Health inspection·June 3, 2021

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to update the plan of care for Resident #50 to establish an objective, measurable weight goal for a physician prescribed weight loss diet. This affected one (Resident #50) of seven residents reviewed for nutrition. Findings included: Record review was conducted for Resident #50 who was admitted to the facility on [DATE] with diagnoses including hemiplegia following a stroke, unspecified convulsions, neuromuscular dysfunction, panic disorder, major depression, anxiety disorder and oropharyngeal dysphagia. Review of Resident#50's Minimum Data Set assessment dated [DATE] revealed she had intact cognition and required extensive assistance of two staff for bed mobility and transfers, total dependence of one person for toileting, set up only and supervision for eating and extensive assistance of one staff for hygiene. Resident #50's medical record showed an active physician order dated 12/22/2020 for a weekly weight. Review of the weight records revealed her weight on 11/01/2020 had been 168.2 pounds. On 02/04/2021 she weighed 156.0 pounds. On 04/04/2021 her weight was 150 pounds. Record review of Resident #50's annual Nutritional assessment dated [DATE] and authored by Registered Dietitian (RD) #793 indicated the resident should have no unintentional weight changes, had lost 9.5% body weight in six months and the resident expressed an interest in losing weight. She was educated on the importance of gradual weight loss. There were no measurable, objective weight goal set in the assessment for the weight loss. Record review was conducted of the plan of care for Resident #50 with a date initiated of 04/20/2021. It indicated Resident #50 had nutritional problems related to history of dysphagia, history of COVID 19, expressed an interest of losing weight and had poor intake at times. The goal was to maintain adequate nutritional status through target date of 07/18/2021. There was no objective weight goal. Interventions included identify food/beverage preferences, monitor meal intake, nutritional consult on admission, quarterly and as needed, observe for signs of aspiration and dysphagia, obtain labs per orders, offer substitutes if meal is declined, position resident properly for eating, provide meal assistance as needed, provide a regular diet and snacks three times a day and have the speech or occupational therapist see the resident as needed. Review of Resident #50's weight record revealed she was not weighed since 04/04/21 until the Page 1 of 27 365633 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0656 surveyor asked for a weight on 05/24/2021 which was 136.2 pounds. Level of Harm - Minimal harm or potential for actual harm On 05/26/2021 a physician order for Resident #50 was activated for a physician prescribed weight loss regimen. Residents Affected - Few Review of Resident #50's weight record on 05/27/2021 revealed the resident again weighed 136.2 pounds. Interview was conducted on 05/27/2021 at 10:51 A.M. with MDS RN #733 who verified there was no measurable, objective weight goal added to the nutritional plan of care. Interview was conducted on 05/27/2021 at 10:55 A.M. with Licensed Practical Nurse (LPN) #770 who revealed she had known the resident for a long time, she had put on a lot of weight over the years due to inactivity and probably did want to lose some weight but not sure she would want to lose as much weight as she had lost. She said she was not able to make good decisions for herself since having a stroke. LPN #770 verified there had been no weight obtained in May until 05/24/2021. When the LPN was asked by the surveyor if the resident would be able determine a healthy weight she said no due to her cognition varying day to day related to a stroke. Interview was conducted on 05/27/2021 at 11:01 A.M. with Resident #50 who was laying in bed with her eyes open and covered with a blanket to her waist line. She appeared to be a normal weight for her frame and there was evidence of muscle wasting in the chest, arms and clavicle region with lack of muscle tone in those areas. She made eye contact with the surveyor but would not respond to simple nor open ended questions. When the surveyor asked her if she was trying to lose weight she did not respond. When asked if she knew how much she weighed she did not respond. When asked if she knew what a healthy weight was for her she did not respond. 365633 Page 2 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a bladder program was implement to restore Resident #1 bladder function to his base line. This affected one (Resident #1) of two residents reviewed for decline in activities of daily living (ADL). Residents Affected - Few Findings include: Resident #1 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, benign prostatic hyperplasia without lower urinary tract symptoms, and dementia with behavior disturbance. Resident #1's quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/29/20, revealed the resident required minimal assistance with toileting. Resident #1's annual comprehensive MDS assessment, dated 05/27/21, indicated the resident was severely cognitively impaired, and required extensive assistance with toileting. Interview on 05/19/2021 at 8:12 A.M. with State Tested Nursing Assistant (STNA) #711 revealed the resident was incontinent of urine, and would urinate inappropriately on the floor. Interview on 05/24/2021 at 5:35 P.M. with Therapy #788 revealed Resident #1 had a toileting program they were working on prior to discharge from therapy and Therapy #765 know more about what the toileting program was. Interview on 05/25/2021 at 8:49 A.M. with Therapy #765 revealed therapy worked with Resident #1 on safely getting on and off toilet, managing his clothing, and hygiene after using the bathroom, but no actual bowel or bladder retraining. Interview on 05/26/2021 at 3:10 P.M. Administration revealed the facility had no restorative programs at this time, confirming Resident #1 had a decline in bladder function without any intervention to improve or maintain bladder function. Observation on 05/26/201 at 4:35 P.M. of Resident #1's room revealed the room was noted to have a urine smell. 