Health inspection·November 7, 2023

F 0572 Give residents a notice of rights, rules, services and charges. Level of Harm - Minimal harm or potential for actual harm Based on review of the resident council meeting minutes and resident and staff interviews, the facility failed to ensure ongoing communication to residents about their various rights at the resident council meetings. This affected 15 residents (Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) of 15 residents present at the resident council meeting. The facility census was 110. Residents Affected - Some Findings include: Review of the facility Resident Council Meeting minutes from January 2023 to October 2023 revealed there was not a new resident right reviewed at each meeting. Meetings conducted on 01/30/23 revealed they reviewed smoking rights. Meetings conducted on 02/24/23, 04/13/23, 05/18/23, 06/15/23, and 07/20/23 revealed they reviewed the right to have resident council meetings. Meetings conducted on 08/17/23, 09/21/23 and 10/05/23 revealed they did not review any resident rights during the council meetings. Interview on 10/17/23 at 4:15 P.M. with Activities Director (AD) #805 revealed she was unaware she was to review a different resident right at each resident council meeting. AD #805 confirmed she only spoke to the residents regarding the right to smoke and the right to have a resident council meeting and there were several months she did not review any resident rights at the resident council meetings. Interviews conducted on 10/23/23 at 2:00 P.M. with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87 #103, and #362 during the resident council meeting conducted by the state surveyor as part of the annual survey process revealed all residents were alert and oriented, actively participated in the meeting and expressed the staff did not go over a resident right at each meeting. They stated they only review the right to have a resident council meeting and the facility smoking policy. They stated there were meetings where they did not go over any rights at all. Page 1 of 40 365633 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility did not ensure the authorized parties were notified of changes in the resident's treatment for Resident #15 and Resident #19. This affected two residents (Residents #15 and #91) of 26 residents reviewed for notification of change. The facility census was 110. Findings Include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Resident #15's family member was listed as the authorized primary contact. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the physician's orders revealed on 09/11/23 Resident #15 was started on Macrobid (an antibiotic) 100 milligrams (mg) twice a day for a urinary tract infection (UTI). Review of the nursing progress notes revealed no documentation the resident's authorized primary contact was notified of an antibiotic being started. 2. Resident #91 was admitted to the facility on [DATE] with diagnoses including diabetes, restlessness and agitation, heart disease, congestive heart failure, major depression, and vascular dementia with mood disturbance. Resident #91's wife was listed as the authorized primary contact. Review of physician orders dated 10/02/23 revealed an order was written to give Seroquel 25 mg orally every afternoon for anxiety. Review of the physician's orders for Resident #91 revealed on 10/04/23 an order was written to give Seroquel (an antipsychotic medication) 25 mg give a half tablet orally every evening for major depression. On 10/13/23 an order was written for Depakote Sprinkles 125 mg give two capsules by mouth three times a day for dementia with agitation. Review of the progress notes from August through October 2023 revealed no documentation regarding the authorized primary contact being notified of the medication changes. Interview with Licensed Practical Nurse (LPN) #804 on 10/25/23 at 8:45 A.M. confirmed the authorized primary contact should have been notified for Resident #15 and #91 as soon as possible with any change in treatment or condition. In an emergent situation it may take a little longer until the situation is stabilized before they are notified. Notification should always be documented. Interview with LPN #846 on 10/25/23 at 8:55 A.M. confirmed the responsible party should be notified as soon as possible about a change in condition but she sometimes waits until the end of her shift to make her calls. Review of the facility's undated Notification of Change in Condition policy,undated, revealed the facility must inform the responsible party or authorized family member or legal power of attorney or guardian when circumstances require a need to alter a resident's treatment. 365633 Page 2 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0580 Review of the facility's undated Clinical Documentation Standards revealed documentation should include resident changes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 3 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to ensure resident assessments were accurate. This affected two residents (Residents #15 and #40) of 26 residents reviewed for resident assessments. The facility census was 110. Residents Affected - Few Findings Include: 1. Review of the medical records revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Review of the nursing progress notes for Resident #15 from admission through the present revealed on 09/06/23 the resident had increased confusion, wandering, exit seeking, agitation, and believed others were stealing her belongings. No other behaviors were documented. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired and exhibited the behavior of wandering for one to three days during the assessment period. Review of the Medication Administration Record (MAR) for August, September, and October 2023 for Resident #15 regarding behavior monitoring revealed the resident exhibited no behaviors. Review of the nurse aide documentation for the previous 30 days prior to 10/19/23 revealed Resident #15 exhibited no behaviors. Review of the quarterly comprehensive MDS assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired and had hallucinations and delusions. Other behaviors included physical and verbal behaviors directed towards others and other behaviors not directed towards others. She also rejected care and wandered one to three days of the assessment. Interview with Social Services Designee (SSD) #802 on 10/19/23 at 10:33 A.M. revealed she was the one who completed the behaviors section of the MDS assessment. She obtained her behavior coding from the nursing assistants documentation in the electronic health record. She also spoke with Licensed Practical Nurse (LPN) #851 who was the primary nurse on the secured unit where Resident #15 resided. SSD #802 confirmed there was a major change in behaviors from the 09/11/23 assessment and the 09/19/23 assessment which did not match the documentation on the MAR behavior tracking and the nurse aide documentation. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses including a left femur fracture, a left radius fracture, cirrhosis of the liver, end stage renal disease dependent on dialysis, congestive heart failure, diabetes, bipolar disorder, delusional disorder, depression, anxiety, and chronic pain. Review of the comprehensive quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and received no special treatments such as hemodialysis. Interview with Registered Nurse (RN) #807 on 10/23/23 at 3:00 P.M. confirmed Resident #40 should 365633 Page 4 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0641 have had hemodialysis marked in the Special Treatments evaluation of the quarterly MDS assessment dated [DATE] and she would correct it. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 5 of 40 365633 11/07/2023 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 record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident who was dependant on staff for assistance with activities of daily living (ADLs) received the assistance needed with bathing and personal hygiene. This affected one resident (Resident #68) of two residents reviewed for ADLs. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #68 revealed he was admitted on [DATE] with diagnoses including alcohol-induced dementia, myoclonus, anorexia, osteoarthritis, and lack of coordination. Review of Resident #68's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition with no signs or symptoms of delirium. Further review of the MDS revealed Resident #68 was dependent for bathing and required one person assistance with locomotion, dressing, eating, toileting, personal hygiene. The MDS further revealed Resident #68 had no instances of rejecting care. Review of Resident #68's last annual MDS assessment dated [DATE] listed his preference to choose between a tub bath, shower, bed bath, or sponge bath as very important. Review of Resident #68's care plan revealed he had a deficit in the ability to perform self-care and required assistance with ADLs. Interventions included providing extensive to total assistance with bathing and extensive assistance with personal hygiene, dressing, and transfers. His bathing preferences were not indicated on the care plan. Review of Resident #68's electronic medical record plan of care (POC) response history for type of bath received over the last 30 days (09/25/23 to 10/24/23) had zero responses indicating a bath of any type was given. There was no documentation of Resident #68 refusing a bath during this time. Review of Resident #68's electronic medical record POC response history for 30 days (09/20/23 to 10/19/23) regarding his ability to perform the tasks of washing, rinsing, and drying himself revealed Resident #68 required supervision, touching assist and helper cues on 09/28/23 and was totally dependent on 09/29/23, 10/02/23, 10/04/23, and 10/06/23. Further review revealed no attempts of washing Resident #68 were made since 10/06/23 and on 10/13/23 and 10/18/23 it was noted attempts were not made due to the resident's medical condition. A review of the POC response history for change in condition showed there was no change in condition between 09/20/23 and 10/18/23. There was no documentation of resident refusals on the bathing ability task sheet. Review of Resident #68's electronic medical record POC personal hygiene response history for 30 days (09/25/23 to 10/24/23) revealed personal care tasks including combing hair, shaving, and washing/drying face and hands. Further review of the personal hygiene response history revealed Resident #68 received no assistance with personal hygiene on 09/25/23, 09/26/23, 09/27/23, 09/30/23, and 10/19/23 and there is no documentation Resident #68 was unavailable or refused care on these dates. Review of paper shower sheets for residents on Resident #68's unit for September 2023 and October 2023 revealed there were zero shower sheets for Resident #68. 