Health inspection·December 12, 2019

F 0689 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 12/11/19 at 2:25 P.M. with the Director of Nursing (DON). The DON stated Resident #17 had made it out to the porch of the facility on 08/25/19. The DON indicated Resident #17's Roam Alert had needed to be replaced, and Resident #17 was moved to the second floor of the facility as a result of the incident. The DON stated the MDS staff were responsible for completing elopement assessments. Residents Affected - Few An interview was conducted on 12/11/19 at 3:25 P.M. with the Director of Maintenance (DOM) #401. DOM #401 stated eight doors were checked with a Roam Alert pendant each month to ensure the system would chirp then alarm. DOM #401 explained the system was passive, and the individual Roam Alert watchlet's did not have a battery. An interview was conducted on 12/11/19 at 3:46 P.M. with LPN #402. LPN #402 explained nursing staff were to sign off in the treatment administration record (TAR) the Roam Alert was physically on a resident daily, and the individual Roam Alert device was checked for functioning weekly. Interviews were conducted on 12/11/19 at 4:07 P.M. with MDS Nurse #403 and MDS Nurse #404. Both nurses shared elopement risk assessments were completed upon admission and various staff completed these assessments thereafter. A follow-up interview with the DON on 12/11/19 at 4:31 P.M. verified no further assessment of Resident #17's elopement risk was available for surveyor review. The DON verified nursing staff were to check a resident's individual Roam Alert device weekly to ensure proper function and sign off in the TAR. The DON confirmed Resident #17 did not have an order in her medical record for staff to check her Roam Alert device weekly to ensure proper function and shared no further information regarding Resident #17 being found in the parking lot was available for review. An interview was conducted on 12/12/19 at 10:31 A.M. with LPN #406. LPN #406 verified her nurses' note from 08/25/19 and shared Resident #17 had been on the steps outside the front door of the facility that led to the parking lot. LPN #406 recalled the light had been blinking on the Roam Alert keypad, but it did not emit any sound. LPN #406 thought night shift was to check the Roam Alerts for functioning. She stated she was told to write a nurses' note and had not completed any further documentation regarding this incident. Review of the facility policy, Roam Alert Resident Bracelet revised 08/16/17 revealed a Roam Alert bracelet would be initiated when a resident experienced a decrease in the ability to guard self from accident or injury due to elopement. A resident would be evaluated upon admission and quarterly thereafter. Elopement was defined as when a patient or resident who was cognitively impaired left the facility unnoticed and/or prior to their scheduled discharge. A listed procedure included monthly testing of Roam Alert bracelets/system completed monthly by maintenance and once initiated, the Roam Alert function was to be checked weekly. Review of maintenance records revealed once a month, maintenance staff checked the operation of door monitors of the patient wandering system. Review of facility policy and procedure on elopement, revised 06/01/16 defined elopement as unauthorized leave from the facility premises without prior communication by the resident or responsible party to facility staff. Charge nurse was to document pertinent medical information in the clinical records; if found off-premises and/or any injuries sustained, an incident report would be completed. Post-elopement, the elopement risk assessment form would be reviewed and updated; the plan of care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 2 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would be reviewed and updated; the watchlet policy would be reviewed and initiated; the resident could be moved to the second floor of the facility if not already residing there; a post-elopement investigation and documentation was to be completed by Administrator/designee. Review of the Roam Alert instruction manual dated October 1999 revealed the function of the Roam Alert system was to monitor areas within a building for the presence of Roam Alert transponders. A transponder was sensed when it entered a radio frequency (RF) exciter field that was set up using the Roam Alert controller. Roam Alert was designed to assist nursing staff in providing a higher degree of safety for wandering patients but was not intended as the sole means of protection in preventing a wandering patient leaving the premises. Review of the Roam Alert controller instruction manual dated August 2012 revealed the manufacturer's systems were designed to assist staff in providing a high degree of safety for people and assets and therefore should be used as a component on a comprehensive security programs of policies, procedures and processes. As with any security system one must perform regular system operational checks to verify functional integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 3 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to monitor Resident #70's bowel movements and implement bowel medications per physician orders to prevent constipation. This affected one resident (Resident #70) of one resident reviewed for constipation. The facility census was 71. Findings included: Review of medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and constipation. Review of Resident #70's care plan dated 06/05/19 revealed he had a potential for constipation related to altered mobility and medication usage. Interventions included administer Colace (stool softener), Milk of Magnesia (laxative), Dulcolax (laxative) and Senna (laxative) per physician orders, assess abdomen at least daily for tenderness, distension, bowel sounds and firmness, follow facility bowel protocol for bowel management, record bowel movement pattern each day, and monitor, document, report to physician as needed sign and symptoms of complications related to constipation. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition and required extensive assist of two people for bed mobility, transfers and toileting. He was always incontinent of bowel and bladder. Review of physician orders for the months of November 2019 and December 2019 revealed Resident #70 had a physician order to receive Milk of Magnesia 30 milliliters (ml) by mouth every 24 hours as needed for constipation if no bowel movement in two days. He also had an order for Bisacodyl suppository (Dulcolax) insert ten milligram (mg) suppository rectally every 24 hours as needed for lack of bowel movement. Review of Medication Administration Record (MAR) for November 2019 revealed Resident #70 received Milk of Magnesia 30 milliliters (ml) by mouth as needed on 11/16/19, 11/17/19, and 11/29/19. He did not receive a Bisacodyl suppository. Review of form labeled, POC (Plan of Care) Response History dated from 11/11/19 to 12/10/19 revealed staff documented Resident #70's bowel movements. Resident #70 had no bowel movements recorded from 11/13/19 through 11/16/19 (four days), from 11/18/19 through 11/21/19 (four days), and from 11/25/19 through 11/29/19 (five days). Interview with the Director of Nursing on 12/10/19 at 2:21 P.M. verified Resident #70 was to receive Milk of Magnesia as needed if he did not have a bowel movement after two days per his physician order. She verified he should have received Milk of Magnesia on 11/15/19, 11/20/19 and 11/27/19 per physician order as he did not have a bowel movement for two days. She verified Resident #70's physician order was not followed. Review of undated facility policy labeled, BM (Bowel Movement) Protocol revealed the facility was to assist with maintaining a good bowel regimen and prevent constipation. Bowel movements would be marked everyday by the nurse's aides and then the nurse would review the bowel record on 6:00 P.M. to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 4 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0690 6:00 A.M. shift and note which residents needed Milk of Magnesia and pass on in report to the day shift. Level of Harm - Minimal harm or potential for actual harm Review of facility policy labeled, Medication Administration dated 06/21/17 revealed the facility did not ensure medications were administered per acceptable standards of practice. The nurse was to open the medication administration record and note any changes on the medication administration record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 5 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure Resident #70 were not medicated with as needed Haloperidol (anti-psychotic medication) prior to non- pharmacological interventions being attempted. This affected one of five residents reviewed for use of unnecessary medications. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis. Review of the care plan dated 05/17/19 revealed Resident #70 received psychotropic medications related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician and the facility did not address the recommendation. Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as anti-psychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale. Review of the physician orders for October 2019 revealed Resident #70 had an order for Haloperidol tablet two milligrams by mouth every 12 hours as needed for agitation. Review of the Medication Administration Record (MAR) for October 2019 revealed Resident #70 received Haloperidol tablet two milligrams by mouth every 12 hours as needed for agitation on 10/07/19 at 7:07 A.M., 10/08/19 11:12 A.M., 10/13/19 4:16 A.M., and at 1:57 P.M., 10/14/19 at 9:54 A.M., 10/17/19 at 7:39 A.M. and 10/22/19 at 9:41 A.M. Review of the nursing note by Licensed Practical Nurse (LPN) #600 dated 10/07/19 at 9:13 A.M. revealed Resident #70 was raising his fist at another resident. The nurse medicated the resident with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 6 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Haloperidol for behaviors. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the nursing note by LPN #955 dated 10/08/19 at 12:16 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review the of nursing note by LPN #964 dated 10/13/19 at 5:09 A.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the nursing note by LPN #955 dated 10/13/19 at 2:32 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the nursing note by LPN #901 dated 10/17/19 at 9:33 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the nursing note by LPN #955 dated 10/22/19 at 10:07 A.