Health inspection·August 10, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and record review the facility failed to give residents the correct form when they were cut from therapy services and stayed in the facility. This affected two (Resident #12 and #35) of three residents reviewed for beneficiary notices. The facility census was 74. Residents Affected - Few Findings include: 1. Record review of Resident #12 revealed an admission date of 09/19/22 and she was cut from therapy services on 07/03/23 and stayed in the facility and her pay source was Medicare part A. The resident had pertinent diagnoses including: stroke, hypertension and diabetes. Review of beneficiary notice date 06/29/23 revealed Resident #12 was being cut from therapy services on 07/03/23 and she did not receive CMS form 10055 that gives them the option to appeal, pay for it themselves, or agree to cut services. Interview with the Administrator on 08/09/23 at 2:00 P.M. verified there was no CMS form 10055 for Resident #12 given. 2. Record review of Resident #35 revealed an admission date of 04/18/23 and he was cut from therapy services on 05/04/23 and stayed in the facility and his pay source was Medicare part A. The resident had pertinent diagnoses including: hemiplegia, hypertension, anxiety, depression and hyperlipidemia. Review of beneficiary notice date 05/02/23 revealed Resident #35 was being cut from therapy services on 05/04/23 and he did not receive CMS form 10055 that gives them the option to appeal, pay for it themselves, or agree to cut services. Interview with the Administrator on 08/09/23 at 2:00 P.M. verified there was no CMS form 10055 for Resident #35 given. Page 1 of 15 365584 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to prevent staff to resident abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State Tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. The facility reported the incident to the residents daughter, the physician, and the Abuse Coordinator. The agency LPN #555 was from was notified of the incident and LPN #555 was removed from working at the facility. The facility Social Worker assessed the psychosocial well-being of the resident. The resident had continued on with their normal daily function that evening and currently. Review of the facility Report of Concern form, dated 06/28/23 and initiated by STNA #222, revealed documentation Resident #14 reported LPN #555 and STNA #333 closed the residents door and yelled at her to quit crying. Resident #14 stated she told them not to, but they did anyway's. Review of the facility Witness Statement Form, dated 06/29/23, revealed Resident #48 stated at 4:00 A.M. I got up to use the restroom. I heard the nurse yelling at the old lady. She told her to shut up and quit crying. She stated you are going to wake up everybody. The nurse then shut her door. After the nurse shut her door, I went over to try to get her to calm down. When I left her room I left the door open. Review of the facility Witness Statement Form, dated 06/29/23, revealed STNA #333 reported Resident #14 was crying all night saying her finger hurt. I asked the nurse (LPN #555) for something for pain for Resident #14 and was told she did not need anything, she was just in a mood. I went back and sat with Resident #14 for 30 minutes then went back to LPN #555. LPN #555 said again Resident #14 was fine and she was not going to put up with it. LPN #555 then shut the door to Resident #14's room and told her to quit crying. Review of the hand-written statement from STNA #222, dated 07/03/23, revealed STNA #222 was in Resident #14's room the morning after the incident in question. STNA #222 went into Resident #14's room 365584 Page 2 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to check on her at shift change and the resident was in her bed crying and reaching for her to hug her, saying she was glad to see her. Resident #14 went on to say the night before LPN #555 came into her room because she was crying out loud saying her hands were hurting and LPN #555 told her to stop crying alligator tears or she was going to shut the door. Resident #14 stated this happened a couple times then LPN #555 shut her door. Resident #14 stated she was claustrophobic and did not want her door shut but LPN #555 and STNA #333 kept shutting her door anyway's. Interview with Resident #14's daughter on 08/07/23 at 9:44 A.M. revealed Resident #14 was crying and verbalizing complaints of pain during the night shift. The agency nurse who was working that night told resident #14 to stop crying or she was going to shut the door to the room. When Resident #14 continued to cry due to pain, the agency nurse shut the door. Telephone interview with STNA #333 on 08/07/23 at 2:03 P.M. revealed STNA #333 was in a room two doors down from Resident #14 and heard her start screaming. STNA #333 responded and Resident #14 stated her finger was hurting. STNA #333 stated she asked LPN #555 for pain medication for the resident and LPN #555 stated Resident #14 did not need it. STNA #333 stated she went and sat with Resident #14 for almost an hour and calmed her down some, but she was still hurting. STNA #333 stated LPN #555 then came to the room and shut Resident #14's door and said something along the line of When you