Inspection·October 31, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the BMP lab result dated 09/05/24 revealed Resident #78's sodium was 129 (normal 136 to 145), potassium 3.7 (normal 3.5 to 5.1), blood urea nitrogen (BUN) was 5 (normal 7 to 18) and creatinine was 0.79 (normal 0.55 to 1.02). Review of the fluid volume deficit care plan updated 09/10/24 revealed Resident #78 had potential for fluid volume deficit with an intervention to monitor labs as ordered. Review of the BMP lab result dated 09/09/24 revealed Resident #78's sodium was 128 (low) and creatinine was 1.16 (high). Review of the physician order dated 09/10/24 revealed Resident #78 was ordered a 2000 milliliter (mL) fluid restriction, to encourage salt intake and BMP in one week. Review of the BMP lab result dated 09/17/24 revealed Resident #78's sodium was 128 (low) and creatinine was 2.19 (high). Review of the physician orders dated 09/17/24 revealed Resident #78's fluid restriction was discontinued, two liters of intravenous (IV) sodium chloride 0.9% at 75 mL/hour was ordered, a BMP was to be rechecked in one week, and if Resident #78's nausea and vomiting continued to worsen, could send to emergency department. Review of the health status note dated 09/23/24 timed 10:00 P.M. revealed Resident #78 complained of ongoing nausea with emesis of bile and saliva. Ginger ale and as needed Zofran (used to treat nausea and vomiting) was administered at 7:40 P.M. and was not effective. On call physician was notified and order given for an additional dose of Zofran 4 mg. Resident #78 was aware of order and medication administered. Resident #78 refused part of bedtime medications due to nausea. Primary care physician (PCP) notified of continued nausea and medication refusal. No diarrhea was noted that shift. Review of the physician order dated 09/24/24 revealed Resident #78 was ordered omeprazole oral tablet delayed release 20 mg once a day at bedtime for indigestion and if nausea and vomiting worsened could send to emergency room for CAT scan. Review of BMP lab results dated 09/24/24 revealed Resident #78's sodium was 127 (low), potassium 3.3 (low), and creatinine was 2.09 (high). Review of the nursing progress notes and assessments from 09/24/24 to 10/09/24 revealed there was no evidence Resident #78's physician (Physician #600) and/or NP (NP #603) was notified of Resident #78's 09/24/24 abnormal lab results. Interview on 10/21/24 at 2:40 P.M. with the Director of Nursing (DON) verified Resident #78's labs were abnormal on 09/24/24 and verified there was no evidence that Resident #78's physician and/or NP was notified of the resident's 09/24/24 abnormal labs. Interview on 10/22/24 at 9:45 A.M. with Physician #600 revealed Resident #78 was dehydrated on 09/17/24 resulting in the new order of the two liters of IV fluids being administered. Physician #600 verified he was not aware of Resident #78's abnormal labs on 09/24/24 and if he would have been notified of the abnormal potassium and sodium values, Physician #600 would have likely ordered oral potassium and another round of IV fluids to correct the sodium value. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 2 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/22/24 at 3:15 P.M. with NP #603 for Physician #600 revealed she could not recall if she was notified of Resident #78's 09/24/24 abnormal labs. Normally when NP #603 received a lab, she reviewed the lab then wrote orders or consulted with Physician #600. Review of the facility's Notification of Change in Resident Condition policy updated January 2022 revealed the facility would ensure that the resident, physician, resident representative and/or the resident responsible party or family member (unless otherwise directed by resident, where the resident did not want family member informed) was notified when the following occurred, involving the resident: significant change in the resident's physical, mental or psychological status. This deficiency represents non-compliance investigated under Complaint Number OH00158806. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 3 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #25 revealed an admission date of 06/23/22 with diagnoses including diabetes mellitus, pressure ulcer to the sacral region and hypertension. Residents Affected - Few Review of the physician's orders revealed Resident #25 had an order dated 10/16/24 for an appointment at the wound center on 10/21/24 at 9:00 A.M. He was to go via his wheelchair by facility transportation. Interview and observation on 10/21/24 at 8:50 A.M. with Resident #25 revealed he was waiting for transportation to an appointment with the wound care center which had been rescheduled numerous times. He stated when he returned from the wound care center he would provide additional information. Interview on 10/21/24 at 10:04 A.M. with the Director of Nursing (DON) revealed Resident #25 was unable to