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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
366230
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
366230
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Country Pointe
2765 North Elyria Road
Wooster, OH 44691
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 - 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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366230
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
366230
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/13/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Country Pointe
2765 North Elyria Road
Wooster, OH 44691
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 - 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366230
If continuation sheet
Page 3 of 3
