Health inspection·August 30, 2018

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility failed to develop a baseline care plan for a resident who was administered an anticoagulant medication. This affected one (#256) of six residents reviewed for unnecessary medication use. The census was 57. Findings include: Review of the medical record for Resident #257 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic bronchitis, upper respiratory infection, chronic obstructive pulmonary disease, hypertension, chronic atrial fibrillation, atherosclerotic heart disease, alcohol abuse, morbid obesity, hypersomnia, acute metabolic encephalopathy, hyponatremia, and hypokalemia. Review of Resident #257's physician orders dated 08/17/18, revealed an order for the anticoagulant medication Pradaxa (dabigatran) 150 milligrams (mg) one capsule to be administered by mouth two times a day. Review of the medication administration record dated 08/18 revealed Pradaxa was administered to Resident #257 twice a day on 08/18/18, 08/19/18, 08/20/18, 08/22/18, 08/23/18, and 08/24/18, and once a day on 08/25/18, 08/26/18, and 08/28/18. Review of the baseline care plan dated 08/17/18 revealed the care plan was incomplete. The baseline care plan did not identify Resident #257 was ordered an anticoagulant medication and did not include monitoring for anticoagulant side effects. Interview on 08/30/18 at 1:33 P.M. with the director of nursing (DON) verified the baseline careplan for Resident #257 was incomplete. The DON verified the careplan did not identify Resident #257's anticoagulant use or monitoring for anticoagulant medication side effects. The DON further verified the medical record for Resident #257 contained no documentation of the facility monitoring for anticoagulant medication side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 2 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure justification for a resident's urinary catheter. This affected one (#2) of one residents reviewed for urinary catheters. The facility identified one resident with a urinary catheter. Facility census was 57. Findings include: Review of Resident #2's medical record revealed an admission date of 07/24/16. Medical diagnoses included diabetes mellitus, constipation, hypertension, major depressive disorder, dementia without behavioral disturbance, polyneuropathy, retention of urine, and cerebral atherosclerosis. Review of the resident's physician's orders revealed an order written on 06/11/18 for a urinary catheter to help with healing of a wound. On 06/25/18, an order was written to change the diagnosis for the urinary catheter to urinary retention. Review of the resident's nursing notes revealed an entry on 07/23/18 indicating the resident's coccyx wounds were healed, but remained tender. Continued review of the medical record revealed no evidence indicating the resident had been checked for urinary residuals. Review of the resident's care plan dated 06/18/18 revealed the resident was at risk for complications from usage of urinary catheter to help promote healing of skin due to moderate skin erosion. On 06/26/18, the care plan was revised to include a new diagnosis of urinary retention. Interview with the Director of Nursing (DON) on 08/29/18 at 2:47 P.M. verified there was no clinical justification for the resident's diagnosis of urinary retention. She stated she spoke with the medical director regarding the resident's urinary catheter and requested supporting documentation. The medical director gave the DON an order to discontinue the urinary catheter and to check for residual every shift, call the medical director if residual greater than 300 milliliters. The DON verified there was no documentation of residuals prior to 08/29/18. Review of an undated facility policy titled Incontinence Management revealed appropriate indications for use of a chronic indwelling catheter in the long-term care setting included urinary retention that: causes persistent overflow incontinence, symptomatic infections, or renal dysfunction, cannot be corrected surgically or medically, cannot be practically managed with intermittent catheterization, short-term for skin wounds or pressure ulcers when other measures are not viable and healing is enhanced by keeping the area dry, provision of palliative care or care of severely impaired residents for whom bed and clothing changes are uncomfortable or disruptive, preference of a resident who has not responded to more specific treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 3 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on time sheet review, review of staff schedule, and staff interview, the facility failed to provide registered nurse (RN) coverage for eight consecutive hours seven days a week. This had the potential to affect all 57 residents residing at the facility. The census was 57. Finding include: Review of Registered Nurse (RN) #330's time sheet dated 08/01/19 to 08/26/18, revealed on Saturday, 08/04/18 RN #330 provided six hours of coverage at the facility. Further review of the time sheet revealed on Saturday, 08/25/18, the RN provided coverage at the facility for five and a half hours (10:00 A.M. to 3:30 P.M.) and on Sunday, 08/26/18, RN coverage was provided for five and a half hours (12:00 P.M. to 5:30 P.M.). Review of the director of nursing's (DON)'s monthly schedule dated 08/18, revealed the DON was not at the facility on 08/04/18. Continued review of the DON's schedule revealed the DON was at the facility on 