stop acting like a toddler I will open the door up. STNA #333 stated she wanted to open the door, but was told not to. STNA #333 stated Resident #14 screamed for almost two hours. STNA #333 stated she opened up the door around 4:00 A.M. to 4:30 A.M. when she was passing ice. STNA #333 stated she did not report the incident during that night to management and LPN #555 continued to work the remainder of the night shift. STNA #333 stated she felt the incident which occurred was abuse. Telephone interview with STNA #222 on 08/08/23 at 10:17 A.M. revealed STNA #222 was doing her morning walk through and saw the door to Resident #14's room was closed, which was abnormal. STNA #222 stated Resident #14 was lying in bed crying and reaching for her and told her they closed the door on her and were not listening to her about her pain. STNA #222 stated staff knew the resident did not like her door closed. STNA #222 stated there was a sign put on the residents door by her daughter to keep the door open because the resident was claustrophobic but it was taken down. STNA #222 stated Resident #14 told her LPN #555 told her to dry up her alligator/crocodile tears or I will close your door. STNA #222 stated she filled out a concern form with the resident and gave it to LPN #999. STNA #222 stated she felt the residents report of the incident constituted abuse. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 stated she interviewed Resident #14 who would not disclose much information during the interview and just kept saying she wanted her daughter. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed abuse was defined by the facility as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Staff should immediately all incidents/allegations of abuse immediately to the Administrator or designee. If a staff member is accused or suspected the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. 365584 Page 3 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure timely reporting of an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State Tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. Review of the facility Report of Concern form, dated 06/28/23 and initiated by STNA #222, revealed documentation Resident #14 reported LPN #555 and STNA #333 closed the residents door and yelled at her to quit crying. Resident #14 stated she told them not to, but they did anyway's. Review of the facility Witness Statement Form, dated 06/29/23, revealed STNA #333 reported Resident #14 was crying all night saying her finger hurt. I asked the nurse (LPN #555) for something for pain for Resident #14 and was told she did not need anything, she was just in a mood. I went back and sat with Resident #14 for 30 minutes then went back to LPN #555. LPN #555 said again Resident #14 was fine and she was not going to put up with it. LPN #555 then shut the door to Resident #14's room and told her to quit crying. Review of the hand-written statement from STNA #222, dated 07/03/23, revealed STNA #222 was in Resident #14's room the morning after the incident in question. STNA #222 went into Resident #14's room to check on her at shift change and the resident was in her bed crying and reaching for her to hug her, saying she was glad to see her. Resident #14 went on to say the night before LPN #555 came into her room because she was crying out loud saying her hands were hurting and LPN #555 told her to stop crying alligator tears or she was going to shut the door. Resident #14 stated this happened a couple times then LPN #555 shut her door. Resident #14 stated she was claustrophobic and did not want her door shut but LPN #555 and STNA #333 kept shutting her door anyway's. Interview with Resident #14's daughter on 08/07/23 at 9:44 A.M. revealed Resident #14 was crying and verbalizing complaints of pain during the night shift. The agency nurse who was working that night told resident #14 to stop crying or she was going to shut the door to the room. When Resident #14 365584 Page 4 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0609 continued to cry due to pain, the agency nurse shut the door. Level of Harm - Minimal harm or potential for actual harm Telephone interview with STNA #333 on 08/07/23 at 2:03 P.M. revealed STNA #333 was in a room two doors down from Resident #14 and heard her start screaming. STNA #333 responded and Resident #14 stated her finger was hurting. STNA #333 stated she asked LPN #555 for pain medication for the resident and LPN #555 stated Resident #14 did not need it. STNA #333 stated she went and sat with Resident #14 for almost an hour and calmed her down some, but she was still hurting. STNA #333 stated LPN #555 then came to the room and shut Resident #14's door and said something along the line of When you stop acting like a toddler I will open the door up. STNA #333 stated she wanted to open the door, but was told not to. STNA #333 stated Resident #14 screamed for almost two hours. STNA #333 stated she opened up the door around 4:00 A.M. to 4:30 A.M. when she was passing ice. STNA #333 stated she did not report the incident during that night to management and LPN #555 continued to work the remainder of the night shift. STNA #333 stated she felt the incident which occurred was abuse. Residents Affected - Few Telephone