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. He had physical behaviors one to three days and he wandered one to three days. Review of the Abnormal Involuntary Movement Scale (AIMS) test dated 11/22/19 for Resident #70 revealed he scored a six and had lip smacking present and his tongue thrusted moderately as adverse effects of the psychotropic medications. Review of Resident #70's physician orders for current month of December 2019 revealed he had an order for Haloperidol tablet one milligram by mouth every six hours as needed for agitation. Review of Resident #70's Medication Administration Record (MAR) for December 2019 revealed he received Haloperidol tablet one milligram by mouth every six hours as needed for agitation on 12/06/19 at 10:38 A.M. and on 12/10/19 at 6:04 A.M. Review of the nursing note per LPN #600 dated 12/06/19 at 11:22 A.M. revealed she medicated Resident #70 with as needed Haloperidol at 10:38 A.M. for agitation with positive effect noted. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Review of the nursing note per LPN #600 dated 12/10/19 at 6:54 A.M. revealed she medicated Resident #70 with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 7 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications. Interview on 12/11/19 at 3:45 P.M. with LPN #955 revealed Resident #70 does have lip smacking daily as a side effect of his psychotropic medications. He revealed at times one on one or activities would help calm him down and decrease his behaviors. Interview with the Director of Nursing on 12/10/19 at 2:24 P.M. revealed prior to the nurse administering a as needed psychotropic medication they were to attempt non-pharmacological interventions prior to administration. The nurse was to document the non-pharmacological interventions in the nursing notes that had been attempted prior to administration of the as needed psychotropic medication. She verified non-pharmacological interventions for Resident #70 prior to him receiving his as needed Haloperidol were not documented in the nursing notes for October 10/07/19 at 7:07 A.M., 10/08/19 11:12 A.M., 10/13/19 4:16 A.M., and at 1:57 P.M., 10/14/19 at 9:54 A.M., 10/17/19 at 7:39 A.M. and 10/22/19 at 9:41 A.M. and on 12/06/19 at 10:38 A.M. and on 12/10/19 at 6:04 A.M. She verified she did not have documentation of nonpharmacological interventions attempted prior to the administration of the Haloperidol. Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. Nursing staff was to document in detail an individual's behavioral symptoms. Non-pharmacological interventions would be attempted and documented following the resolution of the acute psychiatric situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 8 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure pharmacy medication review recommendations were addressed and followed up on. This affected three residents (Residents #37, #53, and #70) of five residents reviewed for use of unnecessary medications. The facility census was 71. Findings included: 1. Review of medical record for Resident #53 with an admission date of 10/04/18 revealed diagnoses including generalized anxiety, major depression, post- traumatic stress disorder, and dementia without behaviors disturbances. Review of care plan dated 10/09/18 for Resident #53 revealed he received psychotropic medications related to anxiety, depression, and post- traumatic stress disorder. Interventions included administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly. Review of pharmacy medication regimen review dated 02/22/19 for Resident #53 per Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed Hydroxyzine order for anxiety. The pharmacist stated if the as needed Hydroxyzine remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility. Review of form labeled Note To attending Physician/ Prescriber dated 7/26/19 per Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for as needed Hydroxyzine and the pharmacist recommended to the facility comply with current guidelines to add to the order a duration of therapy if the medication remained necessary. The form was blank and not addressed by the physician or facility. Review of pharmacy medication regimen review dated 10/22/19 from Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was re-admitted late September and continued to have an as needed Hydroxyzine physician order without a stop date as of late October. The Pharmacy Consultant #951 recommended to discontinue the Hydroxyzine used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility. Review of physician orders for December 2019 revealed Resident #53 continued to have an order for Hydroxyzine hydrochloride tablet 25 milligrams (mg) by mouth every six hours as needed for anxiety with a start date of 09/24/19 and no stop date or duration of therapy was noted per the order. Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19, and 10/22/19 regarding Resident #53's order for as needed Hydroxyzine was not addressed per the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified Resident #53 had a Hydroxyzine as needed order without a stop date that was re-ordered on his readmission on [DATE] and continued to have a Hydroxyzine as needed physician order used for anxiety without a stop date per the order or rationale documented in his clinical record for a duration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 9 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0756 therapy. Level of Harm - Minimal harm or potential for actual harm 2. Review of medical record for Resident #37 revealed an admission date of 02/19/19 and diagnoses including alcoholic hepatitis without ascites, post-traumatic stress disorder and anxiety. Residents Affected - Some Review of care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects. Review of pharmacy medication regimen review dated 06/27/19 from Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed Lorazepam (anti-anxiety medication). The form was blank and not addressed per the physician or facility. Review of pharmacy medication review recommendation dated 09/27/19 from Pharmacy Consultant #951 revealed Resident #37 had physician orders recently titrated Lyrica (anti-convulsant medication) 50 milligram three times a day and Gabapentin (anti-convulsant) 600 milligrams four times a day. The pharmacist revealed each medication had similar mechanism of action and administration of both these medications could represent a therapeutic duplication. He revealed Resident #37 had renal dysfunction that could result in the accumulation of both the Lyrica and Gabapentin increasing the risk of central nervous system effects such as sedation, confusion, falls and dizziness. He recommended to review for dose or regimen titration's that were indicated. The recommendations were blank and not addressed per the physician or the facility. Review of form labeled, Pharmacy Communication as Needed Psychotropic Notice Form dated 11/08/19 revealed Resident #37 had an order for Lorazepam .5 milligram (mg) one tablet by mouth every eight hours as needed for agitation. The communication form recommended the medication should be limited to 14 days unless the prescriber documented the rationale for the medications and a duration for the medication. The Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order. Review of Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the Lorazepam or give the Lorazepam a two-week limitation. Review of physician orders for current month December 2019 revealed Resident #37 continued to have an order for Lorazepam 0.5 milligram (mg) give one tablet by mouth every eight hours as need for agitation or loss of temper. There was no stop date or duration of this medication per Psychiatrist #708's recommendation on 11/22/19. Resident #37 had an order for Lyrica capsule 100 milligrams by mouth three times a day and Gabapentin capsule 600 milligram by mouth two times a day. Review of Medication Administration Record (MAR) for December 2019 revealed he received the Lorazepam 0.5 mg by mouth every eight hours as needed for agitation or loss of temper on 12/06/19 at 2:17 A.M. and 12/10/19 12:54 A.M. after the medication was to be discontinued. Interview with Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's Lorazepam was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given Lorazepam 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 10 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some either stop the Lorazepam or continue only for 14 days. She verified the Lorazepam for Resident #37 was never stopped or given a 14-day duration per recommendation. She verified the pharmacy recommendation dated 09/27/19 regarding the Lyrica and Gabapentin dose or regimen titration's was not addressed per the physician as she did not have documentation and verified the recommendation was blank. 3. Review of medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis. Review of care plan dated 05/17/19 revealed Resident #70 received psychotropic medications related to behavioral management, and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of Resident #70's physician orders for June 2019, July 2019, August 2019, September 2019 and October 2019 revealed he had a physician order for Haloperidol (anti-psychotic) tablet two milligrams (mg) by mouth every 12 hours as needed for agitation that started on 06/07/19. There was no stop date or duration of this medication per the order during these months until the medication was discontinued on 10/22/19. Review of pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician or the facility did not address the recommendation. Review of pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as anti-psychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale. Review of Resident #70's current physician orders for December 2019 revealed he had an order for Haloperidol tablet one milligram give one milligram by mouth every six hours as needed for agitation that did not include a duration of 14 days. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 11 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications. Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for Haloperidol tablet two milligrams give by mouth every 12 hours as needed for agitation. She verified he had this order from 06/07/19 to 10/22/19 without a duration or rationale documented. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed Haloperidol was an anti-psychotic medication and should have been limited to a 14- day duration and rationale should have been documented justifying the use of the as needed Haloperidol. She also verified Resident #70 was recently ordered Haloperidol one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order. Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. revealed the facility did not have a policy or procedures for the monthly drug regimen review that included, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident or how the physician addresses the drug regimen review recommendation. Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address psychotropic medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescriber's for periodic re-evaluation of medication and to prompt the facility to update their documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 12 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview, and record review the facility failed to ensure residents were free of unnecessary medications as their as needed psychotropic orders were not limited to 14 days and/ or a documented physician rationale was not in the resident's medical record to indicate the duration of the as needed psychotropic medication order. This affected three residents (Residents #37, #53, and #70) out of five residents reviewed for use of unnecessary medications. The facility census was 71. Findings included: 1. Review of the medical record for Resident #53 with an admission date of 10/04/18 revealed diagnoses including generalized anxiety, major depression, post-traumatic stress disorder and dementia without behaviors disturbances. Review of the care plan dated 10/09/18 revealed he received psychotropic medications related to anxiety, depression and post- traumatic stress disorder. Interventions included: administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly. Review of the pharmacy medication regimen review dated 02/22/19 completed by Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed Hydroxyzine order for anxiety. The pharmacist stated if the as needed Hydroxyzine remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility. Review of the form labeled, Note To attending Physician/ Prescriber dated 7/26/19 completed by Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for as needed Hydroxyzine and the pharmacist recommended to the facility comply with current guidelines to add to the order a duration of therapy if the medication remained necessary. The form was blank and not addressed by the physician or facility. Review of the pharmacy medication regimen review dated 10/22/19 completed by Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was re-admitted late September and continued to have an as needed Hydroxyzine physician order without a stop date as of late October. Pharmacy Consultant #951 recommended to discontinue the Hydroxyzine used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility. Review of the physician orders for December 2019 revealed Resident #53 continued to have an order for Hydroxyzine hydrochloride tablet 25 milligrams (mg) by mouth every six hours as needed for anxiety with a start date of 09/24/19 and no stop date or duration of therapy was noted per the order. Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19 and 10/22/19 regarding Resident #53's order for as needed Hydroxyzine was not addressed by the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 13 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #53 had a Hydroxyzine as needed order without a stop date that was re-ordered on his readmission on [DATE], and he continued to have a Hydroxyzine as needed physician order used for anxiety without a stop date per the order or rationale documented in his clinical record for a duration of therapy. 2. Review of the medical record for Resident #37 revealed an admission date of 02/19/19 and diagnoses including alcoholic hepatitis without ascites, post-traumatic stress disorder and anxiety. Review of the care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included: follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects. Review of the pharmacy medication regimen review dated 06/27/19 completed by Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed Lorazepam (anti-anxiety medication). The form was blank and not addressed by the physician or facility. Review of the form labeled, Pharmacy Communication as Needed Psychotropic Notice Form dated 11/08/19 revealed Resident #37 had an order for Lorazepam 0.5 milligram (mg) one tablet by mouth every eight hours as needed for agitation. The communication form recommended the medication should be limited to 14 days unless the prescriber documented the rationale for the medications and a duration for the medication. Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order. Review of the Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the Lorazepam or give the Lorazepam a two-week limitation. Review of the orders for current month December 2019 revealed Resident #37 continued to have an order for Lorazepam 0.5 milligram (mg) give one tablet by mouth every eight hours as need for agitation or loss of temper. There was no stop date or duration of this medication per Psychiatrist #708's recommendation on 11/22/19. Review of the Medication Administration Record (MAR) for December 2019 revealed he received the Lorazepam 0.5 mg by mouth every eight hours as needed for agitation or loss of temper on 12/06/19 at 2:17 A.M. and 12/10/19 12:54 A.M. after the medication was to be discontinued. Interview with the Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's Lorazepam was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given Lorazepam 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to either stop the Lorazepam or continue only for 14 days. She verified the Lorazepam for Resident #37 was never stopped or given a 14-day duration per recommendation. 