Health inspection·July 27, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to adequately inform/specify in writing, skilled services that would be discontinued. This affected three residents (#6, #203, and #204) of three residents reviewed for beneficiary notices. The census was 41. Residents Affected - Many Findings Include: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, partial intestinal obstruction, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #6's Notice of Medicare Non-Coverage (NOMNC) form, dated 02/10/23, revealed services would discontinue on 02/14/23. The NOMNC form did not specify which services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 02/14/23. 2. Medical record review revealed Resident #203 was admitted to the facility on [DATE] with diagnoses including acute respiratory disease, multiple sclerosis, muscle wasting, and contractures. Review of Resident #203's Notice of Medicare Non-Coverage (NOMNC) form, dated 02/10/23, revealed services would discontinue on 02/12/23. The NOMNC form did not specify which services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 02/12/23. 3. Medical record review revealed Resident #204 was admitted to the facility on [DATE] with diagnoses including sepsis, phlebitis of the lower, left extremity, muscle wasting and atrophy, and atrial fibrillation. Review of Resident #204's Notice of Medicare Non-Coverage (NOMNC) form, dated 02/10/23, revealed services would discontinue on 02/15/23. The NOMNC form did not specify which services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 02/15/23. During interview on 07/26/23 at 3:46 P.M., Business Office Manager #17 confirmed that the NOMNC forms for Resident #6, Resident #203, and Resident #204 did not specify which type of skilled services would be ending and only indicated the ending date of services. Page 1 of 19 365880 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review, policy review, and interview, the facility failed to implement interventions to prevent further potential abuse after allegations of staff being rough and making inappropriate comments were reported to staff. This affected one resident (Resident #7) of 11 residents interviewed regarding abuse. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times. Resident #7's daughter requested the STNA not care for Resident #7. RN #18 assigned another STNA to care for Resident #7 for the remainder of the shift. The Director of Nursing (DON) was made aware. There was no documentation indicating any further investigation or action was taken to investigate the voiced concerns or to protect Resident #7. Review of a nursing note dated 01/02/23 at 1:31 A.M., a nurse documented during the bedtime medication pass, Resident #7 stated she did not want day shift staff to get her out of bed in the future because they were mean and rough with her. When asked to explain, Resident #7 stated they were just mean and nasty to her. There was no evidence the allegation was reported or investigated to provide protection to the resident or determine if additional education needed provided to staff. During an interview on 07/24/23 at 9:49 A.M., Resident #7 stated State Tested Nursing Assistant (STNA) #1 was very rough and rude. Resident #7 stated she had reported her concerns to staff (not specified) twice but no action was taken. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no evidence of an investigation into the allegations made by Resident #7's daughter. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no evidence of the nurse reporting the allegations so an investigation was not completed. Review of the facility's Abuse, Neglect and Misappropriation of Property policy, last revised 10/17/22, revealed it was the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property and to assure that all alleged violations of federal or state laws which involved abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property were investigated and reported immediately to the facility Administrator, the State Survey Agency, and other appropriate State and local 365880 Page 2 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few agencies in accordance with Federal and State law. The organization's policy was that the Facility Administrator, or his designee, would conduct a reasonable investigation of each such alleged violation, unless he or she had a conflict of interest or was implicated in the alleged violation. The Facility Administrator was responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation, withholding of goods or services, or any other statements a reasonable person would consider to be humiliating, demeaning or threatening to a resident. Physical abuse included, but was not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that did not have an appropriate therapeutic purpose, and that was not reasonably related to the appropriate provision of ordered care and services. Verbal abuse was defined as the use of any oral, written or gestured language that included any threat, or any frightening disparaging or derogatory language, to residents or their families or within their hearing distance, regardless of age, ability to comprehend or disability. An allegation of abuse meant a report, complaint, grievance, statement, incident or other facts that a reasonable person would understand to mean that abuse was occurring, had occurred or plausibly might have occurred. All alleged violations involving abuse, neglect, exploitation or mistreatment were required to be reported immediately, but no later than two hours after the allegation was made. The Administrator was responsible for investigating