365633 Page 6 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/16/23 at 10:59 A.M. revealed Resident #68 with his hair appearing greasy, sticking up, and containing multiple white particles throughout. Further observation at that time revealed Resident #68's mustache had grown over his lower lip and was curling into his mouth with mustache hairs pointing in several directions. Observation on 10/17/23 at 4:25 P.M. revealed Resident #68 lying in bed with his hair sticking up, long mustache hairs curing into his mouth, and slight smell of body odor. Observation on 10/18/23 at 1:08 P.M. revealed Resident #68 lying in bed, hair uncombed, white flakes in hair, mustache hairs hanging over his top lip and mashed potatoes and gravy clumped on his mustache. Interview on 10/18/23 at 1:08 P.M. with Resident #68 confirmed he could feel the mustache hairs hanging over his top lip and he didn't know when it was last trimmed. He then proceeded to make a hand motion with his right pointer and middle fingers opening and closing like scissors moving from right to left across the front of his mustache stating he needs some one to trim it and then he said he was going to do it himself. Observation and interview on 10/23/23 at 12:15 P.M. revealed Resident #68 in bed with his mustache hanging over his top lip and small amount of white substance clumped left of center in his mustache. During this observation, Resident #68 stated he had not received a shower or washed today. Interview on 10/23/23 at 12:27 P.M. with state tested nursing assistant (STNA) #853 confirmed she was the aide caring for Resident #68 this date. Further interview with STNA #853 confirmed Resident #68 was supposed to shower twice per week and verified in the shower book his scheduled shower days were Tuesdays and Thursdays on third shift, which she confirmed meant 11:00 P.M. to 7:00 A.M. STNA #853 further confirmed Resident #68's mustache hairs were folding over his top lip into the mouth and the hairs were clumped together by a small amount of whitish substance. During the interview, STNA #853 stated it was not uncommon for Resident #68 to sit with food in his mustache after meals. At this time, Resident #68 stated he needed to shave and was going to trim his mustache. STNA #853 told Resident #68 staff would have to help him. Interview on 10/23/23 at 4:55 P.M. with STNA #892 confirmed she typically worked 3rd shift and has performed bed baths on Resident #68 but does not know when she last bathed him. When asked if Resident #68 prefers bed baths or showers, STNA #892 stated she gives him bed baths because it is probably easier when she is in a rush and realized around the end of her shift that he had not been bathed by the previous shift between 7:00 P.M. and 11:00 P.M. STNA #892 observed Resident #68 with surveyor at this time and verified his mustache had gotten long. STNA #892 then stated she had never shaved Resident #892 but thinks someone on another shift would need to shave him and provide mustache trimming and grooming since she typically worked third shift. Review of facility policy titled Daily Skin Care, effective 07/01/2016, stated it is policy that residents receive skin care daily. Further review of the policy revealed residents should be monitored for their ability to perform self-care and staff must assist or provide care as needed. 365633 Page 7 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations and interviews the facility failed to provide therapeutic activities as scheduled on the activity calendar and failed to provide evening activities to meet the needs and preferences of all the residents in the facility. This affected 15 residents (#12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) residing on the A,B and C units and had the potential to affect all residents residing on the A, B, C units excluding Residents #16, #41, #264, #80, #2, #77, #45, #39, #66, #15, #42, #74, #89, #38, #86, #35, #37, #90, #91, #69, #93, #92, #75, #97 and #6 who resided on the secured unit D. The facility census was 110. Residents Affected - Some Findings include: Review of the facility activity calendars for October 2023 for the A, B, and C units, revealed on all 31 days in October 2023, the last activity was scheduled at 4:00 P.M., and no evening activities were offered during the month. The scheduled activities for 9:30 A.M. included coffee and chit chat. On Sunday the activity was listening to gospel music at 10:30 A.M. and church service and music in the dining room with one-to-one at 4:00 P.M On Monday the activities included coffee and chit chat, 10:30 A.M. was listen to the oldies and color, and at 2:00 P.M. trivia fun. Tuesday's activities consisted of coffee and chit chat, craft time and bingo with the last activity at 4:00 P.M. Wednesday's activities included coffee and chit chat, fun with yarn craft and a movie with the last activity at 2:00 P.M. Thursday's activities included coffee and chit chat, 10:30 A.M. travel the world, 2:00 P.M. bingo and on some Thursdays 1:1's was offered. Fridays activities included at 10:30 A.M. listen to classical music and color, 2:00 P.M. movie and on some Fridays 1:1 was offered. Review of the activity staff schedule for 10/01/23 revealed there was only one Activity Aide (AA) from 9:00 A.M. to 5:00 P.M. and one AA 1:00 P.M. to 8:00 P.M. On 10/07/23 from 9:00 A.M. to 5:00 P.M. there were only two AA's, on 10/09/23 from 9:00 A.M. to 5:00 P.M. there was one AA scheduled, and on 10/14/23 there were two AAs from 9:00 A.M. 5:00 P.M. and one AA from 1:00 P.M. to 8:00 P.M On 10/21/23,10/22/23 and 10/28/23 there was only one AA from 9:00 A.M. to 5:00 P.M. scheduled with activities on the calendar for 6:00 P.M. and 7:00 P.M. Interview conducted on 10/17/23 at 4:15 P.M. with Activity Director (AD) #805 who revealed she did not have the proper education to hold the role of Activity Director. The facility did not send her to receive any of the proper education required by law although they stated they would. AD #805 verified there were no therapeutic activities provided after 4:00 P.M. on the A, B, and C units. Observation and interview were conducted on 10/23/23 at 10:30 A.M. with the AD #805 regarding the pumpkin painting activity that was to occur at 10:30 A.M. AD #805 revealed she could not find any pumpkins for the activity, she did not inform the Administrator so she changed the activity to coloring a black and white printed paper pumpkin. The residents were upset and left the activity. Interviews were conducted on 10/23/23 from 2:00 P.M. to 3:15 P.M. with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362 present at the resident council meeting. The residents were alert and oriented to person, place, time, and situation. All residents present at the meeting stated the activity calendar listed more activities than what was actually provided in the facility. For example, they were supposed to paint actual pumpkins on 10/23/23 at 10:30 A.M. however they were told by the AD #805 she was unable to find any pumpkins available to paint so she printed black pumpkins on white paper and handed them out. All residents in attendance left and did not participate. All residents who participated in the resident council meeting revealed they were 365633 Page 8 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tired of coloring or crafts with yarn. They felt these activities did not meet their intellectual needs or wants. The residents in attendance at the meeting were mobile throughout the facility and agreed they do not see the activities being done at the scheduled times, and when they go to the activity room to see what was going on the activity aide (AA) #812, AA #813, AA #814, AA #815, AA #816, and AA #817 are sitting in the office on their cell phones. The residents in attendance at the resident council meeting revealed they have brought these issues up in the meeting many times, but nothing is ever done about it. The residents have asked for more activities on the weekends and at night and it was just not being addressed as requested. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00147820. 365633 Page 9 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility did not ensure the activity director was qualified to establish and provide a therapeutic activity program to meet the needs and interests of the resident population in the facility. This affected all 110 residents living in the facility. Residents Affected - Many Findings include: Review of the employee file for Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. As stated in the Purpose/Belief statement the position of the AD establishes an activity program of wide variety for the residents, enhancing the resident's wellness, in harmony with the overall plan of care set forth by the health care team, and in accordance with state and federal regulations. This position plans, implements, supervises and supports all operations of the activities department. While focusing on delivery of quality care, the position must also manage the assigned resources. As listed in the Qualifications/Knowledge/Skills and Abilities section, the AD role requires either a bachelor's degree in therapeutic recreation or related field or 90 hour course for activity professionals and continuing education, prior management, supervisory, leadership experience preferably in a health care environment, prior work/life experiences, preferably in a healthcare setting, they must be knowledgeable of activity practices, standards of practice, state practice acts and procedures, as well as laws, regulations, and guidelines that pertain to long-term care. They must be able to plan, organize, and conduct a variety of activities and must be willing to seek out new methods and principles and be willing to incorporate them into existing activity practices. There was no evidence found in the employee file for AD #805 to indicate she met requirements in the job description. Interview on 10/17/23 at 4:15 P.M. with AD #805 revealed she did not have a bachelor's degree in therapeutic recreation or related field, she did not complete the 90-hour course for activity professionals and had no continuing education. She stated Social Service Director (SSD) # 802 had her activity qualification so the facility had her working under that certification but SSD #802 did not over see any of the activity department functions or programs. AD #805 stated she developed all the activity calendars herself and did all the scheduling of the activity aides working in the activity department. Interview on 10/19/23 at 11:35 A.M. with the Administrator revealed she sent AD #805 to activities boot camp which was a 13.5 hour training. She stated AD #805 did not have any of the requirements described in the job description for the Activities Director. She stated SSD #802 had her qualifications which the Administrator felt was sufficient to meet the requirement. This deficiency respresents non-compliance identified during the investigation of Complaint Number OH00147820. 365633 Page 10 of 40 365633 11/07/2023 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 closed medical record review and interview, the facility failed to properly assess and document skin concerns for Resident #363. This affected one resident (#363) out of five residents reviewed for skin concerns. The facility census was 110. Residents Affected - Few Findings include: Review of the hospital discharge reconciliation report dated 12/12/22 revealed Resident #363 was ordered collagenase (removes damaged tissue from skin ulcers) to left planter foot daily and as needed with last administered date of 12/11/22 at 9:10 A.M. Review of the medical record revealed Resident #363 was admitted on [DATE] and discharged on 12/23/22 with diagnoses including chronic kidney disease, fracture of cervical vertebras, type two diabetes mellitus, chronic obstructive pulmonary disease, methicillin susceptible staphylococcus aureus, end stage renal disease, sarcoidosis, neuromuscular dysfunction of bladder, and neurogenic bowel. A nurse note dated 12/16/22 at 6:11 P.M. revealed Resident #363 was admitted with no open skin areas and his buttocks were red. Review of physician orders dated 12/16/22 at 7:47 P.M. revealed Resident #363 was ordered collagenase ointment to the left plantar foot topically in the morning and as needed. A nurse note dated 12/16/22 at 8:49 P.M. revealed Resident #363 had granulated (new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process) skin to right heel. Review of the plan of care dated 12/19/22 revealed Resident #363 had impaired skin integrity of reddened buttocks and a left plantar foot diabetic ulcer. Interventions included to administer medications as ordered, administer treatments as ordered by medical provider, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, evaluate existing wound daily for changes, and notify resident/resident representative, medical provider of any decline in wound healing. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #363 required extensive assistance for bed mobility, transfers, and toilet use. Resident #363 had no skin impairments. Review of the medication administration record (MAR) revealed a treatment was completed to Resident #363's left foot as ordered from 12/17/22 to 12/23/22. Further review of the medical record for Resident #363 revealed no evidence of documentation including skin assessments of red buttocks, granulated tissue to right heel, or the area to the left foot where treatment was completed from 12/17/22 to 12/23/22. Email correspondence on 10/17/23 at 2:30 P.M. Registered Nurse (RN) #911 verified there was documentation of an order for treatment to Resident #363's left foot and the treatment being completed without any assessment of the wound to Resident #363's left foot. 365633 Page 11 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0684 This deficiency represented non-compliance identified during the investigation of Complaint Number OH00146430. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 12 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one resident (#24) of one resident reviewed for hearing ancillary services. The census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 04/19/21 with diagnoses including alcohol dependence, schizoaffective disorder, emphysema, and post-traumatic osteoarthritis of his right hip. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact with minimum hearing difficulty. No hearing appliance was used in the conduction of this assessment. Further review of the MDS revealed Resident #24 exhibited no behaviors and had no rejection of care. Review of Resident #24's care plan revealed he had difficulty hearing, had hearing aids, and did not always choose to wear his hearing aids. Interventions included ensuring hearing aids were in place, observing effectiveness of communication and hearing devices, and refer to audiology for consults as needed. Review of physician orders revealed no current or past orders related to Resident #24's hearing aids. Review of the audiologist visit report dated 03/01/23 revealed the provider was unable to test Resident #24's hearing aids due to bilaterally occluded ear canals. Further review of the report revealed the audiologist recommended cerumen management (CM, or the removal of earwax from the ear canal) and follow-up audiometric testing after CM had been completed per recommendation. According to this report, Resident #24's degree of hearing loss was unable to be determined secondary to occlusion of both ear canals. This report also contained recommendations to the attending medical doctor and/or nursing staff for Resident #24 to continue daily hearing aid use, to be seen post CM for further hearing aid testing, and to contact Michigan Ear Care to coordinate services. Review of social services progress notes for Resident #24 dated between 03/01/23 through 10/25/23 revealed no mention of arrangements or attempts to make follow-up appointments for Resident #24's CM management or re-evaluation of audiometric and hearing aid testing upon completion of cerumen removal. Interview on 10/16/23 at 12:05 P.M. with Resident #24 revealed he had had hearing aids for a few years but had only had one appointment since he had been a resident of the facility. Resident #24 added testing was unable to be completed at the time of that appointment because he needed to have his ears cleaned out first and the audiologist's office did not provide that service. Resident #24 further stated he had experienced hearing problems for a long time, he was unable to hear any better with his hearing aids now, and nobody had addressed his ears needing cleaned since that appointment, so he sees no point to wear his hearing aids. He stated he had tried cleaning the hearing aids himself and even took a woman's [NAME]-pin and tried to clean out his ears himself, but he still cannot hear well with his current hearing aids. 365633 Page 13 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/19/23 at 10:39 A.M. with Social Services Designee (SSD) #802 confirmed she was responsible for making ancillary appointments for residents and was aware Resident #24 was unable to have his audiology appointment fully completed on 03/01/23 due to his blocked ear canals, resulting in a recommendation for referral to Michigan Ear Care for cleaning. Further interview with SSD #802 verified Michigan Ear Care will not come to the facility unless there are at least 30 residents with needs and the facility was not contracted with any other company that providing this service. No other arrangements had been made at this time. SSD #802 was unable to confirm whether the certified nurse practitioner (CNP), CNP #917, who visited the facility was made aware of the audiologist's recommendations made for Resident #24 during his appointment on 03/01/23. 365633 Page 14 of 40 365633 11/07/2023 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 record review, interview, and policy review, the facility failed to ensure a thorough investigation to identify and analyze hazards and risk factors for falls was conducted regarding falls for Resident #15, #94 and #102. This affected three residents (Resident #15, #94, and #102) of five residents reviewed for falls. The facility census was 110. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses of dementia with anxiety, chronic obstructive pulmonary disease, atrial fibrillation, high blood pressure, and macular degeneration of the left eye. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired and had hallucinations and delusions. The resident was identified as having a fall with major injury. Review of the care plans for Resident #15 revealed the falls care plan was initiated on 08/28/23. The interventions implemented at that time included to assess fall risk on admission, ensure the resident was wearing appropriate non-skid footwear, ensure the bed locks were engaged, and place the call light in reach and remind the resident to call for assistance. Additional interventions were added on 09/01/23 to initiate neurological checks if a fall was unwitnessed or the resident hits their head and to observe for medication side effects. Review of the nursing progress notes for Resident #15 revealed on 09/10/23 at 6:00 A.M. the resident was found on the floor of her bathroom sitting on her bottom. The residents legs were in front of her and her arms were at her side and she was attempting to stand up. The resident said she had to urinate and it came on too fast. The floor was wet from urine and she slipped in it. Resident #15 denied hitting her head. Bruising was noted to the back of her left upper arm. The on-call physician was notified and had no new orders. At 7:50 A.M. the resident complained of pain in her left upper/mid back area and the nurse found the area was bruised. The physician was notified and STAT x-rays were ordered of the lumbar and thoracic spine and ribs. Tylenol was provided for pain. The x-ray results came back later that evening and Resident #15 had posterior lateral left ninth and tenth rib fractures. Review of the facility's related fall investigation for Resident #15 revealed State Tested Nursing Assistant (STNA) #884 found the resident on the floor of her bathroom. The resident was wearing slippers at the time of the fall and not the non-skid footwear as care planned. The new interventions put in place were to complete a three day bowel and bladder tracker and to implement non-skid footwear. Review of the nursing documentation revealed no information regarding the Interdisciplinary Team (IDT) review, what conclusion the IDT determined or if the interventions in place were successful, and the results of the three day bowel and bladder tracker were not reviewed. Interview with Registered Nurse (RN) #911 on 10/19/23 at 9:30 A.M. revealed she did not know where the information from the IDT regarding Resident #15's fall was and what permanent intervention was put in place to prevent further falls. RN #911 also did not know where the three day bowel and bladder tracking information was but thought it would be located in the STNA documentation. RN #911 365633 Page 15 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0689 confirmed the STNA documentation may not be accurate. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Fall Prevention and Management policy, last revised 06/01//22, revealed an investigation into each fall should be conducted. An intervention should be put in place after each fall. All interventions and notifications should be documented in the electronic health record. The care plan should be updated with the new interventions put in place. The IDT should review all information for all falls at the next Daily Clinical Meeting. The fall should be discussed, what the potential causes of the fall were, what interventions were put in place and if they are effective. A progress note should be documented in the electronic health record of the IDT discussion. Residents Affected - Few 2. Review of the medical record for Resident #94 revealed an admission date of 09/19/22 with diagnoses including a displaced fracture of the left femur, Alzheimer's, dementia, type two diabetes mellitus, moderate protein calorie malnutrition, and hypertension. Review of the quarterly MDS dated [DATE] revealed Resident #94 had severely impaired cognition, required extensive assist by two staff members for all ADLs including bathing, eating, repositioning, and required assistance by two staff members and the use of a mechanical lift for all transfers. Review of the care plan dated 09/04/23 revealed Resident #94 was at risk for falls related to wandering, observed balanced problems, history of falling, and psychotropic medication use. Additional risk factors included diagnoses of Alzheimer's dementia with agitation, exit-seeking behaviors, incontinence, and use of antihypertensive medications. Interventions included anti-rollbacks to wheelchair, assess risk for falls on admission/readmission, quarterly and as needed, bed in lowest position, dycem to wheelchair cushion, encourage resident to be in a common area while awake, encourage to wear appropriate footwear, ensure bed locks are engaged, non-skid strips next to the bed, and observe for medication side effects that may increase the risk for falls. Review of a facility fall investigation report for Resident #94 revealed on 09/25/23 at approximately 8:00 P.M. the nurse on duty was called to residents room by an STNA. The resident was observed on the floor in his room near his wheelchair. The resident was lying on his left side and complaining of pain in his left hip. The roommate stated Resident #94 was in his wheelchair and stood up and fell down. The wheelchair was not locked, and the roommate was unsure if he hit his head. Neurological checks were initiated. The resident was not able to roll to his back without difficulty or assistance and was yelling out in pain. The resident was assisted into his bed on a blanket lift with staff assistance. The resident was unable to move his leg when asked to do so. The Nurse Practitioner (NP) was notified and gave an order to send the resident to the hospital for evaluation and treatment. The Assistant Director of Nursing (ADON) and the residents daughter were notified. Review of progress notes from 09/25/23 to 10/24/23 revealed there was no documentation to evidence the IDT met and had a discussion related to the residents fall and what interventions were put in place, and if they were effective. Interviews conducted on 10/24/23 from 4:01 P.M. to 4:20 P.M. with Licensed Practical Nurse (LPN) #800, LPN #843, LPN #846, LPN #851, STNA #859, STNA #868, STNA #882, STNA #890, the Administrator, the DON and the ADON revealed it would not have been appropriate to transfer Resident #94 off the floor post-fall if he was unable to roll on to his back and was complaining of back pain, and would not transfer any resident who was a mechanical lift off the floor after a fall with a blanket. They stated they would of tried to make the resident as comfortable as possible on the floor and call 911 for assistance to move the resident. 