go to his wound care center appointment on 10/21/24 due to a mix-up with their transportation. She stated the facility's back-up driver did not know Resident #25 had the appointment as their regular driver was off. Review of the nursing progress note dated 10/21/24 timed 10:17 A.M. for Resident #25 revealed he had missed his wound center appointment and would be seen by the in-house wound care nurse practitioner. Interview on 10/21/24 at 11:00 A.M. with Resident #25 revealed he had missed four wound care center appointments due to the facility not setting up transportation for him. He stated the facility knew about his appointments but never set-up the transportation correctly. Interview on 10/21/24 at 1:41 P.M. with Wound Clinic Manager #602 revealed Resident #25 had to be rescheduled due to the lack of transportation. Resident #25 missed appointments on 10/11/24, 10/16/24, 10/18/24 and 10/21/24. Resident #25 was seen on 09/25/24 and was to be seen in two weeks. Resident #25 should have been seen on 10/11/24 but the facility stated he could not make it due to not having transportation available. Wound Clinic Manager #602 rescheduled his appointment to 10/16/24 which Resident #25 called two hours after his appointment and stated the transportation never showed up to bring him to his appointment. Clinic Manager #602 then rescheduled him for 10/18/24 and he did not show up to this appointment. The facility called the clinic and stated their transportation was in Cleveland and could not make it back to bring Resident #25 to his appointment. Wound Clinic Manager #602 rescheduled his appointment to 10/21/24 and he did not show up due to transportation. This was the fourth time Wound Clinic Manger #602 had to reschedule his appointment due to the facility not appropriately setting up transportation. Interview on 10/21/24 at 3:41 P.M. with the Administrator and DON verified Resident #25's wound care appointments had to be rescheduled on the dates listed above due to transportation not being set-up. The DON stated there were times Resident #25 did not provide paperwork detailing his appointment related to his next scheduled appointment date. The DON verified the nursing staff had not followed up to get the documentation from the wound clinic and that was why there were no additional physician's orders or transportation scheduled. Interview on 10/23/24 at 9:04 A.M. with Receptionist #604 revealed she set-up transportation for the residents at the facility. She stated when a resident had an appointment the nursing staff would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 4 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety update her, or she would review the physician's orders to ensure transportation was set-up either with their own transportation person or an outside entity. She stated if she was not updated or the nursing staff did not place an order in the computer, she would not know the resident needed transportation. She stated Resident #25 had been scheduled with the facility's transportation service for his appointment on 10/21/24. However, he did not get to his appointment because the facility did not know their regular driver, Transportation #521, was off work that day thus causing him to miss his appointment. Residents Affected - Few Review of the facility policy titled, Resident Transportation/Appointment Policy, dated October 2014, revealed the facility would set-up transportation if family was unavailable and if there were no restrictions, the facility would assist in setting up a local provider as needed. 3. Review of the medical record for Resident #71 revealed an admission date of 02/02/24 with diagnoses including diabetes mellitus and hypertension. Review of Resident #71's care plan dated 02/20/24 revealed he had the potential for hyperglycemia (high blood sugar). Interventions included checking the blood sugar per the physician's order and as needed and to observe for hypoglycemia (low blood sugar) and hyperglycemia. Review of the Medication Administration Record (MAR) for October 2024 for Resident #71 revealed his blood sugar on 10/03/24 at bedtime was 210 and upon rising on 10/04/24 was 400 (normal blood sugar is 74-106 fasting). Resident #71 did receive his diabetic medications as ordered. Review of the nursing progress note dated 10/04/25 at 7:14 A.M. for Resident #71 revealed at 2:40 A.M. he had activated his call light and notified the aide that he did not believe the nurse took his blood sugar and that he felt it was high. The nurse went to the resident and informed him that his blood sugar would be assessed at 5:00 A.M. Resident #71 then stated to the nurse that he had not received his scheduled diabetic medications causing an increase in his blood sugar. Licensed Practical Nurse (LPN) #539 then educated Resident #71 on the importance of monitoring his diet and following proper portion control. There was no documentation that