all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse. The Administrator might delegate some of all of the investigation as appropriate but the Administrator retained the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident. Complete and thorough documentation of the investigation was to be provided to the extent possible. Every Stakeholder must immediately report any allegation of abuse or suspicion of crime. If the suspected perpetrator was a Stakeholder, they would be immediately removed from the resident care areas and suspended while the matter was investigated. If a suspected perpetrator was anyone other than a Stakeholder, the Administrator or designee would immediately take all appropriate measures to secure the safety and well-being of the affected resident. Any abuse allegation must be reported to State within two hours from the time the allegation was received. Any allegation of neglect, exploitation, mistreatment or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. 365880 Page 3 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, policy review, and interview, the facility failed to report allegations of rough handling by staff, inappropriate intimidating remarks made to residents, and allegations of misappropriation of property. This affected one resident (Resident #7) of 11 residents interviewed regarding abuse and missing items. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times. Resident #7's daughter requested the STNA not care for Resident #7. RN #18 assigned another STNA to care for Resident #7 for the remainder of the shift. The Director of Nursing (DON) was made aware. There was no documentation indicating the allegations were reported to the State agency. Review of a nursing note dated 01/02/23 at 1:31 A.M., a nurse documented during the bedtime medication pass, Resident #7 stated she did not want day shift staff to get her out of bed in the future because they were mean and rough with her. When asked to explain, Resident #7 stated they were just mean and nasty to her. There was no evidence the allegation was reported to the Administrator or the State agency. During an interview on 07/24/23 at 9:49 A.M., Resident #7 stated State Tested Nursing Assistant (STNA) #1 was very rough and rude. Resident #7 stated she had reported her concerns to staff (not specified) twice but no action was taken. On 07/24/23 at 9:52 A.M., Resident #7 reported her soda came up missing and she believed night shift was taking it without her permission. Resident #7 stated she had reported her suspicions but the sodas kept coming up missing. On 07/25/23 at 10:59 A.M., Social Service Director #19 stated when residents complained of missing items he filed a grievance report. At 11:21 A.M., Social Service Director #19 reported Resident #7 had reported a missing ring on 07/24/23 which had been located. Social Service Director #19 stated he was unaware of Resident #7 reporting other items missing or of allegations of misappropriation of her soda. Social Service Director #19 stated he would report the allegations to the Administrator. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no evidence of the allegations being reported to the State agency. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no 365880 Page 4 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0609 evidence of the nurse reporting the allegations so an investigation was not completed. Level of Harm - Minimal harm or potential for actual harm Review of the information the facility submitted to the Ohio Department of Health revealed no report of allegations of misappropriation of Resident #7's personal property. Residents Affected - Few On 07/26/23 at 1:07 P.M., Social Service Director #19 stated he did discuss the missing soda with Resident #7 and she was very adamant someone was taking her sodas and the information was reported to the Administrator. An internal complaint/grievance report was completed. Social Service Director #19 had no knowledge as to whether the Administrator had submitted the allegation of theft (misappropriation) to the Ohio Department of Health as required. Review of a complaint/grievance report initiated by Social Service Director #19 indicated Resident #7 reported she only drank one can of soda a day and two cases had been used so there was a lot missing. The mom of a mother and daughter staff that worked at the facility was who she suspected of taking a few cans. This happened at night time. The report indicated Resident #7 stated she believed it happened a couple weeks ago. Resident #7 stated she was not sharing her drinks and she kept ending up with less and less. Other than the report being initiated there was no evidence of action taken to prevent further misappropriation. Review of the system used for facilities to report misappropriation to the Ohio Department of Health revealed the allegation of misappropriation had not been reported. On 07/26/23 at 1:16 P.M., the Administrator verified he was aware of allegations that somebody was taking Resident #7's sodas without her permission. The Administrator verified it had not been reported to the State agency because he did not realize it was a reportable incident. The Administrator was also interviewed about the allegations made against staff on 01/01/23 and 01/02/23 as recorded in nursing notes with no evidence of reporting. The Administrator was unable to provide additional information. On 07/26/23 at 4:30 P.M., Corporate Registered Nurse (RN) #63 acknowledged nurses were documenting allegations made by Resident #7 but there was no evidence the allegations were reported. Review of the facility's Abuse, Neglect and Misappropriation of Property policy, last