365633 Page 16 of 40 365633 11/07/2023 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 facility's Fall Prevention and Management policy, last revised 06/01//22, revealed an investigation into each fall should be conducted. An intervention should be put in place after each fall. All interventions and notifications should be documented in the electronic health record. The care plan should be updated with the new interventions put in place. The IDT should review all information for all falls at the next Daily Clinical Meeting. The fall should be discussed, what the potential causes of the fall were, what interventions were put in place and if they are effective. A progress note should be documented in the electronic health record of the IDT discussion. 3. Review of the medical record for Resident #102 revealed an admission date of 04/14/23 and re-admission date of 08/06/23 with diagnoses including a wedge compression fracture of the second and fifth lumbar vertebrae, type two diabetes, vascular dementia, end-stage renal disease, dependence on renal dialysis, congestive heart failure, age-related physical debility, chronic pain syndrome, anxiety, depression, polyneuropathy, muscle weakness, age-related osteoporosis, osteoarthritis, and convulsions. Review of the admission initial assessment, dated 04/15/23, revealed Resident #102 was not at risk for falls and required extensive assistance for activities of daily living (ADLs). Review of the care plan, dated 04/27/23, revealed Resident #102 was at risk for falls due to observed balance problems during transitions, history of falling in six months prior to admission, bowel and bladder incontinence, impaired mobility, opioid use, and pain. Interventions included bed against wall with mat to floor on open side of bed, bed in lowest position, bolsters to bed, non-skid footwear, adequate lighting, and call light within reach. Review of the progress note dated 07/09/23 at 7:19 A.M. indicated Resident #102 was seen at the bedside on the floor lying on her back. Resident #102 was assisted to bed via a mechanical (hoyer) lift and had been witnessed in bed by the nurse 10 minutes prior to the fall. All vital signs were normal, skin was normal for the resident and Resident #102 was moving all four extremities with good range of motion (ROM). Resident #102 did state to the nurse during the shift that she was trying to get up and was told by the nurse she was immobile. Resident #102 acted as if she was unaware of this. The responsible parties were notified and the medical doctor was made aware. The nurse would continue to monitor Resident #102. Review of the fall investigation provided by the facility for the fall incident on 07/09/23 revealed the fall investigation notes were time-stamped 10/24/23 from 10:54 A.M. to 11:03 A.M. and provided a conclusion statement entered by the Director of Nursing (DON) on 10/24/23 at 11:03 A.M. The conclusion statement referencing the fall incident on 07/09/23 but dated 10/24/23 said Resident #102 was noted to be lying on her back on the floor. Resident #102 was asked what she had been attempting to do and Resident #102 stated she was trying to get up around 3:00 A.M. Resident #102 was noted to be wearing non skid slippers, the area was clean and dry, well lighted and clutter free. A head to toe assessment was completed with no visible signs of injury. ROM completed without difficulty. Vital signs were within normal limits. The call light was in reach, fully functional and not used by Resident #102. The incident was not witnessed. Neurological checks were initiated and at baseline with normally reactive pupils. The resident was assisted up to her bed by two staff members via mechanical lift. Resident #102's Brief Interview for Mental Status was 13 (cognitively intact). The resident was last seen awake in bed 10 minutes prior. The responsible party and medical doctor were notified. The bed was placed against the wall for positioning purposes with a mat next to the bed. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/15/23, revealed Resident #102 365633 Page 17 of 40 365633 11/07/2023 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 had intact cognition. Resident #102 required extensive assistance for ADLs, was not steady, and was only able to stabilize with staff assistance. Review of the facility's incident log from October 2022 through October 2023 indicated Resident #102 experienced one fall on 09/22/23. No other fall incidents were identified on the incident log for Resident #102. On 10/16/23 at 11:18 A.M., observation of Resident #102's room revealed the fall mat in the floor was positioned at a 45-degree angle from the bed. On 10/16/23 at 11:21 A.M., interview with LPN #804 verified Resident #102's fall mat was not positioned appropriately. On 10/16/23 at 11:22 A.M., interview with Physical Therapy Assistant (PTA) #918 stated Resident #102 had bolsters to mattress, bed low, and fall mat on floor because she would try to get herself up without assistance. He said the interventions were in place to try to prevent injury if a fall occurred. On 10/17/23 at 10:40 A.M., interview with Resident #102 stated she had fallen two or three times since she arrived at the facility. She did not like having the bolsters on her bed. On 10/23/23 at 10:48 A.M., observation of Resident #102's room revealed the bolster on the open side of her bed was hanging off the edge of the bed and touching on the floor. On 10/23/23 at 10:51 A.M., interview with STNA #829, who also served as transportation staff, confirmed Resident #102's bolster was not in the correct position on the bed. She stated Resident #102 had kicked the bolster off the bed. On 10/24/23 at 8:36 A.M., observation of Resident #102's room revealed the bolster on the open side of her bed was on the floor. Interview at the time of observation with STNA #868 verified the bolster was not in the appropriate position on the bed. On 10/24/23 at 10:15 A.M., interview with Registered Nurse (RN) #911 verified the facility's incident log did not include Resident #102's fall that occurred on 07/09/23. She also stated the nurse's notes and post-fall assessment contained all the information pertaining to the incident and no additional details would be included in a fall investigation. On 10/24/23 at 4:20 P.M., interview with the DON stated all information included in the fall investigation conclusion dated 10/24/23 was obtained from the nurses note and a post-fall evaluation. On 10/24/23 at 4:28 P.M., interview with the DON verified she could not locate the information included in her fall investigation conclusion anywhere in Resident #102's medical record of the fall that occured on 07/09/23. She then stated the information was obtained during an interview with the nurse who was working at the time of the fall (which contradicted her previous statement on 10/24/23 at 4:20 P.M. indicating the information was found in the nurse's note and post-fall assessment). The DON also confirmed the fall investigation contained no witness statement from the nurse and the DON could not provide any evidence or witness statement regarding her interview with the nurse. This deficiency represents non-compliance identified during the investigation of Complaint Number 365633 Page 18 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0689 OH00147820. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 19 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 physician's order was obtained for oxygen administration. This affected one resident (Resident #54) of three residents reviewed for oxygen therapy. The facility identified six other residents (Residents #13, #17, #34 #57, #67 and #79) identified by the facility as using oxygen therapy. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 05/10/22 with diagnoses including end stage kidney disease, diabetes, chronic obstructive pulmonary disease (COPD) and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #54 was totally dependent on two people for transfers, required extensive assistance of two people for bed mobility, dressing and toilet use and extensive assistance of one person for hygiene. She did not receive oxygen therapy. Review of the physician's orders for October 2023 revealed no evidence of an order for oxygen. Review of the care plan dated 10/11/23 revealed the resident had shortness of breath while lying flat due to COPD. Interventions included administering medications as ordered, keeping the head of the bed elevated while lying flat and oxygen therapy as ordered. Observation on 10/17/23 at 8:14 A.M. of Resident #54 revealed she was using oxygen with a setting at two liters at the time of the interview. She confirmed she had been on oxygen for a long time and always wore it when she was in bed. Interview on 10/17/23 at 1:40 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #54 was on oxygen therapy and a physician's order was not obtained. Review of the facility policy titled Oxygen-Medical Gas Use, undated, revealed oxygen would be ordered by a physician. 365633 Page 20 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure a physician's order was obtained for dialysis treatment for two residents (Residents #51 and #102) and that pre and post dialysis assessments were completed for Residents #40, #51 and #102. This affected three residents (#40, #51 and #102) of three residents reviewed for dialysis treatment. The facility census was 110. Residents Affected - Few Findings include: 1. Review of the medical record revealed resident #40 was admitted to the facility on [DATE] with diagnoses including end stage renal disease dependent on dialysis. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the physician's orders for October 2023 revealed Resident #40 received dialysis three days a week. Review of the pre and post dialysis assessments since admission revealed no pre-dialysis assessments were completed on 08/07/23, 08/11/23, 08/16/23, 08/21/23, 08/23/23, 08/28/23, 09/04/23, 10/11/23, or 10/13/23. No post dialysis assessments were completed on 09/01/23 or 09/27/23. Interview on 10/17/23 at 1:40 P.M. with the Assistant Director of Nursing (ADON) confirmed the above findings for Resident #40. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including end stage renal failure dependent on renal dialysis. Review of the comprehensive quarterly MDS assessment dated [DATE] for Resident #51 revealed the resident had moderately impaired cognition and required the special treatment of dialysis. Review of the physician's orders for Resident #51 for October 2023 revealed no evidence of an order for dialysis treatment. Review of Resident #51's care plan dated 10/13/23 revealed the resident would be free from signs and symptoms of complications from dialysis. Interventions included administering medications per physician's orders, communicating with the dialysis center and monitoring vital signs. Review of the pre and post dialysis assessments for Resident #51 revealed no pre-dialysis assessments were completed on 06/05/23, 07/10/23, 07/21/23, 07/28/23, 07/31/23, and 08/09/23. No post-dialysis assessments were completed on 07/19/23, 07/21/23, 08/04/23, and 09/01/23. Interview on 10/17/23 at 1:40 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #51 did not have an order for dialysis. 3. Review of the medical record for Resident #102 revealed an admission date of 04/14/23 and re-admission date of 08/06/23 with diagnoses including end-stage renal disease, and dependence on renal dialysis. 365633 Page 21 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS assessment, dated 08/15/23, revealed Resident #102 had intact cognition. The assessment indicated Resident #102 received dialysis treatments. Review of the care plan, revised 06/16/23, revealed Resident #102 required dialysis therapy three times weekly on Monday, Wednesday, and Friday. Interventions included provide medications as ordered, monitor vital signs, monitor the dialysis port site for bleeding, and evaluate the resident following dialysis treatments. Review of the dialysis assessments for August 2023 through October 2023 for Resident #102 revealed no pre-dialysis assessment was completed on 08/11/23, 08/14/23, 08/23/23, 08/28/23, 08/30/23, 09/08/23, 09/20/23, 10/04/23, 10/06/23, 10/09/23, 10/13/23, 10/18/23, and 10/20/23. Further review of the dialysis assessments for August 2023 through October 2023 for Resident #102 revealed no post-dialysis assessment was completed on 08/07/23, 08/09/23, 08/11/23, 09/01/23, 09/20/23, 09/25/23, 10/02/23, and 10/09/23. Review of the physician's orders for October 2023 identified no orders for Resident #102 to receive dialysis treatments. Further review of the orders revealed the most recent order for dialysis treatments was discontinued on 07/27/23. There were no physician's orders for dialysis treatments in August 2023, September 2023, or October 2023. On 10/23/23 at 4:49 P.M., interview with Regional Registered Nurse (RRN) #920 verified Resident #102's order for dialysis was discontinued at the time of her last hospitalization (07/27/23) and was not re-ordered upon her return to the facility (08/06/23). She stated a physician's order for dialysis was added on 10/23/23. On 10/24/23 at 2:01 P.M., interview with the ADON verified Resident #102 did not have both a pre-dialysis and post-dialysis assessment completed on every dialysis day. Review of the facility's undated Hemodialysis Care and Monitoring revealed pre and post dialysis assessments were to be completed on each treatment day and residents would be evaluated for appropriateness by the physician. Residents would be assessed by a physician to determine the need for dialysis, the ordering physician would establish medication administration orders for dialysis days, residents would be evaluated within four hours prior to being transported to dialysis and evaluated immediately upon returning from dialysis. 365633 Page 22 of 40 365633 11/07/2023 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview, the facility failed to provide medication as ordered for Resident #363. This affected one (Resident #363) out of five residents reviewed for medications. The facility census was 110. Findings include: Review of the medical record revealed Resident #363 was admitted on [DATE] and discharged on 12/23/22 with diagnoses including chronic kidney disease, fracture of cervical vertebras, type two diabetes mellitus, chronic obstructive pulmonary disease, methicillin susceptible staphylococcus aureus, end stage renal disease, sarcoidosis, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of physician orders dated 12/16/23 at 8:20 P.M. revealed Resident #363 was ordered Oxycodone (narcotic for moderate to severe pain) 20 milligrams (mg) every six hours for pain and Oxycodone 20 mg every three hours as needed for pain. Review of medication administration note dated 12/17/22 at 2:59 P.M. revealed Oxycodone was not administered due to waiting on prescription for pharmacy delivery. On 12/17/22 at 5:01 P.M. a medication administration note revealed the facility was awaiting pharmacy delivery. A medication administration note dated 12/18/22 at 12:00 A.M. and 6:23 A.M. revealed Oxycodone was on order. On 12/18/22 at 12:14 P.M. the doctor was notified a prescription was needed for Oxycodone for Resident #363. Medication administration notes dated 12/19/22 at 12:10 A.M., 6:38 A.M., and 1:03 P.M. revealed Oxycodone was marked as on order. The plan of care dated 12/19/22 revealed Resident #363 had the potential for complaints of pain. Interventions included to administer non-pharmacological interventions, complete pain assessment on admission/readmission, quarterly, significant change, and as needed, observe for pain every shift, and provide medication as ordered. Review of medication administration note dated 12/20/22 at 1:25 A.M. revealed Oxycodone was on order. Oxycodone was administered the first time as scheduled to Resident #363 on 12/20/22 at 6:00 A.M. with Resident #363 rating pain a five on a scale of zero to ten with ten being the worse pain. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #363 required extensive assistance for bed mobility, transfers, and toilet use. Email communication on 10/17/23 at 2:30 P.M. revealed Registered Nurse (RN) #911 communicated the order for Resident #363's Oxycodone that was transcribed on 12/16/22 to be started on 12/17/22. RN #911 verified pharmacy was unable to obtain a valid prescription until 12/19/22 and the Oxycodone was received on 12/20/22 at 6:51 A.M. Interview on 10/17/23 at 3:20 P.M. RN #911 verified Resident #363 was ordered Oxycodone on 12/16/22 and Oxycodone was not available to be administered until 12/20/22. 365633 Page 23 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 3. Resident #80 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorder, anxiety, congestive heart failure, chronic obstructive pulmonary disease, and major depression. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment, dated 10/04/23, revealed the resident was moderately cognitively impaired and exhibited no behaviors. Review of the physician's orders revealed Resident #80 was receiving an antipsychotic medication for a diagnosis of delusional disorder. Review of the August, September and October 2023 Medication Administration Record (MAR) for Resident #80 for behavior monitoring revealed the resident had four days with behaviors in October, and no behaviors were exhibited in September or August. Review of the State Tested Nursing Assistants (STNA) behavior monitoring for Resident #80 for the past 30 days revealed the resident exhibited no behaviors. Review of the nursing progress notes revealed no behaviors were observed from August through October 2023. Interview with the Director of Nursing (DON) on 10/16/23 at 4:59 P.M. revealed Resident #80 did not have an appropriate diagnosis for use of an antipsychotic. The DON confirmed Registered Nurse (RN) #911 was currently updating the resident's diagnosis to reflect use of an appropriate diagnosis for the use of the antipsychotic. Interview with Psychiatric Nurse Practitioner (PNP) #910 on 10/18/23 at 12:03 P.M. revealed an attempt was made recently to decrease Resident #80's use of Seroquel (an antipsychotic medication) and she did not do well on the decreased dose. She had increased aggression and delusions which became progressively worse. PNP #910 confirmed she did not rely on nursing's documentation of behaviors but instead would interview the nurse for more reliable information. Review of the facility's undated Antipsychotic Second Clinical Review policy revealed there should be documentation to support use of antipsychotic medication including staff documentation of supporting systems. 4.Resident #91 was admitted to the facility on [DATE] with diagnoses including diabetes, major depression, congestive heart failure, restlessness and agitation, peripheral vascular disease, and a stroke. Review of the quarterly comprehensive MDS assessment dated [DATE] revealed Resident #91 was severely cognitively impaired, had delusions, and other behavioral symptoms not directed towards others for one to three days of the assessment period. Review of the MAR for August, September, and October 2023 revealed Resident #91 had two days with behaviors in August, one day of behaviors in September, and no exhibited behaviors in October. 365633 Page 24 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of the STNA behavior monitoring for Resident #91 revealed the resident had exhibited no behaviors in the previous 30 days. Review of the nursing progress notes for Resident #91 revealed no documentation of the resident exhibiting behaviors since August 2023. Residents Affected - Some Interview with PNP #910 on 10/18/23 at 12:03 P.M. revealed she ordered Depakote for Resident #91 to treat his aggressive behaviors which have been showing improvement since starting it. PNP #910 confirmed she did not rely on nursing's documentation of behaviors but instead would interview the nurse for more reliable information. Review of the facility's undated Antipsychotic Second Clinical Review policy revealed there should be documentation to support use of antipsychotic medication including staff documentation of supporting systems. Based on record review and interview, the facility failed to ensure anti-psychotics were used to treat appropriate diagnoses. This affected five (#34, #80, #89, #91, and #264) of seven residents reviewed for unnecessary medications. The census was 110. Findings include: 1. Review of the medical record for Resident #89 revealed an admission date of 06/03/21 with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, restlessness, agitation, major depressive disorder, insomnia, soft tissue disorders, glaucoma, and muscle weakness. Review of the care plan, dated 09/29/23, revealed Resident #89 used an anti-psychotic medication for restlessness and agitation. Interventions included consult with pharmacy and medical provider to consider dosage reduction when clinically appropriate, educate resident representative or risks and benefits as well as side effects of medication use, observe behaviors, observe for side effects of anti-psychotic medications, provide anti-psychotic medications per physician's orders, and consult psychiatric services as needed. Review of the physician's orders for October 2023 identified orders for Olanzapine (an anti-psychotic) five milligrams (mg) by mouth twice daily for restlessness or agitation (ordered 10/04/23). On 10/16/23 at 4:59 P.M., interview with the Director of Nursing (DON) verified Resident #89 was ordered an anti-psychotic medication without an appropriate diagnosis. The DON also stated that Registered Nurse (RN) #911 was currently auditing anti-psychotic orders for all residents to ensure appropriate diagnoses were reflected on the orders. On 10/18/23 at 12:30 P.M., interview with Psychiatric Nurse Practitioner (NP) #910 confirmed Resident #89 was ordered an anti-psychotic related to his agitation. She stated she did not use the facility's behavior tracking documentation because she could not trust that it was accurate. Review of the facility policy titled Antipsychotic Second Clinical Review, dated 10/17/23, indicated antipsychotics were not appropriate nor approved for treatment of residents with dementia-related psychosis, residents would not receive antipsychotic medications which were not clinically indicated to treat a specific condition, and nursing staff was required to document supporting symptoms. 