LPN #539 took his blood sugar or assessed him when he voiced a concern that he felt his blood sugar was high. Interview on 10/22/24 at 1:03 P.M. with the Director of Nursing (DON) verified LPN #539 should have checked Resident #71's blood sugar and assessed him when he stated he felt his blood sugar was high. This deficiency represents non-compliance investigated under Complaint Number OH00158913, OH00158806, and OH00158619. Based on observation, open and closed medical record review, fax sheet review, policy review, and interview, the facility failed to ensure all residents received adequate, timely and necessary care and treatment. The facility failed to ensure Resident #78 received timely and adequate treatment and care and medical intervention to treat a change in condition. Resident #78 was admitted to the facility on [DATE] following a hospitalization for acute ischemia (reduced blood flow) of small intestine with perforation status post right hemicolectomy (removal of part of the large intestine), septic shock and gastroenteritis (inflammation of the lining of the stomach). Between 09/05/24 and 09/18/24 Resident #78 exhibited increased nausea/vomiting, diarrhea and abdominal pain. In addition, Resident #78 had orders for levothyroxine (used to treat thyroid disorders) with concerns the medication was not ordered/provided at an appropriate dose to meet the resident's needs. During this time, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 5 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility failed to take appropriate action by updating the physician on a change of condition which included abnormal laboratory values and meal refusals for Resident #78. On 09/18/24, Resident #78's thyroid stimulating hormone (TSH) level was elevated at 44.9 (0.358 to 3.740 normal). Upon notification of the abnormal TSH level, the physician, who was unaware Resident #78 was already receiving levothyroxine, ordered levothyroxine at a lower dose. This resulted in Immediate Jeopardy and actual harm with the potential for serious impairment and/or death beginning on 09/24/24 when Resident #78's laboratory testing obtained on this date was abnormal with sodium of 127 (normal 136-145), potassium 3.3 (normal 3.5-5.1) and creatinine 2.09 (normal for woman 0.55 -1.02) without evidence the physician was notified. From 09/24/24 through 10/09/24, Resident #78 continued to have nausea, vomiting, diarrhea, abdominal pain, decreased appetite with refusal of meals and supplements, weight loss and weakness. On 10/09/24, Resident #78 presented with coffee ground emesis, exhibited (abdominal) pain rated a 10 out of 10 and low blood pressure (hypotension) and was transferred to the emergency room. Resident #78 was subsequently admitted to the hospital with severe dehydration, severe malnutrition and abnormal TSH which was noted to possibly be a contributing factor of the resident's gastrointestinal (GI) issues. The resident's sodium was noted to be abnormally low at 120, blood urea nitrogen (BUN) was abnormally high at 70 (normal 7-18) and her TSH level was abnormally high at 85.7 (normal 0.358 -3.740). The resident required intravenous fluids and intravenous levothyroxine. In addition, a concern that did not rise to Immediate Jeopardy occurred when the facility failed to ensure Resident #25 was transported to scheduled appointments to ensure continuity care and failed to assess Resident #71 timely related to an elevated blood sugar. This affected three residents (#78, #25 and #71) of 12 residents reviewed for change in condition and/or continuity of care/transportation. The facility census was 77. On 10/28/24 at 5:27 P.M., the Administrator, Director of Nursing (DON), Regional Clinical Registered Nurse (RCRN) #605, Regional Director of Operations (RDO) #606 and [NAME] President of Operations (VPO) #612 were notified Immediate Jeopardy began on 09/24/24 when the facility failed to identify a change in Resident #78's condition and provide physician notification of continued abnormal laboratory testing. Between 09/24/24 and 10/09/24 the facility failed to provide adequate medical/nursing intervention to ensure the resident received timely and necessary treatment. On 10/09/24, Resident #78 was admitted to the hospital intensive care unit (ICU) with severe dehydration, severe malnutrition and abnormal TSH level. The resident was hospitalized until 10/16/24 and did not return to the facility. Prior to the hospitalization, the resident exhibited increased nausea/vomiting, diarrhea, abdominal pain and weight loss without evidence of adequate intervention or communication to the physician for necessary and adequate treatment. The Immediate Jeopardy was removed on 10/29/24 when the facility implemented the following corrective actions. • On 10/09/24 Resident #78 was transferred to the emergency room and did not return to the facility. • On 10/28/24 by approximately 3:00 P.M., the DON conducted a whole house audit to ensure all resident labs in the last 30 days had documented evidence of physician notification. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 6 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 10/28/24 by approximately 7:00 P.M., the DON conducted a whole house audit to ensure any resident who refused meals in the last 72 hours had physician and registered dietitian (RD) notification and documentation. • On 10/28/24 at approximately 8:00 P.M., the DON educated Registered Dietitian (RD) #613 on communicating meal refusals with the facility nursing management. • On 10/28/24 by approximately 7:30 P.M., Licensed Practical Nurse (LPN) #578/Unit Manager conducted a whole house audit for all resident's nursing progress notes from the previous 72 hours (since 10/26/24) to ensure any change in condition had proper notification and documentation. • On 10/28/24 by approximately 8:15 P.M., the DON educated all nurses on the proper process for reporting labs, observing new orders and ensuring appropriate documentation of all notifications and new orders. The education also included current medications related to lab values should be relayed to the physician at the time of notification. • On 10/28/23 by approximately 8:30 P.M., the DON completed verbal education to all facility physicians and nurse practitioners regarding verifying the current dose of any medication related to a lab value before changing the dose. • On 10/28/24 by approximately 8:30 P.M., the DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition. • On 10/28/24 by approximately 8:30 P.M., Registered Nurse (RN) #583/Unit Manager conducted a whole house audit for all residents ordered levothyroxine to ensure labs within the last 30 days were managed appropriately. All orders were verified for accuracy. Any concerns were addressed and documented. • On 10/28/24 at approximately 8:30 P.M., Physician #600, who was the Medical Director, was notified of the concern related to Resident #78 and notified of the facility current corrective action plan. • On 10/28/24 at approximately 8:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, RDO #606, VPO #612, RCRN #605, LPN #593/Minimum Data (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 7 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Set Nurse, RN #583/Unit Manager, LPN #578/Unit Manager, and with Physician #600 via telephone. Discussion included requirements of visits, labs, notifications, communication, current orders, and resident conditions. • Beginning on 10/29/24, the DON/designee would audit all labs for results, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly. • Beginning on 10/29/24, the DON/designee would audit all nurses' notes for a change in condition and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly. • Beginning on 10/29/24, the DON/designee would audit meal intakes on five residents each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly. • Beginning on 10/29/24, the DON/designee would audit four residents on Levothyroxine each week to check for notification of physician as warranted, if new orders were reviewed and were appropriate, documentation of labs, new order notification to family, and if any needed follow up was completed immediately for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly. Although the Immediate Jeopardy was removed on 10/29/24, the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: 1. Review of the closed medical record for Resident #78 revealed the resident was admitted to the facility on [DATE] with diagnoses of acute ischemia of small intestine, status post right hemicolectomy, infectious gastroenteritis, acute respiratory failure with hypoxia, diastolic heart failure, hypothyroidism, and need for personal care. The resident was transferred/discharged to the hospital on [DATE] and did not return to the facility. Review of the physician/nurse practitioner progress note dated 08/29/24 authored by Nurse Practitioner (NP) #603 revealed Resident #78 was admitted to the facility on [DATE] from the hospital where she was treated for ischemic small bowel perforation, septic shock, acute kidney injury and acute hypoxemic respiratory failure. Resident #78 had gone to the emergency department on 08/20/24 complaining of severe abdominal pain and nausea and was found to have small bowel ischemia with perforation and was taken to the operating room for right hemicolectomy with re-anastomosis. On 08/21/24, Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 8 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #78 experienced hypotensive shock requiring pressors (medication). There was concern for further bowel ischemia and Resident #78 was transferred to a larger hospital. Labs from 08/27/24 to 08/28/24 included sodium 131 (low), potassium 4.0 (normal), BUN 7 (normal) and creatinine 0.66 (normal). Review of symptoms revealed Resident #78 was eating