revised 10/17/22, revealed it was the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property and to assure that all alleged violations of federal or state laws which involved abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property were investigated and reported immediately to the facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The Facility Administrator was responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation, withholding of goods or services, or any other statements a reasonable person would consider to be humiliating, demeaning or threatening to a resident. Physical abuse included, but was not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that did not have an appropriate therapeutic purpose, and that was not reasonably related to the appropriate provision of ordered care and services. Verbal abuse was defined as the use of any oral, written or gestured language that included any threat, or any 365880 Page 5 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few frightening disparaging or derogatory language, to residents or their families or within their hearing distance, regardless of age, ability to comprehend or disability. An allegation of abuse meant a report, complaint, grievance, statement, incident or other facts that a reasonable person would understand to mean that abuse was occurring, had occurred or plausibly might have occurred. All alleged violations involving abuse, neglect, exploitation or mistreatment were required to be reported immediately, but no later than two hours after the allegation was made. Every Stakeholder must immediately report any allegation of abuse or suspicion of crime. Any abuse allegation must be reported to State within two hours from the time the allegation was received. Any allegation of neglect, exploitation, mistreatment or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. 365880 Page 6 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review, and interview, the facility failed to investigate allegations of staff being rough and making inappropriate comments toward residents. This affected one resident (#7) of 11 residents interviewed regarding abuse. The census was 41. Residents Affected - Few Findings include: Review of Resident #7's medical record revealed diagnoses including major depressive disorder, multiple sclerosis, contractures of both hands, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder, spondylolisthesis of the lumbar region, and intervertebral disc disorders of the thoracic region. Review of a nursing note dated 01/01/23 at 5:12 P.M. revealed Resident #7's daughter spoke to Registered Nurse (RN) #18. Resident #7 had informed her daughter a STNA told Resident #7 she needed to be repositioned in bed for safety. Resident #7 reported when she refused the STNA said well fall on the floor then. RN #18 documented she explained all care was provided by two staff at all times. Resident #7's daughter requested the STNA not care for Resident #7. RN #18 assigned another STNA to care for Resident #7 for the remainder of the shift. The Director of Nursing (DON) was made aware. There was no documentation indicating an investigation was completed regarding the allegation. Review of a nursing note dated 01/02/23 at 1:31 A.M., a nurse documented during the bedtime medication pass, Resident #7 stated she did not want day shift staff to get her out of bed in the future because they were mean and rough with her. When asked to explain, Resident #7 stated they were just mean and nasty to her. There was no evidence the allegation was investigated. During an interview on 07/24/23 at 9:49 A.M., Resident #7 stated State Tested Nursing Assistant (STNA) #1 was very rough and rude. Resident #7 stated she had reported her concerns to staff (not specified) twice but no action was taken. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no evidence of an investigation into the allegations made by Resident #7's daughter. On 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 stated she could locate no evidence of the nurse reporting the allegations so an investigation was not completed. On 07/26/23 at 1:16 P.M., the Administrator was interviewed about the allegations made against staff on 01/01/23 and 01/02/23 as recorded in nursing notes with no evidence of a thorough investigation being completed. The Administrator was unable to provide additional information. On 07/26/23 at 4:30 P.M., Corporate Registered Nurse (RN) #63 acknowledged nurses were documenting allegations made by Resident #7 but there was no evidence the allegations were investigated. Review of the facility's Abuse, Neglect and Misappropriation of Property policy, last revised 10/17/22, revealed it was the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property and to assure that all 365880 Page 7 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alleged violations of federal or state laws which involved abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property were investigated and reported immediately to the facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization's policy was that the Facility Administrator, or his designee, would conduct a reasonable investigation of each such alleged violation, unless he or she had a conflict of interest or was implicated in the alleged violation. Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation, withholding of goods or services, or any other statements a reasonable person would consider to be humiliating, demeaning or threatening to a resident. Physical abuse included, but was not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that did not have an appropriate therapeutic purpose, and that was not reasonably related to the appropriate provision of ordered care and services. Verbal abuse was defined as the use of any oral, written or gestured language that included any threat, or any frightening disparaging or derogatory language, to residents or their families or within their hearing distance, regardless of age, ability to comprehend or disability. An allegation of abuse meant a report, complaint, grievance, statement, incident or other facts that a reasonable person would understand to mean that abuse was occurring, had occurred or plausibly might have occurred. The Administrator was responsible for investigating all allegations, reports, grievances and incidents that potentially could constitute allegations of abuse. The Administrator might delegate some or all of the investigation as appropriate but the Administrator retained the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident. Complete and thorough documentation of the investigation was to be provided to the extent possible. 365880 Page 8 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #7's medical record revealed diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder. A nursing note dated 05/30/23 at 5:50 P.M. indicated Resident #7's urine was dark, blood-tinged and cloudy. Resident #7's face was flushed and Resident #7 complained of not feeling well. An order was received to start Levaquin (antibiotic) 500 milligrams (mg) orally every day for seven days for a urinary tract infection (UTI). A nursing note dated 05/31/23 at 11:59 P.M. indicated a few hours after receiving medications ordered at bedtime Resident #7 requested she be sent to the hospital because she did not feel well. An order was received to send Resident #7 to the hospital for evaluation and treatment. A nursing note dated 06/01/23 at 3:20 A.M. indicated the hospital notified the facility Resident #7 was admitted to the hospital with a UTI and sepsis (sepsis is the body ' s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body.). There was no documentation of a written transfer notice being provided to Resident #7 or her legal representative. During an interview on 07/24/23 at 10:08 A.M., Resident #7 verified she had been hospitalized for a UTI. Resident #7 stated she did not recall receiving a transfer notice. During an interview on 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 reported no residents had received a transfer/discharge notice since December 2022. Review of the facility's Transfer/Discharge Notice policy, last revised 11/01/22, indicated residents who were sent emergently to the hospital were considered facility-initiated transfers because the resident's return was generally expected. In the event of a facility initiated transfer/discharge the facility was to notify the resident/resident representative in writing of the reason the facility had initiated the transfer to another legally responsible institutional or non-institutional setting, the effective date of the transfer or discharge, the location to which the resident was transferred or discharged , the resident's right to appeal the decision, and how to contact the State Long Term Care Ombudsman. 2. Review of Resident #49's medical record revealed an admission date of 05/16/23 with diagnoses that included bowel perforation, acute respiratory failure, tracheostomy and alcoholic cirrhosis of the liver. Further review of the medical record, including nursing notes and physician orders, revealed Resident #49 was transferred to the hospital and admitted on [DATE] due to abdominal abscesses. No evidence of transfer notification for the hospital transfer was found within the medical record. On 07/25/23 at 2:45 P.M. interview with Assistant Director of Nursing #35 verified the facility did not provide the resident or the resident's family written notice of transfer. 365880 Page 9 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0623 Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure residents and/or resident representatives were provided with transfer notices following hospital transfers. This affected three residents (#46, #49, and #7) of three residents reviewed for hospitalization and discharge and had the potential to affect all 41 residents residing in the facility. The census was 41. Residents Affected - Many Findings include: 1. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including cellulitis of corpus cavernosum and penis, retention of urine, acute kidney failure, and muscle wasting and atrophy. The resident was hospitalized from [DATE] to 06/23/23 for diagnoses of acute kidney injury. Further review of the resident's medical record revealed no evidence that a transfer/discharge form was completed and given or sent to the resident/resident representative. During interview on 07/26/23 at 2:47 P.M., Social Services Director (SSD) #19 confirmed there was no evidence that a transfer form was completed and was given to the resident/resident representative in writing when the resident was transferred to the hospital on [DATE]. 