Inspection·February 6, 2020

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of Resident #32's activities of daily living plan of care dated 08/10/19 revealed a shower with nail care twice weekly. Review of Resident #2's shower sheets for February 2020 revealed Resident #2 received a shower on 02/04/20. Residents Affected - Few Observation of Resident #2 on 02/04/20 at 8:13 A.M. revealed the nails on right hand had a dark substance under them. The same was observed on 02/04/20 at 1:24 P.M. and 3:45 P.M., on 02/04/20 at 4:56 P.M. and on 02/05/20 at 8:35 A.M. Interview of RN #223 on 02/05/20 at 8:35 A.M. confirmed Resident #32's nails needed cleaned. Review of the facility's bath, shower/tub policy (revised February 2018) revealed staff were to assist residents with dressing and grooming as needed. Based on observation, interview and record review, the facility failed to ensure residents received nail care as indicated. This affected three of four residents reviewed for nail care, Residents #22, #2 and #32. Findings Include: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, depression, diabetes mellitus type two, hallucinations and legally blind. Review of the quarterly Minimum Data Set (MDS) assessment completed on 11/13/19 revealed Resident #22 was cognitively impaired and required extensive assistance for activities of daily living. Review of Resident #22's care plan dated 11/18/19 indicated she had a self care performance deficit in activities of daily living related to Alzheimer's disease, dementia and blindness. The care plan indicated podiatry services as desired by resident, and shower two times per week with hair and nail care. Review of the progress notes for Resident #22 revealed on 12/26/19 the resident's toenails were in good repair, no sharp edges were noted to toenails and no skin issues to feet. No further documentation regarding Resident #22's nails was available. Review of the electronic record and shower book revealed Resident #22 received showers on Wednesday and Saturday and was showered on 02/04/20. Observation on 02/03/20 at 4:25 P.M. revealed Resident #22's toenails were long and jagged. Resident #22 stated her toenails felt like they needed to be trimmed. During an interview on 02/05/20 at 10:26 A.M. Registered Nurse (RN) #223 reported toenails were routinely checked by nursing staff and when State Tested Nursing Assistants (STNAs) reported concerns during showers. RN #223 stated a list of residents with toenail concerns was emailed to the Director of Nurses (DON) and she alerted the Podiatrist of residents who needed to be added to their list at the next visit. RN #223 reported she did not think Resident #22 was on the list due to the progress note dated 12/26/19 indicated she did not have any concerns. On 02/05/20 at 10:33 A.M. RN #223 confirmed Resident #22's toenails were long, jagged and needed to be trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 02/05/20 at 10:35 A.M. revealed RN #223 had just notified her of the need to add Resident #22 to the podiatry list. The DON stated STNAs normally reported to the nurse when a resident's nails were long and needed trimmed or the nurse would note nails that required trimmed when completing the weekly skin evaluation. The DON indicated there had been no previous report of concerns regarding Resident #22's toe nails. Residents Affected - Few Interview with STNAs #216 and #357 on 02/05/20 at 2:43 P.M. revealed any concerns with toe nails would be reported to the nurse, unit manager or DON. STNA #216 said she had been caring for Resident #22 and had not observed any concerns with the resident's toenails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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, review of the facility's investigation, policy review and staff interview, the facility failed to ensure a resident received the proper level of supervision to prevent her from eloping from the facility. This affected one (Resident #43) of one resident reviewed for elopement. The facility identified four other residents (Resident #19, #29, #38, and #53) who had the use of wander management bands. Findings include: Review of Resident #43's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia without behavioral disturbances, major depressive disorder, muscle weakness, muscle wasting and atrophy, abnormalities of the gait and mobility, and difficulty walking. A review of Resident #43's active physician's orders included the use of a wander management band on at all times. The order included the need to check it's function every shift. The order originated on 07/26/19. Review of Resident #43's wandering risk assessment dated [DATE] revealed the resident was considered to be at low risk for wandering. Her risk factors included being disoriented and being forgetful or having a short attention span. She was identified as having early dementia and took antidepressants that increased her risk. She was not indicated to have had a history or being known for wandering. A review of Resident #43's nurses' progress notes revealed a note dated 11/27/19 at 10:15 P.M. that indicated the nurse had been alerted by another nurse while she was passing medications that the resident was brought back to the facility by the local police department as the resident was found out by the road. The wander management band was checked by the staff by taking the resident to the front door and it was found to be functioning properly. The resident was assessed and not found to have had any injuries. She was placed on every 15 minute checks and all exits were also checked and found to be working. A review of an incident report dated 11/27/19 at 10:15 P.M. confirmed the above incident as documented in the nurse's progress