Health inspection·August 9, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Nursing Home Resident's [NAME] of Rights, medical record review, and interview the facility failed to respect a resident's right to determine when to go to bed. This affected one (Resident #145) of two residents reviewed for choices (18 residents were interviewed regarding choices). Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #145 was able to make himself understood and was able to understand others. Resident #145 was assessed with moderate cognitive impairment. Resident #145 required extensive assist with transfers. On 08/02/21 at 3:40 P.M., Resident #145 indicated a few days earlier State Tested Nursing Assistant (STNA) #210 refused to assist him to the bedside commode and placed him in bed against his will. On 08/04/21 at 7:07 P.M., STNA #210 verified after lunch one day over the prior weekend Resident #145 requested assistance to transfer to the bedside commode. However, the nurse had instructed him to place Resident #145 in bed so he placed Resident #145 in bed although he was aware that was not Resident #145's preference. Resident #145 did tell STNA #210 he did not want to go to bed. Review of the Nursing Home Resident's [NAME] of Rights revealed residents had the right to be treated with respect, as well as make their own schedule. Residents had the right to decide when they went to bed. This deficiency substantiates Complaint Number OH00124207. Page 1 of 14 365259 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the facility failed to ensure an allegation of abuse was reported. This affected one (Resident #145) of three residents reviewed for abuse. Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #145 was able to make himself understood and was able to understand others. Resident #145 was assessed with moderate cognitive impairment. Resident #145 required extensive assist with transfers. On 08/02/21 at 3:40 P.M., Resident #145 alleged a few days earlier State Tested Nursing Assistant (STNA) #210 refused to assist him onto the bedside commode and tossed him in bed against his will. Resident #145 indicated he filed a police report because he considered it abusive. Resident #145 stated Licensed Practical Nurse (LPN) #230 was aware. Resident #145 indicated STNA #210 continued to work. On 08/02/21 at 4:21 P.M., the Administrator stated she was unaware of a police report being filed or allegations that Resident #145 was abused by STNA #210. Therefore, the allegation was not reported to the state agency. On 08/03/21 at 8:46 A.M., LPN #230 stated on 08/01/21 she received a physician's order to call the police department about another resident. While police were there, Resident #145 reported STNA #210 put him in bed roughly. LPN #230 stated she informed the unit manager of what happened but should have reported the allegation of abuse to the Administrator and Director of Nursing (DON). LPN #230 stated she did not believe Resident #145 was abused. On 08/04/21 at 7:07 P.M., STNA #210 verified after lunch one day over the prior weekend Resident #145 requested assistance to transfer to the bedside commode. However, the nurse had instructed him to place Resident #145 in bed so he placed Resident #145 in bed although he was aware that was not Resident #145's preference. Resident #145 did tell STNA #210 he did not want to go to bed. STNA #210 stated Resident #145 told him he was going to report him for being rough because of him putting him to bed against his will. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy (dated 11/21/16) indicated all allegations of abuse were required to be reported to immediately to the Administrator or designee. All alleged violations must then be reported to other officials, including the State Survey Agency. This deficiency is a recite from the survey dated 05/20/21. 365259 Page 2 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interview the facility failed to ensure one (Resident #145) of four residents reviewed for activities of daily living received bathing assistance. The facility identified 81 residents who required assistance with or who were dependent on staff for bathing. Residents Affected - Few Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Daily Set (MDS) assessment indicated Resident #145 was able to make himself understood and was moderately cognitively impaired. Resident #145 was dependent on staff for bathing. On 07/14/21, an order was written for showers on Wednesday and Saturday on second shift. Review of bathing records indicated Resident #145 received bed baths on 07/15/21, 07/16/21, 07/24/21 and 07/25/21. On 08/02/21 at 3:49 P.M., Resident #145 stated he had only received one shower since his admission on [DATE]. Resident #145 stated he would prefer a shower a minimum of every other day. Resident #145 stated he was scheduled for showers on Wednesday and Saturday on night shift but he would take one any time as long as he could get one. On 08/03/21 at 9:01 A.M., Resident #145 reported he still had not received a shower and requested the surveyor tell staff