365880 Page 10 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #7's medical record revealed diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder. A nursing note dated 05/30/23 at 5:50 P.M. indicated Resident #7's urine was dark, blood-tinged and cloudy. Resident #7's face was flushed and Resident #7 complained of not feeling well. An order was received to start Levaquin (antibiotic) 500 milligrams (mg) orally every day for seven days for a urinary tract infection (UTI). A nursing note dated 05/31/23 at 11:59 P.M. indicated a few hours after receiving medications ordered at bedtime Resident #7 requested she be sent to the hospital because she did not feel well. An order was received to send Resident #7 to the hospital for evaluation and treatment. A nursing note dated 06/01/23 at 3:20 A.M. indicated the hospital notified the facility Resident #7 was admitted to the hospital with a UTI and sepsis (sepsis is the body ' s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body.). There was no documentation of a written bed hold notice being provided to Resident #7 or her legal representative. During an interview on 07/24/23 at 10:08 A.M., Resident #7 verified she had been hospitalized for a UTI. Resident #7 stated she did not recall receiving a bed hold notice. During an interview on 07/25/23 at 2:45 P.M., Assistant Director of Nursing (ADON) #35 reported no residents had received a bed hold notice since December 2022. Review of the Facility Bedhold policy, last revised 11/12/18, revealed the facility was to provide written notices of the bed hold and re-admission policies before a resident's transfer to the hospital and include it in the resident's transfer packet. The facility's Social Worker or Licensed Nurse were to document verbal and written notification in the medical record. In an emergency, time of admission or time of transfer might mean up to 24 hours. The facility's written bed hold information would include the duration of the facility's bed hold policy. 2. Review of Resident #49's medical record revealed an admission date of 05/16/23 with diagnoses that included bowel perforation, acute respiratory failure, tracheostomy and alcoholic cirrhosis of the liver. Further review of the medical record including nursing notes and physician orders revealed Resident #49 was transferred to the hospital and admitted on [DATE] due to abdominal abscesses. No evidence of resident or resident family notification of bed hold days remaining once hospitalized was found within the medical record. On 07/25/23 at 2:45 P.M. interview with Assistant Director of Nursing (ADON) #35 verified the facility did not provide the resident or the resident's family notification of remaining bed hold days once admitted to the hospital. 365880 Page 11 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0625 Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure residents and/or resident representatives were provided with bed hold notices following hospital transfers. This affected three residents (#46, #49, and #7) of three residents reviewed for hospitalization and discharge and had the potential to affect all 41 residents residing in the facility. Residents Affected - Many Findings include: 1. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including cellulitis of corpus cavernosum and penis, retention of urine, acute kidney failure, and muscle wasting and atrophy. The resident was hospitalized from [DATE] to 06/23/23 for diagnoses of acute kidney injury. Further review of the resident's medical record revealed no evidence that a bed hold notice was completed and given or sent to the resident/resident representative. During interview on 07/26/23 at 2:47 P.M., Social Services Director (SSD) #19 confirmed there was no evidence that a bed hold notice was completed and given to the resident/resident representative in writing when the resident was transferred to the hospital on [DATE]. 365880 Page 12 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

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** 2. Review of Resident #28's medical record revealed an admission date of 05/07/19 with diagnoses that included Parkinson's disease, adult failure to thrive, diabetes mellitus type II and chronic obstructive pulmonary disease. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 04/16/23 indicated Resident #28 had a significant weight loss. Further review of the medical record including Resident #28's weights revealed no evidence of a significant weight loss over a one month period or six month period. Weight records revealed on 04/07/23 Resident #28 weighed 168.0 pounds. The month prior on 03/07/23 Resident #28 weighed 174.8 pounds. A 3.89 % weight loss was noted between April 2023 weight and March 2023 weight. On 10/03/22 Resident #28 weighed 180.2 pounds. A weight gain was noted between October 2022 and April 2023 . On 07/25/23 at 9:45 A.M. interview with Registered Dietician (RD) #62 verified no significant weight loss over the month between March and April 2023 or the prior 6 months of October 2022 and April 2023 as reported in the quarterly MDS assessment with a reference date of 04/16/23. On 07/25/23 at 9:55 A.M. interview with Licensed Practical Nurse (LPN) #22 verifies Resident #28's Quarterly MDS with a reference date of 04/16/23 was inaccurate and indicated Resident #28 had a significant weight loss and there is no evidence of a significant weight loss. Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected opioid medication use and significant weight loss. This affected two residents (#28 and #29) of five residents reviewed for unnecessary medications. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included unspecified open wound of vagina and vulva, colostomy, chronic obstructive pulmonary disease, muscle wasting and atrophy, chronic pain. Review of the admission Minimum Data Set (MDS) assessment, dated 06/30/23, inaccurately revealed that Resident #29 received opioid medication for zero days during the look-back period. Review of a physician order, dated 06/28/23, revealed an order for Dilaudid (opioid pain medication) eight milligrams (mg), one tablet every four hours, as needed for pain. Review of a physician order, dated 06/24/34, revealed an order for Methadone (opioid pain medication) 10 mg, one tablet every eight hours. Review of the June 2023 Medication Administration Record (MAR) revealed Resident #29 received Dilaudid 8 mg, one tablet, on 06/30/23 and received Methadone 10 mg, one tablet, from 06/24/23 through 06/30/23. Interview on 06/25/23 at 4:00 P.M. with MDS/Licensed Practical Nurse (LPN) #22 verified the MDS assessment, dated 06/30/23, contained an inaccurate assessment of Resident #29's opioid use. 365880 Page 13 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #35's medical record revealed an admission date of 05/13/22 with admission diagnoses that included major depression, anxiety disorder and bipolar disorder. On 05/15/23 a new diagnosis of schizophrenia was added by Resident #28's physician. Review of Preadmission Screening and Resident Review (PASARR) revealed no evidence of PASARR resubmitted after a new serious mental health diagnosis of schizophrenia was added to Resident #35's diagnosis list. 07/25/22 at 11:50 A.M. interview with Social Services Designee (SSD) #19, verified the facility did not resubmit a new PASARR after new diagnosis of schizophrenia was added on 05/15/23 for Resident #35. Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #35 and #40) of three residents reviewed for PASARR documents. The census was 41. Findings Include: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including sepsis, pressure ulcers, depression, bipolar disorder, and paraplegia. Review of Resident #40's PASARR document, dated 05/30/23, revealed under Section E, there were no diagnosis listed. Review of the resident's diagnoses list revealed bipolar disorder and depression were added on 06/09/23. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/15/23, revealed the resident was cognitively intact, and had diagnoses of depression and bipolar disorder. During interview on 07/25/23 at 11:25 A.M., Social Services Director (SSD) #19 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of depression and bipolar disorder. During interview on 07/25/23 at 11:50 A.M., the Assistant Director of Nursing (ADON) confirmed the SSD is responsible for checking PASARR for accuracy and referring the resident for a Level II PASARR (evaluates and determines whether nursing facility services and specialized services are needed) if indicated. The ADON confirmed Resident #40 had not been evaluated by psychiatry since his admission on [DATE], but had an upcoming psychiatry evaluation scheduled for 07/27/23. 365880 Page 14 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure Resident #7 and/or her representative was provided an opportunity to participate in the development and revisions of the plan of care. This affected one resident (Resident #7) of 11 residents interviewed regarding participation in planning care. The census was 41. Findings include: Review of Resident #7's medical record revealed diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, major depressive disorder, generalized anxiety disorder, lupus anticoagulant syndrome, asthma, emphysema, panic disorder neuromuscular dysfunction of the bladder, and insomnia. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #7 was able to make herself understood and was able to understand others. Resident #7 was assessed as cognitively intact. There was no documentation indicating Resident #7 nor her family were invited to participate in the care planning process or review of the care plan for possible revisions that might be needed. During an interview on 07/24/23 at 9:57 A.M., Resident #7 was asked about her participation in the development of and revision of her plan of care. Resident #7 stated she was unable to recall when was last offered a care conference. Resident #7 stated she had reported some concerns but had not observed any changes. Resident #7 did not recall she or her family being informed of or invited to care conferences. On 07/25/23 at 2:22 P.M., Social Services Director #19 stated he arranged care conferences when there was a significant change in a resident's condition, if a resident was pending discharge, or upon request. On 07/25/23 at 2:22 P.M., Social Services Director #19 verified he could find no documentation that indicated Resident #7 had been offered or had a care conference. Social Services Director #19 stated he received input from residents as he was completing the portions of the MDS he was assigned to complete. Otherwise, the resident was involved by providing day to day input. During an interview on 07/27/23 at 8:07 A.M., Corporate Registered Nurse (RN) #64 stated when residents were admitted the 48 hour care plan was completed and discussed with residents. A comprehensive care plan was completed with comprehensive assessments. The care plan was reviewed quarterly and updated daily with changes. Letters were sent to responsible parties to invite them to care conferences to provide input into residents care. Care plan meeting were conducted at bedside of residents a minimum of quarterly. On 07/27/23 at 10:33 A.M., Corporate RN #64 verified she was unable to locate any documentation regarding a care conference for Resident #7. Review of the facility's policy, Comprehensive Care Plans, last reviewed 04/14/21, revealed the nurse/Interdisciplinary Team (IDT) developed and maintained a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. The comprehensive care plan would be developed with participation from the resident, resident's family or resident representative as indicated. Each resident had the right to participate in choosing treatment 365880 Page 15 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few options and would be given the opportunity to participate in the development, review and revision of their care plan. The comprehensive care plan was prepared by an IDT including at least the attending physician or nurse practitioner/physician assistant, registered nurse who shared responsibility for the resident, member of the food and nutrition services team, and the resident and the resident representative would participate to the extent practicable. Care plans were ongoing and revised as information about the resident and the resident's condition change. When and if a resident refused to participate in the development of his/her care plan and medical and nursing treatments, appropriate documentation would be entered into the resident's medical record. 