note. The incident report included the same information but also indicated the resident was laughing about the incident and indicated she went out for a walk. A review of the facility's investigation of Resident #43's elopement on 11/27/19 revealed the resident had the use of a wander management band since 07/26/19. The investigation report indicated, on 11/27/19, the resident was last seen at 9:50 P.M. on the [NAME] wing (300/400 hall) working a puzzle. A State Tested Nursing Assistant (STNA) stopped to assist her with placing two pieces of the puzzle the resident had in her hand. At 10:15 P.M., the facility received a call from the local police department that they were bringing a resident into the facility that was sitting in a wheelchair near the road. The resident reported she was just going for a walk and laughed about the incident. The resident was not noted to have any injuries as a result of the incident. Her wander management band was found to be functioning properly at the time of the incident. She was placed on every 15 minute checks with daily monitoring for evidence of exit seeking behaviors. Staff interviews were conducted as part of the facility's investigation. It was not able to be determined what door the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exited from but was believed by the facility to have been the front door. One STNA reported in her interview that she had heard a door alarm go off and it was cleared by another STNA, however the facility was not able to verify that. It was not clear who responded to the door alarm, which door alarm was activated or who the STNA was that cleared the alarm. The staff were re-educated on responding to door alarms. The witness statements obtained from the staff noted a statement from STNA #404. She reported she had last seen the resident around 9:45 P.M. The resident was observed working a puzzle when the STNA returned from break. STNA #404 reported she returned to the hall at 9:50 A.M., after assisting the resident with placing a couple of the puzzle pieces in place. A statement from Licensed Practical Nurse (LPN) #413 revealed she last saw the resident around 8:30 P.M. when she gave the resident her medications in the hall on the 200 unit. The resident headed towards the nurses' station after she took her medications. The nurse indicated in her statement that alarms had been going off when another resident's family came in sometime around 9:30 P.M. or 9:40 P.M. A statement from STNA #419 revealed she last saw the resident when she was coming in from break around 9:40 P.M. The resident was sitting on the 300 hall working on a puzzle. The STNA denied hearing a door alarm or the resident's wander management band go off. A review of Resident #43's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was usually able to make herself understood. She had adequate hearing and was usually able to understand others. Her cognition was severely impaired and she was known to have hallucinations and delusions. She was not indicated on the MDS as having had any wandering during the seven day assessment period. She required an extensive assist of one for transfers. She required supervision with the assist of one for locomotion on and off the unit. Ambulation in her room only occurred once and she required a one person physical assist. Ambulation in the hall did not occur. A wheelchair was indicated to be the only mobility device used. A review of Resident #43's active care plans revealed she had a care plan in place for the use of a wander management band due to her having a decreased safety awareness with a history of wandering behaviors. She was unaware of her safety needs due to her diagnosis of dementia. The wander management band was used to alert the staff of the resident's need for assistance and supervision when going outside. The wander management band was also to improve the resident's functional status by allowing her to maintain her independence with locomotion and mobility within the facility with increased safety. The interventions included to ensure the wander management band was on at all times and to check function every shift and as needed. The resident also had a care plan for having a history of wandering behavior and elopement. The goal was for the resident's safety to be maintained. The interventions included the staff being alert to door alarms and respond quickly and efficiently to determine the desire of the resident to go outside, be aware of any increase agitation, her verbalizing wanting to go home or to go for a walk, initiate appropriate activities to distract the resident, increase monitoring of the resident's location, distract the resident from wandering by offering pleasant diversions such as structured activities, food, conversation, television, or books. They were also to identify the resident's pattern of wandering, was it purposeful, aimless, or escapist? They were to intervene as appropriate and she was to have a wander management band on at all times. On 02/05/20 at 1:55 P.M., an interview with STNA #419 revealed she had been employed by the facility for a little over a year. She worked all shifts on a part time basis. She was familiar with Resident #43 and did consider her to be at risk for wandering and elopement. She confirmed she worked on 11/27/19 when the resident was found outside of the facility in the parking lot by the local police department. She was not sure how the resident got out but thought she got out the exit door at the end of the 100 hall. She reported the resident had a wander management band at the time but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the exit doors at the end of the halls were not equipped with the wander guard system. She stated