he would like to have a shower. The request was communicated to State Tested Nursing Assistant (STNA) #231 at that time. At 1:37 P.M., Resident #145 was observed propelling himself in his wheelchair toward the elevator. Resident #145 stated he was told he could only be bathed by male staff and repeated he wanted a shower. Licensed Practical Nurse (LPN) #230 overheard Resident #145 and stated to him that he could get a shower and asked what time was convenient for him. Resident #145 stated he was willing to get a shower at that time as he just wanted a shower. Resident #145 repeated he was told only males could give him a shower to which LPN #230 stated she would check. On 08/03/21 at 1:50 P.M., LPN #202 stated she was unable to locate any documentation of Resident #145 receiving a shower. The facility maintained documentation of showers in a binder at the nursing station. LPN #202 stated Resident #145 was sexually inappropriate with female staff so only male staff could bathe him. On 08/04/21 at 11:15 A.M., Resident #145 stated he had still not received a shower and again stated a desire to have one. LPN #230 was present. On 08/04/21 at 12:03 P.M., LPN #202 stated she had communicated Resident #145's request for a shower to the night shift on 08/03/21. LPN #202 verified there was no evidence Resident #145 was offered and refused a shower. This deficiency substantiates Complaint Number OH00124207. 365259 Page 3 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview the facility failed to ensure an activity program was implemented in accordance with a resident's assessment and preferences. This affected one (Resident #59) of two residents reviewed for activities. Residents Affected - Few Findings include: Review of Resident #59's medical record revealed diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, tracheostomy status, congestive heart failure, and bipolar disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was sometimes able to make herself understood and was sometimes able to understand others. Resident #59 was assessed with short and long term memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated it was very important for Resident #59 to have reading material, listen to music she liked, keep up with the news, do her favorite activities, go outside and get fresh air when weather was good, and participate in religious services or practices. An activities assessment dated [DATE] indicated Resident #59 preferred to spend her time with others with a preference for group activities. Community activity interest included rides, shopping, and entertainment. Creative activity interests included television, movies, and cooking/baking. Other interests included magazines, Bible study/devotions, and animals/pets. Resident #59 provided responses to questions. A plan of care initiated 06/29/21 revealed Resident #59 was dependent for meeting emotional, intellectual, physical and social needs related to physical limitations. Interventions included ensuring the activities were compatible with physical and mental capabilities, compatible with known interests and preferences and adapted as needed. Another intervention indicated Resident #59 needed one on one bedside/in-room visits and activities if she was unable to attend out of room events. Planned activities included readings of the Bible, music, manicures, hand massages, and games. An activity assessment dated [DATE] revealed no changes in Resident #59's activity preferences. Review of activity logs revealed: On 06/29/21, ten minutes was spent for manicures/relaxing music. Response was documented as good. On 06/30/21, ten minutes was spent for Genesis quotes about [NAME] and Eve. Response was documented as good. On 07/12/21, ten minutes was spent for the newspaper. Response was listed as great. On 07/14/21, ten minutes was spent for Exodus quotes and reading the Bible. Response was listed as good. On 07/20/21, ten minutes was spent for the newspaper. Response was listed as good. On 07/28/21, ten minutes was spent on Bible Study, preaching, and starting a family. Response was recorded as good. 365259 Page 4 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/02/21 at 11:31 A.M. and 3:14 P.M., 08/03/21 at 9:25 A.M., 12:15 P.M., and 2:05 P.M., 08/04/21 at 11:49 A.M., 1:20 P.M. and 1:28 P.M., and 08/05/21 at 9:00 A.M., Resident #59 was observed lying in bed. The television was playing but no other activity was noted. On 08/03/21 at 2:14 P.M., State Tested Nursing Assistant (STNA) #231 stated she was unaware of any activities being offered for Resident #59 other than the television. STNA #231 stated she believed Resident #59 would benefit from more activity. On 08/05/21 at 1:10 P.M., the Administrator was informed of concerns regarding the activity assessment indicating Resident #59's preferred group activities and preferred to spend time with others without activity logs indicating such activities were offered. Activity participation logs were reviewed for frequency and time spent in activities and the Administrator voiced understanding of concerns. 