Health inspection·October 14, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive care plan for pain for Resident #11, who received pain medication. This affected one resident (#11) of six residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, anxiety disorder, dysphagia, cognitive communication deficit, pain in leg, major depressive disorder, type two diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed Resident #11 had impaired cognition. The resident received opioid medications seven days during the look back period. Review of the physician's orders for October 2021 revealed an order for Tramadol 50 milligrams (mg) every day for pain and Tramadol 50 mg as needed for pain. Review of the Medication Administration Record (MAR) for October 2021 revealed Resident #11 received Tramadol 50 mg daily as ordered, she did not use the as needed Tramadol in October. Review of the resident's plan of care revealed no plan of care for pain had been developed for the resident. On 10/14/21 at 3:21 P.M. interview with Registered Nurse #204 confirmed the plan of care did not address the resident's pain or pain medications. Page 1 of 5 366314 366314 10/14/2021 Otterbein at Granville 2158 Columbus Road Granville, OH 43023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow up on pharmacy recommendations in a timely manner for Resident #11 and Resident #12. This affected two residents (#11 and #12) of five reviewed for unnecessary medication use. Findings include: 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, anxiety disorder, dysphagia, cognitive communication deficit, major depressive disorder, type two diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident had impaired cognition. Review of the pharmacist recommendation, dated 08/03/21 revealed the pharmacist suggested adding a six month stop date to the as needed every eight hours Ativan 0.25 milligram (mg) medication. The physician responded on 09/01/21 and indicated he disagreed with the recommendation. On 10/14/21 at 9:13 A.M. interview with the Director of Nursing (DON) confirmed there was a delay in the physician following up with the pharmacist's recommendation. She was unsure of the cause in the delay and revealed pharmacy recommendations were put in a book for the physician to review weekly. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. Review of the pharmacy recommendation dated 09/01/21 revealed the pharmacist recommended trying a reduction of Depakote from 250 mg twice a day to 125 mg twice a day. The physician followed up on 09/29/21 and indicated he disagreed with the recommendation. On 10/14/21 at 3:21 P.M. interview with RN #204 confirmed the physician took 28 days to respond to the pharmacist's recommendation for Resident #12. RN #204 was unsure what caused the delay and reported the physician usually followed up on recommendations weekly. 366314 Page 2 of 5 366314 10/14/2021 Otterbein at Granville 2158 Columbus Road Granville, OH 43023

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 record review and staff interview the facility failed to ensure non pharmacological interventions were attempted prior to administering pain medication. This affected one resident (#10) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bladder cancer, anemia, atrial fibrillation, chronic kidney disease, asthma, protein calorie malnutrition, insomnia and chronic respiratory failure. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the physician's orders for 10/2021 revealed the resident had an order for the pain medication, Tramadol 50 milligrams (mg) every four hours as needed for pain. Review of the MAR for 08/2021 revealed the resident received Tramadol 50 mg every four hours as needed for pain on 08/25/21 and 08/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received Tramadol 50 mg on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/23/21, 09/24/21, 09/25/21, 09/26/21, 09/27/21, 09/28/21, 09/29/21 and 09/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 10/2021 revealed the resident received Tramadol 50 mg on 10/05/21, 10/07/21, and 10/10/21 with no attempts of non pharmacological interventions prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. MDS Coordinator #204 revealed she was aware of concerns with nursing documentation and indicated they had been reminding and educating the nurses to document thoroughly. 366314 Page 3 of 5 366314 10/14/2021 Otterbein at Granville 2158 Columbus Road Granville, OH 43023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and staff interview the facility failed to ensure non-pharmacological interventions were attempted prior to administering psychotropic medications and/or failed to ensure appropriate diagnosis for use of psychotropic medication. This affected three residents (#7, #10 and #12) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including right sided hemiplegia, ataxia, dysphagia, dementia, acute kidney failure, moderate protein calorie malnutrition and aphasia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/15/21 revealed the resident was cognitively impaired, required extensive assistance from staff for bed mobility, transfers and toilet use and required extensive assistance from one person for dressing and personal hygiene. Review of the medication administration record (MAR) for 09/21 revealed the resident received Trazadone (antidepressant/sedative) 50 milligrams (mg) on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/15/21, 09/16/21, 09/17/21, 09/18/21, 09/19/21, 09/20/21, and 09/21/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received Haloperidol (antipsychotic) 0.5 mg on 09/04/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 10/21/21 revealed the resident received Seroquel (antipsychotic) 25 mg on 10/01/21 with no documented reasoning or non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the above dates prior to administering the medications. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly. 2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bladder cancer, anemia, atrial fibrillation, chronic kidney disease, asthma, protein calorie malnutrition, insomnia and chronic respiratory failure. Review of the most recent MDS 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the MAR for 08/2021 revealed the resident received Trazadone 50 milligrams (mg) on an as needed basis on 08/04/21, 08/05/21, 08/09/21, 08/10/21, 08/11/21, 08/12/21, 08/15/21, 08/16/21, 366314 Page 4 of 5 366314 10/14/2021 Otterbein at Granville 2158 Columbus Road Granville, OH 43023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/17/21, 08/19/21, 08/20/21, 08/23/21, 08/24/21, 08/25/21, 08/26/21, 08/27/21, 08/30/21, and 08/31/21 with no attempts of non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly. 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. The only behavior documented during the look back period was rejection of care which occurred four to six days. Review of the plan of care dated 08/24/21 revealed Resident #12 was receiving an antipsychotic drug for dementia with behavioral symptoms with the potential for adverse side effects. Interventions included administering medications as ordered by physician and monitoring for side effects, monitor and document resident's behavior for desired effects, obtain psychiatric and social service consultation for assessment, and anticipating needs. Review of the current physician's orders revealed Resident #12 had an order for Depakote 250 milligram (mg) tablet to be administered twice a day for diagnoses of dementia with behavioral disturbance. The order was initiated on 05/04/21. Review of the Medication Administration Record (MAR) for 05/04/21 through 10/13/21 revealed the resident received the medication as ordered except when one dose was refused on 06/30/21, 07/31/21, 08/17/21, 09/13/21, 09/29/21, 10/01/21 and 10/04/21. Review of the Depakote delayed-release tablets prescribing information (dated June 2021) revealed the indications for use were treatment of manic episodes associated with bipolar disorder, some seizure types and prophylaxis of migraine headaches. On 10/14/21 at 11:55 A.M. interview with Registered Nurse (RN) #204 confirmed Resident #12 was on Depakote related to dementia with behavioral disturbance. She additionally confirmed the prescribing information for Depakote extended release did not include dementia as an indicated use. 366314 Page 5 of 5