Health inspection·June 13, 2023

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, email review, policy review and interview, the facility failed to provide requested copies of resident medical records timely. This affected one resident (Resident #1) of three residents reviewed for medical records. The census was 59. Findings include: Review of Resident #1's medical record revealed an admission date of 06/03/22 with diagnoses including anoxic brain damage, nontraumatic intracerebral hemorrhage, presence of cerebrospinal fluid drainage device, need for assistance with personal care, contracture left elbow, right hand, left hand, muscle wasting and atrophy. Review of the admission five day Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident was never understood, extensive two-person physical assist with bed mobility, and dressing, total dependence, and two-person physical assist with transfer, eating, and toileting. The Quarterly MDS assessment dated [DATE] revealed the resident was never understood, had no psychosis, no behaviors or rejection of care. Total dependence, two-person assist for bed mobility, transfer, and personal hygiene. The resident was total dependence, one-person assist for dressing and eating. The resident had functional range of motion (ROM) impairment on both sides of upper and lower extremities. The resident had an indwelling catheter, and was always incontinent of bowel. Interview on 06/12/23 at 12:13 P.M. with Medical Records #86 revealed the guardian had requested medical records three times. Review of emails revealed on 09/03/22 a request from the residents brother, who was filing for guardianship, was emailed to the admission Director #83 for care plans. The email was forwarded to medical records on 09/06/22. Also on 09/06/22 Admissions sent the guardian an email that requests for medical records would need to go through Medical Records #86. Medical Records #86 was copied on the email. There was no evidence of Medical Records #86 forwarding a release of medical record form to the guardian. On 09/13/22 the guardian emailed Medical records #86 as well as the Administrator informing them he had not heard back on the care plan documents and he also requested the emergency evacuation plan for his sister who was totally dependent on staff. He said he filed for guardianship and was waiting on the background check. He emailed again on 09/14/22 and asked if he could get the medical records on his sister by 09/15/22. On 09/15/22 Admissions #83 emailed the guardian medical records was off. On 09/16/22 Medical Records #86 emailed the brother 29 pages of care plans without proof of guardianship or a signed medical release. On 09/21/22 Medical Record's #86 sent an email to the Page 1 of 12 365342 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0573 Level of Harm - Minimal harm or potential for actual harm company's lawyer. She wrote the brother was going for guardianship and she doesn't feel comfortable with this (providing medical information). He (the company lawyer) emailed her back the same day and told her to give the resident's brother a release form as the first step and explain the facility can only give the information based on the criteria on the form. Medical Records sent the brother an Authorization for Release of Health information on 09/21/22. Residents Affected - Few After being informed Resident #1 reached her maximum potential in therapy on 11/18/22 the guardian emailed a request to Director of Therapy #90 as well as the Administrator, Social Services #90, for Resident #1's start to finish dates for therapy and day to day exercises that were performed. On 11/23/22 the guardian sent a follow up email to the same staff expressing he did not receive a response related to his request. The Administrator emailed the guardian and stated she did not realize medical records was not copied on the email and advised him to go through medical records, who she copied on the email. The guardian sent an email to medical records on 11/23/22 requesting physical and speech therapy records, time and date of attempts on the following: concussion specialist, cardiology referral, and date change of the cat scan of the brain in 03/2022 to evaluate for reoccurrence of aneurysm. Medical Records #86 sent him an authorization for release on 11/25/22. The guardian returned the request the same day requesting physical and speech therapy records. He noted the office had a copy of the guardianship from probate court. Medical Records #86 sent him a copy of the cost to obtain the medical records 09/28/22 and he paid the fee the same day electronically. The records were available for pick up on 11/29/22. On 05/31/23 the guardian sent an email to Activities #138, Social Services #82, Medical Records #86, Registered Nurse #139, Director of Rehabilitation #90, the Director of Nursing and Registered Nurse #121 with a release form for what exercises or program was provided and completed during physical and occupational therapy, the baseline data and progress reports, information on how often the restorative information would be reviewed and what exercises, therapies would it entail and if activities had worked with the resident prior to now. The Director of Rehabilitation emailed him back on 06/01/23 and informed him he could request therapy documentation from medical records that would show the baseline and progress made. The Director of Rehabilitation Informed him therapy screened every three