08/18/18 from 12:00 P.M. to 7:00 P.M. and on 08/19/18 from 1:30 P.M. to 8:30 P.M. Documentation revealed on 08/18/18 and 08/19/18 the hours worked by the DON were to provide state tested nurse aid (STNA) hours. Further review of the DON's schedule revealed the DON was at the facility on 08/25/18 from 9:00 P.M. to 12:00 A.M. Documentation revealed the hours worked by the DON on 08/25/18 were for STNA duties. Review of the DON's schedule dated 08/26/18 revealed the DON logged hours work on from 12:00 A.M. to 12:30 A.M. and 7:00 P.M. to 9:30 P.M. Documentation revealed the hours worked by the DON 08/26/18 were worked to provide residents with STNA care. Review of RN #330's time sheet and the DON's monthly schedule revealed RN coverage was not provided for eight consecutive hours on 08/04/18, 08/18/18, 08/19/18, 08/25/18, or 08/26/18. Interview on 08/29/18 at 4:00 P.M. with the DON revealed the DON did not work weekend. The DON reported the ADON was responsible for providing RN coverage every weekend. The DON revealed the ADON was paid a set salary wage during the week for the ADON position and clocked in and out on the weekends when providing the required RN coverage. Interview on 08/30/18 at 9:50 A.M. with RN #330 revealed the RN worked at the facility every weekend unless he/she had personal things to do. RN #330 verified six hours of RN coverage was provided on Saturday 08/04/18. The RN further verified he/she was not at the facility on Saturday, 08/11/18; Sunday, 08/12/18; Saturday, 08/18/18, or Sunday, 08/19/18. RN #330 verified RN coverage was provided on Saturday, 08/25/18 for five and a half hours, and on Sunday, 08/26/18 for five and a half hours. The facility confirmed this had the potential to affect all 57 residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 4 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and resident and staff interviews, the facility failed to administer anticoagulant medication as ordered by the physician. This affected one (#257) of six residents reviewed for unnecessary medication use. Facility census was 57. Findings include: Review of the medical record for Resident #257 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic bronchitis, upper respiratory infection, chronic obstructive pulmonary disease, hypertension, chronic atrial fibrillation, atherosclerotic heart disease, alcohol abuse, morbid obesity, hypersomnia, acute metabolic encephalopathy, hyponatremia, and hypokalemia. Review of Resident #257's physician orders dated 08/17/18, revealed an order for the anticoagulant medication Pradaxa (dabigatran) 150 milligrams (mg), one capsule to be administered by mouth two times a day. Review of the medication administration record (MAR) dated 08/18, revealed Pradaxa was not administered to Resident #257 on 08/21/18 at 8:00 A.M. and 4:00 P.M., 08/25/18 at 4:00 P.M., 08/26/18 at 4:00 P.M. and 08/27/18 at 8:00 A.M. and 4:00 P.M. Continued review of the MAR revealed documentation the Pradaxa was not available from pharmacy. Review of the nurse progress notes dated 08/20/18 to 08/27/18 revealed no documentation of the physician being notified Resident #257 was not administered Pradaxa. Interview on 08/27/18 at 10:32 A.M. with Resident #257 revealed Pradaxa was not administered for the last three days. Resident #257 reported the staff were made aware of the importance of the anticoagulant medication by this resident on several occasions. Resident #257 reported being told by staff the medication was not available from the pharmacy. Interview on 08/28/18 at 2:40 P.M. with licensed practical nurse (LPN) #320 revealed the nurse was unable to locate Resident #257's Pradaxa this morning. LPN #320 revealed after searching the medication cart, the Pradaxa was found in the wrong drawer. Interview on 08/28/18 at 4:06 P.M. with a registered pharmacy technician revealed a 14 day supply of Pradaxa for Resident #257 was delivered to the facility on [DATE]. Interview on 08/29/18 at 7:38 A.M. with LPN #310 revealed when initials are circled on the MAR it indicated a medication was not administered to the resident. LPN #310 verified Pradaxa was not given to Resident #257 on 08/21/18 at 8:00 A.M. and 4:00 P.M., 08/25/18 at 4:00 P.M., 08/26/18 at 4:00 P.M. and on 08/27/18 at 8:00 A.M. and 4:00 P.M. LPN #310 reported the Pradaxa was not administered to Resident #257 because it was not available from pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 5 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure an as needed (PRN) antianxiety psychotropic medication was time limited to fourteen days. In addition, the facility failed to ensure a resident received non-pharmacological interventions (NPI's) prior to the administration of an as needed antianxiety psychotropic medication. This affected one (#56) of five residents reviewed for unnecessary medications. The facility identified 19 residents who receive antianxiety psychotropic medications. The facility census was 57. Findings include: Review of Resident #56's medical record revealed an admission date of 08/04/18. Medical diagnoses included orthopedic aftercare, diabetes mellitus, chronic kidney disease, peripheral vascular disease, and osteoarthritis. Review of the resident's Minimum Data Set (MDS) dated [DATE] revealed the resident received antianxiety medication six times during the look back assessment period. The resident's brief interview for mental status exam score was 11, indicating moderate impairment in cognition. Review of the resident's