Health inspection·May 17, 2021

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** 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of cirrhosis of liver, liver transplant, and atrial fibrillation (irregular heart rate). Review of Resident #5's pharmacy recommendation dated 01/12/21 revealed the physician accepted the recommendation to have a thyroid stimulating hormone (TSH) level to be drawn on the next convenient lab day. There was no evidence in the medical record the lab was ever completed. Interview with the DON on 05/13/21 at 12:00 P.M. confirmed she could not produce documentation of the results of the TSH lab, or confirm the lab was ever drawn. Based on medical record review, staff interview, and facility policy review, the facility failed to act on pharmacy recommendations for labs and gradual dose reductions. This affected three residents (#51, #55, and #5) of five reviewed for pharmacy recommendations. The facility census was 75. Findings include: 1. Review of Resident #51's medical record revealed she admitted to the facility 05/04/16. Diagnoses included type two diabetes, bipolar disorder, major depressive disorder, schizophrenia, and Parkinson's Disease. Review of Resident #51's pharmacy recommendation dated 01/29/21 revealed Resident #51 had not had an A1C (for diabetes) completed in the last six months and it was recommended one be completed. Resident #51's physician agreed with the recommendation and signed it on 02/01/21. There was no evidence in the medical record the A1C had been completed. During an interview on 05/12/21 at 10:34 A.M. with the Director of Nursing (DON) confirmed Resident #51 did not have her A1C lab draw as recommended because an order was never written. Review of a facility policy titled , Diabetes-Clinical Protocol, dated 2001, revealed the physician would order pertinent screening for A1C . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, insomnia, Alzheimer's disease, and major depressive disorder. Review of Resident #55's pharmacy recommendation dated 04/02/21 revealed the pharmacist recommended a reduction of Trazodone (antidepressant/sedative) to reduce the future potential risk of falls. The physician's response was to decline the recommendation with no reason given. Additionally, a recommendation was made for a trial dose reduction of Mirtazapine, with the goal of discontinuation since weight had been stable. The physician's response was to decline recommendation with no reasoning given. Interview on 05/13/21 at 9:05 A.M. with the DON verified Resident #55's physician did not give a rational as to why the medications were not reduced per the pharmacy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 2 of 4 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 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** 2. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including encephalitis and encephalomyelitis, memory deficit following cerebral infarction (stroke), multiple myeloma not having achieved remission, anemia in neoplastic disease. Review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had extreme cognitive deficit. She was not listed as having any behaviors or mood disorders. Review of the resident's physician order dated 04/01/21 revealed an order for Seroquel 50 milligrams (mg), give one tablet by mouth, two times a day, for mood disorder. Review of Resident #34's progress notes dated 02/04/21 through 05/13/21 revealed no behaviors or mood disorders. Interview with the DON on 05/13/21 at 12:00 P.M. confirmed the facility had no evidence the resident had behaviors or mood disorders. Review of a facility policy titled, Psychotropic Medication Use, effective 11/28/16, revealed the facility would comply the State Operations Manual and all other applicable laws related to the use of psychoactive medications, including gradual dose reductions. The policy revealed psychotropic medications would be ordered to treat behaviors to address specific underlying medical or psychiatric causes of behavioral symptoms. Antipsychotic medications used to treat behavioral or psychological symptoms of dementia must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. Further review of the policy revealed the prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. Based on medical record review, staff interview, and review of facility policy, the facility failed to provide a rationale for declining pharmacy recommendations for a gradual dose reduction for a resident on antipsychotic medications. The facility further failed to show justification for the use of an antipsychotic medication for one resident. This affected two residents (#51 and #34) of five residents reviewed for unnecessary medications. The facility census was 75. Findings include: 1. Review of Resident #51's medical record revealed she admitted to the facility 05/04/16. Diagnoses included type two diabetes, bipolar disorder, major depressive disorder, schizophrenia, and Parkinson's Disease. Review of her physician orders revealed the following orders: 03/09/21 Bupropion 150 milligrams (mg) for depression, twice daily; 11/28/20 Seroquel an antipsychotic 50 mg at bedtime for mood disorder. Review of the resident's pharmacy recommendations dated 02/26/21 and 04/02/21 revealed Resident #51 was on an antipsychotic medication and was due for a gradual dose reduction. The pharmacist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 3 of 4 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requested if the physician declined the GDR, to provide a rationale and risk versus benefit to continue the medications as ordered. The physician indicated no change, signed each, however provided no rationale for the declining the recommendation. Further review of Resident #51's medical record revealed no evidence of behaviors warranting the use of an antipsychotic medication. Interview on 05/13/21 at 11:41 A.M. with Director of Nursing (DON) confirmed the physician did not provide a rationale for declining Resident #51's GDR on 02/26/21 and 04/02/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 4 of 4