well and anxious. A physical exam indicated Resident #78 was ambulatory with assist and walker since hospitalization and alert and oriented to person, place, time and situation. The assessment/plan indicated infectious gastroenteritis and colitis status post right hemicolectomy. Follow up with surgeon (Physician #608) on 09/06/24 as scheduled. Regarding hypothyroidism the note indicated to continue levothyroxine and monitor labs. Recheck basic metabolic panel (BMP) in one week. Review of the physician orders from August 2024 revealed Resident #78 was ordered potassium chloride extended-release oral tablet 20 milliequivalent (mEq) one tablet by mouth two times a day for hypokalemia, spironolactone (a diuretic) oral tablet 50 milligrams (mg) by mouth in the morning for hypertension, meclizine HCl oral tablet 25 mg give one tablet by mouth every six hours as needed for dizziness, levothyroxine sodium oral tablet 75 micrograms (mcg) give one tablet by mouth in the morning evening Monday, Tuesday, Wednesday and Thursday and levothyroxine sodium oral tablet 75 mcg give 1.5 tablets by mouth in the morning on Friday, Saturday and Sunday for hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #78 was cognitively intact, required setup or clean-up assistance with eating, needed partial/moderate assistance with toileting, and was always continent of bowel. Review of a fax sheet from the facility to Physician #600's office dated 09/04/24 authored by RN #581 revealed Resident #78 had complaints of nausea most of the day and had dry heaved off and on. The fax noted the resident was here (at the facility) after bowel surgery. Abdomen was soft, nondistended and not painful. Bowel sounds active throughout. She also had a soft/loose stool this evening. On 09/05/24, the resident refused all medications due to nausea. The NP wrote on the fax sheet dated 09/05/24 to complete a Kidney, Ureter and Bowel (KUB) x-ray. Review of the health status note dated 09/05/24 timed 6:54 A.M. revealed Resident #78 had complaints of nausea off and on all night. Staff documented the resident's abdomen was soft, not distended, and not painful. Bowel sounds were active throughout. Resident #78 also had a single loose stool. Labs were drawn. The note further indicated the nurse practitioner was aware and would assess that day. Review of the results of the BMP dated 09/05/24 revealed Resident #78's sodium was 129 (low), potassium 3.7 (normal), (BUN) was 5 (low) and creatinine was 0.79 (normal). Review of the nurse's note dated 09/05/24 revealed Resident #78 continued to complain of nausea. The nurse practitioner was in for a visit and gave order for Zofran (anti-nausea medication) and KUB x-ray. Review of the physician orders dated 09/05/24 revealed Resident #78 was ordered ondansetron (Zofran) oral tablet disintegrating four mg one table by mouth every six hours as needed for nausea and vomiting, Stat (immediate) KUB x-ray and BMP on 09/09/24. Review of the nutritional status care plan dated 09/05/24 revealed Resident #78 was at risk for decreased nutritional status and dehydration due to septic shock, required pressors, ischemic bowel status post right hemicolectomy, colitis, acute kidney injury, respiratory failure, morbid obesity. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 9 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few care plan included nausea was currently affecting intakes and Resident #78 was at risk for malnutrition. Interventions included monitor for signs and symptoms of dehydration and monitor oral intakes. Review of the surgical physician, Physician #608's progress note dated 09/06/24 revealed Resident #78 had a laparotomy (an incision into the abdominal cavity performed to examine the abdominal organs and aid diagnosis of any problems) on 08/20/24. Resident #78 reported nausea and not tolerating much of a diet. She was having liquid stool. The progress note indicated Resident #78 could return in two weeks for a follow-up. Review of the fluid volume deficit care plan updated 09/10/24 revealed Resident #78 had potential for fluid volume deficit with an intervention to monitor labs as ordered. Review of the altered comfort level care plan updated 09/10/24 revealed Resident #78 had potential for altered comfort level related to gastrointestinal discomfort, hemicolectomy related to ischemic necrosis of small bowel and colitis with interventions to report abdominal pain, report episodes of diarrhea and vomiting and report complaints of nausea. Review of the BMP lab result dated 09/09/24 revealed Resident #78's sodium was 128 (low) and creatinine was 1.16 (high). Review of the physician order dated 09/10/24 revealed Resident #78 was ordered a 2000 milliliter (mL) fluid restriction, to encourage salt intake and BMP in one week. Review of the BMP lab dated 09/17/24 revealed Resident #78's sodium was 128 (low) and creatinine was 2.19 (high). Review of a fax sheet from the