365633 Page 25 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the medical record for Resident #264 revealed an admission date of 10/11/23 with diagnoses including wedge compression fracture of the T11 and T12 vertebra, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, Alzheimer's disease, subsequent encounter for fall, and personal history of venous thrombosis and embolism. Review of the physician's orders for October 2023 identified orders for Quetiapine Fumarate (an antipsychotic) 25 milligrams (mg) half a tablet twice daily and one tablet once daily for mental/mood health (ordered 10/11/23). Review of the Hospital Exemption from Preadmission Screening Notification, dated 10/11/23, revealed Resident #264 did not have a diagnosis of schizophrenia, mood disorder, delusional disorder, panic or severe anxiety disorder, somatic symptom disorder, personality disorder, other psychotic disorder, or another mental disorder that may lead to a chronic disability. Review of the care plan, dated 10/24/23, revealed Resident #264 used anti-psychotic medication related to Alzheimer's dementia with agitation. Interventions included consult with pharmacy and medical provider to consider dosage reduction when clinically appropriate, educate resident representative or risks and benefits as well as side effects of medication use, observe behaviors, observe for side effects of anti-psychotic medications, provide anti-psychotic medications per physician's orders, and consult psychiatric services as needed. On 10/16/23 at 4:59 P.M., interview with the Director of Nursing (DON) verified Resident #264 was ordered an anti-psychotic medication without an appropriate diagnosis. The DON also stated that Registered Nurse (RN) #911 was currently auditing anti-psychotic orders for all residents to ensure appropriate diagnoses were reflected on the orders. On 10/18/23 at 12:30 P.M., interview with Psychiatric Nurse Practitioner (NP) #910 confirmed Resident #264 was ordered an anti-psychotic related to her dementia with psychotic behaviors. She stated she did not use the facility's behavior tracking documentation because she could not trust that it was accurate. Review of the facility policy titled Antipsychotic Second Clinical Review, dated 10/17/23, indicated antipsychotics were not appropriate nor approved for treatment of residents with dementia-related psychosis, residents would not receive antipsychotic medications which were not clinically indicated to treat a specific condition, and nursing staff was required to document supporting symptoms. 5. Review of the medical record for Resident #34 revealed an admission date of 06/14/15 with diagnoses including dementia, anxiety, psychotic disorder with delusions, chronic obstructive pulmonary disease (COPD), major depressive disorder, and type II diabetes mellitus. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 dated 07/13/23 revealed no indicators of psychosis and the presence of inattention, disorganized thinking, and memory issues. Further review of the MDS 3.0 revealed Resident #34 was dependent with bed mobility, locomotion, personal hygiene, and toileting. Review of the care plan revealed Resident #34 had behavior issues including tearfulness, delusions, withdrawal from daily activities, and yelling out. Interventions included approaching and speaking with Resident #34 in a calm manner, monitoring behavior episodes to determine underlying cause, and non-pharmacological interventions, including one to one interaction, emotional support, diversional 365633 Page 26 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0758 activities, and offering food and drinks. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders revealed an order dated 09/05/23 to administer 0.5 milligrams (mg) of Ativan (an anti-anxiety medication) by mouth every eight hours as needed for anxiety. This order did not contain a stop date and was listed as Indefinite. Residents Affected - Some Interview on 10/17/23 at 01:06 P.M. with the assistant director of nursing (ADON) verified the Ativan 0.5mg every eight hours as needed order dated 09/05/23 contained no stop date. Further interview with the ADON confirmed the as needed antianxiety medication orders should be limited to 14 days. Interview on 10/18/23 at 12:25 P.M. with Psychiatric Nurse Practitioner #910 confirmed Ativan being used on an as needed basis is typically ordered for 14 to 30 days at a time and not ordered indefinitely. She further verified supportive documentation for any duration greater than 14 days would be in her visit progress notes. 365633 Page 27 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0760 Ensure that residents are free from significant medication errors. 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 insulin was given per physician's orders. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110. Residents Affected - Few Findings include: Medical record review for Resident #362 revealed an admission date of 10/05/23 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy, morbid obesity with alveolar hypoventilation, pulmonary hypertension, depression, and cerebrovascular disease. Review of Resident #362's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had moderately impaired cognition. She was independent with eating and personal hygiene and required set-up or clean-up assistance with bathing and dressing her lower body. Mobility devices included a wheelchair and a walker, and she required supervision with transfers. Review of physician orders for Resident #362 revealed an order dated 10/06/23 for five units of Humalog to be administered subcutaneously before meals for diabetes mellitus using a Humalog KwikPen 100 units/milliliter pen-injector. Observation on 10/19/23 at 12:00 P.M. of medication administration to Resident #362 by Licensed Practical Nurse (LPN) #800 revealed LPN #800 did not prime the insulin needle by dialing and wasting two units prior to setting the dose in the insulin pen to the ordered five units. Interview on 10/19/23 at 12:04 PM with LPN #800 confirmed she did not prime Resident #362's insulin needle with two units prior to setting the ordered dose of five units on the Humalog pen per the manufacturer's direction and administering the medication. LPN #800 further confirmed she was unaware of the manufacturer's instructions to prime the needle with two units prior to Humalog administration. Review of manufacturer instructions titled Instructions for Use HUMALOG KwikPen insulin lispro injection (rDNA origin) directs the user to prime before each injection. Further review revealed failure to prime prior to administration may cause too little or too much insulin to be administered. Step five directs the user to turn the knob to two units after placing the needle on the pen. Step seven directs the user to push the dose knob until it stops on zero and a stream of insulin is seen coming from the needle prior to dialing the ordered insulin dose. Review of the facility policy titled Medication Administration revised on 04/20/17 revealed medications should be given as ordered and full attention should be maintained while preparing medications. 365633 Page 28 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure medications were stored and labeled in a manner that prevented the risk of residents receiving insulin that belonged to another resident. This affected one resident (Resident #362) of six residents reviewed for medication administration. The facility census was 110. Findings include: Medical record review for Resident #362 revealed an admission date of 10/05/23 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy, morbid obesity with alveolar hypoventilation, pulmonary hypertension, depression, and cerebrovascular disease. Review of Resident #362's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had moderately impaired cognition. She was independent with eating and personal hygiene and required set-up or clean-up assistance with bathing and dressing her lower body. Mobility devices included a wheelchair and a walker, and she required supervision with transfers. Review of physician orders for Resident #362 revealed an order dated 10/06/23 for five units of Humalog to be administered subcutaneously before meals for diabetes mellitus using a Humalog KwikPen 100 units/milliliter (units/ml) pen-injector. Observation on 10/19/23 at 12:00 P.M. of medication administration to Resident #362 by Licensed Practical Nurse (LPN) #800 revealed LPN #800 removed an insulin pen from a brown tinted plastic bag labeled with information including Resident #362's name, ordered drug (Humalog KwikPen 100 units/ml), and ordered dose and frequency (five units Humalog subcutaneously before meals for diabetes mellitus). Further observation revealed the insulin pen removed from the bag was labeled as insulin Lispro 100 units/ml for Resident # 46. Interview on 10/19/23 at 12:04 PM with LPN #800 confirmed the insulin Lispro for Resident #46 had been stored in the brown tinted plastic bag labeled with information for Resident #362. Review of the Food and Drug Administration (FDA) patient information sheet for Humalog (revised 2023) provides instructions to check the insulin label each time insulin is administered to ensure it is correct. Review of the facility policy titled Medication Administration last revised on 04/20/17 revealed nurses must observe the five rights for medication administration (right resident, right time, right medicine, right dose, right method of administration). Further examination of the policy revealed staff must review labels multiple times and compare them to the medication administration record (MAR). The policy also states not to give a medication labeled for another resident. Review of pharmacy policy titled GENERAL GUIDELINES FOR MEDICATION STORAGE, effective 08/01/09, revealed Remedi dispenses medications in packaging or containers that meet legal requirements, all medications are to be kept stored in this packaging, and transfer of medications into other packaging or containers is not permitted, unless by a licensed pharmacist or as necessary if a resident goes on 365633 Page 29 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0761 an unplanned leave of absence from the facility for less than 24 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365633 Page 30 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation and interview, the facility failed to ensure dietary staff were competent to complete their duties. This had the potential to affect all 109 residents who received meals from the kitchen except one resident (Resident #98) who the facility identified as eating nothing by mouth. The census was 110. Findings include: Review of the staff on-boarding packets for all dietary staff hired within the last six months revealed three staff (Cook #818, Dietary Aide #819, and State Tested Nurse Aide [STNA] #869) answered the on-boarding quiz questions incorrectly despite the correct answers being listed immediately following the questions. On 10/16/23 at 8:42 A.M., observation of the kitchen revealed food was stored on the floor in the walk-in refrigerator, walk-in freezer, and dry storage. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 stated new staff did not get the appropriate training to know how to put away food items after they were delivered to the facility. On 10/18/23 at 11:20 A.M., observation of the lunch meal tray line revealed four residents (#6, #14, #73, and #105) did not have an entree listed on their meal tickets. [NAME] #820 put one serving of potatoes and one serving of peas on each of those four plates. Dietary Aide #824 checked the meal tickets, confirmed what was on the plate matched the meal ticket, and covered each of those four plates for service. At the time of the observation, interview with [NAME] #820 and Dietary Aide #824 both verified there was no main entree on the meal tickets for Residents #6, #14, #73, and #105, and confirmed that the trays would be served with just one serving of potatoes, one serving of peas, and no entree or protein. [NAME] #820 stated he only provided what was listed on the meal tickets and if there was no entree listed, then no entree was served on that tray. On 10/18/23 at 6:30 P.M., interview with Registered Dietitian (RD) #909 stated there was a lot of turnover with staff in the kitchen and there was no permanent dietary manager to ensure new staff received adequate training. She stated kitchen staff probably needed training on problem solving due to not recognizing an issue when some lunch tickets only included the potatoes and peas with no protein. She said staff were trained to read the tickets to ensure accuracy, but they should have recognized that something was wrong when there was no protein (main entree) on those trays. 365633 Page 31 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected three residents (#14, #24, and #94) of five residents reviewed for food and nutrition. The census was 110. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 05/18/23 with diagnoses including type two diabetes, chronic kidney disease, congestive heart failure, and chronic obstructive pulmonary disease. Review of the nutrition care plan, revised 08/10/23, revealed Resident #14 had the potential for altered nutrition status due to type two diabetes, chronic kidney disease, hypertension, lymphedema, chronic obstructive pulmonary disease, altered skin integrity, and therapeutic diet. Interventions included identify resident food and beverage preferences, and monitor meal intake, Review of the physician's orders for October 2023 identified orders for a controlled carbohydrate diet with regular texture and thin liquid consistency. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/10/23, revealed Resident #14 had no cognitive impairment. Review of the dietary dislikes for Resident #14 revealed dislikes for beef group, fish group, seafood group, shellfish group, baked fish, tuna, Italian sausage, Italian sausage filling for sub, Italian sausage for sub, and mashed potatoes. On 10/16/23 at 11:32 A.M., interview with Resident #14 stated preferences were not followed and the only alternate provided to her was a peanut butter and jelly sandwich. On 10/18/23 at 5:44 P.M., observation revealed Resident #14 had eaten most of her dinner meal and had an Italian sausage on her plate. Observation of her meal ticket on her tray indicated she was to receive an Italian sausage substitute with peppers and onions. Interview at the time of the observation with Resident #14 stated she had told the facility she did not like Italian sausage and that she just ate the bread with the peppers and onions. On 10/18/23 at 6:30 P.M., interview with Registered Dietitian (RD) #909 verified Resident #14 had dislikes for Italian sausage, Italian sausage filling for sub, and Italian sausage for sub. She also verified Resident #14's meal ticket for dinner included Italian sausage sub with peppers and onions. RD #909 stated the menu and meal ticket system utilized resident likes and dislikes to create their meal tickets. She stated in this instance, Resident #14 had three dislikes for Italian sausage products and verified the Italian sausage sub with peppers and onions was not marked as a dislike in the system, stating that was why it was included on her meal ticket. 2. Review of the medical record for Resident #24 revealed an admission date of 04/19/21 with diagnoses including hypertension, schizoaffective disorder, epilepsy, major depressive disorder, dementia, and Wernicke's encephalopathy. 365633 Page 32 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the nutrition care plan, revised 04/03/23, revealed Resident #24 had a potential for alteration in nutritional status due to schizoaffective disorder, dementia, hypertension, depression, dysphagia, and psychosis. Interventions included provide meals per diet orders, monitor meal intake, and offer substitutions if provided meal was declined. Review of the quarterly MDS assessment, dated 08/21/23, revealed Resident #24 had no cognitive impairment. Review of the physician's orders for October 2023 identified orders for a regular diet with regular texture and thin liquids. On 10/18/23 at 12:50 P.M., observation of Resident #24's lunch tray revealed he received a hamburger, au gratin potatoes, peas, and a piece of cake. Observation of the meal ticket included on his tray revealed Resident #24 was ordered meatloaf, au gratin potatoes, peas, dinner roll, and caramel apple upside down cake. Interview at the time of observation with Resident #24 stated he wanted meatloaf and he did not know why he was given a plain hamburger instead of meatloaf. On 10/18/23 at 6:28 P.M., observation of Resident #24's dinner tray revealed he did not receive tropical fruit salad or a dinner roll, both of which were included on the meal ticket on his tray. Interview at the time of the observation with Licensed Practical Nurse (LPN) #804 verified Resident #24 did not receive tropical fruit salad or a dinner roll and both were printed on the dinner meal ticket included on his tray. On 10/18/23 at 5:55 P.M., interview with State Tested Nurse Aide (STNA) #867 said it was a frequent occurrence for the meals served to not match what was printed on the meal ticket. 3. Review of the medical record for Resident #94 revealed an admission date of 09/19/22 with diagnoses including Alzheimer's disease, dementia, type two diabetes, moderate protein-calorie malnutrition, chronic kidney disease, coronary artery disease, anemia, and adult failure to thrive. Review of the nutrition care plan, revised 04/07/23, revealed Resident #94 had the potential for alteration in nutritional status due to Alzheimer's disease, dementia, hypertension, chronic kidney disease, coronary artery disease, hyperlipidemia, depression, failure to thrive, type two diabetes, anemia, protein-calorie malnutrition, and abnormal weight loss. Interventions included monitor meal intake, provide meals per diet ordered, and provide assistance with meals as needed. Review of the physician's orders for October 2023 identified orders for regular diet with regular texture and thin liquids. Review of the comprehensive MDS assessment, dated 10/04/23, revealed Resident #94 had severe cognitive impairment. Review of the dietary dislikes for Resident #94 revealed dislikes for fish group, ham group, pork group, seafood group, shellfish group, and baked fish. On 10/18/23 at 5:55 P.M., observation of Resident #94's dinner tray revealed he was served an Italian sausage sub with peppers and onions. Observation of the meal ticket included on his tray revealed the ticket indicated Resident #94 was to get a breaded chicken on a bun. The meal ticket did not include an Italian sausage sub with peppers and onions. 365633 Page 33 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/18/23 at 5:55 P.M., interview with State Tested Nurse Aide (STNA) #867 confirmed Resident #94's meal ticket indicated he was to receive breaded chicken on a bun. She verified his tray had an Italian sausage sub with peppers and onions and there was no chicken sandwich. She said it was a frequent occurrence for the meals served to not match what was printed on the meal ticket. On 10/18/23 at 6:30 P.M., interview with Registered Dietitian (RD) #909 stated there was a lot of turnover with staff in the kitchen and no permanent dietary manager to ensure new staff received adequate training. She stated additional training for tray accuracy needed to be completed with all kitchen staff. On 10/19/23 at 2:16 P.M., during the Resident Council Meeting, interview with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #103, and #362 stated food preferences were not followed and no other options were provided, so they had food delivered from outside the facility. Review of the facility policy titled Dining and Food Preferences, dated 09/2017, revealed residents would complete a food preferences interview within 48 hours of admission, food preferences would be entered into the medical record and the menu management system, the tray ticket would identify all food items appropriate food items for residents based on their allergies or preferences and their diet order, and residents would be able to select an alternate meal of comparable nutritional value. 365633 Page 34 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on record review, interview, and review of facility policy, the facility failed to provide snacks per resident preferences and the plan of care. This affected seven (#12, #51, #62, #67, #71, #79, and #85) of seven residents reviewed for snacks and had the potential to affect all residents (except Resident #98) residing in the facility. The census was 110. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/05/23 with diagnoses including end stage renal disease, dependence on renal dialysis, congestive heart failure, major depressive disorder, type two diabetes, and gastroesophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/31/23, revealed Resident #12 had intact cognition. Review of the nutrition care plan, revised 08/04/23, revealed Resident #12 had the potential for altered nutritional status due to end stage renal disease dependent on hemodialysis, type two diabetes, gastroesophageal reflux disease, hypertension, fatty liver, congestive heart failure, obesity, anemia, diverticulosis, and depression. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #12 on 09/28/23, 09/30/23, 10/03/23, 10/05/23, 10/10/23, 10/12/23, 10/17/23, 10/19/23, and 10/24/23. 2. Review of the medical record for Resident #51 revealed an admission date of 06/17/16 with diagnoses including alcohol induced dementia, type two diabetes, major depressive disorder, gastroesophageal reflux disease, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/06/23, revealed Resident #51 had intact cognition. Review of the nutrition care plan, revised 03/08/23, revealed Resident #51 had a nutritional problem due to dementia and high body mass index (BMI). Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #51 on 09/28/23, 09/30/23, 10/05/23, 10/10/23, 10/12/23, and 10/24/23. 3. Review of the medical record for Resident #62 revealed an admission date of 05/04/18 with diagnoses including Parkinson's disease, psychotic disorder, chronic kidney disease, hyperlipidemia, dementia, chronic obstructive pulmonary disease, major depressive disorder, and anxiety. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 09/29/23, revealed Resident #62 had intact cognition. 