Health inspection·June 30, 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** #3: Record review of Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, cognitive communication deficit, restlessness and agitation, and acute psychosis. She had an active order for 25 milligrams of Seroquel (an antipsychotic) to be given twice per day as needed (PRN) for behaviors including hitting, scratching, and screaming. The order was dated 12/02/21. A psychiatric service visit dated 05/26/22 noted her PRN seroquel order was to be continued. The surveyor could not find evidence the PRN seroquel was specifically reviewed and renewed every 14 days. Record review of Resident #23's medication administration record revealed she received the PRN seroquel twice in April 2022 on 04/11/22 and 04/15/22, and no times in May or June 2022 as of the time of the record review. Review of a pharmacy record review for Resident #23 dated 01/28/22 revealed the pharmacy recommendation that the PRN Seroquel order be made to only last 14 days, and to be renewed every 14 days. The provider checked 'disagree' on the response list at the bottom and wrote to continue the medication as-ordered. Review of the facility's psychotropic medication policy dated 03/01/21 revealed antipsychotic medications were limited to 14 days and could not be renewed unless the physician evaluated the resident for appropriateness for another 14 days. The surveyor confirmed the above findings with the Director of Nursing on 06/29/22 at 10:25 A.M. 2. Review of the medical chart for Resident #3 revealed an admission date of 03/15/22. Diagnoses include but not limited to vascular dementia without behavioral disturbance, torticollis, and brachial plexus disorders. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/22/22, revealed Resident #3 had severely impaired cognition and required extensive assistance with two staff for activities of daily living except eating required supervision with set up only. Review of the physician's orders for June 2022 revealed Resident #3 was ordered 1.0 milligrams (mg) of lorazepam on 03/16/22 for muscle spasm as needed (PRN) with a maximum dose of three tablets with no stop date. Interview on 06/30/22 at 8:07 A.M. with Registered Nurse (RN) #538 verified that there was no stop date for lorazepam PRN. Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. Based on record reviews and interviews the facility failed to ensure as needed medication orders for psychotropic drugs were limited to 14 days. This affected three (Residents #3, #23, and #34) of six residents reviewed for unnecessary medication. The census at the time of the survey was 90 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365581 If continuation sheet Page 2 of 3 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 365581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Breckenridge Village 36855 Ridge Rd Willoughby, OH 44094 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 residents. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1.Record review for Resident #34 revealed the resident was readmitted to the facility on [DATE]. Pertinent diagnoses for the resident included unspecified dementia, other dissociative and conversion disorders, cognitive communication deficit, chronic pain, anxiety disorder, and major depressive disorder. The brief interview for mental status (BIMS) from MDS dated [DATE] revealed the resident had a score of five indicating severe cognitive impairment. Review of physician orders for Resident #34 revealed on 03/09/22 the physician had ordered the antipsychotic medication Seroquel one 50 milligram (mg) tablet by mouth every six hours as needed (PRN) for unspecified dementia with behavioral disturbance with no end date. The medication administration record (MAR) for Resident #34 was reviewed for the month of June 2022 and had documented administrations of the PRN antipsychotic medication Seroquel as followed: one administration on 06/04/22, one administration on 06/05/22, one administration on 06/10/22, one administration on 06/20/22, one administration on 06/24/22, and one administration on 06/28/22. The facility failed to provide evidence the physician had reviewed the continued and frequent use of the PRN psychotic medication for Resident #34. No evidence was presented to confirm the 14 day re-assessment and reorder interval was completed. These findings were verified during interview with the Director of Nursing on 06/29/22 at 10:21 A.M. Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365581 If continuation sheet Page 3 of 3