365633 Page 3 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient eating assistance to Resident #37. This affected one (Resident #37) of eight residents reviewed for activities of daily living. Residents Affected - Few Findings include: Resident #37 was admitted on [DATE] with diagnoses including dementia with behaviors, visual function, psychotic disorder, depression, anxiety, anemia, incontinence, hypertension, and hyperlipidemia. Observation on 05/17/21 from 11:40 A.M. to 12:45 P.M. revealed Resident #37's meal was in a divided plate with a dinner roll in one of the smaller compartments, carrots and green peas in the other small compartment, and the main entrée of pork and mashed potatoes were in the large compartment. The resident ate everything on the right side of her plate and left everything on the left side uneaten. Resident #37 was scraping the bottom of the empty right side of the plate, totally ignoring the food on the left side as if it did not exist. She consumed 100% coffee which was also on the right side. Upon surveyor intervention, Licensed Practical Nurse (LPN) #746 observed the resident's actions and as LPN #746 observed Resident #37 eat she revealed the only visual issues she was aware that the resident had was needed glasses and did not have them on. Surveyor asked the nurse to reposition the residents plate so that the food that was on the left was now on the right. The nurse turned the plate 180 degrees. The resident immediately stated oh, became excited and picked up her spoon and began to eat. The nurse also moved the residents cake from the left to the right. The resident became excited about the cake but kept eating the pork and the mashed potatoes. As the resident ate, the plate slid across the table and away from the right side of vision. Resident #37 stopped eating. STNA #711 who had finished feeding Resident #54, came over and moved the residents cake back to the left side, and was unaware the nurse had moved the cake to the right and within the residents line of sight. Resident #37 seemed to no longer acknowledge that the dessert was to her left and did not eat any of it. During these observations the resident was not noted to use her left arm and the staff were unaware her food had to be on the right side of Resident #37's to be in line with her vision. Interview on 05/17/2021 at 4:17 P.M. with Therapy #765, Therapy #780, and Therapy #787 revealed they were unaware Resident #37 may require an anti-slip material under her plate to prevent it from traveling across the table. Therapy #765 stated the resident does have the use of her left arm, but forgets the arm is there. She stated if you were to tap her arm and raise it into her line of vision she will say oh as if she had just grown the arm. She stated the resident doesn't recognize the left side of her body (Hemineglect), confirming staff need to be aware that items should be on the ride side of Resident #37 in her line of vision. 365633 Page 4 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to provide restorative nursing services to Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #57. This affected six (Resident #14, Resident #37, Resident #38, Resident #37, Resident #50, and Resident #) of six residents reviewed for restorative nursing programs. Residents Affected - Some Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including unspecified abnormalities of gait and mobility and other intellectual disabilities. Resident #14's physician order dated 12/09/2020 revealed the resident was to receive skilled physical therapy (PT) services five times a week for four weeks, focusing on therapeutic exercise, therapeutic activity, mobility, transfers, gait, activity tolerance, safety awareness, falls prevention, and patient education. Review of Resident #14's Physical Therapy Discharge summary dated [DATE] revealed the resident had a good prognosis to maintain his current level of function with staff follow through. The discharge recommendation was for a restorative nursing program (RNP) for contact guard assist (CGA) to minimal assistance for all transfers. Review of the Therapy Referral to Restorative document, undated, revealed the goal for Resident #14 was to walk with a front wheeled walker once around the facility once a day, seven times a week with stand by assistance by staff. Further review of the medical records revealed RNP services had not been provided to Resident #14 throughout the duration of the survey nor prior since discharged from therapy on 12/17/20. Review of the Interdisciplinary Therapy Screen form dated 05/25/2021 authored by Therapy Manager (TM) #765 indicated he was still appropriate for the same restorative nursing program that was recommended on 12/17/2020. Interview was conducted on 05/25/2021 at 9:06 A.M. with Certified Nursing Assistant (CNA) #745 who revealed there were no RNP's being done in the facility, no restorative nurse nor restorative aides. She said there use to be a book at the nurses stations so the aides knew who was getting restorative but she had not seen the book for some time. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed there were no RNP's being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was 365633 Page 5 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the facility prior to the hire of the current DON on 04/27/2021. Interview was conducted on 05/26/2021 at 12:00 P.M. with Minimum Data Set Registered Nurse (MDS RN) #733 who revealed she was the only MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #14 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, difficulty walking, other lack of coordination and Alzheimer's dementia. Resident #37's physician order dated 02/15/2021 revealed she was recertified to get physical therapy three times a week for one week for transfers, therapeutic exercise and activity, fall prevention and patient education. Review of the PT Discharge summary dated [DATE] revealed the resident had a good prognosis to maintain current level of function with staff follow-through. Review of the Therapy Referral to Restorative document, undated, revealed the goal for Resident #37 was to do sit-to-stand transfers five times a day and twice a day with stand by assistance and contact guard assistance by staff. Further review of the medical records revealed RNP services had not been provided to Resident #37 throughout the duration of the survey nor prior since discharged from therapy on 02/23/21. Review of the Interdisciplinary Therapy Screen form dated 05/25/2021 authored by Therapy Manager (TM) #765 indicated he was still appropriate for the same restorative nursing program that was recommended on 12/17/2020. Interview was conducted on 05/25/2021 at 9:06 A.M. with CNA #745 who revealed there were no RNP's being done in the facility, no restorative nurse nor restorative aides. She said there use to be a book at the nurses stations so the aides knew who was getting restorative but she had not seen the book for some time. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, DON and ADON revealed there were no RNP's being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the 365633 Page 6 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 facility prior to the hire of the current DON on 04/27/2021. Level of Harm - Minimal harm or potential for actual harm Interview was conducted on 05/26/2021 at 12:00 P.M. with MDS RN #733 who revealed she was the only MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #37 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. Residents Affected - Some 3. Resident #38 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, unsteadiness on feet, difficulty walking and other lack of coordination. Resident #38's physician order dated 09/20/2020 revealed she was to get skilled PT services three times a week for four weeks, focusing on therapeutic exercises and activity, transfers, gait, falls prevention, safety awareness, and patient education. Resident #38's PT Discharge summary dated [DATE] referred her to the RNP for her to be up ad lib in her room in a wheelchair, with one person staff assistance for walking with a front wheeled walker (FWW), as well as seated therapeutic exercises to her bilateral extremities. Further review of the medical records revealed RNP services had not been provided to Resident #38 throughout the duration of the survey nor prior since discharged from PT on 01/10/20. Review of the Therapy Referral to Restorative form, undated, indicated a goal to walk to dining with supervision 200 feet with FWW and seated therapeutic exercises. Review of the Interdisciplinary Therapy Screen form dated 05/25/21 authored by TM #765 indicated she had no decline and was still appropriate for the restorative program set upon discharge from PT on 01/10/2020. Interview was conducted on 05/25/2021 at 9:06 A.M. with CNA #745 who revealed there were no RNP's being done in the facility, no restorative nurse nor restorative aides. She said there use to be a book at the nurses stations so the aides knew who was getting restorative but she had not seen the book for some time. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, DON and ADON revealed there were no RNP's being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the facility prior to the hire of the current DON on 04/27/2021. 365633 Page 7 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview was conducted on 05/26/2021 at 12:00 P.M. with MDS RN #733 who revealed she was the only MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #38 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. 4. Resident #47 was admitted to the facility on [DATE] and readmitted [DATE]. The resident had diagnosis of difficulty walking, other abnormalities of gait and mobility, generalized muscle weakness, morbid obesity, and heart failure. Resident #47's physician order dated 02/15/2021 for physical therapy revealed she was receiving treatment for overall strengthening. Review of the PT Discharge summary dated [DATE] revealed Resident #47 had reached her maximum potential on PT and was being referred to the RNP for static stance for one to five minutes at a time, two to three times a day. Review of the Therapy Referral to Restorative, undated, indicated she was to have a range of motion program with the goal of completing static stance twice a day, five times a week for one to five minutes at a time with stand by assistance and verbal cues by staff for safety. Further review of the medical records revealed RNP services had not been provided to Resident #47 throughout the duration of the survey nor prior since discharged from therapy on 02/19/21. Review of the Interdisciplinary Therapy Screen dated 05/25/2021 by TM #765 revealed Resident #47's restorative program should not be started due to a blister on her right lower extremity and therapy would reassess her after her blister healed. Interview was conducted on 05/25/2021 at 9:06 A.M. with CNA #745 who revealed there were no RNP's being done in the facility, no restorative nurse nor restorative aides. She said there use to be a book at the nurses stations so the aides knew who was getting restorative but she had not seen the book for some time. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, DON and ADON revealed there were no RNP's being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the facility prior to the hire of the current DON on 04/27/2021. Interview was conducted on 05/26/2021 at 12:00 P.M. with MDS RN #733 who revealed she was the only 365633 Page 8 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #47 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. 5. Resident #57 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic pain, generalized muscle weakness and lack of coordination. Resident #57's physician order dated 08/11/2020 revealed she was to start PT for strengthening of gait, mobility, transfers, safety awareness, fall prevention and education. Review of Resident #57's PT Discharge summary dated 0922/2020 revealed she was being discharged due to refusing the care. Review of the Therapy Referral to Restorative, undated, indicated she was to have a RNP for ambulating to and from the bathroom with the use of a FWW and contact guard assistance by one staff. Further review of the medical records revealed RNP services had not been provided to Resident #57 throughout the duration of the survey nor prior since discharged from therapy on 09/22/20. Review of the Interdisciplinary Therapy Screen dated 05/26/2021 by TM #765 revealed she was refusing any RNP as she did not want to ambulate distance at this time. She was also refusing any therapy preferring to lay in bed. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, DON and ADON revealed there were no RNP's being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the facility prior to the hire of the current DON on 04/27/2021. Interview was conducted on 05/26/2021 at 12:00 P.M. with MDS RN #733 who revealed she was the only MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #57 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. 6. Resident #50 was admitted to the facility on [DATE] with diagnoses including stroke and hemiplegia. 