Health inspection·November 21, 2019

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 medical record review and staff interview; the facility failed to complete a level one preadmission screening and resident review (PASRR) prior to the 30th day following admission to the facility from the hospital. This affected one (#75) of one resident reviewed for preadmission screening and resident review. The census was 96. Residents Affected - Few Finding include: Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE]. Diagnoses include psychosis, congestive heart failure, hypertension, chronic kidney disease stage three, repeated falls, muscle weakness, hyperlipidemia, and arthritis. Review of the medical record for Resident #75 revealed a document titled, Hospital Exemption from Preadmission Screening Notification dated 10/19/19. Review of the document revealed the nursing facility accepted the admission of Resident #75 only after receipt and review of this notification form for 100 percent accuracy and completion. Further review of the document revealed the nursing facility accepted responsibility for requesting a resident review prior to the 30th day following admission from the hospital. Interview on 11/19/19 at 1:16 P.M. with social service director (SSD) #250 revealed the SSD was not aware of Resident #75's need for a level one prescreening. SSD #250 verified the level one PASRR was not completed prior to the 30th day following Resident #75's admission to the facility from the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 2 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview; the facility failed to develop and implement a person-centered comprehensive care plan related to anxiety and the use of antianxiety medication. This affected one (#77) of five resident reviewed for unnecessary medication. The census was 96. Findings include: Review of the medical record for Resident #77 revealed the resident was admitted to the facility on [DATE]. Diagnoses include anxiety, osteoarthritis, muscle weakness, major depressive disorder, hypokalemia, colitis, osteoporosis, constipation, vascular disorder of of intestines, polyneuropathy, insomnia, chronic embolism, and epilepsy. Review of a physician order start date 07/24/19, revealed Resident #77 had an order for Clonazepam (antianxiety medication) tablet 0.5 milligram (mg); administer 0.25 mg by mouth two times a day related to anxiety disorder. Review of a quarterly minimum data set (MDS) assessment assessment dated [DATE], revealed the resident was administered antianxiety medication on seven days during the seven day reference period. Review of Resident #77's medication administration record (MAR) dated 11/19, revealed the residents was administered Clonazepam two times a day as ordered by the physician. Review of the medical record for Resident #77 revealed there was no care plan developed to address Resident #77's diagnoses of anxiety. Continued review of the medical record revealed there was no care plan was developed to address the use of antianxiety medication. Interview on 11/21/19 at 11:54 A.M. with the Director of Nursing (DON) verified Resident #77 had a physicians order for and was being administered the antianxiety medication Clonazepam for the diagnoses of anxiety. The DON further verified there was no care plan developed to address anxiety or antianxiety medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 3 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, review of a physician notification sheet, observation and resident and staff interview, the facility failed to follow through with a nurse practitioners treatment recommendation. This affected one (#75) of one resident reviewed for infection. The census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE]. Diagnoses include psychosis, congestive heart failure, hypertension, chronic kidney disease stage three, repeated falls, muscle weakness, hyperlipidemia, and arthritis. Review of a nurse progress note dated 11/10/19 at 9:30 P.M. revealed Resident #75's right eye was red with swelling observed. Documentation revealed notification was left for the physician. Review of a physician notification sheet dated 11/10/19, revealed the nurse practitioner (NP) was notified of the resident having red swollen eye. Documentation revealed the resident was to have a warm compress as needed and continue to monitor. Review of the medical record for Resident #75 revealed there was no physician order for the warm compress and no evidence of the warm compress being offered or provided. Interview on 11/18/19 at 2:13 P.M. with Resident #75 revealed the resident right eye was bothering the resident. The resident revealed he/she reported the red/irritated eye to staff many days ago but there had been no follow up from the staff. Resident #75 revealed the right eye was not painful but was very irritated. Observation during the interview revealed Resident #75's right eye sclera was red. The resident's lower eye lid appeared to be drooping and red. Interview on 11/19/19 at 1:23 P.M. with Registered Nurse (RN) #245 revealed Resident #75's right eye had been red and irritated since admission to the facility. RN #245 verified the resident did not have a treatment or medication orders for the treatment of the residents red/irritated eye. Interview on 11/20/19 at 10:30 A.M. with the Director of Nursing (DON) revealed on 11/10/19 a notification was placed on the physician notification sheet to notify the the physician of Resident #75's right eye being assessed as red and swollen. Continued interview with the DON revealed on 11/12/19 the nurse practitioner (NP) addressed the notification with an order for warm compress as needed and continue