Health inspection·September 13, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 the comprehensive Minimum Data Set (MDS) 3.0 assessments were completed accurately. This affected five residents (Residents #10, #29, #34, #40, and #61) of six residents reviewed for pain and anxiety medication usage. The facility census was 102. Residents Affected - Some Findings Include: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, cardiogenic shock, diabetes, heart disease, and partial paralysis of the left side after a stroke. Review of the physician's orders for Resident #10 revealed an order dated 08/31/23 for Oxycodone (a narcotic pan medication) 5 milligrams (mg) every eight hours as needed for pain. Attempt and document non-pharmacological interventions dated 08/31/23. Review of the comprehensive 5-day MDS assessment for Resident #10, dated 09/08/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the Director of Nursing (DON) on 09/11/23 at 11:50 A.M. revealed MDS #205 was new to the facility and confirmed the pain assessment of the Health Conditions section was not completed. 2. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, end stage renal disease, diabetes, hypertension, a stroke, gout, and arthritis. Review of the physician's orders for Resident #29 revealed an order dated 06/23/23 for Hydrocodone-Acetaminophen 5-325 mg (a narcotic pain medication) every six hours as needed for pain. Attempt and document non-pharmacological interventions. Review of the comprehensive quarterly MDS assessment for Resident #29, dated 07/26/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the DON on 09/11/23 at 11:50 A.M. revealed MDS #205 was new to the facility and confirmed the pain assessment of the Health Conditions section was not completed. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including a stroke, diabetes, a cardiac pacemaker, a history of falls. Review of the physician's orders for Resident #34 revealed an order dated 10/31/22 for Lyrica 75 mg (a controlled substance used to treat pain) every 12 hours routinely for pain. Attempt and document non-pharmacological interventions. Page 1 of 6 365604 365604 09/13/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the comprehensive quarterly MDS assessment for Resident #34, dated 06/28/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the DON on 09/11/23 at 11:50 A.M. revealed MDS #205 was new to the facility and did not complete the pain assessment of the Health Conditions section. Residents Affected - Some 4. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. Review of the physician's orders for Resident #40 revealed an order dated 08/14/23 for Oxycodone 5 mg every four hours as needed for pain. Attempt and document non-pharmacological interventions. Review of the comprehensive quarterly MDS assessment for Resident #40, dated 07/13/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the DON on 09/11/23 at 11:50 A.M. revealed MDS #205 was new to the facility and did not complete the pain assessment of the Health Conditions section. 5. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, congestive heart failure, and end stage renal disease. Review of the physician's orders for Resident #61 revealed an order dated 06/27/23 for Oxycodone 5 mg every eight hours as needed for pain. Attempt and document non-pharmacological interventions. Review of the comprehensive quarterly MDS assessment for Resident #61, dated 08/14/23, section J Health Conditions revealed the pain assessment section was not completed. Interview with the DON on 09/11/23 at 11:50 A.M. revealed MDS #205 was new to the facility and did not complete the pain assessment of the Health Conditions section. This deficiency represents non-compliance investigated under Complaint Number OH00145822. 365604 Page 2 of 6 365604 09/13/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

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 staff interview, record review, and pharmacy dispensing records the facility failed to implement a gradual dose reduction for psychotropic anxiety medication as ordered. This affected one resident (Resident #84) of six residents reviewed for controlled substance usage. The facility census was 102. Findings Include: Medical review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia without behavioral disturbance, arthritis, autistic disorder, bipolar disorder, anxiety, and glaucoma. Review of the physician's orders for Resident #84 revealed an order dated 08/09/21 for Ativan (a psychotropic anti-anxiety medication) 0.5 milligrams (mg) orally every evening at bedtime. On 08/07/23 an order was written to decrease the dosage to 0.25 mg every evening at bedtime. Review of the August 2023 Medication Administration Record (MAR) for Resident #84 revealed the Ativan 0.25 mg dosage was administered at bedtime from 08/07/23 through the end of the month. Review of the September 2023 MAR also indicated Resident #84 received the Ativan through 09/12/23. Review of the pharmacy dispensing records for Licensed Practical Nurse (LPN) #220 and LPN #221 from 08/01/23 through 09/11/23 revealed both nurses pulled Ativan 0.5 mg from the facility's medication dispensing machine for Resident #84. Review of the narcotic sign out sheet for Resident #84's Ativan 0.5 mg revealed only three times during that time period was 0.25 mg wasted and the correct dose administered. Interview with the Director of Nursing on 09/12/23 at 12:10 P.M. confirmed the nurses providing care to Resident #84 had administered the incorrect dose of Ativan from 08/07/23 through the present. The pharmacy had not been notified the psychiatric provider had decreased Resident #84's dose of Ativan to 0.25 mg orally at bedtime. Only three times in that time span was the correct dose administered. This deficiency represents non-compliance investigated under Complaint Number OH00145822. 