Health inspection·February 6, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the Beneficiary Notice worksheet, review of the Notice of Medicare Non-Coverage (NOMNC) 10123 instructions, and record reviews, the facility failed to provide the Quality Improvement Organization (QIO) name and contact information. This affected four (Resident #1, Resident #11, Resident #33, Resident #34) of five residents reviewed for beneficiary notification. Residents Affected - Few Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with a diagnoses including atrial fibrillation, dysphagia, muscle weakness, and cognitive communication deficit. Review of entrance conference worksheet for Beneficiary Notice (resident who has been discharged from Medicare covered Part A stay with benefits days remaining in the past six months) undated revealed Resident #34 was discharged from skilled services on 12/26/24 and had remained in the facility. Review of Notice of Medicare Non-Coverage (NOMNC) 10123 dated 12/24/24 revealed the QIO name and contact information was not provided on the form. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypokalemia, anxiety, multiple sclerosis, and pulmonary embolism. Review of the entrance conference worksheet for Beneficiary Notice undated revealed Resident #11 was discharged from skilled services on 01/26/25 and discharged to home or lesser care. Review of Notice of Medicare Non-Coverage (NOMNC) 10123 dated 1/24/25 revealed the QIO name and contact information was not provided on the form. 3. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including anemia, vascular dementia, adult failure to thrive, and myocardial infarction. Review of the the entrance conference worksheet for Beneficiary Notice undated revealed Resident #33 was discharged from skilled services on 09/13/24 and remained in the facility. Review of the NOMNC 10123 dated 9/11/24 revealed the QIO name and contact information was not provided on the form. 4. Record review revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses Page 1 of 16 365922 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0582 including arthritis, hypertension, cognitive communication deficit, and cerebral infarction. Level of Harm - Minimal harm or potential for actual harm Review of the the entrance conference worksheet for Beneficiary Notice undated revealed Resident #1 was discharged from skilled services on 09/29/24 and remained in the facility. Residents Affected - Few Review of the NOMNC 10123 dated 9/26/24 revealed the QIO name and contact information was not provided on the form. Review of the NOMNC 10123 instruction form dated 12/31/11 revealed the facility was to insert the Quality Improvement Organization (QIO) name and phone number on the NOMNC 10123. QIO was the independent reviewer authorized by Medicare to review the decision to end the services if the resident chose to appeal the decision Interview on 02/06/25 at 09:14 AM with the Administrator confirmed that the QIO name and contact information listed on the notice for the appeal was not provided for Resident #34 and Resident #11, Resident #1 and Resident #33. 365922 Page 2 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident personal items were safe guarded from potential theft. This affected one resident (Resident #15) of one residents reviewed for personal property. Findings included: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type II diabetes, hypertension, dysphagia, major depressive disorder, end stage renal disease and dialysis dependent. Review of Resident #15's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview of mental status score (BIMS) of 15 (out of 15), meaning cognition intact. Interview on 02/03/25 at 9:01 A.M. with Resident #15 revealed his personal snacks, located in his drawer, have come up missing. The resident believed Resident #6, who shared a [NAME] and [NAME] bathroom, comes in through the bathroom door and takes his snacks. The resident had reported the missing snacks several times to staff, however it continued to happen. Interview on 02/04/25 at 11:28 A.M. with Certified Nursing Aide (CNA) #102 stated about one month ago she saw Resident #6 go into Resident #15's room and take a snack while he was out at dialysis. The CNA stated she had reported it to a nurse but was unable to recall who the nurse was at this time. Interview on 02/04/25 at 11:38 A.M. with Registered Nurse (RN) #105 confirmed Resident #15 did have some complaints of missing snacks. The RN shared that when Resident #15 leaves the facility for dialysis, the staff close the door to his room. Interview on 02/04/25 at 3:25 P.M. with Social Service (SS) #101 revealed she was the person responsible to report resident concerns. SS #101 confirmed no one had reported any issues to her regarding Resident #15's missing snacks. Interview on 3:35 P.M. on 02/04/25 with the Director of Nursing (DON) revealed she has not heard that Resident #15 had any issues with missing items. Interview on 