months to check for a decline and nursing would also notify therapy if there were concerns. The restorative program would consist of passive range of motion to the upper and lower extremities up to five days a week. Palm guards/hand rolls up to six hours daily. The guardian replied the same day he attached the release in the first email and included Medical Records #86. He also asked to please confirm he did the correct process so he could get the records in a timely manner. The Administrator replied the same day that Medical Records works part time. Medical Records was added to the email on 05/31/23 and would reach out to him directly with any concerns. Each new request needed a new signed request. If Medical Records is out of the building another staff would fill the request. She informed him Medical Records could email the information or fax if he preferred. The guardian responded the same day, on 06/01/23 asking medical records to let him know as soon as possible if medical records needed anything else signed. He asked that the records be left at the front desk for his mother to pick up. If this is an issue or will hold up getting the information to him he will provide a secure email/fax. Last time he was told she did not do that. Also asked that the cost be sent to him so he could log in to pay the fee. The resident's brother was not provided the therapy records until 06/08/23. The activity records were not provided at that time. Interview on 06/12/23 at 1:47 P.M. with Medical Records #86 revealed she did not respond to the 09/03/22 request for medical records timely. She did not reach out to the resident's brother and inform him of the need for a signed release and the fee schedule to obtain the medical records. The resident's brother had requested medical 365342 Page 2 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few records 09/03/22 and they were not provided until 09/16/23. Further, she provided the records without a signed release or proof of guardianship. For the 11/18/22 request no one sent her the email to inform her of the request until 11/23/22. She was off and no one else provided the release of information authorization to the guardian which delayed them being ready until 11/29/22. On 05/31/23 the guardian requested information and copied her on the email. The guardian was not provided the requested records until 06/08/23. With that the activity records were not provided because there were none available. Review of the facility release of medical records policy revised 06/2023 revealed request for records to be referred to the Director of Nursing or Administration or another staff member previously designated by the facility. Upon request to assess or obtain copies of medical records the facility should review the authorization to ascertain access rights of that person. Authority to assess or release records is only granted by the resident or the resident's legal representative. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. A valid request for medical information concerning a resident, by a party other than the resident includes: name of resident, name and address of facility and name and address of individual or organization requesting information, specific information reports requested, period of stayed for which information is to be released, date of request, signature of the resident or legally appointed representative authorizing release of information. Upon receipt of a request for medical record copies the facility should notify the requesting party in writing of the cost for obtaining records, and that records are available two days after receipt of payment for the copies. Copy should not be released prior to receipt of payment for copying charges. The resident and or his legal representative may receive a copy of his or her record within two working days after the request has been made. Family has no right to assess the resident's medical record without a valid authorization by the resident or his her legal representative. This deficiency represents noncompliance investigated under Master Complaint Number OH00143484 and Complaint Number OH00138029. 365342 Page 3 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0641 Ensure each resident receives an accurate assessment. 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 and interview, the facility failed to ensure assessments accurately reflected activities of daily living (ADL) assistance level. This affected one resident (Resident #1) of three residents reviewed for ADLs. The census was 59. Residents Affected - Few Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, anoxic brain damage, poisoning by unspecified drugs, presence of cerebrospinal fluid drainage device, paraplegia, muscle wasting, and neuromuscular dysfunction of bladder. Review of a hospital history and physical report, dated 05/04/22, revealed Resident #1 responded to noxious stimuli, opened eyes, was unable to follow commands, and unable to voice needs. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 06/07/22, revealed the functional assessment for bed mobility indicated Resident #1 was totally dependent without attempts to initiate and had flaccid muscle tone. Review of the Minimum Data Set (MDS) 3.0 Five-Day assessment, dated 06/10/22, inaccurately revealed that Resident #1 required extensive, two-person physical assistance for bed mobility and dressing. During interview on 06/12/23 at 11:29 A.M., Licensed Practical Nurse (LPN) #120 confirmed Resident #1 is totally dependent on two-staff for bed mobility and dressing. During interview on 06/12/23 at 5:45 P.M., MDS/LPN #80 stated the MDS 3.0 5-Day assessment, dated 06/10/22, was incorrect and should have indicated the resident required total dependence with bed mobility and dressing. This deficiency represents non-compliance investigated under Master Complaint Number OH00143484. 