365633 Page 9 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #50's physician order dated 01/27/2021 for occupation therapy (OT) services revealed Resident #50 was to have OT five times a week to help improve her activities of daily living skills. Review of Resident #50's OT Discharge summary dated [DATE] revealed she was to be discharged to a RNP to maintain her current level of function in order to prevent a decline in dressing, eating/self-feeding and transfers. Review of the Therapy Referral to Restorative form, undated, indicated a goal of feeding at set-up level, upper body dressing with moderate cues by staff for participation and transfers with minimal assistance by staff. Further review of the medical records revealed RNP services had not been provided to Resident #50 throughout the duration of the survey nor prior since discharged from therapy on 04/16/21. Review of the Interdisciplinary Therapy Screen dated 05/27/2021 revealed the goal for RNP remained appropriate. Interview was conducted on 05/25/2021 at 9:06 A.M. with CNA #745 who revealed there were no RNP's being done in the facility, no restorative nurse nor restorative aides. She said there use to be a book at the nurses stations so the aides knew who was getting restorative but she had not seen the book for some time. Interview was conducted on 05/25/2021 at 9:27 A.M. with CNA #768 who said she thought the physical therapists did the RNP. Interview was conducted on 05/25/2021 at 9:40 A.M. with CNA #749 who said she was not aware of any residents receiving a RNP. Interview was conducted on 05/25/2021 at 3:56 P.M. with the Administrator, DON and ADON who revealed there was no RNP being implemented in the facility. The Administrator shared she started in the facility in November 2020 and the RNP was initiated as a quality improvement project in April 2021, but nothing had been started since she was waiting for the hire of the DON so he could give input on how to proceed with implementing the RNP. The Administrator shared there had been interim DON's in the facility prior to the hire of the current DON on 04/27/2021. Interview was conducted on 05/26/2021 at 12:00 P.M. with MDS RN #733 who revealed she was the only MDS RN for the entire facility since the second MDS nurse quit in December 2019. MDS RN #733 identified herself as the person responsible for implementing the RNP upon referral from therapy. MDS RN #733 continued to explain since COVID 19 pandemic started she would take the RNP referrals from the therapists, put them into a folder and not do anything further with the referrals because she did not have time. She verified Resident #50 had not been provided RNP services prior to 05/25/2021 when the program was questioned by the surveyor. 365633 Page 10 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #43 smoked safely. This affected one (Resident #43) of three residents reviewed for accident hazards. Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia, and chronic obstructive pulmonary disease. Review of Resident #43's signed smoking contract, revealed on 12/15/20 the resident's son signed the facility's smoking policy. The resident smoking policy and standard procedures dated 04/01/16 revealed a supervised smoker is a resident that is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. Also, sharing, bartering, or selling smoking materials with others, including other residents is not permitted; non-compliance may result in a change to smoking status and/or discharged from the facility. Facility staff will: secure smoking materials in a locked area when not in use by the resident for both independent and supervised smokers. Smoking safety instructions for all smokers will include supervised smoking will be performed by a staff member. Review of the Resident #43's quarterly Minimum Data Set (MDS) 3.0 dated 04/02/21 revealed Resident #43 was cognitively impaired and required supervision ambulating in her room and in the hall. Resident #43's care plan dated 04/02/21 revealed she wished to smoke and had been assessed as a supervised smoker. Interventions included being oriented/reminded where the smoking area was and the posted times for supervised smoking, focusing on her hands during weekly skin checks to ensure there were no burns, monitor her safety during smoking, provide protective equipment of a smoking apron, and ensure smoking materials were secured. Observation on 05/24/21 at 2:06 P.M. revealed Resident #43 was sitting on the side of her bed with a lit cigarette in her right hand and a strong smell of the lit cigarette permeated the room and hall. Upon immediate surveyor intervention, Licensed Practical Nurse (LPN) #706, who was standing at the medication cart located at the nurse's station, rushed to Resident $43's room. Resident #43 no longer had the lit cigarette in her hand but there were ashes on the floor by the bed where she was sitting. LPN #706 asked where the cigarette was and began looking in the bathroom. The extinguished cigarette was found in the trash can near the resident. The trash can was lined with a new clear trash bag and no other contents were in the trash can. Observation on 05/24/21 at 2:07 P.M. revealed LPN #706 was in the hall by the door that leads outside to the smoking area and another residents stated a resident gave Resident #43 a cigarette but did not know who the resident was. Interview on 05/24/21 at 2:10 P.M. with Resident #43 revealed she was very remorseful and begged to not tell her son. She could not remember if she was supervised during her smoke break when she begged a cigarette from another resident whom she could not identify. 365633 Page 11 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident supervised smoking schedule updated 10/29/19 revealed smoking breaks will be available for residents at 6:00 A.M., 10:00 A.M. 2:00 P.M. and 6:00 P.M. Nurses/State Tested Nursing Assistants (STNA) must remain with residents during the smoke break, smoke breaks are 15 minutes which allows for two cigarettes, smoking aprons must be worn during smoke time and smoking articles, (lighters and cigarettes) must be kept in the designated locked area and the key is to be kept at the nurses station. The schedule indicated no oxygen should be worn or in the designated smoking area at any time. 365633 Page 12 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately obtain, monitor and assess weight changes for Residents #22, #30, #44, #50 and #58. This affected five residents (Residents #22, #30, #44, #50 and #58) of seven residents reviewed for nutrition. Residents Affected - Some Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnosis of psychosis, type II diabetes, and dysphagia. Review of Resident #44's quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment, had a mechanically altered diet, needed setup for eating, and had a weight loss of 5% or more in the last month or weight loss of 10% or more in last six months, and was on an unprescribed weight loss regimen. Review of Resident #44's weights revealed the resident sustained a weight loss between 01/01/2021 (179.5) and 02/01/2021 (148.2) of 31 pounds. This triggered a weight warning in the computerized charting and a re-weigh was request on 02/02/2021. There was no evidence the re-weigh was completed. Interview on 05/25/2021 at 3:15 P.M. through 3:56 P.M. with the Registered Dietician (RD) #793 verified the re-weigh had not been completed. RD #793 revealed after the weight loss was identified on 02/01/21 additional nutrition interventions were not implemented until 04/12/21 which included weekly weights. 