365633 Page 35 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the nutrition care plan, revised 09/21/23, revealed Resident #62 had the potential for altered nutritional status due to Parkinson's disease, psychotic disorder, anxiety, major depressive disorder, dementia, hypertension, dysphagia, chronic obstructive pulmonary disease, cognitive communication deficit, and hyperlipidemia. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #62 on 09/28/23, 09/30/23, 10/06/23, 10/10/23, 10/12/23, and 10/24/23. 4. Review of the medical record for Resident #67 revealed an admission date of 12/15/22 with diagnoses including end stage renal disease, dependence on renal dialysis, severe protein-calorie malnutrition, congestive heart failure, chronic obstructive pulmonary disease, type two diabetes, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 07/19/23, revealed Resident #67 had intact cognition. Review of the nutrition care plan, revised 10/23/23, revealed Resident #67 had the potential for altered nutritional status due to end stage renal disease on hemodialysis, hypertension, diabetes, heart failure, hyperlipidemia, gastroesophageal reflux disease, and major depressive disorder. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #67 on 09/27/23, 09/30/23, 10/06/23, 10/09/23, and 10/22/23. 5. Review of the medical record for Resident #71 revealed an admission date of 05/24/21 with diagnoses including type two diabetes, chronic kidney disease, dementia, major depressive disorder, gastroesophageal reflux disease, hypertension, and anemia. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 09/08/23, revealed Resident #71 had intact cognition. Review of the nutrition care plan, revised 08/25/23, revealed Resident #71 had the potential for a nutritional problem due to diabetes, hypertension, psychosis, anemia, chronic kidney disease, gastroesophageal reflux disease, depression, and anxiety. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #71 on 09/28/23, 09/30/23, 10/08/23, 10/11/23, 10/14/23, 10/15/23, 10/19/23, 10/20/23, and 10/23/23. 6. Review of the medical record for Resident #79 revealed an admission date of 12/14/21 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, type two diabetes, bipolar disorder, depression, anxiety, and borderline personality disorder. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/19/23, revealed Resident #79 had intact cognition. Review of the nutrition care plan, revised 07/28/23, revealed Resident #79 had the potential for nutritional problems due to congestive heart failure, bipolar disorder, depression, anxiety, 365633 Page 36 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0809 Level of Harm - Minimal harm or potential for actual harm hyperlipidemia, obesity, diabetes, and anemia. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #79 on 09/29/23, 09/30/23, 10/03/23, 10/06/23, 10/09/23, 10/16/23, and 10/22/23. Residents Affected - Some 7. Review of the medical record for Resident #85 revealed an admission date of 04/30/21 with diagnoses including type two diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, anemia, skin cancer, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/06/23, revealed Resident #85 had intact cognition. Review of the nutrition care plan, revised 10/02/23, revealed Resident #85 had nutritional risk due to diabetes, coronary artery disease, anxiety, anemia, chronic obstructive pulmonary disease, hyperlipidemia, and gastroesophageal reflux disease. Interventions included provide snacks per the facility protocol. Review of the snacks tracking for the last 30 days revealed no bedtime snacks were provided to Resident #85 on 09/28/23, 09/30/23, 10/06/23, 10/08/23, 10/12/23, 10/14/23, 10/15/23, 10/17/23, 10/19/23, 10/20/23, and 10/23/23. On 10/19/23 at 2:16 P.M., during the Resident Council Meeting, interview with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #103, and #362 stated snacks after dinner and at bedtime were not always provided. On 10/24/23 at 12:21 P.M., interview with State Tested Nurse Aide (STNA) #868 verified snacks were not passed routinely and said snacks were given to residents if they requested them. On 10/24/23 at 12:25 P.M., interview with STNA #916 confirmed snacks were only provided to residents upon request. Review of the facility policy titled Snacks, dated 09/2017, revealed bedtime snacks would be provided for all residents and additional snacks would be available upon request for all residents. 365633 Page 37 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, review of facility policy, and review of the Ohio Uniform Food Safety Code, the facility failed to ensure food items were stored at least six inches off the floor. This had the potential to affect all 109 residents who received food from the kitchen and excluded Resident #98 who received nothing by mouth. The census was 110. Findings include: On 10/16/23 at 8:42 A.M., observation of the kitchen revealed a crate containing 12 cartons of milk was on the floor of the walk-in refrigerator, one box of chopped spinach was on the floor of the walk-in freezer, and the following items were observed on the floor of the dry storage room: one box of pasta, one case containing 12 cans of tomato juice, one box of cranberry juice, one box containing 150 packets of hot cocoa mix, and one box containing three gallons of pancake and waffle syrup. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 verified the multiple boxes of food items that were on the floor of the dry storage room. Dietary Aide #824 stated new staff did not get the appropriate training to know how to put away food items after they were delivered to the facility. On 10/16/23 at 9:15 A.M., interview with Human Resources (HR) Manager #808 verified there was a crate containing 12 cartons of milk on the floor of the walk-in refrigerator. HR Manager #808 stated there was no dietary manager and the corporate dietary manager was out sick. She stated the facility management team took turns overseeing the kitchen and she was overseeing the kitchen on this day. HR Manager #808 said she did not know all the rules of the kitchen and did not know food could not be stored on the floor. On 10/16/23 at 9:17 A.M., interview with [NAME] #826 verified there was a box of spinach on the floor of the walk-in freezer. Review of the facility policy titled Receiving and Storage of Food, not dated, revealed foods must be stored at least six inches off the floor. Review of the State of Ohio Uniform Food Safety Code indicated food should be stored at least six inches above the floor to protect from contamination. 365633 Page 38 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interviews, the facility administrator did not ensure a qualified activity director was hired to administer a therapeutic activity program to meet the needs and interests of the residents. This had the potential to affect all 110 residents living in the facility. Residents Affected - Many Findings include: Review of the position description for the executive director, signed by the Administrator on 11/23/2020, revealed it was the Administrator's responsibility to provide leadership to all staff to ensure care standards were met in accordance with state and federal regulations and the highest degree of quality resident care was provided at all times. Review of the employee file for the Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. It was stated in the AD job description her direct report was the Administrator. As listed in the Qualifications/Knowledge/Skills and Abilities section the AD role required either a bachelor's degree in therapeutic recreation or related field or 90 hour course for activity professionals and continuing education, prior management, supervisory, leadership experience preferably in a health care environment, prior work/life experiences, preferably in a healthcare setting, they must be knowledgeable of activity practices, standards of practice, state practice acts and procedures, as well as laws, regulations, and guidelines that pertain to long-term care. They must be able to plan, organize, and conduct a variety of activities and must be willing to seek out new methods and principles and be willing to incorporate then into existing activity practices. There was no evidence found in the employee file for AD #805 to verify AD #805 had any of the qualifications in the job description. Interview on 10/17/23 at 4:15 P.M. with AD #805 revealed she did not have a bachelor's degree in therapeutic recreation or related field, she did not complete the 90-hour course for activity professionals and had no continuing exudation. She stated Social Service Director (SSD) # 802 had her activity qualification and the facility had her working under that certification but SSD #802 did not over see any of the activity department. AD #805 stated she made all the activity calendars, and scheduled all of the activity department staff. AD #805 stated she attended the Quality Assurance Performance Improvement (QAPI) meetings as the AD. AD #805 stated she did not receive over-site by SSD #802 and received very little over-site by the Administrator. Observations made throughout the survey from 10/16/23 to 10/25/23 revealed there was no over site by the Administrator or by SSD # 802 over the activity department. Interview on 10/19/23 at 11:35 A.M. with the Administrator revealed she sent AD #805 to activities boot camp which was a 13.5 hour training. The Administrator stated AD #805 did not have any of the requirements described in the job description for the Activities Director, but SSD #802 had the qualifications so the Administrator felt this was sufficient. 365633 Page 39 of 40 365633 11/07/2023 The Colony Healthcare Center 563 Colony Park Drive Tallmadge, OH 44278

F 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Payroll Based Journal (PBJ) report, review of staffing schedules, review of the facility assessment and interview, the facility failed to ensure accurate PBJ reporting. This had the potential to affect all 110 residents residing in the facility. Findings include: Review of the Payroll Based Journal (PBJ) staffing information for the second quarter of Fiscal Year 2023 (01/01/23 to 03/31/23) revealed the facility had excessively low weekend staffing and a one-star staff rating. Review of the facility assessment dated [DATE] through 10/30/23 revealed the facility would provide six to nine direct care nurses per day and 20 to 28 nurse aides per day. Review of the facility schedules for February and March 2023 revealed the following dates had less than 20 aides working: 02/10/23, 02/18/23, 03/24/23 and 03/25/23. Review of the daily posted staffing information for 02/01/23 through 03/31/23 revealed the following dates had less than 20 aides working: 03/19/23, 03/24/23 and 03/26/23. The daily posted staffing information also revealed two Licensed Practical Nurses (LPN)'s working and one Registered Nurse (RN) working on 03/19/23 and five LPN's working on 03/26/23. Interview on 10/24/23 at 1:56 P.M. with the Administrator revealed the facility process for reporting staffing information had changed in the past year and that change may have led to inaccurate payroll reporting for fiscal year quarter two of 2023. The Administrator revealed staff who were no longer employed with the facility but had been employed with the facility during 01/01/23 to 03/31/23 did not show up on the schedules provided for review for February 2023 and March 2023. The Administrator said two separate systems were used to report PBJ information, which did not always have the same information leaving room for inaccurate reporting. 365633 Page 40 of 40