365259 Page 5 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, medical record review and staff interview the facility failed to ensure physician's orders for foot care were implemented and provided as ordered. This affected one (Resident #36) of one resident reviewed for foot care services. The facility census was 95. Residents Affected - Few Findings include: Interview with Resident #36 on 08/02/21 at 12:51 P.M. revealed no foot care was being completed as ordered by the physician. Review of Resident #36's medical record revealed an admission date of 01/24/18 with diagnosis that included diabetes mellitus type two. Further review of the medical record including physician's orders revealed on 04/08/21 Resident #36 was ordered foot soaks in warm soapy water for 15 minutes for one week. Review of the treatment administration record (TAR) revealed no evidence the foot soak was transcribed onto the TAR and completed as ordered. Interview with Regional Staff #216 on 08/05/21 at 8:45 A.M. verified foot soaks for Resident #36 were not provided as ordered. 365259 Page 6 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, resident interview, medical record review and staff interview the facility failed to provide restorative range of motion services as indicated. This affected two (Residents #69 and #76) of three residents reviewed for range of motion. The facility census was 95. Findings include: 1. Observation of Resident #69 on 08/02/21 at 10:15 A.M. identified bilateral contractures to the hands and wrists with no evidence of any type of splint device in place. Continued observations identified no splint devices in place. Review of Resident #69's medical record revealed an admission date of 07/28/16 with diagnoses that include cerebrovascular accident. Further review of the medical record including the State Tested Nurse Aide (STNA) Tasks identified Resident #69 was to receive nursing rehabilitation services including active assist range of motion (AROM) to the bilateral upper extremities including hands, fingers, wrists, elbows and shoulders. Further review of the STNA Tasks for the last 30 days from 07/04/21 to 08/03/21 indicated the AROM assistance was provided only on 07/24/21, 07/25/21, 07/28/21, 08/02/21 and 08/03/21. Interview with STNA #213 on 08/04/21 at 12:10 P.M. verified restorative services were not provided as indicated for Resident #69. 2. Interview with Resident #76 on 08/02/21 at 1:45 P.M. revealed restorative nursing services were not provided daily as ordered. Review of Resident #76's medical record revealed an admission date of 10/03/07 with diagnoses that include quadriplegia and cerebrovascular accident. Physician's orders indicated the use of bilateral resting hand splints up to eight hours during the day. Review of the Treatment Administration Record (TAR) revealed no evidence of splint application as ordered by the physician. Further review of the medical record for Resident #76 including the STNA Tasks indicated a restorative program to provide assistance with splint or brace to bilateral hands for contractures due to quadriplegia and a restorative program for Passive Range of Motion (PROM) to all extremities for contractures due to quadriplegia. Further review of the STNA Tasks for the last 30 days from 07/04/21 to 08/03/21 revealed no evidence of services for splint device and PROM to all extremities were only provided on 07/07/21, 07/08/21, 07/09/21, 07/11/21, 07/12/21, 07/13/21, 07/14/21, 07/17/21, 07/18/21, 07/19/21, 07/22/21, 07/23/21, 07/26/21, 07/27/21, 07/29/21, 07/31/21 and 08/01/21. Interview with STNA #213 on 08/04/21 at 12:05 P.M. verified restorative services were not provided as indicated for Resident #76. This deficiency substantiates Complaint Number OH00124207. 365259 Page 7 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review the facility failed to ensure fall interventions were in place as ordered for one (Resident #62) of four residents reviewed for falls. The facility also failed to ensure monitoring devices were in place as ordered to prevent unwanted exit from the facility for one (Resident #43) of two residents reviewed for supervision. The facility census was 95. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 10/16/18 with diagnoses that include cerebrovascular accident with hemiplegia and hemiparesis. Further review of the medical record revealed a physician's order from 07/27/21 which indicated the use of a low bed for safety following a fall from the resident's bed. Observation of Resident #62 on 08/04/21 at 10:14 A.M. revealed Resident #62 asleep in bed, the bed was observed to be raised approximately two feet off the floor and not in the low position. Interview with Licensed Practical Nurse (LPN) #202 on 08/04/21 at 10:16 A.M. verified Resident #62's bed was not in the low position as ordered. 