2. Resident #22 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, chronic venous insufficiency, morbid obesity, hypertensive heart disease, obstructive sleep apnea. Resident #22's physician order on 04/17/2021 was for tubigrips to right lower legs for swelling and on 05/19/2021 wrap bilateral extremities to the knee for swelling; Resident #22's weight history revealed weights were as followed: 05/26/2021 323.0 Lbs 05/01/2021 308.0 Lbs 04/23/2021 279.4 Lbs 04/16/2021 365633 Page 13 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 278.0 Lbs Level of Harm - Minimal harm or potential for actual harm 04/14/2021 278.0 Lbs Residents Affected - Some 04/02/2021 279.4 Lbs 04/01/2021 279.4 Lbs 03/27/2021 279.2 Lbs 03/27/2021 279.2 Lbs 03/26/2021 279.2 Lbs Review of the Dietary Nutritional assessment dated [DATE] revealed he was to receive a two gram sodium diet and nutritional monitoring would include monitoring of the weights. Review of a Weight Change Note dated 05/04/2021 authored by RD #793 revealed Resident #22 was showing a significant weight gain of over 10% over the last 30 days. The RD wrote request reweight and will follow prn (as needed). No further weights were obtained by the facility until the surveyor asked why a reweigh was not done. The reweigh on 05/26/2021 revealed he had gained another 15 pounds in 25 days. Interview on 05/25/2021 at 3:15 P.M. to 3:56 P.M. with RD #793 and the Director of Nursing (DON) verified a re-weigh had not been completed after her weight change note on 05/04/2021 so she had not assessed the significant weight change. Observation of Resident #22 on 05/26/2021 at approximately 3:00 P.M. showed him self-ambulating in his wheelchair. Both lower legs were wrapped in beige bandages and appeared very swollen. His feet were bare and appeared red and abnormally large and swollen. The resident said he had gained fluid in his legs which was not comfortable but he dealt with it. The resident said he was hoping to go home soon and would most likely not follow a low sodium diet. 3. Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic obstructive lung disease, paraplegia, chronic pain and anxiety disorder. Review of a Dietary Progress Note dated 02/04/2021 by RD #793 revealed she recommended adding him 365633 Page 14 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 to weekly weights and she would follow up as needed. Level of Harm - Minimal harm or potential for actual harm Resident #40's physician ordered dated 02/11/2021 indicated the was to be weighed weekly. Residents Affected - Some Review of the facility document titled Dietary Nutritional Review V2 dated 03/25/2021 authored by RD #793 revealed he was receiving medical food supplements (Health Shake twice a day and Juven protein support supplement twice a day), had skin impairment, and was on weekly weights. Review of Resident #40's weight history revealed weights were as followed: 04/23/2021 05:24 169.2 Lbs 04/01/2021 14:59 168.5 Lbs 04/01/2021 11:27 168.5 Lbs 03/25/2021 10:39 168.8 Lbs 03/18/2021 09:28 170.2 Lbs 03/11/2021 11:44 173.0 Lbs 02/25/2021 12:54 165.0 Lbs 02/18/2021 09:20 165.2 Lbs 02/10/2021 10:34 169.4 Lbs 01/25/2021 13:20 161.2 Lbs 365633 Page 15 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 01/11/2021 14:59 Level of Harm - Minimal harm or potential for actual harm 160.0 Lbs 01/01/2021 14:22 Residents Affected - Some 162.0 Lbs Interview on 05/25/2021 at 3:15 P.M. to 3:56 P.M. with the RD #793 and the DON verified Resident #40's weekly weights were not completed as ordered nor was any weight measured for May 2021 until mentioned by the surveyor. An interview and record review was conducted on 05/27/21 at 10:55 A.M. with LPN #770 who informed the surveyor the nursing aides weighed Resident #40 the morning of 05/27/2021 and he was 156.2# which showed a significant weight loss. LPN #770 said she would ask the staff to get a reweigh to confirm the change. Review of the medical record on 06/03/2021 revealed there had been no nutritional follow up by RD #793 after the staff obtained the weight on 05/27/2021. 4. Resident #50 was admitted to the facility on [DATE] with diagnoses including stroke and hemiplegia. Resident #50's physician order dated 02/22/20 revealed the resident should be weighed monthly. Review of the Nutritional assessment dated [DATE] and authored by RD #793 revealed Resident #50 had poor food intake at times, should have no unintentional weight loss and required a regular diet with snacks three times a day due to varied meal intakes. The assessment also noted the resident expressed an interest in losing weight, eating less and more nutritious. Review of Resident #50's weight history revealed weights were as followed: 05/24/2021 136.2 Lbs 04/4/2021 150.0 Lbs 03/24/2021 150.8 Lbs 03/9/2021 151.2 Lbs 02/23/2021 365633 Page 16 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 152.2 Lbs Level of Harm - Minimal harm or potential for actual harm 02/15/2021 154.0 Lbs Residents Affected - Some 02/4/2021 156.0 Lbs 01/1/2021 152.0 Lbs 11/4/2020 168.2 Lbs 11/1/2020 168.2 Lbs 11/1/2020 166.0 Lbs 10/4/2020 165.8 Lbs Interview was conducted on 05/24/21 at 12:54 P.M. with LPN #722 who verified Resident #50 had a weight taken on 05/24/21 and it was 136.2 pounds which was a 13.8 pound loss since the last weight on 04/04/21. Review of a Weight Change Note dated 05/25/21 by RD #793 revealed the RD requested a reweight due to the weight on 05/24/21 being 136.2 pounds showing a significant weight loss. Review of a physician order dated 05/26/21 indicated the resident was prescribed a weight loss diet. Interview was conducted on 05/27/21 at 10:55 A.M. with LPN #770 who revealed Resident #50 would not be able to determine a safe weight loss goal on her own due to her level of cognition and understanding fluctuating since her stroke. LPN #770 said she was surprised at how much weight the resident had lost and did not think she needed to lose any more weight. Observation and interview of the resident was conducted on 05/27/21 at 11:00 A.M. The surveyor asked the resident if she wanted to lose weight and she did not reply. The resident was also asked if she knew how much she should weigh and she did not reply. The resident appeared to be a normal weight for her frame, was alert with questionable cognitive processing due to her lack of reply. 