interview with Corporate Regional Clinical Director #900 on 08/07/23 at 3:13 P.M. revealed she had come to the facility on [DATE] or a visit and was informed of the incident which had occurred on 06/28/23 for the first time. Corporate Regional Clinical Director #900 stated she filed an SRI with the state agency and filed a report with the local Sheriffs office on 07/03/23 after being informed of the incident. Telephone interview with STNA #222 on 08/08/23 at 10:17 A.M. revealed STNA #222 was doing her morning walk through and saw the door to Resident #14's room was closed, which was abnormal. STNA #222 stated Resident #14 was lying in bed crying and reaching for her and told her they closed the door on her and were not listening to her about her pain. STNA #222 stated staff knew the resident did not like her door closed. STNA #222 stated there was a sign put on the residents door by her daughter to keep the door open because the resident was claustrophobic but it was taken down. STNA #222 stated Resident #14 told her LPN #555 told her to dry up her alligator/crocodile tears or I will close your door. STNA #222 stated she filled out a concern form with the resident and gave it to LPN #999. STNA #222 stated she felt the residents report of the incident constituted abuse. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 verified the police were not notified of the incident, nor was an SRI filed, until 07/02/23 when Corporate Regional Clinical Director #900 was notified of the incident as the Administrator and Director of Nursing (DON) had been out of the facility. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed if any form of abuse was alleged, the Administrator of his/her designee will notify the Ohio Department of Health (ODH) immediately, but no longer than two hours after the allegation was made. For suspected crimes which did not involve serious bodily injury, law enforcement must be notified within 24 hours. 365584 Page 5 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure a timely and thorough investigation was completed following an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Residents Affected - Few Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State Tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. Review of the daily staffing sheet for 06/27/23 revealed there were two nurses and two STNA's scheduled to work on the [NAME] Wing of the facility from 7:00 P.M. on 06/27/23 through 7:00 A.M. on 06/28/23. Review of the facility investigation revealed a Report of Concern form was completed by STNA #222 on 06/28/23 regarding the incident involving Resident #14 and LPN #555 which was provided to LPN #999. A witness statement form detailing the incident was completed for Resident #48 on 06/29/23. A witness statement form was completed for STNA #333 on 06/29/23. Documentation of four resident interviews were completed on 07/03/23. A hand written statement from STNA #222, dated 07/03/23, was included in the investigation packet. No additional interviews with staff working night shift when the allegation of abuse occurred were present in the investigation packet. No statement from Resident #14 or assessment of the resident were included in the investigation packet. Telephone interview with Corporate Regional Clinical Director #900 on 08/07/23 at 3:13 P.M. revealed she had come to the facility on [DATE] or a visit and was informed of the incident which had occurred on 06/28/23 for the first time. Corporate Regional Clinical Director #900 stated she filed a SRI with the state agency and filed a report with the local Sheriffs office on 07/03/23 after being informed of the incident. Corporate Regional Clinical Director #900 further stated LPN #555 was unable to be interviewed regarding the allegation of abuse as the only telephone number the agency she worked for was not her correct phone number and attempts to reach her were unsuccessful. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 verified the police were not notified of the incident, nor was an SRI filed, until 07/03/23 when 365584 Page 6 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Corporate Regional Clinical Director #900 was notified of the incident as the Administrator and Director of Nursing (DON) had been out of the facility. LPN #999 verified the investigation of the incident did not include the other staff members working on [NAME] Wing during the night of the incident and interviews with four residents residing on the same hallway as Resident #14 at the time of the incident had not been conducted until 07/03/23. LPN #999 verified LPN #555 had not been interviewed as the employee had already completed her shift at the facility and left prior to her being notified of the incident and was not reachable by phone. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed the person investigating the incident should generally take the following actions: Interview with resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and/or alleged victim the day of the incident. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. The results of the investigation will be reported to the Administrator, and a final report will be submitted to the Ohio Department of Health (ODH) no longer than five working days after discovery of the incident. 