to monitor. Interview with the DON verified the warm compress treatment was missed by staff. Further interview with the DON revealed the nurse practitioner was made aware of the missed order for the warm compress 11/19/19. The DON revealed a new order was received for an eye ointment as needed and to continue the warm compress orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 4 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 and resident and staff interview, the facility failed to ensure a residents dialysis access site was accurately assessed and documented in the medical record. This affected one (#27) of one residents reviewed for dialysis. The census was 96. Residents Affected - Few Findings include: Review of Resident #27's medical record revealed and admission date of 06/18/17. Diagnose included hypertension, chronic kidney disease, atrial fibrillation, and type II diabetes mellitus. Resident #27's was assessed as being cognitively intact in a Minimum Data Set (MDS) dated [DATE]. Further review revealed Resident #27 had a dialysis catheter to her right upper chest. Review of progress notes dated 10/21/19 at 3:59 P.M. revealed there was positive auscultation of bruit and positive palpation of thrill in a right upper chest arteriovenous (AV) fistula. Review of progress notes dated 10/22/19 at 6:36 P.M. revealed there was positive auscultation of bruit and positive palpation of thrill in a right upper extremity (LUE) arteriovenous (AV) fistula. Review of progress notes dated 11/04/19 at 6:47 P.M. revealed that Resident #27's AV fistula to her right upper chest was palpated for thrill and auscultated for bruit, no bleeding was noted. Interview with Resident #27 on 11/20/19 at 7:33 A.M. revealed she did not have an AV fistula to neither her LUE or left upper chest. A dialysis catheter was observed to Resident #27's right upper chest. Interview with the Director of Nursing (DON) and Registered Nurse (RN) #175 on 11/20/19 confirmed that Resident #27 did not have and had never had an AV fistula. Both the DON and RN #175 confirmed that assessment of an AV fistula was inaccurately assessed/documented. Both confirmed that a dialysis catheter could not be assessed for bruit and thrill. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 5 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 interview, and policy review, the facility failed to prime an insulin flex pen to ensure the accurate dose was administered. This affected one (#79) of one resident observed for the administration of insulin. The census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus type two, low back pain, chronic kidney disease, chronic obstructive pulmonary disease, and diabetic neuropathy. Review of a physician order dated 07/28/19, revealed Resident #79 was to be administered insulin aspart solution per pen-injectors 100 units per milliliter; inject subcutaneously three times a day as per sliding scale: if finger stick blood sugar was 0-150 administer 0 units; 151-200 give administer two units; 201-250 administer four unit; 251-300 administer six units; 301-350 administer eight units; 351-400 administer 10 units; 401-450 administer 12 units and anything over 450 call the physician. Observation on 11/20/19 at 6:16 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #150 was preparing a Novolog flex pen to administer two units of insulin to Resident #79 for a finger stick blood sugar (FSBS) result of 185. The LPN cleansed the tip of the flex pen with an alcohol swab and screwed the pen needle on to the pen. LPN #150 then dialed up two units of insulin, cleansed Resident #79's skin with an alcohol swab, and administered the insulin. There was no observation of LPN #150 priming the flex pen prior to dialing up the two unit dose and administering the insulin. Interview on 11/20/19 at 6:19 P.M. with LPN #150 verified the insulin flex pen was not primed prior to the administration of the insulin to Resident #79. Review of the policy titled, Insulin Pen Administration Instructions revision date 08/31/16, revealed the flex pen was to be primed with two units of insulin prior to dialing up and administering the prescribed dose of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 6 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 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, observation, resident and staff interview, and review of an employee competency checklist, the facility failed to ensure a resident consumed medications that were administered. This affected one (#27) of 22 residents reviewed during stage two of the annual survey. The census was 96. Findings include: Review of Resident #27's medical record revealed and admission date of 06/18/17. Diagnose included hypertension, chronic kidney disease, atrial fibrillation, and type II diabetes mellitus. Resident #27's was assessed as being cognitively intact in a Minimum Data Set (MDS) dated [DATE]. During an interview with Resident #27 on 11/20/19 at 7:30 A.M. medicine cup with a pill inside was observed on top Resident #27 beside chest of drawers. Resident #27 stated she needed more water to take the pill. Inside the medicine cup one pink oval shaped pill was observed. Interview with Licensed Practical Nurse (LPN) #150 on 11/20/19 at 7:32 A.M. confirmed she had left the pill with Resident #27 to take. LPN #150 identified the pill as Protonix (gastrointestinal reflux medication). LPN #150 stated Resident #27 had already eaten when she went to give her the Protonix. Further review of Resident #27's medical record revealed an order dated 10/12/19 for Protonix 40 milligrams (mg) to be given by mouth one time a day. Review of a facility document titled Skills Competency Checklist-Medication Administration dated April 2013 revealed nurse remains till medications are swallowed. Medications are not left at bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 7 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the infection control logs, staff interview and policy review, the facility failed to have an adequate infection control surveillance program in place to ensure proper monitoring as required. This had the potential to affect all 96 residents residing in the facility. Facility census was 96. Residents Affected - Many Findings include: Review of infection control logs/surveillance information for September 2019 revealed multiple missing areas of documentation which included; a lack of all organism being tracked to ensure adequate trending to identified and prevent the spread of infections. