Health inspection·March 7, 2019

F 0641 Ensure each resident receives an accurate assessment. 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 interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for Residents #19, Resident #33, and Resident #41. This affected three of 17 residents reviewed for accurate MDS assessments. Residents Affected - Few Findings include: 1. Resident #19 was initially admitted to the facility on [DATE] with diagnoses including obsessive compulsive disorder, anxiety disorder, major depressive disorder, and mood disorder. Review of the Medication Administration Record (MAR) for March 2018 Resident #19 received the following MDS monitored medications: Abilify (an antipsychotic) 10 milligrams (mg) every morning, Basaglar (an insulin) injection of 10 units at bedtime, and Clomipramine (an antidepressant) 100 mg at bedtime. Resident #19's quarterly MDS assessment with an assessment reference date (ARD) of 03/24/18 stated Resident #19 did not receive any insulin injections, any antipsychotic medication, or any antidepressant medications during the assessment reference period. Review of Resident #19's medical record revealed a pharmacy recommendation dated 03/19/18 which requested a gradual dose reduction (GDR) of Resident #19's Abilify (an antipsychotic). Resident #19's physician responded on 05/21/18 indicating a GDR was clinically contraindicated secondary to prior reduction attempts had failed. Review of Resident #19's quarterly MDS with an ARD of 06/24/18 revealed Resident #19 received seven days of an antipsychotic medication during the reference period. However, this MDS did not reflect the GDR was clinically contraindicated by the physician. The MAR for December 2018 revealed Resident #19 received Abilify (an antipsychotic) 10 mg every morning. Resident #19's medical record also revealed a pharmacy recommendation dated 12/04/18 which requested a GDR of Resident #19's Abilify (an antipsychotic) and Clomipramine (an antidepressant). Resident #19's physician responded on 12/06/18 indicating a GDR was clinically contraindicated due to risks of symptoms worsening on 12/06/18. Review of Resident #19's annual MDS with an ARD of 12/19/18 stated Resident #19 received seven days of antipsychotic medications during the reference period, however under clarification of whether or not antipsychotics were received, the MDS was marked antipsychotics were not received and a GDR attempt was not documented as clinically contraindicated by the physician. The above findings were reviewed and verified with the Administrator and Licensed Practical Nurse (LPN) #504 on 03/07/19 at 11:45 A.M. 2. Resident #33 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses of (continued on next page) 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 5 Event ID: 366346 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 366346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor of Grande Village 2610 East Aurora Road Twinsburg, OH 44087 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)