Inspection·September 5, 2019

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident and staff interview, the facility failed to provide residents with adequate assistance with personal hygiene. This affected two (Resident #51 and #63) of two reviewed for activities of daily living. The total facility census was 78. Residents Affected - Few Findings include: 1. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease and dementia with behavioral disturbance. Review of the admission Minimum Data Set (MDS) assessment, dated 08/02/19, revealed the resident has severe cognitive impairment, no delusions, hallucinations but did wander daily. The resident was coded to require extensive assistance with personal hygiene. Review of Resident #51's care plan revealed the resident required extensive assist with hygiene. The care plan indicated the resident has left sided weakness due to a past cerebrovascular accident and staff were to assist the resident with his hygiene. The interventions included under bathing to check nail length and trim and clean on bath days and as necessary. Review of progress notes revealed the resident had not refused care from staff other than one note stating he had gone to the barber shop and then decided he did not want a hair cut. Observation of Resident #51 on 09/03/19 at 12:04 P.M. revealed the resident's fingernails had dark colored substance under the nails on the right hand and the fingernails were long on both hands. Interview with Resident #51 on 09/04/19 at 11:00 A.M. stated his nails were longer than he desired, and verified that no one had offered to trim his nails for him. Observation of Resident #51 and interview with Licensed Practical Nurse (LPN) #464 at 09/05/19 at 8:24 A.M. revealed the resident had long fingernails with dark substance under the nails. The LPN confirmed the nails were long and had a dark colored material under the nails and stated the staff would trim and clean the nails. Resident #51 stated that would be ok. Interview with LPN #464 on 09/05/19 at 8:27 A.M. revealed daily care included staff examining resident fingernails, and the staff were allowed to trim the nails if they were found to be long. The nurse stated the resident nails should be kept trimmed and clean. 2. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, glaucoma and hyponatremia. Review of the admission Minimum Data Set (MDS) assessment, dated 08/13/19, revealed the resident was cognitively impaired and had no delusions, hallucinations or behaviors. The resident was coded as requiring extensive assistance for personal hygiene. Review of the resident's care plan revealed the resident had a self care performance deficit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 2 of 6 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to her dementia indicating the resident required assistance with personal hygiene assistance from the staff. Review of the progress notes revealed the resident had only one refusal of a shower documented on 08/16/19 at 7:24 P.M. The medical record was silent to the resident refusing to be shaved by the facility staff. Observation of Resident #63 on 09/03/19 at 10:49 A.M. revealed the resident had hair on the edges of the resident mouth and on the resident's chin. Subsequent observations of Resident #63 on 09/04/19 at 8:30 A.M. and on 09/05/19 at 8:27 A.M. revealed the resident was noted to have excessive facial hair on the edges of her mouth and chin. Interview with Licensed Practical Nurse #464 on 09/03/19 at 10:49 A.M. confirmed the resident had excessive hairs on her chin and at the sides of her mouth. The LPN stated as part of morning cares the residents should be shaved and not have long facial hairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 3 of 6 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety disorder and major depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident was noted to have taken seven doses of antianxiety, antidepressants and antipsychotic medications. Residents Affected - Few Review of the care plan, revised on 07/25/19, revealed the resident received antianxiety, antidepressant and antipsychotic medications and placed the resident at risk for drug related adverse reactions. Interventions included to administer medications as ordered and implement behavior interventions. Monitor for adverse effects of antidepressant, antianxiety and antipsychotic medications. Monitor and record occurrence of target behavior symptoms such as yelling, inappropriate response to verbal communication, aggression towards staff/others. Monitor/report any changes that may suggest dose may need adjusted. Review of the physician orders for the month of 09/2019 revealed the resident had an order for Abilify (antidepressant) two milligrams (mg.) daily for depression, buspirone (antianxiety) five mg. daily, clonazepam (antianxiety) 0.5 mg. twice daily and Trazadone (schizophrenia) 50 mg. daily. Review of the nurse's notes from 08/01/19 through 09/05/19 revealed no evidence of any behaviors with interventions used. It also lacked any documentation of monitoring for the possible medication side effects. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 08/01/19 through 09/05/19 lacked any documentation of behavior monitoring or monitoring for medication side effects. On 09/05/19 at 11:25 A.M., interview with Director of Nursing (DON) verified there was no monitoring completed to provide the appropriate care and treatment for the use of antianxiety, antidepressant and psychotropic medications for Resident #1. 4. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including psychosis, anxiety and depression. Review of the care plans revealed the resident had a care plan for use of psychotropic medication and placed the resident at risk for drug related adverse reactions. The care plan interventions included to administer medications as ordered and implement behavior interventions and to notify the physician of any side effects/decline in function or worsening of symptoms. The resident also had a care plan for depression that indicated she has depression related to her loss of husband, son and mother. The interventions included to administer the medications as ordered and to monitor/document for side effects and effectiveness. Review of the annual MDS assessment, dated 07/26/19, revealed the resident was cognitively intact and had no hallucinations, delusions or any documented behavior. The resident was coded as receiving seven days of antipsychotic, antianxiety and antidepressant medications. Review of the Resident #46's orders revealed the resident has the following medications: Trazadone 50 mg. (antidepressant) for major depression, Seroquel 50 mg. (antipsychotic) for behaviors, Lexapro 20 mg. (antidepressant) for major depression, Ativan 0.5 mg. (antianxiety) every eight hours for anxiety and Vistaril 25 mg. (antihistamine) for anxiety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 4 of 6 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of 120 days of progress notes revealed the notes were silent to any behavior documentation for the resident, or monitoring of behaviors or side effects of the high risk medications listed above. Resident #46 had no behavior assessments completed in the electronic health record. During an interview with State Tested Nursing Assistant (STNA) #479, on 09/04/19 at 2:08 P.M., the STNA confirmed the facility STNA documentation does not have a place to document resident's behaviors. During an interview with Licensed Practical Nurse (LPN) #464 on 09/05/19 at 10:45 A.M., it was confirmed the facility documents behaviors in the nurses notes. The LPN stated Resident #46 at times will be bothered by the other residents when they were getting ready to smoke and it was loud causing Resident #46 to have some anxiety, but the resident has Ativan three times daily that she take and it helps to calm the resident. The LPN stated Resident #46 does not have any real behaviors, and commented there were behavior assessments that were completed in the computer when residents have behaviors. During an interview with the Director of Nursing on 09/05/19 at 11:25 A.M., it was confirmed the facility does not perform routine monitoring of the residents who were on psychotropic medications for the effectiveness of the medication or for potential adverse effects of the medications. Based on record review and staff interview, the facility failed to ensure residents received adequate monitoring for the use of psychoactive medications to ensure the medications were effective and there were no adverse effects. This affected four (#1, #13, #23 and #46) of five residents reviewed for unnecessary medications. The facility identified 56 residents receiving psychoactive medications. The facility census was 78 residents. Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), major depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment, dated 06/09/19, revealed the cognitively intact resident displayed no behaviors during the assessment period. Review of the care plan developed on 06/17/19, revealed the resident was at risk for drug related adverse reactions due to the use of anti-anxiety and anti-depressant medications. The goal was to ensure the resident received the lowest possible dose to ensure maximum functional ability. Pertinent interventions included administering medications as ordered, implementing behavior interventions as ordered, monitoring for side effects, and evaluating on a periodic basis for a gradual dose reduction. Review of the physician order sheet, dated 09/2019, revealed the resident was on Bupropion HCL ER 150 milligrams (mg) daily for major depressive disorder, Citalopram 20 mg. daily for major depressive disorder, Trazodone HCL 150 mg. daily for insomnia/depression, and Vistaril 25 mg. twice daily for anxiety. Review of the resident's progress notes 05/29/19 through 09/05/19, revealed the notes were silent to any behavior documentation for the resident. The resident did not have any behavior assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 5 of 6 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0757 completed in her health record or ongoing monitoring of behaviors and monitoring for potential side effects. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing on 09/05/19 at 11:25 A.M., it was confirmed the facility does not perform routine monitoring of the residents who were on psychotropic medications for the effectiveness of the medication or for potential adverse effects of the medications. Residents Affected - Few 2. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included psychosis, major depressive disorder, bipolar disorder, schizoaffective disorder, paranoia, hallucinations, delusions and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/19, revealed the resident was cognitively intact. Review of the care plan, dated 08/04/18, revealed the resident was at risk for mood problems related to schizoaffective disorder. Pertinent interventions included administering medications as ordered, encouraging the resident to express her feelings, and observing for mania, hypomanic, increased irritability, frequent mood changes, pressured speech and flight of ideas. Review of the resident's Abnormal Involuntary Movement Scale (AIMS) test, dated 05/16/19, revealed the resident experienced involuntary movements due to Parkinson's disease. Review of the physician order sheet, dated 09/2019, revealed the resident was on an anti-psychotic, Olanzapine five mg. twice daily to treat schizophrenia. Review of the resident's record, revealed there was no ongoing monitoring of her behaviors including paranoia, hallucinations, and delusions, to ensure the use of the Olanzapine was effective. There also was no ongoing monitoring of the resident's potential for adverse side effects. In the past three months, the nurses documented two behavior related incidents. On 07/28/19 at 1:13 P.M., the resident had an argument with another resident. A staff member intervened and provided one on one conversation and the resident calmed down. On 08/16/19 at 6:53 A.M., the resident was documented as being up all night and started an argument with another resident, accused staff of taking candy and talking about her, and turned off the television in the common area while a resident was watching. No interventions were documented as being attempted. No further behaviors were documented. During an interview with the Director of Nursing on 09/05/19 at 11:25 A.M. it was confirmed the facility does not perform routine monitoring of the residents who are on psychotropic medications for the effectiveness of the medication or for identifying potential adverse effects of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 6 of 6