365584 Page 7 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) was completed following a new diagnosis of psychosis. This affected one resident (#16) out of the three residents reviewed for PASARR's during the annual survey. The facility census was 74. Findings include: Record review for Resident #16 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, osteoarthritis, anxiety disorder, and difficulty walking. A new diagnosis of unspecified psychosis was added for the resident on 01/20/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Further record review for this resident revealed no evidence of a PASARR being completed after a new diagnosis of psychosis was added on 01/20/23. Interview with Licensed Social Worker (LSW) #777 on 08/08/23 at 2:30 P.M. verified a new PASARR had not been completed for Resident #16 following a new diagnosis of psychosis. 365584 Page 8 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on staff interview, observation, and record review the facility failed to have a care plan for Resident #30's skin condition and failed to have an accurate care plan for Resident #47's dialysis port site. This affected two of 17 residents reviewed for care plans. The facility census was 74. Findings include: 1. Record review of Resident # 30 revealed an admission date of 06/09/23 with pertinent diagnoses of: non pressure chronic ulcer of skin, anxiety disorder, hypertension, and cellulitis of abdominal wall. Review of the 06/16/23 admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and was at risk for pressure ulcers and had two arterial or venous ulcers. The MDS triggered in section V for a skin/pressure ulcer care plan to be out in place. Review of the medical record on 08/09/23 revealed the resident had a wound to her abdominal area since admission. Review of the medical record on 08/09/23 revealed there was no care plan for pressure ulcer or skin alterations developed. Interview on 08/10/23 at 10:15 A.M. with the Administrator verified Resident #30 did not have a care plan for pressure ulcer or skin issues. 2. Record review of Resident # 47 and revealed an admission date of 01/10/23 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus, morbid obesity, lymphedema, atrial fibrillation and hypertension. Review of the 07/07/23 quarterly MDS assessment revealed the resident was moderately cognitively impaired and was receiving dialysis services. Review of the care plan dated 01/11/23 revealed Resident #47 has renal failure related to end stage disease and the goal is the resident will be free from infection through the review date. An intervention dated 01/17/23 included dialysis port to left upper extremity. Interview with Resident #47 on 08/10/23 at 9:52 A.M. revealed she has a non functioning port in her right upper arm and a port in her right chest. The Resident stated they never check her site at the facility. She stated she had not had a port in her left arm for a long time probably a year ago. Observation on 08/10/23 at 10:05 A.M. revealed a port in Resident #47 right upper arm and right chest. Interview with Registered Nurse (RN) #105 on 08/10/23 at 10:09 A.M. verified the port was in Resident #47's right arm and chest and the care plan was incorrect and stated it was in her left arm. 365584 Page 9 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure appropriate pain management was provided for a residents complaints of pain. This affected one resident (#14) out of the two residents reviewed for pain management during the annual survey. The facility census was 74. Residents Affected - Few Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. This resident was assessed to exhibit nonverbal indicators of pain daily over past 5 days. Review of the care plan, dated 04/25/23, revealed this resident had a potential for alteration in comfort. Interventions included to administer medications as ordered and pain assessment per facility policy. Review of the physicians order, dated 05/20/23, revealed Resident #14 was to be administered one tablet of Norco (an opioid pain medication) 5/325 milligrams (mg) every four hours as needed for pain. The order was discontinued on 06/28/23. Review of the narcotic count sheet for Norco for Resident #14 revealed no tablets of the medication were documented to have been removed from the card from 7:00 P.M. on 06/27/23 through 7:00 A.M. on 06/28/23. Review of the Medication Administration Record (MAR) for 06/2023 revealed no doses of Norco 5/325 mg were documented to have been administered to Resident #14 between 7:00 P.M. on 06/27/23 through 7:00 A.M. on 06/28/23. Further record review for Resident #14 revealed no documentation of the residents complaints of pain or pain assessment were present. Telephone interview with State Tested Nursing Assistant (STNA) #333 on 08/07/23 revealed STNA #333 was two rooms down from Resident #14's room and heard the resident begin to scream. STNA #333 responded and the resident informed her that her finger was hurting. STNA #333 requested pain medication be administered to Resident #14 by Licensed Practical Nurse (LPN) #555. LPN #555 responded Resident #14 did not need it. STNA #333 stated she went down and sat with Resident #14 for almost an hour to calm her down, but the