02/05/25 7:22 A.M. with Resident #15 revealed the last time he could recall items missing was about a week or two ago. Specifically, he was missing packs of Oreo cookies that have two cookies each in them and a few bags of chips but he was unsure of the exact amount that was missing. Resident #15 stated had told several staff members about this issue, and they said they would get it taken care of but no one had updated him on the issue or came to further investigate the problem with him. Interview on 02/05/25 at 8:15 A.M. with RN #120 stated she had heard through the grape vine that items in Resident #15's room were going missing. The last she heard about the situation was about two weeks ago. The facility was unsure who was taking the items and she thought they were going to start keeping a closer eye on the room on days Resident #15 left for dialysis but has not heard anything 365922 Page 3 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0584 since. Level of Harm - Minimal harm or potential for actual harm Review of concern/missing item log from January 2024 to January 2025 revealed no evidence of missing snacks for Resident #15. Residents Affected - Few Review of missing items policy and procedure revised December 2020 stated the facility will make every attempt to locate any items that come up missing and assist with a resolution. The procedure to be followed is staff will log all missing items and communicate missing items and attempt to locate them, staff will provide information to residents and family about missing items, and lastly family and staff will come up with a resolution that is satisfactory to both parties. 365922 Page 4 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) document accurately reflected an in-patient psychiatric hospitalization/significant change of condition. This affected one (Resident #37) of one residents reviewed for PASRR documents. The census was 34. Findings Include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar disorder, anxiety disorder, dementia, liver disease, multiple sclerosis, anxiety disorder, epilepsy, unspecified intellectual disabilities, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/25, revealed the resident was cognitively intact. Review of a nursing progress note, dated 10/29/24, revealed Resident #5 was admitted for an inpatient psychiatric evaluation. Review of the psychiatric hospital's Discharge Summary revealed Resident #5 was admitted on [DATE] for increased aggression and agitation. The resident was discharged on 11/05/24. Review of the medical record revealed Resident #5's most recent PASRR document was dated 01/31/24 and was not revised/updated following the inpatient psychiatric hospitalization on 10/29/24. Interview on 02/03/25 at 4:25 P.M. with the Administrator confirmed Resident #5's PASRR document was not accurate and did not reflect the inpatient psychiatric hospitalization on 10/29/24. 365922 Page 5 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0679 Provide activities to meet all resident's needs. 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, interviews, observations, and policy review the facility failed to ensure Resident #195 was assessed for activity preferences and offered activities to meet his interests. This affected one (Resident #195) of one residents reviewed for activities. Residents Affected - Few Findings included: Record review revealed Resident #195 was admitted to the facility on [DATE] with diagnoses including depression, cerebral infarction, diabetes type one, and difficulty walking. Review of Resident #195's medical record revealed no evidence of an activity assessment. Review of Resident #195's progress notes revealed on 01/24/25 a social services note was entered at 4:08 P.M., that indicated the resident was dependent for all care and administration of medications. The resident had hearing aids and glasses. His speech was clear, and he was easily understood. There was no evidence that the resident's activity preferences were reviewed. Review of Resident #195's task (Certified Nursing Assistants) documentation dated 01/24/25 to 02/03/25 revealed no evidence of which activities the resident attended. There was an activity tab showing if the resident was active, passive, or observed only for activities. The resident was passive for activity on 01/24/25, 01/27/25, 01/28/25, 01/29/25, and 01/31/25 and observed only on 02/01/25. Review of Resident #195's 48-hour care plan dated 01/24/25 revealed no evidence of an activity plan of care. Review of Resident #195's plan of care revealed no evidence of a comprehensive activity plan of care. Further review of Resident #195's plan of care revealed the resident discharge planning plan of care indicated to encourage the resident to attend activities of interest and the potential for mood problems related to depression plan of care indicated to invite/assist resident to activities of choice. An interview on 02/03/25 at 12:31 P.M., with Resident #195 revealed