365604 Page 3 of 6 365604 09/13/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and staff education, the facility failed to document why as needed pain medications were being administered and what non-pharmacological interventions were attempted prior to administering pain medication. This affected six residents (Residents #10, #29, #45, #61, #65 and #97) of six residents reviewed for pain medication documentation. The facility census was 102. Findings Include: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, cardiogenic shock, diabetes, heart disease, and partial paralysis of the left side after a stroke. Review of the physician's orders for Resident #10 revealed an order dated 08/31/23 for Oxycodone (a narcotic pan medication) 5 milligrams (mg) every eight hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the Medication Administration Record (MAR) for Resident #10 for August and September 2023 revealed the prompts for pain location and non-pharmacological interventions attempted were not answered. Review of the progress notes for Resident #10 in July and August 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Interview with the Director of Nursing (DON) on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. 2. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, end stage renal disease, diabetes, hypertension, a stroke, gout, and arthritis. Review of the physician's orders for Resident # 29 revealed an order dated 06/23/23 for Hydrocodone-Acetaminophen 5-325 mg (a narcotic pain medication) every six hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the MAR for Resident #29 for August and September 2023 revealed the prompts for pain location and non-pharmacological interventions attempted were not answered. Review of the progress notes for Resident #29 in August and September 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Interview with the DON on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. 365604 Page 4 of 6 365604 09/13/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including end stage renal dialysis, injury to the right quadriceps muscle, fascia, and tendon, hypothyroidism, and diabetes. Review of the physician's orders for Resident #45 revealed an order dated 06/23/23 for Hydrocodone-Acetaminophen 5-325 mg every six hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the MAR for Resident #45 for July and August 2023 revealed the prompts for pain location and non-pharmacological interventions attempted were not answered. Review of the progress notes for Resident #45 in July and August 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Interview with the DON on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. 4. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes, congestive heart failure, and end stage renal disease. Review of the physician's orders for Resident #61 revealed an order dated 06/27/23 for Oxycodone 5 mg every eight hours as needed for pain. Attempt and document non-pharmacological interventions. Review of the MAR for Resident #61 for August and September 2023 revealed the prompts for pain location and non-pharmacological interventions attempted were not answered. Review of the progress notes for Resident #61 in August and September 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Interview with the DON on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. 5. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including arthritis, artificial right hip joint, gout, hypertension, and anxiety. Review of the physician's orders for Resident #65 revealed an order dated 06/27/23 for Oxycodone 5 mg every six hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the MAR for Resident #65 for July, August and September 2023 revealed the prompts for 365604 Page 5 of 6 365604 09/13/2023 Green Meadows Skilled Nursing and Rehab 7770 Columbus Road NE Louisville, OH 44641

F 0842 pain location and non-pharmacological interventions attempted were not answered. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes for Resident #65 in July, August and September 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Residents Affected - Some Interview with the DON on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. 6. Medical record review revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, hypothyroidism, diabetes, depression, anxiety, chronic pain, osteoarthritis, end stage renal failure dependent on renal dialysis, and chronic obstructive pulmonary disease. Review of the physician's orders for Resident #97 revealed an order dated 08/28/23 for Oxycodone-Acetaminophen 5-325 mg (a narcotic pain medication) every six hours as needed for pain and to attempt and document non-pharmacological interventions. Review of the MAR for Resident #65 for July, August and September 2023 revealed the prompts for pain location and non-pharmacological interventions attempted were not answered. Review of the progress notes for Resident #65 in July, August and September 2023 revealed no documentation regarding pain or non-pharmacological interventions attempted. Interview with the DON on 09/06/23 at 9:40 A.M. revealed one of the first things she did after starting the job this past June was provide education to the nurses on medication documentation and posted the information in the narcotics book as a reminder. Interview with the DON on 09/12/23 at 1:14 P.M. confirmed nurses were not documenting pain location and non-pharmacological interventions attempted prior to administering pain medicine. Review of the undated education in-service revealed for as needed medications staff were to answer the prompts regarding pain level, location, and non-pharmacological interventions attempted. This deficiency represents non-compliance investigated under Complaint Number OH00145822. 365604 Page 6 of 6