facility to Physician #608 dated 09/17/24 revealed Resident #78 continued to have frequent nausea and vomiting. Currently ordered Zofran as needed and effective short term. Recent KUB negative. Please advise. Physician #608's office responded with, Resident #78 to follow up next with Physician #608. If worsening symptoms, patient will need to go to the emergency room. Appointment on 09/23/24 at 3:00 P.M. Review of Resident #78's physician orders dated 09/17/24 revealed orders to discontinue fluid restriction and administer two liters of sodium chloride 0.9% at 75 mL/hour intravenously, recheck BMP in one week, and if resident's nausea and vomiting continue to worsen, may send to emergency department. Review of the TSH lab result dated 09/18/24 revealed Resident #78's TSH was 44.9 (high). Physician #600 wrote on the lab sheet, start Synthroid 50 micrograms (mcg) by mouth one a day in the morning by itself for one hour (no other food or pills). Review of Surgical Physician #608's progress notes dated 09/23/24 revealed Resident #78 was still complaining of nausea, vomiting and diarrhea. The assessment and plan indicated diarrhea. The note further indicated unsure as to the reason for the vomiting, but Resident #78 would require a CAT scan which the physician would rather have done at the emergency room if the resident was having acute vomiting. The resident's abdomen was not distended, and it was soft. The physician wanted to check/test the resident for Clostridium difficile (a bacterium that can cause diarrhea). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 10 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the nursing progress notes from 09/23/24 to 09/24/24 revealed there was no evidence of an order to obtain a Clostridium difficile culture for Resident #78 and no evidence the testing was completed. Review of the health status note dated 09/23/24 timed 10:00 P.M. revealed Resident #78 complained of ongoing nausea with emesis of bile and saliva. Ginger ale and as needed Zofran administered at 7:40 P.M., not effective. On call physician notified and order given for an additional dose of Zofran 4 mg. Resident aware of order and medication administered. Resident #78 refused part of bedtime medications due to nausea. The primary care physician (PCP) was notified of continued nausea and medication refusal. Resident #78 with no diarrhea noted this shift. Review of the fax sheet from the facility to Physician #600/NP dated 09/23/24 revealed Resident #78 with complaints of frequent nausea with emesis of bile and saliva. Resident #78 was medicated with Zofran 4 mg at 7:40 P.M. without relief. On call physician notified and additional order given for repeat administration of Zofran 4 mg. Continued to complain of nausea. Refused medications due to nausea. Resident #78 had been having more frequent bouts of nausea. The fax indicated Resident #78 had an order for Zofran 4 mg every six hours and asked if the physician/nurse practitioner would consider increasing dose or frequency or additional medication. NP #603 responded on 09/24/24 with direction to start omeprazole (reduces the amount of acid the stomach makes) 20 mg once a day at night. Review of the physician order dated 09/24/24 revealed Resident #78 was ordered omeprazole oral tablet delayed release 20 mg once a day at bedtime for indigestion and if nausea and vomiting worsened could send to emergency room for CAT scan. Review of BMP lab results dated 09/24/24 revealed Resident #78's sodium was 127 (low), potassium 3.3 (normal 3.5-5.2) and creatinine was 2.09 (high). Review of the nursing progress notes and assessments from 09/24/24 to 10/09/24 revealed there was no evidence Resident #78's physician (Physician #600) and/or NP (NP #603) were notified of Resident #78's 09/24/24 abnormal lab results. In addition, there was no evidence Resident #78's physician and/or NP was notified from 09/26/24 to 10/07/24 regarding Resident #78's ongoing nausea, vomiting, diarrhea, refusal of meals and abdominal pain. Review of the health status note dated 09/25/24 timed 11:57 A.M. revealed Resident #78 refused to go to the dining room during the shift and refused to eat meals. Review of the nutrition progress note dated 09/25/24 timed 1:01 P.M. revealed Resident #78 had refused 24 meals and nausea and vomiting was noted in Resident #78's chart. Review of the pharmacy review note dated 09/25/24 authored by Pharmacist #611 revealed Pharmacist #611 reviewed Resident #78's medication regimen and noted any irregularities and/or observations on a separate report to the DON and prescriber. Review of the Consultant Pharmacist's Medication Regimen Review sheet dated 09/30/24 revealed Resident #78 was reviewed during the consultant pharmacist's visit between 09/01/24 and 09/30/24 with no irregularities noted and no pharmacist recommendations. Review of the late-entry Medicare Skilled Assessment note dated 09/27/24 timed 9:48 P.M. revealed