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control logs/surveillance information for October 2019 revealed no organism were identified tracked and trended to identified and prevent the spread of infections. There was documentation of percentages of antibiotic used and percentages of infections. There was a color coded map of infection but no documentation of organism to ensure tracking and trending was accurate. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control log/surveillance for November 2019 lacked any documented information related to infections, organisms or antibiotic use. On 11/20/19 at 4:27 P.M. and interview with Infection Preventionist #200 revealed he acquired the infection control position in September 2019. He then verified the September 2019 infection control logs/surveillance were incomplete to ensure proper tracking and trending of infections. He then verified he does not have the log started for October 2019 to ensure proper tracking and trending of infections. Infection Preventionist #200 verified the Antibiotic Stewardship Program to monitor the use for the antibiotic is not being followed up on when ordered per the physician to ensure it is prescribed for the proper organism or type of infection on a consistent basis following McGeer's criteria for September 2019 and October 2019. He also revealed he was just starting to review antibiotic use, and track and trend infections for November 2019 but had no documentation to provide. The facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of policy and procedure for infection control overview revised 11/02/16 documented the primary purpose for of the infection control plan was to establish guidelines to follow in preventing, identifying, reporting, investigating, and controlling the spread of contagious, infection or communicable diseases. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 8 of 9 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 365422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing & Rehabilitation Center One Country Lane Brookville, OH 45309 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of infection control logs, staff interview and policy review, the facility failed to have an adequate antibiotic stewardship program in place to ensure proper antibiotic usage as required. This had the potential to affect all 96 residents residing in the facility. Facility census was 96. Residents Affected - Many Findings include: Review of infection control logs/surveillance information for September 2019 revealed multiple missing areas of documentation which included; a lack of all organism being tracked to ensure adequate trending to identified and prevent the spread of infections. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control logs/surveillance information for October 2019 revealed no organism were identified tracked and trended to identified and prevent the spread of infections. There was documentation of percentages of antibiotic used and percentages of infections. There was a color coded map of infection but no documentation again of organism to ensure tracking and trending was accurate. Further review of the antibiotic use was not completed to ensure it appropriately use for the identified infection to meet the requirements for antibiotic stewardship program on a consistent basis. Review of infection control log/surveillance for November 2019 lacked any documented information related to infections, organisms or antibiotic use. On 11/20/19 at 4:27 P.M. an interview Infection Preventionist #200 with revealed he acquired the infection control position in September 2019. He then verified September 2019 infection control logs/surveillance were incomplete to ensure proper tracking and trending of infections. He then verified he does not have the log started for October 2019 to ensure proper tracking and trending of infections. Infection Control Preventionist #200 verified the Antibiotic Stewardship Program to monitor the use for the antibiotic is not being followed up on when ordered per the physician to ensure it is prescribed for the proper organism or type of infection on a consistent basis following McGeer's criteria for September 2019 and October 2019. He also revealed he was just starting to review antibiotic use, and track and trend infections for November 2019 but had no documentation to provide. The facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of policy and procedure for antibiotic stewardship dated 10/17/19 documented the review of antibiotics is a vital aspect of the infection prevention and control program. Further review revealed surveillance of antibiotic use is ongoing to include trends, outcome and patterns will be conducted. The facility will review the use of antibiotics for the appropriateness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365422 If continuation sheet Page 9 of 9