he doesn't attend activities due to the facility didn't offer him activities that he was interested in. Observation on 02/03/25 at 3:42 P.M., and 02/04/25 at 2:19 P.M., revealed the resident was in his room and not participating in the activity program. Interview on 02/04/25 at 8:17 A.M. and 2:22 P.M., with Resident #195 confirmed no one had talked to him regarding his activity preference/interest. The resident reported he liked working on model cars/planes. The resident confirmed he doesn't attend the facility activities because he was not interested in the activities the facility had to offer. Interview on 02/04/25 at 1:36 P.M., with Social Service (SS) #101 revealed she was just re-hired as the social service/activity director about three weeks ago. SS #101 confirmed Resident #195 did not have an activity assessment completed nor an individualized plan of care for activities initiated. 365922 Page 6 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few SS #101 confirmed the task didn't include the activity the resident attended and she was not sure what active, and passive referred to under the task for activities. The SS confirmed she had spoken to the resident and his wife but there was no documented evidence they had discussed his activities preferences, nor did she know what activities the resident liked. Interview on 02/04/25 at 1:47 P.M., with Activity Assistant (AA) #100 revealed he had only been the activity assistant since 01/29/25. AA #100 confirmed he had not spoken to the resident regarding his activity preferences. The AA reported there had been a lot of turnovers in the activity department lately. AA #100 confirmed the type of activity the resident attended should be under the task tab, however the resident did not have the task and the only documentation in the task was if the resident was active, passive, or observed in an activity. The AA reported he had taken cake or something into the resident the other day, so he documented passive for that activity. AA reported he thought active meant the resident participated and passive was when the resident required assistance and observed the resident did not participate and just watched an activity. AA reported he was going to speak with administrative staff about adding the type of activity to the resident task. Review of the facility's policy titled Activity Programs dated 06/2018 revealed activities were programs designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Our activity programs are designed to encourage maximum individual participation. 365922 Page 7 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

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 medical record review, observation, interviews, and policy review, the facility failed to ensure an individualized, comprehensive plan of care was in place to ensure safe smoking strategies and skin alterations from smoking were timely identified. This affected one resident (Resident #6) of one residents reviewed for smoking. Findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including delusions, paranoid schizophrenia, depression, diabetes, dementia, behavioral disturbances, Alzheimer's, glaucoma, nicotine dependence (cigarettes), and abnormal involuntary movements. Review of Resident #6 smoking assessment dated [DATE] and 01/03/25 revealed the resident had no cognitive loss or dexterity problems. The resident had a visual deficit. The resident smokes five-10 times a day and used a smoking apron and required supervision. The facility stored the lighter and cigarettes. The plan of care was to assure residents were safe while smoking. There was no evidence the resident had or required an extender to prevent the resident from burning himself with a cigarette. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15, indicating the resident was cognitively intact. No impairment of range of motion to the upper or lower body had been identified. The resident had no skin alterations. The resident was partial to moderate assistance with personal hygiene and supervision for mobility. Review of resident weekly skin assessment dated [DATE] revealed the resident had no skin alterations. Further review of skin assessments and progress notes dated 01/30/25 to 02/03/25 at 12:34 P.M., revealed no evidence of skin alterations to the resident's middle right finger. Observation and interview on 02/03/24 at 12:34 P.M. with Resident #6 revealed the resident had a skin alteration on his right middle finger near the first knuckle. Resident #6 confirmed he had burned himself with a cigarette. The resident reported he had a cigarette extender he used when smoking. A follow-up interview on 02/04/25 at 9:22 A.M., revealed he had burned his finger about five days ago with a cigarette. The skin was starting to peel off on one side of the resident's finger. Observation and interview on 02/04/25 at 9:41 A.M., with Registered Nurse (RN) #105 confirmed the resident was to use an extender on the end of his