evaluate the potential for a dose reduction at that time to determine the lowest effective dose. If clinically contraindicated, please provide a brief note. The note was absent for addressing this medication. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely or never understood. Her functional status was limited assistance for bed mobility, transfers, supervision for eating and extensive assistance for eating. Interview with Quality Assurance Registered Nurse (QARN) #200 on 06/06/19 at 3:15 P.M., verified the physician should have addressed the pharmacy recommendations dated 03/20/19. 2. Medical record review for Resident #69 revealed an admission date of 11/06/18. Medical diagnoses included dementia, Alzheimer's and depression. Review of physician orders dated 11/06/18 for Resident #69 revealed Lexapro 20 mg daily for mood. Review of care plan dated 11/21/18 for Resident #69 revealed the resident used anti-depressant medications. The intervention was to monitor for opportunity to decrease or discontinue the medication. Review of note to the attending physician/prescriber dated 04/06/19 revealed Resident #69 had been taking Lexapro since 11/06/18. The recommendation further revealed to please evaluate the potential for a dose reduction at that time to determine the lowest effective dose. If clinically contraindicated, please provide a brief note. The note was absent for addressing this medication. Review of quarterly MDS dated [DATE] revealed Resident #69 was assessed with intact cognition. Her functional status included supervision for bed mobility, transfers, eating and she required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 4 of 7 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 extensive assistance for toileting. Level of Harm - Minimal harm or potential for actual harm Interview with QARN #200 on 06/06/19 at 3:20 P.M. verified the physician should have addressed the pharmacy recommendations dated 04/16/19. Residents Affected - Few Review of policy entitled Free from Unnecessary Psychotropic Medications/As Needed Use not dated revealed when evaluating the resident's progress, the attending physician should review the plan of care, orders, and the resident's response to the medications and decide whether to continue, modify, or stop a medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 5 of 7 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for Resident #55 and #69. The facility also failed to ensure Lorazepam was reviewed in 14 days and had an end date for Resident #237. This affected three (Resident #55, #69, and #237) of five residents reviewed for unnecessary medications during the annual survey, The facility census was 93. Findings include: 1. Medical record review for Resident #55 revealed an admission date of 10/22/17. Medical diagnoses included dementia and Parkinson's. Review of care plan dated 04/06/18 for Resident #55 revealed the resident used psychotic medications. The intervention was for the physician to consider a dosage reduction when clinically appropriate at least quarterly. Review of physician orders dated 11/07/18 revealed Resident #55 was prescribed Nuplazid 34 milligram (mg) (atypical anti-psychotic) medication. Review of the medical record revealed it was silent for a GDR for Nuplazid for Resident #55. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. Her functional status included limited assistance for bed mobility, transfers, supervision for eating and extensive assistance for eating. Interview with Quality Assurance Registered Nurse (QARN) #200 on 06/06/19 at 3:15 P.M., verified there wasn't a GDR attempted for Resident #55. 2. Medical record review for Resident #69 revealed an admission date of 11/06/18. Medical diagnoses included dementia, Alzheimer's and depression. Review of care plan dated 11/21/18 for Resident #69 revealed the resident used anti-depressant medications. The intervention was to monitor for opportunity to decrease or discontinue the medication Review of quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact. Her functional status included supervision for bed mobility, transfers, eating and extensive assistance for toileting. Review of physician orders dated 11/06/19 for Resident #69 revealed Lexapro 20 mg daily for mood. Review of the medical record for Resident #69 released it was silent for a GDR for Lexapro. Interview with QARN #200 on 06/06/19 at 3:20 P.M. verified there should have been GDR attempt for Lexapro for Resident #69. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 6 of 7 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of policy entitled Free from Unnecessary Psychotropic Medications/As Needed Use (undated) revealed after a prescribing physician has initiated a psychotropic medication , the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. 3. Review of medical record for Resident #237 revealed an admission date of 03/10/18. The resident was admitted with diagnoses including history of traumatic brain injury, mood disorder, major depression disorder and anxiety. Resident #237 was alert and oriented to person, place, and time and required one person assist with activities of daily living. A care plan relative to her medical and psychological needs revealed individualized interventions with measurable goals. Review of the Note to Attending Physician /Prescriber on 03/01/19 and 03/29/19 from the pharmacy requested Resident #237's physician to put a duration on the Lorazepam and to review the medication every 14 days and indicate why the medication was continually given as needed. Review of Resident #237's Medication Review Report from 04/01/19 to 06/01/19 revealed she was prescribed Lorazepam Tablet 0.5 milligrams (mg); one tablet by mouth every six hours as needed for anxiety with no end date. Review of Resident #237's medical record including the physician Progress Notes for Resident #237 revealed the physician did not review the medication every 14 days and did not indicate a rational as to why the medication was continually given as needed. Review of the Medication Administration Record revealed Resident #237 received the Lorazepam medication as needed 31 times between 04/01/19 and 06/01/19. On 06/04/19 at 02:53 P.M., interview with the QARN #200 confirmed the physician did not document the reason for the continuation of the medication Lorazepam. Review of the Free from Unnecessary Psychotropic Medications and as Needed Use Policy (no date) revealed as needed (prn) orders for psychotropic drugs will be limited to 14 days except if the attending or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he/she will document their rationale in the resident's medical record , indicate the duration for the PRN order, and evaluate the resident for the appropriateness of that medicine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 7 of 7