Health inspection·July 19, 2018

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, observation, and resident and staff interview the facility failed to ensure a resident who was prescribed antipsychotic medications had a diagnosis for the medication. This affected one Resident (#299) of eight residents reviewed for unnecessary medications. The census was 44. Findings include: Review of the medical record revealed Resident #299 was admitted to the facility on [DATE] with diagnoses included chronic obstructive pulmonary disease and acute kidney failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed as cognitively intact and exhibiting no behavioral symptoms Resident #299 was coded as having no psychiatric diagnoses and not receiving psychoactive medications. Review of behavioral care plan for Resident #299 initiated 07/02/18 revealed a problem behavior of yelling and screaming at times. Interventions included ensuring resident safety and re-approaching at a later time, providing a calm environment and encouraging to attend activities. Review of the MDS dated [DATE] revealed a cognitive assessment was not completed and that resident was assessed as having delusions and exhibiting verbal behavioral symptoms directed at others less than daily. Resident #299 was coded as having no psychiatric diagnoses and not receiving psychoactive medications. Review of the nurses progress notes revealed that resident was sent to the hospital on [DATE] due to an elevated white blood cell count and was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) . Further review of the nurses progress notes revealed that resident was readmitted to the facility on [DATE]. Review of the hospital records for Resident #299 revealed the resident was treated for an acute exacerbation of COPD. The hospital discharge diagnoses did not include any psychiatric diagnoses. The hospital records listed Risperdal an antipsychotic medication on the list of current medications for Resident #299. Review of antipsychotic medication care plan initiated 07/12/18 revealed a problem statement of taking an antipsychotic medication with interventions including monitoring resident for lethargy, hypotension, restlessness, dark urine, and constipation and to notify the physician of abnormalities. The care plan did not indicate a medical condition or rationale for the antipsychotic medication use. Review of the Medication Administration Record for Resident #299 for July, 2018 revealed the resident received the antipsychotic Risperdal daily at bedtime starting on 07/12/18. Review of a progress note for Resident #299 signed by nurse practitioner #5 dated 07/16/18 revealed the resident had behaviors including hallucinations at night and intense itching of skin and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 2 of 5 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 366439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103 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 resident was taking the antipsychotic medication Risperdal. There was no documentation of a specific diagnosed medical condition or rationale for Resident #299's antipsychotic medication use. Review of current diagnosis list for Resident #299 as of 07/17/18 did not include any psychiatric diagnoses. Observations of Resident #299 on 07/17/18 at 3:14 P.M. and on 07/18/18 at 3:09 P.M. revealed the resident was alert and oriented and exhibited no behaviors or signs and symptoms of distress. An interview with MDS Coordinator, Licensed Practical Nurse (LPN) #27 on 07/18/18 at 11:37 AM confirmed Resident #299 had no psychiatric diagnoses and the resident had returned from the hospital on [DATE] on the antipsychotic medication, Risperdal. LPN #27 was unsure why Resident #299 was on an antipsychotic medication. An interview with the Director of Nursing on 07/19/18 at 8:41 A.M., revealed the DON was not aware Resident #299 was placed on an antipsychotic medication. The DON further confirmed antipsychotic medications should only be used to treat a documented and diagnosed specific medical condition and that antipsychotic medications should only be used as a last resort when all other interventions have failed. An interview with Resident #299 on 07/19/18 at 9:00 A.M. confirmed the resident was in no distress, and that she had slept well the previous night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 3 of 5 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 366439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, review of facility policy, and review of manufacturer's guidelines the facility failed to properly store insulin. This affected one Resident (#8) who resided in the 1116 house and who received insulin. The census was 44. Findings include: Observation of the medication storage refrigerator in the 1116 house on 07/17/18 at 10:00 A.M. revealed a thermometer inside the refrigerator that read 56 degrees Fahrenheit (F). The refrigerator contained an unopened vial of Levemir insulin not assigned to a specific resident, ten unopened Levemir insulin flex pens assigned to Resident #8, and eight unopened Novolog insulin flex pens assigned to Resident #8. Interview with the Director of Nursing (DON) on 07/17/18 at 10:05 A.M. confirmed the thermometer inside the medication storage refrigerator for the 1116 house read 56 degrees F and the temperature of the refrigerator for medication storage should read between 36 and 46 degrees F. Interview with Maintenance Director #52 on 07/17/18 at 12:50 P.M. confirmed he had not received any report of problems with the medication storage refrigerator in the 1116 house until approximately 11:00 A.M. on 07/17/18 when he received verbal notification from the DON there was a concern with the temperature of the medication storage refrigerator in the 1116 house. Review of temperature log for 1116 house medication storage refrigerator revealed temperatures recorded for 07/01/18 at 50 degrees F , 07/02/18 at 50 degrees F , 07/03/18 at 52 degrees F, 07/04/18 at 20 degrees R F, 07/05/18 at 22 degrees F, 07/06/18 at 50 degrees F, 07/07/18 at 28 degrees F, 07/11/18 at 22 degrees F, 07/12/18 at 26 degrees F, 07/13/18 at 54 degrees F, 07/14/18 at 20 degrees F, 07/15/18 at 44 degrees F, and on 07/16/18 at 20 degrees F. No temperatures were recorded for 07/08/18 and 07/09/18. Review of facility policy titled Medication Storage revised 07/20/11 revealed medications requiring refrigeration are to be stored at a temperature not less than 36 degrees Fahrenheit or not more than 46 degrees Fahrenheit. Review of manufacturer's guidelines dated 02/2015 for Levemir insulin vials and flex pens revealed unopened vials and flex pens are to be refrigerated. Review of manufacturer's guidelines dated 4/2017 for Novolog insulin flex pens revealed unopened flex pens are to be refrigerated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 4 of 5 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 366439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of the census and review of facility policy the facility failed to store and properly label foods that were thawing in the refrigerator. This had the potential to affect all nine Residents (#4, #7, #10, #12, #17, #30, #32, #35, #305) who resided in 1119 house. The facility census was 44. Findings include: Observation on 07/17/18 at 9:26 A.M. of the kitchen during tour revealed two packages of Italian sweet sausage dated 06/06/18, one roll of hamburger dated 06/06/18, one roll of hamburger dated 07/04/18, one package of bacon dated 07/11/18 and one package of bacon dated 06/26/18, none had the word thaw or the date they were placed in the drawer to thaw. Interview on 07/17/18 at 9:26 A.M. with Elder Assistant (EA) #10 stated normally someone would write the date on the items when they were placed in the drawer to thaw and the word thaw. EA #10 verified none of the items contained the word thaw or the date they were placed in the drawer to thaw. Interview on 07/17/18 at 12:00 P.M. with Coach #50 stated the items in the thaw drawer were thrown away because they should have had a thaw date on them and they did not. Review of the census revealed nine Residents (#4, #7, #10, #12, #17, #30, #32, #35, #305) resided in 1119 house. Review of facility policy titled Thawing Policy and Procedure dated August 2007 and revised May 2013 revealed frozen foods are to be thawed in one of the following manners: in the refrigerator - the item is to be dated and marked with the word thaw. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366439 If continuation sheet Page 5 of 5