cigarette to prevent him from burning himself. The RN showed the surveyor the extender that was in the cigarette box. The extender was not labeled to identify which resident was to use the extender. Review of Resident #6's nursing note dated 02/03/25 at 10:04 P.M., revealed the nurse noticed an open area on the resident's right middle finger. The resident stated it was a blister that opened. The area was cleaned with normal saline. The physician was notified and new orders received to monitor area every shift and leave open to air. Review of Resident #6 current orders revealed no evidence of an order for an extender to be added 365922 Page 8 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0689 to the cigarette. Level of Harm - Minimal harm or potential for actual harm Review of Resident #6's smoking plan of care revealed the resident was supervision at all times for smoking and an apron was to be worn when smoking. There was no evidence of an extender to be added to the cigarette to prevent theresident from being burned. Residents Affected - Few Interview on 02/04/25 at 9:27 A.M., with Certified Nursing Assistants (CNA) #102 and #103 revealed they had just noticed the skin alteration on the resident's finger today. The CNA's reported that the resident smokes the cigarettes to the filter and he was to have a plastic extender applied to the end of the cigarette to prevent him from burning himself. The CNAs reported laundry and housekeeping usually take the residents out to smoke. An interview on 02/04/25 at 10:16 A.M., with Registered Nurse (RN) #106 revealed the resident reported he had a blister that popped. She was not aware he had burned his finger on a cigarette. The RN confirmed she did not do a skin assessment of the area. Interview on 02/04/25 at 10:41 A.M., with the Director of Nursing (DON) confirmed there was no skin assessment completed for the skin alteration until identified during the survey. A CNA had reported yesterday that the resident had burned himself with a cigarette, but she didn't know when the incident occurred. The facility had not started an investigation to determine the cause of the cigarette burn. The DON also verified there was no order for a cigarette extender, the care plan did not reflect the use of a cigarette extender, and the smoking assessment did not identify the resident needed an extender for his cigarette (to prevent burns despite some staff having knowledge of the use of the cigarette extender). The DON confirmed the resident required supervision with smoking and he had the extender for a while and he was known to remove the extender. Review of the facility's policy titled Smoking dated 08/2023 revealed the resident would be evaluated upon admission and routinely to determine if he or she would be able to smoke safely. The facility would make the best effort to establish and maintain safe resident smoking practice. 365922 Page 9 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of dialysis dietician notes, and medical record review, the facility failed to provide Resident #15 with appropriate diet and snacks as ordered by the dialysis center dietician and failed to ensure communication between the facility dietician and dialysis dietician occurred to provide Resident #15 a comprehensive nutrition plan to meet the resident's needs. This affected one resident (Resident #15) of one reviewed for dialysis. Residents Affected - Few Findings included: Review of Resident #15's medical record revealed an admission date of 09/14/24 with diagnoses including type 2 diabetes, morbid obesity, heart failure, sepsis, hypertension, and end stage renal disease- dialysis dependent. Further review revealed no evidence of dialysis dietician communication notes since 04/23/24. Review of the nutritional communication forms/notes from dialysis dated 10/28/24, 12/18/24 and 01/27/25 (with a faxed date of 02/04/25 on the forms) revealed the dialysis dietician ordered a high protein snack at night, double portions, 132 grams of protein, no added sugar, and no added salt diet. The resident did not meet the albumin goal of greater than or equal to 4.0. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a brief interview of mental status score of 15 out of a possible 15, indicating the resident was cognitively intact. Review of Resident #15's nutrition plan of care dated 01/23/25 revealed a therapeutic diet low in salt, diabetic, low cholesterol, low concentrated sweets, renal fluid restriction, house supplement, with needs for 90-102 grams of protein a day, and 2,000-2,200 calories per day. There was no mention of the high protein snack at night. Review of Resident #15's physician orders dated 01/24/25 revealed renal, high protein, controlled carbohydrates, no added salt, regular diet with thin liquids. Review of Resident #15's orders dated 02/25 revealed no evidence the resident was ordered a high protein snack at night per dialysis orders Review of the dietary supplement list dated 02/05/25 revealed