365342 Page 4 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure care planning conferences were conducted quarterly. This affected one resident (Resident #1) of three residents reviewed for care planning. The facility census was 59. Findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, anoxic brain damage, poisoning by unspecified drugs, presence of cerebrospinal fluid drainage device, paraplegia, muscle wasting, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/19/23, revealed the resident was severely cognitively impaired. Review of Resident #27's care conferences revealed care conferences were conducted on 07/13/22, 09/28/22, 11/15/22, and 04/23/23. Interview on 06/13/23 at 4:10 P.M. with Social Services Designee (SSD) #82 revealed care planning conferences are to be completed quarterly or every three months and Resident #1 did not have a care planning conference between 11/16/22 until 04/22/23. SSD #82 further confirmed there was no evidence of a letter having been sent to Resident #1's responsible party informing them of a scheduled care conference until 04/18/23. Review of the facility policy titled, Participation in Care Conference, revised 06/12/23, revealed care conferences for long-term care residents shall occur on a regular basis (initial, quarterly, annual, significant change and as needed). A letter informing the resident and/or the responsible party shall be provided two weeks in advance of the scheduled conference. This deficiency represents non-compliance investigated under Master Complaint Number OH00143484. 365342 Page 5 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

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 record review, policy review, and interview, the facility failed to provide a sufficient amount of individual activities. This affected one resident (Resident #1) of three residents reviewed for activities. The facility census was 59. Residents Affected - Few Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, anoxic brain damage, poisoning by unspecified drugs, presence of cerebrospinal fluid drainage device, paraplegia, muscle wasting, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/19/23, revealed the resident was severely cognitively impaired. Review of the Activity Interview for Daily and Activity Preferences assessment, dated 06/25/22, revealed the resident was unable to be interviewed. Further review revealed no activities assessments had been completed since 06/25/22. Review of the plan of care, dated 06/19/22, revealed the resident had little or no involvement with activities and needs individualized visits for stimulating her senses and companionship contact. Interventions included to determine and adjust session duration to help resident attain goals, involve responsible party in activity plan of care, to speak to resident throughout visit as she can hear you, and to touch gently and address softly by name. Review of the May 2023 activity attendance sheet for Resident #1 revealed there were two individual activities during the week of 05/07/23 through 05/13/23 and two individual activities during the week of 05/14/23 through 05/20/23. During interview on 06/12/23 at 5:30 P.M., Activities Director #87 confirmed Resident #1 only attended two individual activities during the weeks of 05/07/23 through 05/13/23 and of 05/14/23 through 05/20/23. Activities Director #87 stated that she would expect the resident to receive individual activities three to four times per week. Activities Director #87 further confirmed the resident's quarterly activity assessments were not completed timely. During interview on 06/12/23 at 4:37 P.M., the Administrator stated the previous Activities Director was not providing a variety of activities for the residents. Review of the facility's policy, Activities, dated June 2023, revealed it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Each resident's interests will be assessed on a routine basis. This assessment shall include, but is not limited to activity assessment to include resident's interest, preferences, and needed adaptations. This deficiency represents non-compliance investigated under Master Complaint Number OH00143484. 365342 Page 6 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 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. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure therapy recommendations were implemented upon discontinuation of therapy services. Actual harm occurred when Resident #1 had worsening contractures and decline in range of motion when restorative/maintenance programs for application of hand splints, passive range of motion (PROM) exercises and a timed out of bed schedule was not provided as recommended impacting the resident's mobility and skin integrity. This affected two residents (Resident #1 and #40) of three residents reviewed for range of motion. The census was 59. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 06/03/22 with diagnoses including anoxic brain damage, nontraumatic intracerebral hemorrhage, neuromuscular dysfunction of bladder, presence of cerebrospinal fluid drainage device, need for assistance with personal care, contracture left elbow, right hand, left hand, muscle wasting and atrophy. Review of the admission five-day Minimum Data Set Assessment (MDS) dated [DATE] included the resident was never understood, required extensive two-person physical assist with bed mobility, and dressing; total dependence and two-person physical assist with transfer, eating, and toileting. Review of an impaired range of motion as evidenced by contractures of bilateral hands, left elbow and paraplegia plan of care dated 06/11/22 revealed interventions including to apply any assistive devices needed for contracture management. Review of Resident #1's therapy evaluations revealed she was initially admitted [DATE] and evaluated by occupational therapy on 06/06/22. The resident was totally dependent (on staff) for all activities of daily living. She was unable to follow commands, or track with visual movements. She did open her eyes and fixate (her) gaze on the therapist. She was admitted with resting hand splints (a splint used to maintain hand(s) in functional positioning by supporting the hand and wrist joint during periods of inactivity). The resident was evaluated by physical therapy on 06/07/22. Initial evaluation included the resident was totally dependent for sitting, with no right or left upper or lower extremity strength. The resident was readmitted to the hospital and returned to the facility 06/18/22. The Occupational therapy evaluation (upon re-admission) was unchanged and included she was admitted with two resting hand splints however they would need to be trialed and slightly modified due to bilateral upper extremity contractures and wear tolerance of two hours. The resident had a left elbow contraction with 55-140 degrees of motion on the left and 40-150 degrees on the right elbow (normal ROM of the elbow is 180 degrees). The resident was approved for a specified number of therapy visits, three of which were used for Occupational Therapy, and discharged from therapy on 06/24/22 until she could be re-evaluated under Medicaid part B. She was discharged with hand splints up to two hours a day and weighted stuffed animals to her arms since the left arm brace did not arrive. The resident resumed services on 07/20/22 under Medicaid part B and provided services until 10/10/22. She was thin and the elbow brace was too large for her. The therapists were looking for a pediatric elbow brace and utilized weighted stuffed animals in her arms to extend her elbows. Upon discharge from therapy, restorative/maintenance programs included out of bed up to four hours a day, passive 365342 Page 7 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 Level of Harm - Actual harm Residents Affected - Few range of motion (PROM) bilateral upper extremities two sets of 10 and bilateral resting hand splints four hours on and four hours off after PROM with skin checks. The resident was also to hold a large stuffed animal to left elbow to prevent contracture. Education was provided to the Director of Nursing, Assistant Director of Nursing and restorative/ MDS nurse on donning resting hand splints every four hours and not using washcloths because they do not prevent worsening of contractures. PROM education prior to donning splints was provided. Review of the medical record revealed no evidence a restorative or maintenance program was written for the nursing staff to provide. There were no instructions for the STNAs to follow, there was no physician order or treatment orders written and there was no restorative plan of care. On 03/06/23 a therapy screening was completed for Resident #1 and therapy services for contractures, positioning for promotion of skin integrity, as well as increased out of bed participation was planned. The resident was re-evaluated on 03/08/23 by occupational therapy secondary to having an increase of contractures and poor out of bed tolerance. The resident presented with decreased joint mobility in bilateral upper extremities impacting her positioning and skin integrity. The resident was re-evaluated 03/15/23 by physical therapy due to decreased range of motion in her lower extremities and had a decrease in her prior level of function with PROM of left hip abductor declining from 30 degrees of motion to 15 degrees, left hip flexion declining from 100 degrees of motion to 70 degrees, and PROM to knee extension declining from zero extension to minus 15 degrees. The goal was to improve trunk and lower extremity range of motion to improve positioning in bed and up in chair. The resident had no existing lower extremity contracture. The left lower extremity was tight in all muscle groups. The resident presented with decreasing range of motion in bilateral lower extremities and trunk due to neurological insult of traumatic brain injury and being bedfast. The Quarterly MDS dated [DATE] revealed the resident required total dependence, two-person assist for bed mobility, transfer, and personal hygiene. The resident was total dependence, one-person assist for dressing and eating. The resident had functional range of motion (ROM) impairment on both sides of upper and lower extremities. Review of the 06/01/23 occupational therapy discharge note included a referral for a restorative nursing program and functional maintenance program to be completed to maintain progess. Review of the STNA TASK section and care plans dated 06/02/23 included a