Health inspection·November 6, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed following the addition of a new mental health diagnosis. This affected two (#3 and #7) of the four residents reviewed for PASARR during the annual survey. The facility census was 21. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 06/11/20, with diagnoses including: hypertension, dementia, insomnia, chronic respiratory failure, unspecified psychosis, basal cell carcinoma, macular degeneration, peripheral vascular disease, hallucinations, peripheral vascular disease, chronic embolism and thrombosis, insomnia, schizophrenia, atherosclerosis, and delusional disorders. A diagnosis of unspecified psychosis was added on 07/21/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had severely impaired cognition . Review of completed PASSAR documents revealed the facility did not complete a new PASSAR designation following the addition of the unspecified psychosis diagnosis on 07/21/22. Interview on 11/06/24 at 10:22 A.M., with Licensed Practical Nurse (LPN) #400 verified a new PASSAR had not been completed with the addition of the new diagnosis. 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE], with diagnoses including: muscle weakness, heart failure, and mood disorder. The resident had a new diagnosis of schizoaffective disorder added on 10/13/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/24, revealed the resident was assessed to be rarely/never understood. Further record review for Resident #7 revealed no significant change PASSAR was completed following a new diagnosis of schizoaffective disorder. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed a significant change PASSAR was not completed following the new diagnosis of schizoaffective disorder for Resident #7. Page 1 of 2 366360 366360 11/06/2024 Vineyards at Concord, The 119 West High Street Frankfort, OH 45628

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 a stop date for as needed psychotropic medications. This affected two (#14 and #15) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 21. Findings include: 1. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, allergic rhinitis, and urge incontinence. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 10/16/24, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 10/15/24, revealed an order for 25 milligrams (mg) of Hydroxyzine (an antianxiety medication) to be administered every six hours as needed for anxiety. The order did not contain a stop date. Review of the active physicians order, dated 10/17/24, revealed an order for one mg of Xanax (an antianxiety medication) to be administered every 12 hours as needed for anxiety. The order did not contain a stop date. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed Resident #14's orders for Hydroxyzine and Xanax did not contain a stop date despite being ordered on an as needed basis. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with anxiety and agitation, and depression. Review of the admission MDS assessment, dated 09/02/24, revealed the resident was assessed to have moderately impaired cognition. Review of the active physician's order, dated 08/22/24, revealed an order for a topical gel containing a mixture of one mg of Ativan (an antianxiety medication), 25 mg of Benadryl (an antihistamine medication), one mg of Haldol (an antipsychotic medication), and 10 mg of Reglan (an anitiemetic medication) to be administered topically to the wrists every four hours as needed for agitation. The order did not contain a stop date. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed Resident #14's orders for Hydroxyzine and Xanax did not contain a stop date despite being ordered on an as needed basis. 366360 Page 2 of 2