no high protein snack to be provided to Resident #15 at night. Review of Resident #15's task (Certified Aides Documentation) for February 2025 revealed no evidence the resident was receiving a high protein snack at night. Interview with Resident #15 on 02/05/25 at 8:36 A.M. confirmed he was receiving a snack around 8:00 P.M. daily, however he only received a fudge round or an oatmeal cream pie. He stated the facility does have other things on the cart such as cheese doodles and chips, but he doesn't want those items. Observation of Resident #15's packed lunch on 02/05/25 at 9:44 A.M. revealed the resident received 365922 Page 10 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few one bologna sandwich with cheese, one Styrofoam bowl with a lid containing cottage cheese, one grape juice, and one four count pack of [NAME] shortbread cookies. Interview on 02/05/25 at 9:44 A.M with the Transportation Driver #73 and Resident #15 confirmed the contents of the resident's packed lunch .The resident confirmed he received the same items in his packed lunch on his scheduled dialysis days of Monday, Wednesday and Friday. Interview on 02/05/25 at 10:47 A.M. with the facility Registered Dietician (RD) #302 revealed Resident #15 should receive three ounces of meat such as turkey, chicken, roast beef, tuna, or even egg salad; ham and bologna should not be given due to the high salt content. Further interview with the RD confirmed there was no order for Resident#15 to be given a high protein snack at night. The RD reported there have been issues with the dietary staff changeover and not providing high protein meals and snacks to Resident #15 and she planned to do further education and in-services with the staff. A subsequent interview with RD #302 on 02/05/25 at 10:50 A.M. verified she had not been provided with dialysis dietician communication forms/notes until recently. Interview with dialysis RD #32 on 02/05/25 at 12:41 P.M. revealed she had not been in contact with the facility dietician, and said she was wondering if they even had a dietician. Interview with RD #32 on 02/05/25 at 12:43 P.M. confirmed she has recommended Resident #15 receive a high proteins snack at bedtime due to albumin goals not being met. She shared she had also recommended high protein options for Residents #15 such as tuna or egg salad sandwiches rather than bologna due to the salt content. Lastly, RD #32 confirmed she re-faxed the dialysis nutrition notes to the facility on [DATE]. 365922 Page 11 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

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 observation, interview, review of dialysis communication notes, and record review the facility failed to ensure Resident #15 received medication as ordered and the dialysis plan of care was accurate. This affected one (Resident #15) of one reviewed for dialysis. Residents Affected - Few Findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes, morbid obesity, pneumonia, heart failure, sepsis, hypertension, dysphagia, bundle branch block, major depressive disorder, end stage renal disease dialysis dependent. a. Review of the nutritional communication form from dialysis dated 10/28/24, 12/18/24, and 01/27/25 revealed Resident # 15 did not meet his phosphorous goal of 3.0-3.5. Orders to administer calcium acetate at each meal and snack. Review of un-dated mealtimes (provided by the facility) revealed breakfast was at 7:45 A.M., lunch at 12:00 P.M., and dinner at 5:15 P.M. Review of Resident #15's orders and Medication Administration Records (MAR) dated 02/25 revealed calcium acetate (phosphorus binder) was to be given four times a day by mouth at A.M. (7:00 A.M. to 10:30 A.M.), noon, 3:00 P.M., and between 8:00 P.M.- 11:00 P.M. Review of the medication administration audit report from 02/01/25 through 02/04/25 revealed the calcium acetate (phosphorus binder) 667 milligrams (mg) was administered on 02/01/25 at 11:05 A.M., 11:06 A.M., 5:51 P.M., and 7:32 P.M.; 02/02/25 at 6:48 A.M., 10:19 A.M., 3:54 P.M., and 7:32 P.M. on 02/03/25 at 9:19 A.M., 10:31 A.M., 5:02 P.M. and 8:57 P.M. and on 02/04/25 at 8:32 A.M., 12:22 P.M., 5:25 P.M., and 8:13 P.M. Review of Resident #15's progress note dated 02/03/25 revealed the resident was at dialysis and noon medicine given at 10:31 A.M. Interview with Registered Dietician (RD) #32 on 02/05/25 at 12:42 P.M. confirmed the calcium acetate (phosphorus binder) must be given with meals and snacks. The RD reported she had spoken with a facility staff member on January 24 th, 2025, on the importance of taking the calcium acetate (phosphorus binder) with meals and snacks. Interview with the Director of Nursing (DON) on 02/05/24 at 3:11 P.M. confirmed calcium acetate was not being given during mealtimes. Review of undated liberalized medication administration policy revealed the interdisciplinary team, including health care providers, nursing staff, and pharmacists, should work together to develop and implement flexible medication administration plans. b. Review of Resident #15's dialysis care plan revised on 10/23/24 revealed the resident's dialysis days were Tuesdays, Thursdays, and Saturdays and to obtain weights per order. 