Health inspection·May 19, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed ensure pain management was provided. This affected two residents (#43 and #56) out of three residents reviewed who had pain managed at the facility. The facility census was 56. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #44 revealed an admission date 07/16/22. Diagnoses included acute respiratory failure, type two diabetes, spondylosis, sciatica, and Ogilvie syndrome (a disorder affecting the contraction of the bowel). Resident #44 was alert and oriented. Review of the plan of care dated 03/16/23 revealed Resident #44 was at risk for chronic pain related sciatica, spondylosis, and osteoarthritis. Interventions included administering analgesia per orders, identifying and treating, identify previous pain, monitor pain characteristics, notify the physician if interventions were unsuccessful, and provide the resident with reassurance that pain was time limited. Review of the physician order dated 07/16/22 revealed that Resident #44 had an order for Tylenol Extra Strength 500 milligram take two tablets by mouth every eight hours need for pain. Review of the physician order dated 07/18/22 revealed Resident #44 had an order for pain monitoring, to observe for pain. If pain was present treat trying non-pharmacological interventions such as ice packs, warm compress, repositioning, massage, distraction activity prior to medicating if appropriate and check those utilized, if other document in the progress notes every shift. Review of the physician order dated 12/24/22 revealed Resident #44 had an order for Oxycodone (a narcotic pain medication) five milligram tablet take one by mouth every six hours as needed for pain. Discontinued on 04/27/23. Review of the physician order dated 04/27/23 revealed that Resident #44 had an order for Oxycodone five milligram tablet take one by mouth every eight hours as needed for pain. Review of the Medication Administration Record (MAR) dated from 04/01/23 through 05/19/23 revealed Resident #44 had no non-pharmacological interventions prior to the administration of pain medication on 04/15/23, 04/16/23, 04/17/23, 04/18/23, 04/21/23, 04/23/23, 04/28/23, 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/15/23, and 05/19/23. Interview on 05/19/23 at 4:08 P.M., with the Director of Nursing (DON) who verified the nurse who administered pain medication to Resident #44 had not tried a non-pharmacological pain intervention (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 3 Event ID: 366376 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 366376 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Middletown 105 Atrium Drive Franklin, OH 45005 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)