Resident #78 had abdominal cramping with nausea and stomach cramping. Review of the Medicare Skilled Assessment note dated 09/28/24 timed 10:08 P.M. revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 11 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 #78 complained of abdominal pain, nausea and stomach cramping. Level of Harm - Immediate jeopardy to resident health or safety Review of the health status note dated 09/29/24 timed 8:47 P.M. revealed the author discussed with Resident #78 the importance of eating foods with medications due to frequent complaints of nausea, that food intake could help neutralize acids, and taking multiple medications could increase the chance of nausea. Residents Affected - Few Review of the Medication Administration Record (MAR) from September 2024 revealed Resident #78 received the as needed Zofran 4 mg on 09/05/24 at 8:10 P.M., 09/06/24 at 1:19 P.M. and 8:45 P.M., 09/07/24 at 8:38 A.M., 09/08/24 at 10:04 P.M., 09/09/24 at 10:33 P.M., 09/10/24 at 7:14 A.M. and 8:05 P.M., 09/11/24 at 7:49 A.M., 09/12/24 at 7:42 A.M. and 8:28 P.M., 09/13/24 at 7:52 A.M. and 3:35 P.M., 09/14/24 at 7:48 A.M. and 5:37 P.M., 09/15/24 at 12:14 A.M., 9:06 A.M. and 4:54 P.M., 09/16/24 at 8:00 A.M. and 4:17 P.M., 09/17/24 at 5:21 A.M. and 4:21 P.M., 09/18/24 at 1:19 A.M., 7:41 A.M. and 4:40 P.M., 09/19/24 at 9:12 A.M. and 8:26 P.M., 09/20/24 at 5:51 P.M. and 8:55 P.M., 09/21/24 at 5:32 P.M. and 8:46 P.M.,09/22/24 at 6:01 A.M. and 7:55 P.M., 09/23/24 at 5:44 A.M., 7:44 P.M. and 10:00 P.M., 09/24/24 at 4:22 A.M. at 4:43 P.M., 09/25/24 at 2:50 A.M., 09/26/24 at 1:47 A.M. and 3:25 P.M., 09/27/24 at 8:39 A.M. and 9:09 P.M., 09/28/24 at 7:16 A.M. and 5:23 P.M.,09/29/24 at 6:17 A.M. and 8:14 P.M., and 09/30/24 at 7:28 A.M. and 10:24 P.M. Review of the MAR from September 2024 revealed Resident #78 received the as needed meclizine 25 mg on 09/04/24 at 8:11 P.M., 09/11/24 at 7:49 A.M., 09/14/24 at 9:13 P.M., 09/15/24 at 10:58 P.M., 09/18/24 at 11:51 A.M. and 9:13 P.M., 09/20/24 at 3:34 P.M., 09/21/24 at 7:15 P.M., 09/23/24 at 1:30 P.M. and 8:37 P.M., 09/25/24 at 5:49 A.M. and 7:34 P.M., 09/26/24 at 6:09 A.M. and 7:17 P.M., 09/27/24 at 5:20 A.M. and 4:38 P.M.,09/28/24 at 2:48 A.M., 11:48 A.M. and 9:26 P.M., 09/29/24 at 5:28 P.M., and 09/30/24 at 3:53 A.M. Review of the September 2024 meal intake documentation in the tasks tab of the electronic medical record (EMR) revealed Resident #78 refused meals on 09/07/24 at breakfast, 09/08/24 at breakfast, 09/09/24 at lunch, 09/10/24 at breakfast, lunch and dinner, 09/11/24 at breakfast and dinner, 09/12/24 at breakfast and dinner, 09/13/24 at breakfast and dinner, 09/14/24 at breakfast and dinner, 09/15/24 at breakfast and lunch, 09/16/24 at breakfast and lunch, 09/18/24 at breakfast, 09/19/24 at breakfast and lunch, 09/20/24 at breakfast and lunch, 09/21/24 at breakfast, 09/22/24 at breakfast and lunch, 09/23/24 at lunch, 09/24/24 at breakfast, lunch and dinner, 09/25/24 at breakfast and lunch, 09/26/24 at breakfast, lunch and dinner, 09/27/24 at breakfast, lunch and dinner, 09/28/24 at breakfast, 09/29/24 at breakfast and lunch, and 09/30/24 at breakfast. Review of the September 2024 bowel continence documentation in the tasks tab of the EMR revealed Resident #78 had loose stools or diarrhea on 09/05/24, 09/07/24, 09/09/24, 09/10/24, 09/11/24, 09/12/24, 09/13/24, 09/14/23, 09/15/24, 09/16/24 (two episodes), 09/17/24 (three episodes), 09/19/24, 09/22/24 (two episodes), 09/23/24, 09/24/24, 09/26/24 (two episodes), 09/27/24 (two episodes), 09/28/24, and 09/29/24. Review of the Medicare Skilled Assessment note dated 10/01/24 timed 9:26 P.M. revealed Resident #78 had mild abdominal pain and complaints of nausea frequently. Review of the nutrition progress note dated 10/03/24 timed 9:54 A.M. revealed Resident #78 had refused 27 meals, and nausea and vomiting continued with treatments in place. Resident #78 was independent to set up assistance with some increased assistance from helper at times. Resident #78 was still at risk for malnutrition. The goal indicated meal intakes greater than or equal to 50% once nausea (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 12 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0684 was resolved. Level of Harm - Immediate jeopardy to resident health or safety Review of the health status note dated 10/08/24 timed 6:11 P.M. revealed Resident #78 had a small coffee ground emesis this evening. The physician notified. The note further indicated to see new orders. Residents Affected - Few Review of the health status note dated 10/09/24 timed 7:11 A.M. revealed Resident #78 was noted to have additional coffee ground emesis and complained of intense left upper quadrant and left lower quadrant abdominal pain. Resident #78 stated, worse than before I had my surgery. The note indicated Resident #78 had a bowel obstruction when she was hospitalized prior to the nursing home