365880 Page 16 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to maintain Resident #7's respiratory equipment in a clean manner and ensure the equipment was inspected and air filter exchanged annually as appropriate. This affected one (Resident #7) of one residents reviewed for environmental concerns. The facility identified six residents (Residents #5, #7, #13, #22, #23 and #25) currently utilizing oxygen concentrators. The census was 41. Residents Affected - Few Findings include: Review of Resident #7's medical record revealed an admission date of 12/14/22 with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus type II and lupus. Further review of Resident #7's medical record revealed a quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 06/16/23 which indicated the resident had an intact cognition level. Physician's orders indicated Resident #7 was to utilize supplemental oxygen at two liters per minute (lpm) by nasal cannula. Interview with Resident #7 on 07/24/23 at 9:58 A.M. revealed that her oxygen machine needed cleaned. On 07/26/23 at 10:10 A.M. observation of Resident #7's oxygen concentrator with the facility Maintenance Director (MD) #53 revealed an inspection sticker with inspection date of 02/08/22 and next inspection due date of 02/08/23. The air filter revealed a moderate amount of dirt within the filter. Interview with MD #53 on 07/26/23 at 10:15 A.M. verified the oxygen concentrator had not been inspected since 02/08/22 and should have been inspected on 02/08/23 with the air filter changed at that time. 365880 Page 17 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and policy review the facility failed to ensure antibiotics were assessed for appropriate indication for use prior to initiating antibiotic therapy. This affected one resident (Resident #4) of five residents reviewed for medication use. The facility census was 41. Residents Affected - Few Findings include: Review of Resident #4's medical records revealed an admission date of 04/21/23 with diagnoses that included dementia, atrial fibrillation, hypertension and chronic obstructive pulmonary disease. Further review of the medical record including nursing notes revealed on 06/14/23 at 2:22 P.M. Resident #4 advised nursing staff he was having trouble breathing with coughing and white sputum. The nurse notified the physician at this time who orders Pro-BNP (lab test to determine congestive heart failure (CHF)) and a chest x-ray. Results of the chest x-ray revealed patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend follow-up examination to confirm resolution of findings. On 06/15/23 at 7:06 A.M. the Certified Nurse Practitioner (CNP) was notified of the chest x-ray results. At this time the CNP ordered Levaquin (oral antibiotic) 500 milligram (mg) every day for 10 days for treatment of pneumonia. On 06/15/23 results of the blood revealed a Pro-BNP level of 1,794 picogram per milliliter (pg/ml) normal value is 0 to 450 pg/ml. On 06/15/23 at 8:32 A.M. the CNP was updated on the elevated Pro-BNP level and staff reviewed the resident's symptoms with the CNP at which time the CNP indicated to continue with the Levaquin use. Further review of the medical record revealed on 06/16/23 the interdisciplinary team met to review Resident #28's status including a four-pound weight gain in one week, shortness of breath and elevated Pro-BNP level which could indicate possible congestive heart failure rather than pneumonia. Further review of the medical record found no evidence of any antibiotic assessment completed prior to initiating the use of an antibiotic. Interview with Assistant Director of Nursing (ADON) #35 verified no assessment was completed to ensure appropriate use for the antibiotic. ADON #35 added herself and the Director of Nursing felt the antibiotic was not appropriate due to Resident #28's weight gain, cough and poor lungs sounds, possibly being CHF issues. Review of the facility policy Antibiotic Stewardship with a revision date of 11/07/18 indicated treatment recommendations will be consistent with national guidelines. For indication of the use of antibiotics such as urinary tract infections, pneumonia, skin and soft tissue infections; the recommendations may be optimized with treatment consistent with local susceptibilities. The Licensed Health Profession (LHP) and licensed nurses will use the McGeer's Criteria for infections. 365880 Page 18 of 19 365880 07/27/2023 Signature Healthcare of Coshocton 100 South Whitewoman Street Coshocton, OH 43812

F 0881 Level of Harm - Minimal harm or potential for actual harm Our facility will utilize standards of practice for the assessment of the resident suspected of having an infection using evidence-based guidance. The facility and LHP will utilize diagnostic tests combined with best practices to differentiated asymptomatic bacteria and symptomatic bacteria for reduction in inappropriate antibiotic use. Our facility approves the use of McGeer's Criteria for infections. Residents Affected - Few 365880 Page 19 of 19