365922 Page 12 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #15's orders dated 02/25 revealed the resident attends an outside dialysis center on Monday, Wednesday, and Friday at 10:30 A.M. and there was no evidence of an order to weigh the resident per the plan of care. Observation and Interview of Resident #15 on 02/03/25 at 9:13 A.M. revealed Resident #15 was preparing to leave the facility. The resident reported he leaves around 9:30 A.M. and returns to the facility around 4:30 P.M., on Monday, Wednesday, and Friday. Interview on 02/04/25 at 9:20 A.M. with Registered Nurse (RN) #105 confirmed Resident #15 had dialysis every Monday, Wednesday, and Friday. Interview on 02/04/25 at 3:20 P.M. with the Director of Nursing (DON) confirmed Resident #15 care plan indicated that the resident was to receive dialysis treatment on Tuesdays, Thursdays, and Saturdays however, he goes on Monday, Wednesdays, and Fridays and the care plan had not been updated to reflect the corrected days he goes and the resident did not have an order for weights per the plan of care. 365922 Page 13 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and policy review, the facility failed to ensure appropriate infection control practice were implemented when an indwelling urinary catheter drainage bag was in contact with the floor. This affected one (Resident #185) of one resident reviewed for indwelling urinary catheters. There were no additional residents with urinary catheters residing in the facility. The facility census was 43. Residents Affected - Few Findings include: Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses including obstructive reflex uropathy, acute kidney failure, diabetes mellitus, coronary artery disease, morbid obesity, bipolar disorder, and Fournier gangrene (serious, sometimes fatal, bacterial infection of the external genitalia or scrotum.) Review of the admission Minimum Data Set (MDS) assessment, dated 02/01/25, revealed Resident #5 was cognitively intact. There were no behaviors or rejection of care. The resident required physical assistance from staff for activities of daily living. Review of the Care Plan, dated 02/03/25, revealed Resident #5 had an indwelling supra-pubic catheter related to obstructive uropathy with the goal for the resident to remain free of infection. Interventions included utilizing enhanced barrier precautions and providing catheter care every shift. Observation on 02/03/25 at 8:40 A.M. revealed Resident #5 lying in bed with his indwelling, urinary catheter bag encased within a white, cloth privacy cover. The catheter bag with cover was touching the floor. Subsequent observation on 02/03/25 at 8:55 A.M., revealed the catheter bag with cover continued to touch the floor. During observation and interview on 02/03/25 at 8:56 A.M., the Director of Nursing (DON) confirmed the urinary catheter bag/privacy cover should not be in contact with the floor. Review of the facility's policy titled, Urinary Catheter Care, dated April 2007, revision date 2021, revealed to use standard precautions when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag are kept off the floor. 365922 Page 14 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and comfortable manner by repairing and painting walls properly. This had the potential to affect all 34 residents within the facility. Findings include: Observations throughout the survey from 02/03/25 to 02/06/25 revealed numerous resident rooms and common areas with evidence of repaired drywall which had not been properly painted. Observations with the facility administrator on 02/06/25 from 9:30 A.M. to 9:40 A.M. revealed the following areas of disrepair concerns: • room [ROOM NUMBER] had drywall repair without evidence of repainting • hallway next to room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] had drywall repair without evidence of repainting • room [ROOM NUMBER] drywall repair without evidence of repainting • room [ROOM NUMBER] damaged drywall from resident beds • room [ROOM NUMBER] drywall repair without evidence of repainting • hallway across from 205 drywall without evidence of repainting • 365922 Page 15 of 16 365922 02/06/2025 Sienna Hills Nursing & Rehabilitation 73841 Pleasant Grove Road Adena, OH 43901

F 0921 room [ROOM NUMBER] drywall repair without evidence of repainting Level of Harm - Minimal harm or potential for actual harm • room [ROOM NUMBER] drywall repair without evidence of repainting Residents Affected - Many • hallway between room [ROOM NUMBER] and shower room drywall without evidence of repainting • hallway by room [ROOM NUMBER] drywall without evidence of repainting • 307 drywall repair without evidence of repainting During the observations the facility administrator verified all findings. 365922 Page 16 of 16