admission. Physician #600 was notified. Review of the eINTERACT Transfer Form assessment dated [DATE] timed 7:14 A.M. revealed Resident #78 had an unplanned transfer to the hospital for abdominal pain with a blood pressure of 95/66 (hypotensive) and a pain level rated a 10 out of 10 (with 10 being the most severe pain). Resident #78 had complaints of achy pain, stated constant for the last hour and also had coffee ground emesis. Review of the MAR from October 2024 revealed Resident #78 received as needed Zofran 4 mg on 10/01/24 at 4:53 A.M. and 8:07 P.M., 10/02/24 at 5:43 A.M. and 7:55 P.M., 10/03/24 at 5:10 P.M.,10/04/24 at 10:12 A.M. and 8:01 P.M., 10/05/24 at 3:08 A.M.,10/06/24 at 12:10 P.M. and 6:10 P.M., 10/07/24 at 1:16 A.M., 12:49 P.M. and 11:25 P.M.,10/08/24 at 9:59 A.M. and 4:44 P.M., and 10/09/24 at 4:38 A.M. Review of the MAR from October 2024 revealed Resident #78 received as needed meclizine 25 mg on 10/02/24 at 12:02 P.M., 10/03/24 at 3:00 A.M. and 12:44 P.M.,1[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 13 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were seen by their physician once at least every 30 days for the first 90 days after an admission. This affected four residents ( #9, #10, #78 and #84) of seven residents reviewed for physician visits. The facility census was 77. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 08/24/24 with diagnoses including necrotizing fasciitis (a bacterial infection that results in the death of the body's soft tissue), sepsis, paraplegia and fracture of the left tibia. Review of the nursing progress notes (where the physician and nurse practitioner progress notes were also located) dated 08/24/24 through 10/29/24 revealed Resident #9 was not seen by his physician while at the facility. Resident #9 was seen by Nurse Practitioner (NP) #603 on 08/27/24, 09/19/24, 10/08/24 and 10/17/24. Interview on 10/29/24 at 1:55 P.M. with Resident #9 verified he had never seen Physician #600 while at the facility. He stated he had seen NP #603 and had also went out of the facility to see his surgeon and the wound clinic physician. Interview on 10/29/24 at 2:22 P.M. with Regional Clinical Registered Nurse (RCRN) #605 verified Resident #9 had not been seen by Physician #600 while at the facility. 2. Review of the medical record for Resident #10 revealed an admission date of 08/30/24 with diagnoses including aftercare following joint replacement surgery, diabetes mellitus and chronic kidney disease. Review of the nursing progress notes dated 08/30/24 through 10/29/24 revealed Resident #10 was not seen by her physician while at the facility. Resident #10 was seen by NP #603 on 09/05/24, 09/10/24 and 10/17/24. Interview on 10/29/24 at 2:22 P.M. with RCRN #605 verified Resident #10 had not been seen by Physician #600 while at the facility. 3. Review of the medical record for Resident #78 revealed an admission date of 08/28/24 with diagnoses including acute ischemia (decreased blood flow) of the small intestine, chronic obstructive pulmonary disease, acute respiratory failure, infectious gastroenteritis (inflammation of the stomach and intestines) and hypothyroidism (condition where the thyroid does not produce enough hormone). Resident #78 was discharged to the hospital on [DATE] for an emergent health condition. Review of the nursing progress notes dated 08/28/24 through 10/09/24 revealed Resident #78 was not seen by her physician while at the facility. She was seen by NP #603 on 08/29/24. Interview on 10/28/24 at 11:43 A.M. with RCRN #605 verified Resident #78 had not been seen by Physician #600 while at the facility. 4. Review of the medical record for Resident #84 revealed an admission date of 07/03/24 with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 14 of 15 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses including chronic obstructive pulmonary disease, malignant neoplasm (cancer) of the lung and heart failure. Resident #84 was discharged to the hospital on [DATE]. Review of the nursing progress notes dated 07/03/24 through 08/26/24 revealed Resident #84 was seen by Physician #600 on 08/25/24. There was no other documentation that Resident #84 saw a physician at the facility prior to this date. Resident #84 was seen by NP #603 on 08/01/24 and 08/20/24. Interview on 10/29/24 at 10:40 A.M. with the Director of Nursing (DON) revealed Physician #600 had seen Resident #84 on 08/25/24. The DON provided a physician progress note for Resident #84 dated 08/25/24 that indicated late entry. However, the effective date indicated 08/25/24 and there were no other dates listed on the progress note. The DON verified Resident #84 had not been seen by a physician within 30 days of admission. The DON stated she had spoken to Physician #600 and he could not recall the date he had seen Resident #84 other than the indicated date on the progress note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 15 of 15