Health inspection·November 9, 2022

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** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from the unnecessary medications regarding the use of an antibiotic medication without an adequate indication for use. This affected one (#17) of six residents reviewed for unnecessary medications. The census was 24. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission dated of 01/06/22. Diagnoses listed included epilepsy, dysphagia, aphasia, blindness, and multiple sclerosis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired, required extensive staff assistance with activities of daily living (ADL's), and did not have a urinary tract infection (UTI) in the last 30 days. Review of MDS assessments dated 01/13/22, 04/11/22, 07/12/22, and 09/30/22 revealed Resident #17 had not had a UTI within the last 30 days of those assessments. Review of physician orders revealed an order dated 09/14/22 for Bactrim DS (antibiotic) 800-160 milligrams (mg), give one tablet by mouth (PO) one time a day every Monday, Wednesday, and Friday for monitoring. Further review of physician orders revealed an order dated 03/08/22 for Macrodantin Capsule (antibiotic) 50 mg via gastronomy tube (G-tube) one time a day for prophylactically. The order was discontinued on 09/14/22. Review of medication administration revealed Resident #17 received Macrodantin 50 mg daily starting on 03/09/22. Resident #17 continued to receive Macrodantin 50 mg daily through 09/14/22. Bactrim DS 800-160 mg was started on 09/16/22 and continued to be given through 11/07/22. Review of progress notes dated 03/08/22 revealed a new order was received for Macrodantin 50 mg daily indefinitely prophylactically for a history of an UTI. Review of a facsimile dated 09/12/22 revealed Macrodantin was suggested to be changed to Bactrim by Resident #17's neurologist. Review of physician progress notes dated 03/01/22, 04/05/22, 05/03/22, 06/07/22, 07/05/22, 08/02/22, and 09/06/22 revealed no documentation for the justification of continued use of an antibiotic for an UTI. Further review of Resident #17's medical record revealed no documentation of any UTI's or symptoms of UTI from admission [DATE] through 11/07/22. Interview with the Director of Nursing (DON) 11/09/22 08:35 A.M. confirmed there was no documented justification for the continued use antibiotic for Resident #17. The DON confirmed that Resident #17 has not had any signs of an UTI since admission to the facility. The DON confirmed the the continued use of Resident #17's antibiotic had not been addressed with Resident #17's primary care physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366197 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366197 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at St Henry The 522 Western Avenue Saint Henry, OH 45883 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 through the facility's antibiotic stewardship program. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy titled Antibiotic Stewardship Program revealed residents without proof of review of infection symptoms prior to the initiation of an antibiotic will be reviewed for antibiotic holiday, culture and sensitivity results will be obtained/reviewed for sensitivity. The results of the testing ant eh recommendation for treatment will be discussed with the primary care physician (PCP) to ensure antibiotics are utilized in a responsible effective manner. Prescribers will be required to document dose, duration, and indication for all antibiotic use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366197 If continuation sheet Page 3 of 3