2. Review of the medical record for Resident #43 revealed an admission date of 06/07/21. Diagnoses included metabolic encephalopathy, dementia, type two diabetes mellitus and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had cognitive impairment. He required extensive assistance for transferring, bathing, toileting, locomotion and dressing. He required supervision for eating. Review of the care plan dated 06/09/21 revealed Resident #43 was an elopement risk and wanderer. Interventions included using a wander guard (a bracelet used to define a boundary that alerts staff when a resident attempts to exit the facility) and using diversions. Review of the Wandering Risk Assessments dated 06/14/21 and 07/19/21 revealed the resident was at risk for wandering. Review of the physician orders active on August 2021 revealed an order for a Wanderguard related to elopement risk to be checked for placement to right wrist and to check the function every shift. Review of the TAR for August 2021 revealed the Wanderguard was documented to be on Resident #43's wrist on 08/01/21, 08/02/21 and 08/03/21. Observation on 08/03/21 at 12:22 P.M. of Resident #43 in his room revealed there was no Wanderguard in place as ordered. Interview on 08/03/21 at 12:29 P.M. with Licensed Practical Nurse (LPN) #205 confirmed Resident #43's Wanderguard was not in place as ordered. 365259 Page 8 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 08/03/21 at 3:09 P.M. revealed Resident #43 was not still wearing a Wanderguard. Interview at the time of the observation with LPN #202 confirmed Resident #43's Wanderguard was not in place as ordered. Review of the facility policy titled Wanderguard System Utilization Protocol, revised 05/01/17, revealed a wanderguard device may be utilized as an intervention to identify when wandering and/or elopement behavior occurs. This deficiency is a recite from the survey dated 05/20/21. This deficiency substantiates Complaint Number OH00124207. 365259 Page 9 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and interview the facility failed to ensure implementation of physician orders for residents with tracheostomies. This affected two (Residents #20 and #59) of three residents reviewed for respiratory care. The facility identified two residents with tracheostomies. Residents Affected - Few Findings include: 1. Review of Resident #20's medical record revealed diagnoses including acute and chronic respiratory failure, heart failure, anxiety disorder, and tracheostomy {A surgically created opening through the front of the neck and into the windpipe (trachea) into which a tracheostomy tube (trache) is placed to maintain breathing status.} A nursing note dated 06/29/21 at 5:30 P.M. indicated Resident #20 pulled her trache out and the registered nurse was unable to replace it. Resident #20 was sent to the emergency room for trache replacement. Resident #20 had a physician order dated 06/30/21 to keep a spare trache (size 4 uncuffed Shiley) at the bedside. On 07/30/21 at 10:48 A.M., Registered Nurse (RN) #232 confirmed there was no spare trache (size 4 uncuffed Shiley) at the bedside. 2. Review of Resident #59's medical record revealed diagnoses including acute respiratory failure with hypoxia (below normal level of oxygen in the blood), chronic obstructive pulmonary disease, obstructive sleep apnea, and tracheostomy status. A nursing note dated 07/07/21 at 10:01 P.M. indicated the nurse practitioner was notified of dry sputum causing an increase in mucus plugs. A new order was written for humidification to the trache system every 24 hours for decrease in mucus plugs and increased humidity. On 07/30/21 at 10:30 A.M., Resident #59 was observed lying in bed. The humidification bottle dated 07/18 was empty. At 10:41 A.M., RN #232 verified Resident #59 had humidification ordered and that the bottle was empty. On 08/03/21 at 9:15 A.M., Resident #59's humidification bottle had insufficient fluid in the canister to permit the tubing from the canister to enter the fluid enabling the humidification of the oxygen. The canister was dated 07/31/21 at 11:00 A.M. The Licensed Practical Nurse (LPN) present at the time of the observation verified the humidification bottle was ineffective due to lack of fluid. This deficiency substantiates Complaint Number OH00124207. 365259 Page 10 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure annual performance evaluations and twelve hours of regular in-service education were completed as required for State Tested Nursing Assistants (STNAs). This affected four of four STNA personnel files reviewed and had the potential to affect all 95 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for STNA #200 revealed a hire date of 03/17/13 and the last annual performance evaluation was completed on 05/21/20. There was no documentation in the personnel file of a performance evaluation for STNA #200 since 05/21/20, and no documentation of twelve hours of regular in-service education. Review of the personnel file for STNA #201 revealed a hire date of 03/06/18 and the last annual performance evaluation was completed on 05/21/20. There was no documentation in the personnel file of a performance evaluation for STNA #201 since 05/21/20, and no documentation of twelve hours of regular in-service education. Review of the personnel