the only doors that had the wander guard system installed were the front door and the back door. The doors at the end of each hall alarmed at the nurses' station any time they were opened but did not lock from the inside even if a resident had a wander management band on them. She denied that she was on the floor at the time the resident got out as she believed it occurred around 10:15 P.M. and she thought she was on her 10 minute break then. She claimed she saw the resident at the nurses' station when she went out on break and returned 10 minutes later. She was on the floor for another 10 minutes before it was brought to their attention that the resident was found outside in the parking lot. She suspected, based on those times, the resident was outside for approximately 20 minutes or so. She indicated the resident was in the facility's parking lot out by the sign with the facility's name on it (approximately 50-60 feet from the road) when the police drove by and found her. She was not sure if anyone checked the facility grounds when the door alarm would have sounded as she claimed she was on break at the time. She identified the nurse on duty for the resident's hall that night was LPN #413. She indicated the other STNA on duty that night was STNA #404. On 02/05/20 at 3:15 P.M., an interview with LPN #413 via phone revealed she was the nurse on duty on 11/27/19 when Resident #43 got out of the facility and was found by the local police department in the front parking lot near the road. She stated the incident occurred somewhere between 9:30 P.M. and 10:00 P.M. She indicated the last time she saw the resident was around 9:00 P.M. when she gave her her medications. The resident headed up the hall towards the nurses' station after she received her medications. She was notified by an agency nurse who was also working that night that she received a call from the local police department and was informed they found the resident outside. The agency nurse told her the resident exited the building and the local law enforcement brought her back in as they found her outside when they were passing by. She stated the only alarm they heard sounding was the front door alarm when another resident's family was bringing that resident back after being out with her family. The inner front door to the main entrance was locked as it automatically locked at 9:00 P.M. When the family member tried to gain access it would have sounded an alarm. The other resident's son then came in through the exit door that was at the end of the 100 hall since he could not get in through the front entrance. He then went out to the front door to let his mother in. She stated Resident #43 was still around the nurses' station at the time the son of the other resident came in through the 100 hall exit door. She suspected, after the family member assisted the other resident back to her room, Resident #43 went to the front entrance and followed him out when he exited the building. She stated the front entrance door would have automatically alarmed when the other resident's family member left. She stated any staff member could have went out to the front door to silence the alarm without realizing Resident #43 went out too. She confirmed when the staff member cleared the alarm they should have taken a look outside to make sure a resident did not leave without just assuming it was a family member. She denied the resident exited the 100 hall door as indicated by STNA #419. She stated she was passing medications on the 100 hall at the time and did not think the resident would have been able to pass her without seeing her. She also denied she heard the 100 hall exit door alarm sound if it had been opened. She acknowledged there were times she would have been in a resident's room administering medications and would not have had the 100 hall exit door in view. On 02/05/20 at 3:25 P.M., an interview with the Director of Nursing (DON) revealed the investigation she completed showed the resident likely exited the building at the front entrance but they could not be certain. She confirmed it was mentioned that another resident's family had entered the building at the end of the 100 hall and was indicated to have left through that same exit too. The 100 hall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exit door should have been locked from the outside but it was not able to be determined if it had been opened for that family member by the staff or not. She thought someone had said it was left open after the family member came in but that could not be determined either. They checked that exit at the end of the 100 hall the following morning and there were no signs of the resident taking her wheelchair out that way. She stated the front entrance would have required a staff member to enter a code so a family member could exit without sounding the alarm or a code would have to be entered after the door was opened and the alarm activated to silence the alarm. She acknowledged the staff should be checking the immediate area outside the building when an alarm sounded before silencing the alarm to ensure a resident did not leave the facility. She denied she was able to determine which staff member silenced the alarm and failed to look outside as none of them would own up to it. They inserviced all the staff on the facility's alarms and what steps to take when they were activated and silenced. She denied the resident was out for any significant length of time as she was still warm when brought back into the facility. A review of the inservice and training record the facility provided to the staff on 11/29/19 revealed all staff were educated on all staff being responsible for responding to alarms. They were not to assume someone else