365633 Page 17 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Resident #58 was admitted to the facility on [DATE] with diagnoses include severe protein calorie malnutrition and unspecified dementia with behavioral disturbance. Review of Resident #58's Nutritional assessment dated [DATE] by RD #793 revealed the resident was underweight, had protein calorie malnutrition with evidence of muscle wasting in the clavicle region, shoulder region and fat wasting around the eyes and upper arms. RD #793 recommended adding snacks three times a day and Health Shakes three times a day with a goal of gradual weight gain. Resident #58's weight review raised concerns regarding accuracy of weights, obtaining reweight's in a timely manner and assessment of any weight changes. The weight findings were as followed: 6/3/2021 92.0 Lbs 5/27/2021 91.8 Lbs 5/24/2021 91.8 Lbs 5/20/2021 88.2 Lbs 5/20/2021 86.0 Lbs 05/3/2021 133.0 Lbs 05/01/2021 932.0 Lbs (5/6/2021 by RD #793 Incorrect documentation) 04/13/2021 91.4 Lbs 04/01/2021 95.2 Lbs 03/25/2021 102.0 Lbs 03/01/2021 102.0 Lbs 02/25/2021 106.7 Lbs 02/19/2021 106.8 Lbs 02/18/2021 106.8 Lbs 02/18/2021 106.8 Lbs 02/17/2021 103.0 Lbs 02/15/2021 103.4 Lbs 02/11/2021 103.2 Lbs 02/04/2021 103.0 Lbs 365633 Page 18 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a weight change note 04/22/2021 by RD #793 revealed a weight of 91.4 pounds and noted the resident as underweight and weights would be monitored. Record review of a weight change note 05/11/2021 by RD #793 revealed she suspected an inaccurate weight of 133 Lbs and wrote request reweigh. The reweight was not done until 05/20/2021 when the surveyor brought the issue to the attention of the RD#793. Interview was conducted on 05/20/2021 at 11:06 A.M. with RD #793 who verified she had asked for a reweight on 05/11/2021 in her weight change note but it was not done until 05/20/2021. Interview on 05/20/2021 at 12:43 P.M. RD#793 verified an 18.6 pound (17.4%) weight loss in 3 months from 02/19/2021 to 05/20/2021 and lack of significant weight change assessment as a consequence of not obtaining the reweigh in a timely manner. When asked how she communicated the request she said she would verbally ask the nurses for a reweigh and had not followed up to see if it was done. Observation and interview were conducted on 05/20/2021 at 12:43 P.M. of Resident #58 sitting in her wheelchair with her meal in front of her on a tray table. She presented as alert and oriented to person, place and conversation. She appeared very underweight for her frame, frail and spoke in a soft voice. On her tray was beef in gravy, mashed potato, tossed salad in a cup and a chocolate nutritional shake. When asked how her appetite was she replied she was sometimes hungry but I can not get the food to go down or everything goes right through me. The Resident pointed to her mashed potato and said she ate a couple bites. She said she would not eat the meat and wanted to eat the salad but couldn't eat it. When asked if she had lost weight she replied they weighed me today and I was in the 80's, yes I lost weight. I am trying to drink this here shake they gave me. The resident put her head down, sat expressionless as she shook her head from side to side looking despondent after talking about her weight loss. Record review and interviews were conducted on 05/25/2021 at 3:15 P.M. with the Administrator, DON, ADON and RD #793 to review the concerns as stated above in the citation. The DON verified the weights not being done consistently each month and/or as ordered and shared he was going to educate the staff on the issue. RD #793 verified lack of timely nutritional follow-up and assessments due to weights not being done as requested of the staff. 365633 Page 19 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure the resident narcotics on the controlled drug administration records were signed off in a timely manner for Resident #3, #22, #30, #50, #51, #63 and #68 and failed to ensure Resident #47 received diuretic medication as ordered. This affected seven residents (Resident #3, #22, #30, #50, #51, #63 and #68) of seven residents reviewed on the facility B hall for medication storage, and one resident (Resident #47) of five residents reviewed for medication. Findings include: 1. Resident #3 was admitted on [DATE] with diagnoses including heart failure, cerebral infarction and diabetes mellitus II with diabetic nephropathy. Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 required supervision for all activities of daily living (ADL) and his cognition was intact. Resident #3's May 2021 physician orders revealed an order for Percocet tablet 10-325 milligram (mg), a pain medication every four hours for pain. Review of the controlled drug administration record revealed Licensed Practical Nurse (LPN) #748 did not document on the narcotic count record that the Percocet tablet 10-325 mg (narcotic used for pain) had been pulled from the card and administered on 05/20/21 at 2:00 P.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 2. Resident #22 was admitted on [DATE] with diagnoses including morbid (severe) obesity, acquired absence of left toe(s) and venous insufficiency. Resident #22's May 2021 physician orders revealed orders for Oxycodone 5 mg, a pain medication every six hours for pain. Resident #22's admission MDS dated [DATE] revealed Resident #22 required extensive assistance of two or more, with physical assist, for bed mobility, transfers and toilet use. His cognition was intact. Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Oxycodone 5 mg (narcotic used for pain) had been pulled from the card and administered on 05/20/21 at 12:44 P.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 3. Resident #30 was admitted on [DATE] with diagnoses including paraplegia, chronic obstructive pulmonary disease and chronic pain syndrome. 365633 Page 20 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #30's physician orders revealed an order Oxycodone 10 mg, a pain medication every four hours for pain. Resident #30's MDS dated [DATE] revealed Resident #30 required extensive assistance of one or more staff, with physical assist, for bed mobility, transfers, dressing and personal hygiene. Resident #30's cognition was intact. Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Oxycodone 10 mg (narcotic used for pain) had been pulled from the card and administered on 05/20/21 at 12:44 P.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 4. Resident #50 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, convulsions and chronic pain. Resident #50's May 2021 physician orders revealed an order for Alprazolam 0.5 mg, an anti-anxiety medication ordered for twice a day at 10:00 A.M. and 4:00 P.M. Resident #50's MDS dated [DATE] revealed Resident #50 cognition was intact. Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Alprazolam 0.5 mg (narcotic used for anxiety) had been pulled from the card and administered on 05/20/21 at 11:33 P.