Restorative Range of Motion Program: Needs Passive Range of Motion: Gentle stretching to bilateral upper and lower extremities, three sets of five, two times a day for at least 15 minutes. Ensure completing upper extremity stretching before and after palm guard application. A 06/02/23 Restorative: splint application and removal program-complete passive range motion gentle stretching prior to applying and after removing palm guards. Guards to be encouraged to be in place six to eight hours daily, six to seven days a week, at least 15 minutes of staff restorative direct care per day. Observation on 06/12/23 at 9:28 A.M. revealed Resident #1 sitting in tilt-in-space wheelchair, in the common area beside the nursing station. There were no splints, braces, or rolled washcloths applied to either hand. An observation was completed at 11:18 A.M. and remained unchanged. Observation on 06/12/23 at 11:26 A.M. revealed Resident #1 was removed from the common area to 365342 Page 8 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 receive care. No washcloths, splints, palm guards, or braces were in her hands. Level of Harm - Actual harm Observation on 06/12/23 at 11:52 A.M. revealed Resident #1 was she was in the hall with a stuffed animal in each arm. No washcloths, splints, palm guards or braces were observed to the resident's hands. Residents Affected - Few Interview 06/12/23 at 2:58 P.M. with Certified Occupational Therapy Assistant (COTA) #140 revealed when Resident #1 was screened on 03/08/23 therapy became aware staff were not utilizing the resting hand splints and were not getting Resident #1 up in the custom chair. Some staff said they were providing restorative recommendations from the 10/10/22 discharge from therapy and other staff stated they were not providing the recommendations. Therapy stated facility staff had been educated on out of bed transfers and splint placement in October when therapy was discontinued. The restorative program would have been given to the MDS nurse when the resident was discharged from therapy for follow-up and/or implementation. When the resident was discharged from therapy, she was wearing the resting hand splints. The resident's hands were now rigid. Therapy located her resting hand splints and she was not able to wear them at that time, due to the worsening of her hand contractures. The resting hand splints did not move enough and she could not use them. The COTA stated panacea palm guards were trialed and they were misplaced. She had skin sloughing with them and could not tolerate them (palm guards) and therapy noted the panacea palm guards were heavy. On 05/23/23 COTA #140 emailed supply to order sheep skin palm guards and they have not yet arrived. She included they are currently using washcloth roll ups on Resident #1's hands until the ordered palm guards arrive. The therapy department was never able to restore motion back to her hands to resume use of the resting hand splints. Observation on 06/12/23 at 3:09 P.M. revealed Resident #1 lying in bed on her back. There were no splints, braces, palm guard or rolled washcloths applied to either hand. Interview 06/12/23 at 5:24 P.M. with State Tested Nurse Aide (STNA) #122 revealed she had never been trained on splints. She had never been trained to put washcloths in Resident #1's hands. She had never been told to do it. She has rarely seen washcloths in Resident #1's hands. She verified she did not see washcloths in the resident hands today. She is usually only able to put one finger in her fist to make room to clean her hands. She cannot manually straighten her fingers or elbows. Interview 06/12/23 at 5:31 P.M. with STNA #152 revealed she had not been trained in putting on splints on Resident #1's hands. She has never put them on. She said therapy would put them on. She is not able to straighten the residents fingers out all the way. We put a washcloth in her hand when we shower her and check her nails. The nurse cuts them every other weekend at least; to keep her fingernails from cutting into her palm. She has not been told to put washcloths rolls in her hands during the day but has seen them in there before. She assumed therapy was putting them in. She is not able to straighten the resident's elbows. She always has the weighted stuffed animals in her arms. She is not able to straighten the resident's knees. Observation on 06/12/23 at 6:04 P.M. revealed Resident #1 was in bed with stuff animals in her arms. Her fingers/hands were clenched into fists. There were no splints, braces, or rolled washcloths applied to either hand. Interview and observation 06/12/23 at 6:04 P.M. with STNA #117 revealed she attempted to provide range of motion to Resident #1's fingers and was unable to move them on either hand. STNA #117 was 365342 Page 9 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 Level of Harm - Actual harm Residents Affected - Few able to get the resident's right wrist to straighten but not the left. Both knees were contracted with the left knee worse than the right knee. The STNA was unable to straighten either knee fully. STNA #117 verified the resident did not have a washcloth, splints or palm guards on her hands. Interview 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed the Director of Nursing just started the end of March so she would not of been the one taught about the restorative program for Resident #1 in October. The Administrator verified they did not have a restorative program in October of 