Health inspection·October 27, 2022

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 review of facility policy, the facility failed ensure a resident was free from unnecessary psychotropic medications by ensuring staff documented justification for an increase in a resident's antipsychotic medication. This affected one (#117) of five reviewed for unnecessary medications. The census was 239. Findings include: Review of Resident #117's medical record revealed an admission date of 03/06/20. Diagnoses listed included cerebral atherosclerosis, heart failure, restlessness and agitation, depression, and dementia with agitation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117's brief interview for mental status (BIMS) score was 12, indicating the resident had moderate cognitive impairment. Resident #117 was assessed as not having any psychotic disorders. Review of physician orders revealed an order to increase the antipsychotic medication Seroquel from 25 milligrams (mg) twice a day to 50 mg twice a day (BID) by mouth (PO) dated 04/15/22 for unspecified dementia with behavioral disturbance. Resident #117 remained on Seroquel 50 mg PO BID with an order dated 09/10/22. Review of social services progress notes dated 03/14/22 revealed Licensed Social Worker (LSW) met with Resident #117's daughter via telephone. Resident #117 was adjusting favorably to new living environment with no changes in mood or behavior. Review of physician assistant (PA) progress notes dated 04/15/22 revealed Resident #117 had cerebral atherosclerosis with behaviors and was evaluated for delusions. Resident #117's daughter stated her mother had increased delusions, distressed, and tearful. Resident #117's daughter said many things her mother is saying are not based on reality, such as her spouse is cheating, etc. Resident #117 is currently on Seroquel 25 mg PO BID. Review of an facility internal email dated 04/14/22 from Licensed Social Worker (LSW) #9 to members of the Interdisciplinary Team (IDT) members revealed LSW #9 spoke with Resident #117's daughter who expressed concerns regarding her mother's demeanor, citing that Resident #117 had become increasingly delusional, distressed, and tearful. Resident #117's daughter reported Resident #117 says many things that are not based in reality (such as spouse is cheating on her) and wanted the physician to (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: 365493 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 365493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village 6451 Far Hills Avenue Dayton, OH 45459 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)