physician's orders dated 08/08/18 revealed an order for alprazolam (psychotropic antianxiety medication) one milligram (mg) by mouth three times daily (tid) PRN for anxiety, 90 tablets. There was no justification to extend the order beyond 14 days. Review of the resident's Medication Administration Record (MAR) for August 2018 revealed the resident received the PRN alprazolam ten times. Continued review of the MAR revealed the back of the MAR contained three entries (08/04/18, 08/05/18, and 08/25/18) regarding the administration of alprazolam for increased anxiety. There was no documentation of NPI's attempted prior to the administration of the alprazolam. Review of the resident's nursing notes from 08/04/18 through 08/30/18 revealed an entry on 08/08/18 and 08/21/18 indicating the resident requested and received her PRN alprazolam. Review of the resident's care plan dated 08/14/18 revealed a care plan for the resident's risk of side effects due to use of psychotropic drug use related to anxiety/depression. Interventions included behavior tracking per facility policy. There was no intervention to address NPI's prior to the administration of alprazolam. Interview with the Director of Nursing (DON) on 08/30/18 at 10:00 A.M. verified the resident's PRN alprazolam order was not time limited to 14 days and there was no justification to extend the order past 14 days. She also verified there were only five times the nursing staff documented when the resident received her PRN alprazolam. She stated they did not document NPI's prior to giving PRN alprazolam as the resident just requested it. Review of an undated facility policy titled Behavior Management revealed the interdisciplinary team was to ensure the following was completed before a psychoactive medication was administered: appropriate NPI's have been identified prior and implemented based on an individual resident assessment that included modification of the resident's environment, modification/elimination of psychological stressors to accommodate the resident's previous lifelong activities, habits or roles, modification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 6 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 staff/resident interactions and behavioral interventions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 7 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility infection control surveillance, staff interview, and review of a facility policy, the facility failed to ensure culture results were monitored and tracked. This had the potential to affect all 57 residents. Facility census was 57. Residents Affected - Many Findings include: Review of the facility monthly infection control surveillance logs for July and August 2018 revealed there were no results of cultures obtained and it was not indicated if a culture was obtained in every instance. Interview with Assistant Director of Nursing (ADON) #330 on 08/30/18 at 1:36 P.M. verified the facility infection control log did not contain results of cultures and did not always indicate if a culture was obtained. The facility confirmed this had the potential to affect all 57 residents residing in the facility. Review of a facility policy titled Antibiotic Stewardship Program revealed the infection control coordinator will track all new antibiotics for clinical assessment, prescription documentation, antibiotic selection, amount of antibiotics used in the facility, in-house infection rates, community based infection rates, antibiotic use patterns, impact of antibiotic stewardship program, organisms identified, adverse outcomes, and resistant organisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 8 of 9 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 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of facility infection control surveillance, staff interview, and review of a facility policy, the facility failed to ensure an adequate antibiotic stewardship program. This had the potential to affect all 57 residents. Facility census was 57. Residents Affected - Many Findings include: Review of the facility monthly infection control surveillance logs for July and August 2018 revealed there were no results of cultures obtained and it was not indicated if a culture was obtained in every instance. Additionally, the floor nurse was responsible for completing a facility form dated 06/16 titled, Infection/Antibiotic Report for each antibiotic prescribed. The form included McGreer's Criteria (criteria for infections in long term care facilities) for infections but did not indicate what criteria indicated a true infection and did not contain the most updated McGreer's criteria guidelines. Interview with Assistant Director of Nursing (ADON) #330 on 08/30/18 at 1:36 P.M. verified the facility form Infection/Antibiotic Report did not indicate what criteria indicated a true infection and did not contain the most updated McGreer's criteria guidelines. She verified not all infections listed on the log qualified as true infections based on current McGreer's Criteria. The facility confirmed this had the potential to affect all 57 residents residing in the facility. Review of a facility policy titled Antibiotic Stewardship Program revealed the infection control coordinator would track antibiotic starts, monitoring adherence to McGreer's Criteria. The facility would follow McGreer's infection criteria for determination of actual infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365483 If continuation sheet Page 9 of 9