2022. They had a maintenance program the aides were to do. The Administrator and Director of Nursing verified they could not find where the October programs were written for Resident #1. A paper referral would have been written for nursing. They verified the staff would not know to do it when the programs were not written in the TASK or treatments. They included a nurse was trained for restorative 03/16/23 and they started a restorative program 03/29/23. A new unit manager had been hired with restorative experience, but he had not started yet. 2. Review of Resident #40's medical record revealed a 04/23/21 admission with diagnosis including wedge compression fracture of first lumbar vertebra, Vitamin D deficiency, dementia with behavioral disturbance and mood disturbance, spinal stenosis, and Alzheimer. Review of the 03/02/23 Quarterly MDS revealed the resident was severely impaired for daily decision making with delusions, but no rejection of care or other behaviors. The resident was extensive, two-person assistance for bed mobility, transfer, and toileting. Extensive, one-person assistance for dressing, and walking in room. The resident was supervision, one-person assistance for eating. She had no impairment of the upper or lower extremities. Mobility devices included a walker and wheelchair. She was always incontinent of urine and frequently incontinent of bowel with no venous or pressure ulcers. Review of therapy records revealed the resident was in occupational therapy from 01/02/23 to 03/02/23 working on sitting with functional endurance, bilateral upper extremity strength, good positioning in bed for feeding, improving wheelchair posture and the ability to complete toileting with contact guard assist. Review of the Occupational therapy discharge revealed a 03/02/23 discharge date . The discharge read a referral was completed to the restorative nursing/functional mobility program. There was no evidence of what the program was related to and no evidence the program was written by the nursing department. There were no instructions in Task for the State Tested Nurse Aides to follow, there was no physician order or treatment orders written. There was no restorative plan of care for March of 2023. Interview 06/12/23 at 7:21 P.M. with COTA #140 revealed the resident was picked up for therapy based on a screening. A handwritten referral sheet would have been given to nursing outlining what the restorative program was to include/address. COTA #140 included the resident was picked up by physical therapy on 03/17/23. Interview on 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed they did not have any evidence of the resident receiving a restorative/maintenance program after her 03/02/23 discharge from occupational therapy. The facility did not provide a restorative program policy. 365342 Page 10 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0688 This deficiency represents noncompliance investigated under Master Complaint Number OH00143484 and Complaint Number OH00138029. Level of Harm - Actual harm Residents Affected - Few 365342 Page 11 of 12 365342 06/13/2023 Carriage Inn of Cadiz Inc 308 West Warren Street Cadiz, OH 43907

F 0790 Provide routine and 24-hour emergency dental care for each resident. 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 and interview, the facility failed to provide timely dental services for one resident (Resident #1) of three residents reviewed for dental services. The census was 59. Residents Affected - Few Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, anoxic brain damage, poisoning by unspecified drugs, presence of cerebrospinal fluid drainage device, paraplegia, muscle wasting, and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/19/23, revealed the resident was severely cognitively impaired. There were no behaviors or rejection of care. The MDS further revealed Resident #1 was totally dependent on two-person assistance with personal hygiene, transfer, bed mobility, and toileting. There was no mouth or facial pain. Review of an oral surgery referral, dated 09/08/22, revealed a referral for tooth extraction. Review of the dental summary report revealed Resident #1 was examined by the dentist on 09/08/22 for an emergency examination due to broken teeth, upper and lower jaws. The area has been a problem for several months. Extraction was recommended. Further review of the dental summary report revealed on 03/29/23 the dentist noted the resident has not had teeth extracted per the social worker. During interview on 06/13/23 at 2:04 P.M., Transportation Scheduler #126, revealed she was not the scheduler at the time of the referral, however, when she assumed the position in February 2023, she was informed the reason for the delay was due to finding an oral surgeon who would accept the resident's insurance. Transportation Scheduler #126 stated that she notified the Administrator, Director of Nursing (DON) and the Social Services Designee of the inability to find an oral surgeon who would accept Resident #1's referral. During interview on 06/13/23 at 4:04 P.M., Social Services Designee #82 confirmed the resident's tooth extraction had not yet occurred, however, an appointment is scheduled for 06/27/23. SSD #83 confirmed there is no evidence the referring dentist was notified of the delay in obtaining an oral surgery appointment until 03/29/23. This deficiency represents non-compliance investigated under Complaint Number OH00143484. 365342 Page 12 of 12