3. Review of the medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis. Review of the care plan dated 05/17/19 revealed Resident #70 received psychotropic medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 14 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of Resident #70's physician orders for June 2019, July 2019, August 2019, September 2019 and October 2019 revealed he had a physician order for Haloperidol tablet (anti-psychotic) two milligrams (mg) by mouth every 12 hours as needed for agitation that started on 06/07/19. There was no stop date or duration of this medication per the order during these months until the medication was discontinued on 10/22/19. Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician or the facility did not address the recommendation. Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as antipsychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed the medication for 14 days but provided no rationale. Review of Resident #70's current physician orders for December 2019 revealed he had an order for Haloperidol tablet one milligram by mouth every six hours as needed for agitation that did not include a duration of 14 days. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications. Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for Haloperidol tablet two milligrams give by mouth every 12 hours as needed for agitation. She verified he had this order from 06/07/19 to 10/22/19 without a duration or rationale documented. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed Haloperidol was an anti-psychotic medication and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 15 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete should have been limited to a 14-day duration and rationale should have been documented justifying the use of the as needed Haloperidol. She also verified Resident #70 was recently ordered Haloperidol one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order. Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address psychotropic medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescribers for periodic re-evaluation of medication and to prompt the facility to update their documentation. Event ID: Facility ID: 365937 If continuation sheet Page 16 of 17 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 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 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. Based on interview, observation, record review and policy review, the facility failed to ensure insulin's were dated when opened for Resident #24 and Resident #46. This affected two medication carts with undated insulin for Residents #24 and Resident #46 of three medications carts reviewed for medications storage and labeling. This had the potential to affect 11 residents (Residents #11, #22, #24, #33, #36, #37, #46, #47, #65, #70 and #274) receiving insulin. The facility census was 71. Findings include: 1. Review of medical record for Resident #46 with an admission date of 03/31/16 and diagnoses of type one diabetes mellitus with diabetic autonomic neuropathy. Review of Resident #46's current physician orders for December 2019 revealed she had an order for Tresiba FlexTouch Solution Pen-injector 100 units per milliliter (ml) inject 52 units subcutaneously at bedtime for diabetes. Observation of medication storage on 12/09/19 at 4:45 P.M. of North Floor One medication cart with Licensed Practical Nurse (LPN) #600 revealed Resident #46 had a opened Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) in the medication cart undated when it was opened. Interview on 12/09/19 at 4:47 P.M. with LPN #600 verified Resident #46's Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) was not dated when the insulin was opened and revealed when the insulin was opened the nurse should have dated the insulin. 2. Review of medical record for Resident #24 with an admission date of 03/11/19 and diagnoses of diabetes mellitus with hyperglycemia. Review of Resident #24's current physician orders for December 2019 revealed she had an order for Lantus Solution Pen- injector 100 units per milliliter (ml) inject 36 units subcutaneously one time a day for diabetes. Observation of medication storage on 12/09/19 at 4:55 P.M. with LPN #601 of [NAME] Cart Two revealed Resident #24 had a opened Lantus Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened. Interview on 12/09/19 at 4:57 P.M. with LPN #601 verified Resident #24's Lantus Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened. Review of facility policy titled, Medication Administration dated 06/17/17 revealed insulin was a high risk drug and warranted additional precautions for the safe and effective administration. The nurse was to ensure that all opened insulin was dated when opened by documenting on the vial or pen. The policy revealed vials and pens without an open date recorded should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365937 If continuation sheet Page 17 of 17