Health inspection·October 13, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on record review and staff interview the facility failed to ensure advance directives matched in the electronic health record and paper medical record. This affected one resident (#9) of 18 residents reviewed for advance directives. Findings include: Review of Resident #9's medical record revealed an admission date of 06/20/13 with admission diagnoses that included diabetes mellitus, dementia with behaviors, paranoid schizophrenia and bipolar disorder. Review of the electronic health record revealed a physician's order, dated 02/02/21 which indicated Resident #9's advance directive (code status) was a Do Not Resuscitate Comfort Care - Arrest (DNRCC-A). Further review of the EHR also revealed the resident information code status indicated DNRCC-A. Review of the hard chart/paper medical record included a resident face sheet which indicated a code status of Full Code. Further review of the paper medical record found no evidence of advance directives or a DNR form which indicated a DNRCC-A code status was in place. Interview with the Director of Nursing (DON) on 10/12/22 at 8:45 A.M. verified the electronic health record and hard chart/paper medical record for the resident did not match. The DON revealed the hard chart should have indicated Resident #9 was a DNRCC-A and also contain the physician and resident representative signed DNRCC-A form. Page 1 of 3 366230 366230 10/13/2022 Country Pointe 2765 North Elyria Road Wooster, OH 44691

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview the facility failed to ensure pharmacy recommendations were complete and provided rationale for the continued use or psychoactive medications (with or without gradual dose reductions) for Resident #19. This affected one resident (#19) of five residents reviewed for unnecessary medication use. Finding include: Record review revealed Resident #19 was admitted to this facility on 08/14/20 with admitting diagnoses including type II diabetes, cellulitis of right lower limb, open wound of right great toe, repeated falls, heart failure, post traumatic seizures, depressive disorder and schizoaffective disorder. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/30/22 revealed the resident had severe cognitive impairment, required extensive assistance from one staff for dressing and supervision from one staff for bed mobility, transfers, toilet use and personal hygiene. The MDS assessment revealed the resident received anti-psychotic, anti-anxiety and anti-depressant medications during the assessment reference period. Review of the pharmacy review and monitoring for Resident #19 revealed on 02/16/22 and 08/07/22 the pharmacy sent a gradual dose reduction letter to Resident #19's physician. The letter on 02/16/22 noted the resident received the following psychoactive medications: - Clozapine 50 milligrams (mg) daily - Clozapine 100 mg two tablets at bed time - Clonazepam 1 mg three times a day - Trazodone 100 mg at bedtime - Haldol 5 mg give one and one half tablet (7.5 mg) two times a day - Haldol 5 mg every 6 hours as needed for agitation - Haldol 5 mg/ml give every 6 hours intramuscularly as needed for agitation - Vibryd 40 mg daily - Duloxetine 60 mg daily The recommendation revealed to please update the facility psychoactive medication documentation by completing the information requested. However, nothing was filled out to show if a gradual dose reduction was clinically indicated or contraindicated. There was no rational listed as to why dose reductions would be indicated or contraindicated. The physician only signed his name to the form. 366230 Page 2 of 3 366230 10/13/2022 Country Pointe 2765 North Elyria Road Wooster, OH 44691

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The pharmacy recommendation, dated 08/07/22 was almost a duplicate copy of the 02/16/22 notice with the exception of two additional medications added (Prazosin 3 mg at bedtime and Prazosin 2 mg at bedtime; not to exceed 3 mg). There was no evidence the physician addressed the recommendation to provide evidence as to whether a a gradual dose reduction was indicated or contraindicated. There was no rationale included indicating why the dose reductions were indicated or contraindicated. Again, the physician just signed his name to the form. Interview with the Director of Nursing on 10/13/22 at 8:15 A.M. verified the above findings and verified his documentation as well as the psychiatrist documentation did not address whether gradual dose reductions were indicated or contraindicated at the time of the pharmacist review in 02/2022 and 08/2022. 366230 Page 3 of 3