file for STNA #209 revealed a hire date of 01/17/20. There was no documentation in the personnel file of twelve hours of regular in-service education. Review of the personnel file for STNA #210 revealed a hire date of 10/31/16. There was no documentation in the personnel file of twelve hours of regular in-service education. Review of facility provided in-service titled, Abuse, Neglect, and Exploitation, undated, revealed STNA #200, #201, #209 and #210 attended the in-service and there was no documentation of the length of the in-service provided. Review of facility provided in-service titled, Behaviors, undated, revealed STNA #200, #201, #209 and #210 attended the in-service and there was no documentation of the length of the in-service provided. Review of facility provided in-service titled, Six Reasons Why You Should Get the COVID-19 Vaccine, dated 07/07/21, revealed STNA #200, #201, #209 and #210 attended the in-service and there was no documentation of the length of the in-service provided. Review of facility provided in-service titled, Bloodborne Pathogens, undated, revealed STNA #200, #201, #209 and #210 attended the in-service and there was no documentation of the length of the in-service provided. Review of facility provided in-service titled, Handwashing, undated, revealed STNA #200, #201, #209 and #210 attended the in-service and there was no documentation of the length of the in-service provided. Interview on 08/03/21 at 3:12 P.M. with Human Resources #202 verified there were no annual performance evaluations completed for STNA #200 and #201 since 05/21/20. Interview on 08/04/21 at 1:07 P.M. with Human Resources #202 confirmed STNA #200, #201, #209 and 365259 Page 11 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0730 Level of Harm - Minimal harm or potential for actual harm #210 had no documentation of twelve hours of in-services in their personnel files, and verified the facility in-services provided for review had no documented dates or times to determine hours of training for the STNAs. Residents Affected - Many 365259 Page 12 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, policy review, and interview the facility failed to maintain infection control practices during tracheostomy care. This affected one (Resident #59) of one resident observed for tracheostomy care. Residents Affected - Few Findings include: Review of Resident #59's medical record revealed diagnoses including acute respiratory failure with hypoxia (below normal level of oxygen in the blood), chronic obstructive pulmonary disease, obstructive sleep apnea, and tracheostomy (trache) status {A surgically created opening through the front of the neck and into the windpipe (trachea) into which a tracheostomy tube (trache) is placed to maintain breathing status.} A care plan intervention initiated 08/03/21 indicated Resident #59 was to be suctioned as necessary. During observation of trache care on 08/04/21 at 1:20 P.M., Licensed Practical Nurse (LPN) #230 was observed opening a tracheal suctioning kit. A pack of sterile gloves was removed. One glove was donned. The gloved hand was used to reposition flexible tubing lying on the bed and across Resident #59's chest. The contaminated glove was then used to apply the other glove which had been sterile. The gloved hands were then used to turn on the suction machine and move the table prior to suctioning through the trache. On 08/04/21 at 1:29 P.M. LPN #230 verified she had contaminated the gloves used to provide tracheal suctioning. Review of the facility's policy, Respiratory: Suctioning Tracheostomy (revised April 2009) revealed secretions could be suctioned from the trachea as often as necessary. To reduce the possibility of contamination, a sterile technique was essential. This deficiency substantiates Complaint Number OH00124207. 365259 Page 13 of 14 365259 08/09/2021 Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview the facility failed to ensure antibiotic assessments were used to ensure appropriate antibiotic use. This affected one (Resident #62) of five residents reviewed for medications. The facility census was 95. Residents Affected - Few Findings include: Review of Resident #62's medical record revealed an admission date of 10/16/18 with diagnoses that included cerebrovascular accident. Further review of the medical record including medication orders revealed antibiotic orders on 03/20/21 for Levaquin (antibiotic) 500 milligram (mg) every day for five days for a toe infection, 04/15/21 Bactrim DS (antibiotic) one every day for 10 days for a toe infection, 05/04/21 Bactrim DS one every day for 10 days for a toe infection and 05/30/21 gentamicin (antibiotic) 120 mg/100 milliliter (ml) intravenous every eight hours for 14 days for a toe infection. Further review of the medical record found no evidence of any type of assessment completed to determine if antibiotic use was appropriate. Interview with the Director of Nursing on 08/04/21 at 8:50 A.M. verified no assessment was completed for Resident #62 prior to utilizing antibiotic therapy. 365259 Page 14 of 14