resident was still hurting and complaining of pain. STNA #14 stated she again notified LPN #555 of the residents complaints of pain and continued crying and LPN #555 responded by telling Resident #14 to stop acting like a toddler and I will open the door as she closed the door. STNA #333 stated Resident #14 continued to scream for almost two hours. Telephone interview with Corporate Regional Clinical Director #900 on 08/07/23 at 3:13 P.M. 365584 Page 10 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed Resident #14 had poked her finger with a sewing needle and had developed osteomyelitis (an infection of the bone) in the finger of her left hand. Telephone interview with STNA #222 on 08/08/23 at 10:17 A.M. revealed on the morning of 06/28/23 Resident #14 reported to her the night shift nurse had shut her door and was not listening to her about her pain. Interview with LPN #999 on 08/08/23 at 10:45 A.M. verified there was not evidence of an assessment of Resident #14's complaints of pain during night shift on 06/28/23 or of pain medication being administered to Resident #14 following the residents complaints of pain. Review of the facility policy titled Administering Pain Medications, reviewed 08/2022, revealed pain management was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents choices related to pain management. Pain management was defined as the process of attempting to treat the residents pain based on his or her clinical condition and established of treatment goals. Pain management was a multidisciplinary care process that included the following: recognizing the presence of pain, identifying the characteristics of pain, attempting to address the underlying causes of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. Pain assessments were to be conducted upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and as needed. 365584 Page 11 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, observation, resident interview, and record review the facility failed to provide dialysis care with professional standards when they failed to document checks of the dialysis port. This affected one (Resident #47) of one resident who was receiving dialysis services. The facility census was 74. Residents Affected - Few Findings include: Record review of Resident # 47 revealed an admission date of 01/10/23 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus, morbid obesity, lymphedema, atrial fibrillation and hypertension. Review of the 07/07/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and was receiving dialysis services. Review of the care plan dated 01/11/23 revealed Resident #47 has renal failure related to end stage disease and the goal is the resident will be free from infection through the review date. Review of Resident #47's medical record on 08/10/23 revealed there was no documented evidence that the dialysis site was checked for infection, bleeding, bruit or thrill, or patency. Interview with Resident #47 on 08/10/23 at 9:52 A.M. revealed she has a non functioning port in her right upper arm and a port in her right chest. The Resident stated they never check her site at the facility. Observation on 08/10/23 at 10:05 A.M. revealed a port in Resident #47's right upper arm and right chest. Interview with Registered Nurse (RN) #105 on 08/10/23 at 10:09 A.M. verified the port was in Resident #47's right arm and chest and there was not documentation where the site was ever checked for infection, bleeding, bruit or thrill, or patency. 365584 Page 12 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure pain levels and interventions for pain were monitored and documented when pain medication was administered. This affected two residents (#14 and #18) out of the two residents reviewed for pain management during the annual survey. The facility census was 74. Residents Affected - Few Findings include: 1. Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the care plan, dated 04/25/23, revealed this resident had a potential for alteration in comfort. Interventions included administer medications as ordered and pain assessment per facility policy. Review of the Narcotic Count Sheet for Resident #14's Norco (an opioid pain medication) revealed one tablet of the medication was documented to have been removed by Licensed Practical Nurse (LPN) #444 on 06/21/23 at 2:00 P.M., on 06/26/23 at 9:00 A.M., on 06/27/23 at 12:00 P.M., and on 06/27/23 at 6:00 P.M. Review of the Medication Administration Record (MAR) for Resident #14 revealed no doses of Norco and no assessment of pain level prior to administration or effectiveness of the medication were documented to have been administered by LPN #444 on 06/21/23 at 2:00 P.M., on 06/26/23 at 9:00 A.M., on 06/27/23 at 12:00 P.M., or on 06/27/23 at 6:00 P.M. Interview with LPN #444 on 08/09/23 at 9:27 A.M. verified there was no evidence of her assessing Resident #14's pain, administering Norco, or assessing the effectiveness of the pain medication administered on 06/21/23, 06/23/23, and 06/27/23. 