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 5. Resident #51 was admitted on [DATE] with diagnoses including diabetes mellitus with diabetic polyneuropathy, surgical amputation and acquired absence of the right great toe and other right toes. Resident #52's May 2021 physician orders revealed orders for Oxycodone IR 5 mg, a pain medication ordered for every four hours for pain. Resident #52's MDS dated [DATE] revealed Resident #51 was independent or required supervision for all ADL's and his cognition was fully intact. Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Oxycodone IR 5 mg (narcotic used for pain) had been pulled from the card and administered on 05/20/21 at 11:30 A.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 6. Resident #63 was admitted [DATE] with diagnoses including chronic kidney disease stage three, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder and acquired absence of right hip joint. 365633 Page 21 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0755 Level of Harm - Minimal harm or potential for actual harm Resident #63's May 2021 physician orders revealed orders for Belbuca Film 600 micrograms (mcg). a pain medication ordered for every 12 hours for pain ,and Lyrica 50 mg once a day for pain. Resident #63's MDS dated [DATE] revealed Resident #63 cognition was intact and required extensive assistance of two or more staff for bed mobility, transfers, dressing and toileting. Residents Affected - Some Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Belbuca Film 600 mcg and Lyrica 50 mg (narcotics used for pain) had been pulled from the card and administered on 05/20/21 at 11:21 A.M. and 11:19 A.M. respectively, in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. 7. Resident #68 was admitted on [DATE] with diagnoses including heart failure, chronic gout of ankle and foot and a thoracic aortic aneurysm without rupture. Resident #68's physician orders revealed orders Tramadol 50 mg, a pain medication ordered for every six hours for pain. Resident #68's MDS dated [DATE] revealed Resident #68's cognition was intact and required extensive assistance of one staff, physical assist for all ADL's. Review of the controlled drug administration record revealed LPN #748 did not document on the narcotic count record that the Tramadol 50 mg (narcotic used for pain) had been pulled from the card and administered on 05/20/21 at 8:31 A.M. in a timely manner. An interview with LPN #748 on 05/20/21 at 3:16 P.M. verified she had administered the medication but did not sign it off on the narcotic count record following administration. Review of the medication administration, dated 04/20/17 revealed to sign out narcotic controlled substances from the narcotic count card when removed. 8. Resident #47 was admitted to the facility on [DATE] and readmitted [DATE]. The resident had diagnosis of schizoaffective disorder, malignant neoplasm of lung, morbid obesity, and heart failure. Review of Resident #47's quarterly MDS assessment dated [DATE] revealed the resident did not have a diuretic within the last seven days. Review of Resident #47's physician orders dated 05/07/2020, revealed a diuretic, Bumex, was ordered to be given as 1 MG twice a day for congestive heart failure. Review of Resident #47's April and May 2021 Medical Administration Record (MAR) revealed there was omitted documentation the medication was given 13 times in April, and five times in May. Observation on 05/25/2021 at 12:12 P.M. revealed Resident #47 was motorizing her wheelchair to the nurses station and requested medication. The resident had her bilateral legs elevated, and they appeared swollen and tight and shiny. The resident right leg was wrapped in a tan color elastic wrapping. 365633 Page 22 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0755 Interview on 05/26/2021 at 1:38 P.M. with the ADON verified the missing documentation that Resident #47's diuretic medication was administered as ordered. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 365633 Page 23 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #32 had bowls for all meals to assist with eating. This affected one resident (Resident #32) of seven residents reviewed for nutrition. Residents Affected - Few Findings include: Resident #32 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's disease type 2 diabetes and dysphagia. Resident #32's quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required extensive assistance with eating, that he held food in his mouth/cheeks or residual food in his mouth after meals. Review of Resident #32's physician orders dated 03/04/2021 revealed Patient needs food in individual bowls for every meal. Observation on 05/17/2021 at 11:40 A.M. and 4:10 P.M. Resident #32 was observed eating his lunch and his dinner meals off of a plate. Interview on 05/17/2021 at 4:17 P.M. with Therapy #765, Therapy #780, and Therapy #787 confirmed Resident #32 should have bowls with all of his meals. Interview on 05/18/2021 at 11:46 A.M. with Registered Dietician (RD) #793, and Director of Nursing (DON) confirmed the resident should have bowls for his meals. 365633 Page 24 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to implement a restorative nursing program after reviewing it as a systemic problem at the Quality Assurance and Assessment meeting. This affected six residents (#14, #37, #38, #47, #50 and #57) of six residents who were identified by the facility as needing a restorative nursing program. Findings included: Record review was conducted of the facility document titled Quality Assessment and Performance Improvement Team Documentation, dated 04/14/2021. The identified problem was the restorative program. The goal was to develop a functional restorative program. The root causes for the lack of a restorative program were listed as COVID 19, not utilizing a process to enter restorative orders and write a restorative program, staffing challenges and not having a steady Director of Nursing since 12/25/2020. Interview was conducted on 05/25/2021 at 12:36 P.M. with Therapy Manager (TM) #765 who revealed there were currently six residents who were referred for restorative nursing programs (RNP) between 01/10/2020 and 04/16/2021 but there was currently no RNP. The therapy director said she had screened all six of them the morning of 05/25/2021 and they all remained appropriate for the same RNP and were without declines in there level of functioning. Interview was conducted on 05/27/2021 at 12:03 P.M. with the Administrator who revealed there had been interim Directors of Nursing (DON) filling in at the facility since the last DON resigned in December 2020 and prior to the current DON starting