was responding. They were not to turn off an alarm without investigating the cause of the alarm. If they could not determine the cause of the door alarm, they were to notify the supervisor and ensure all residents were accounted for and safe. They were not to give out the door alarm codes. A review of the facility's policy on Wandering and Elopements revised March 2019 revealed the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the residents. The policy was not specific as to the response to any door alarms that were activated. It only included directives on what to do if an employee observed a resident leaving the premises, if a resident was identified as being missing, and what to do when a resident returned to the facility after being missing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure a resident with an unplanned weight change and a resident with changes in skin condition had comprehensive nutrition assessments. This affected two of four sampled residents reviewed for nutrition (Resident #15 and #76). Residents Affected - Few Findings include: 1. Review of Resident #76's medical record revealed he was admitted on [DATE] with diagnoses that included end stage renal disease, fracture of nasal bones, chronic embolism, hypertension, fracture of right clavicle, irritable bowel syndrome, anxiety disorder, dependence on renal dialysis, type two diabetes, and peripheral vascular disease. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76's speech was clear, he usually understands, usually was understood, and his cognition was moderately impaired. Resident #76 had no behavior and did not reject care. Resident #76 was independent with no set up help for bed mobility, supervision of two staff to transfer, and independent with set up help to eat. Resident #76 had no significant weight changes. Review of Resident #76's weights revealed on 12/23/19 he weighed 150.9 pounds on 01/30/20 Resident #76 weighed 141.7 pounds. This represented a 9.2-pound weight loss and a six percent weight loss in a month. There was no nutritional assessment of Resident #76's significant weight loss. There was no assessment that estimated Resident #76's caloric, fluid, and protein needs. Interview with the director of nursing (DON) on 02/06/20 at 11:27 A.M. confirmed the lack of a nutritional assessment for Resident #76. 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included cerebral infarction, repeated falls, dysphagia, heart failure, anxiety disorder, major depressive disorder, dementia without behavioral disturbance, gastro-esophageal reflux, and cognitive communication deficit. Review of Resident #15's admission MDS assessment dated [DATE] revealed her speech was clear, she usually understands, was usually understood, and her cognition was severely impaired. Resident #15 had no behaviors and did not resist care. Resident #15 required extensive assistance of two staff for bed mobility, to transfer, and extensive assistance of one staff to eat. Resident # 15 had no swallowing problems, was 61 inches, 99 pounds, and had no significant weight loss. Resident # 15 had three stage one pressure injuries (intact skin that was red and non-blanchable) on admission. Review of Resident #15's nutrition documentation revealed no comprehensive nutrition assessment. There was no assessment that estimated Resident #15's caloric, fluid, and protein needs. There was no assessment regarding Resident #15's estimated needs due to pressure injuries. Further medical record review revealed Resident #15 developed an unavoidable stage two pressure injury (partial loss of skin exposing the dermis) on 12/17/19 and there was no assessment of her nutritional needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Interview of the DON on 02/06/20 at 11:27 A.M. confirmed the lack of a nutritional assessment for Resident #15. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure Resident #2 did not receive insulin without adequate indications for its use. This affected one of five residents reviewed for unnecessary medications (Resident #2). Residents Affected - Few Findings include: Review of Resident #2's medical record revealed she was admitted on [DATE] with diagnoses that included; obesity, dysphagia, major depressive disorder, hypertension, type two diabetes, palliative care, heart failure, dementia without behavioral disturbance, anxiety disorder, and altered mental status. Review of Resident #2's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #2's speech was clear, she usually understands, usually understood, her cognition was moderately impaired. Resident #2 had no behaviors and did not reject care. Resident # 2 required extensive assistance of two staff for bed mobility and to transfer. In the previous seven days Resident # 2 received insulin injections seven days. Review of Resident #2's January 2020 and February 2020 physician orders revealed insulin (Novolin) 46 units in the morning (8:00 A.M.). If Resident #2 did not eat more than 50 percent of meal the insulin was to be held. Review of Resident #2's January 2020 meal intake and medication administration record (MAR) revealed on 01/09/20, 01/27/20, 01/28/20, and 01/31/20 she ate 26 percent to 50 percent of her morning meal and she received the Novolin insulin. On 01/26/20, and 01/29/20 she refused her morning meal and received the Novolin insulin. Review of Resident #2's February 2020 meal intake and MAR revealed on 02/01/20, 02/02/20, 02/03/20, 02/04/20, and 02/05/20 she ate 26 percent to 50 percent of her morning meal and she received the Novolin insulin. Interview of the Director of Nursing (DON) on 02/06/20 at 8:40 A.M. confirmed Resident #2's morning insulin order was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 10 of 10