2. Review of the medical record for Resident #18 revealed an admission date of 07/06/23 and had diagnoses including: wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing, acute kidney failure, type 2 diabetes mellitus without complications, rheumatoid arthritis, and atherosclerotic heart disease of native coronary artery without angina pectoris and no known allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating resident had no cognitive deficits. The resident was assessed to require extensive assistance from two staff persons physical assist for bed mobility, dressing, toileting, and transfer activity occurred only once or twice with two persons' physical assist. Resident #18's pain was coded as frequent. 365584 Page 13 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/08/23 at 08:24 A.M. with Resident #18 revealed continuous pain and takes pain medication for it daily and as needed. Review of the physician orders for Resident #18 revealed a start date of: 07/09/23 at 2:30 P.M. for oxycodone hcl 5 milligram (mg) tablet, give 1 tablet by mouth every 6 hours as needed for lumbar back pain/rheumatoid arthritis 1 to 2 tablets. Review of the Medication Administration Record (MAR) for Resident #18 revealed for the month of July 2023 the oxycodone hcl 5 mg tablet was received once on: 07/10/23, 07/11/23, 07/14/23, 07/16/23, 07/17/23, 07/19/23, 07/20/23, 07/22/23, 07/25/23, 07/26/23, 07/27/23, and 07/28/23 and twice a day on: 07/12/23, 07/15/23, 07/18/23, 07/21/23, 07/23/23, 07/24/23, 07/29/23, 07/30/23, and 07/31/23. For the month of August 2023, the oxycodone hcl 5 mg tablet was received once on: 08/03/23, 0706//23, 07/07/23, 07/08/23 and twice on: 08/01/23, 08/04/23, and 08/05/23. For the month of August 2023 Resident #18 received the oxycodone hcl 5 mg tablet. The MAR did not indicate when the medication was received on all those dates if one or two tablets were given to Resident #18. Review of the care plan dated 07/10/23, revealed Resident #18 had a potential for alteration in comfort related to rheumatoid arthritis. Interventions included administer medications as ordered and pain assessment per facility policy. It further indicated Resident #18 was on pain medication therapy and an intervention included: administer analgesic medications as ordered by physician. Interview on 08/09/23 at 12:43 P.M. with the Director of Nursing (DON) verified the MAR for Resident #18 for the oxycodone hcl 5 mg tablet for administration for July and August 2023 did not indicate if one or two tablets were given to the resident per physician order and there were no records of how many tablets the resident received. Review of the facility policy titled Administering Pain Medication, reviewed 08/2022, revealed the purpose of the procedure was to provide guidelines for assessing the residents level of pain prior to administering analgesic pain medication. Pain management was a multidisciplinary process which included the following: recognizing the presence of pain, identifying the characteristics of pain, attempting to address the underlying causes of pain, monitoring the effectiveness of interventions, and modifying interventions as necessary. Steps in the procedure included: provide for resident privacy, explain the purpose of the assessment to the resident, conduct a pain assessment as indicated, administer pain medication as ordered, and re-evaluate the residents level of pain after administering. Document the following in the residents medical record: results of the pain assessment, medication, dose, route of administration, and results of medication. 365584 Page 14 of 15 365584 08/10/2023 Ayden Healthcare of Rosemount Pavilion 20 Easter Drive Portsmouth, OH 45662

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected two residents (Resident #34 and Resident #74) out of five residents reviewed for unnecessary medications. The facility census was 74. 1. Record Review of Resident #34 on 08/09/23 at 07:41 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: acute kidney failure, Schizoaffective disorder, osteomyelitis, left femur fracture, abdominal wall abscess, chronic ulcers, congestive heart failure, adult failure to thrive, Alzheimer's disease, anxiety, depression, and dementia. Review of the Minimum Data Set (MDS) assessment completed on 05/02/23 revealed this resident has severe cognitive impairment. Review of physician orders revealed this resident is receiving the following medication: Seroquel 25 milligrams (mg) 1 tablet by mouth daily at bedtime for agitation. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with the Director of Nursing on 06/27/23 at 10:15 A.M. verified agitation is an unacceptable diagnosis for the use of Seroquel. 2. Record Review of Resident #74 on 08/09/23 at 09:41 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: metabolic encephalopathy, dementia, Alzheimer's disease, atrial fibrillation, cerebrovascular disease, chronic kidney disease, anxiety, hypothyroidism, mood disorder, wandering, and hallucinations. Review of the MDS assessment completed on 07/19/23 revealed this resident has severe cognitive impairment. Review of physician orders revealed this resident is receiving the following medication: Risperidone 0.5 mg 1 tablet by mouth twice daily for Alzheimer's disease with agitation. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with the Director of Nursing on 06/27/23 at 10:15 A.M. verified Alzheimer's disease with agitation is an unacceptable diagnosis for the use of Risperidone. 365584 Page 15 of 15