at the facility on 04/27/2021. The Administrator wanted to wait for input from the new DON before restarting the restorative nursing program. The Administrator verified there were six residents needing an RNP but were not getting it. 365633 Page 25 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure a family member visiting Resident #182 adhered to the proper use of personal protective equipment in a quarantine room for droplet isolation for potential COVID 19, and also failed to ensure clean hoyer pad straps were stored without the straps sitting on the floor. This affected one resident (Resident #182) of three residents reviewed for transmission based precautions and had the potential to affect all 15 of 15 residents (Resident #7, #13, #29, #32, #53, #55,#54,#61, #62, #63, #67, #180, #181, #182, and #184) who used hoyer pads. Residents Affected - Some Findings included: 1. Record review was conducted for Resident #182 who was admitted to the facility on [DATE] with diagnoses including Alzheimer dementia and unspecified psychosis. The resident resided on the A unit which the facility identified as the isolation unit for newly admitted or readmitted residents. An observation and interview was conducted on 05/18/2021 at 11:48 A.M. of Resident #182 sitting in her room right beside a female visitor who was dressed in street clothing and wore a cloth face mask. On the door were posted signs indicating the resident was in droplet isolation and anyone entering the room should first put on a gown, gloves, eye protection and a medical grade face mask. The visitor identified herself as the resident's daughter and said she was never told by the staff she had to put on anything but her cloth face mask before entering her mom's room. Interview was conducted on 05/18/2021 at 11:49 A.M. with Licensed Practical Nurse (LPN) #722 who was the assigned nurse on the A unit. He verified the visitor in Resident #182's room needed to be in full personal protective equipment (PPE) for droplet isolation and was in the room in only a cloth mask. LPN #722 said he was unaware the visitor was on the unit and he did not see her enter the room. Interview was conducted on 05/18/2021 at 12:08 P.M. with the Director of Nursing (DON) who verified the isolation rooms on the A unit were not to have visitors in the room without being in full PPE because the resident's on that unit did not have their COVID 19 vaccines. 2. Observation of the laundry area on 05/20/21 at 10:35 A.M. revealed 10 clean Hoyer pads hanging on the wall had their straps lying on the dirty floor next to the dusty broom and dust pan that was used to clean lint from under the dryers. Interviews on 05/20/21 at 10:35 A.M. Laundry Aide #795 and Account Manager #796 verified 10 clean Hoyer pad hanging on the wall were lying on the dirty floor next to a dusty broom and dust pan that was used to clean lint from under the dryers. Review of a facility provided list of residents who use Hoyer pads revealed the following residents used Hoyer pads: Resident 7, #13, #29, #32, #53, #55,#54,#61, #62, #63, #67, #180, #181, #182, and #184. Review of the infection control practices for laundry/linens policy, dated 10/25/18 revealed clean linen storage areas/carts will be covered when not in use. 365633 Page 26 of 27 365633 06/03/2021 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interviews, the facility failed to maintain a food processor, used to make pureed foods, in proper working order. This had the potential to affect all 10 residents (#8, #10, #19, #20, #27, #40, #53, #54, #62 and #184) on a pureed diet. Residents Affected - Some Findings included: Record review was conducted of the facility dinner menu for 05/19/2021. The main entree selection for the pureed diets included BBQ pork. A review of the pureed BBQ pork recipe showed a portion size was a half cup and the final product should be smooth. An observation was conducted with Culinary Director (CD) #704, District Manager (DM) #794 and [NAME] #738 on 05/19/21 from 2:49 P.M. to 3:47 P.M. of [NAME] #738 demonstrating how she prepared pureed BBQ pork for the dinner meal. [NAME] #738 used a seven quart Robo Coup R602Y Series E food processor to puree a premeasured amount of pork pieces in BBQ sauce she identified as being 13 half-cup portions. She dumped the entire amount into the Robo Coup and began blending the pork at 2:51 P.M. When asked by the surveyor what consistency she wanted the pureed pork, [NAME] #738 replied the consistency of smooth mashed potato. From 2:49 P.M. to 3:47 P.M. she stopped the processor eight times to sample the texture of the pureed pork along with DM #794. DM #794 gave directives each time to continue to process the pork because it still had small pieces of pork instead of a smooth consistency. The cook expressed agreement that it needed to process more. The surveyor asked the cook and DM #794 if the Robo Coup being used was what they usually used to make the pureed food. [NAME] #738 replied she had been using a different food processor that morning but it had been removed from the kitchen by DM #794 because it kept shutting off while using it. DM #794 explained he had taken it out of the kitchen for repairs because he wanted it looked at to make sure it was not shorting out. DM #794 added the food processor in use for the demonstration was passed around to any facility in his district in need of a back up. [NAME] #738 said DM #794 brought it into the kitchen that morning so the other could go out for repair. The surveyor was given a sample of the pureed pork at 3:47 P.M. and it was not the appropriate consistency for pureed as it had multiple rice sized pieces of intact pork within the pureed mixture. [NAME] #738 interjected she had used the other robot coupe that was sent out for repairs to prepare non BBQ pureed pork chops that morning and the consistency had come out like smooth pudding consistency. She pointed to CD#704 who was observed setting up the steam table and putting the pan of pureed, non-BBQ pork onto the steam table. The surveyor asked for a sample of it and the consistency was appropriate for the pureed diets. [NAME] #738 verified she had used the kitchen's usual food processor to make that pureed pork, but it was removed from the kitchen because it would spontaneously shut off and she thought it may have an electrical problem. [NAME] #738 verified she should not have to puree any food item for almost an hour, as it typically took her just minutes to puree any food if the processor was in proper working order. Interview on 05/20/2021 at 10:40 A.M. with DM #794 verified the facility kitchen did not have a properly working food processor and the plan was to purchase a new one. 365633 Page 27 of 27