Health inspection·June 18, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a gradual dose reduction (GDR) or documentation of a clinical contraindication for not attempting a GDR for a resident on two antipsychotics. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: Record review of Resident #16 revealed this resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment completed on 04/02/25 revealed Resident #16 had cognitive impairments. Review of the physician orders revealed Resident #16 was on the following medications: on 02/11/23, Perphenazine (antipsychotic) 8.0 milligrams (mg) one tablet by mouth four times a day for paranoid schizophrenia. On 02/21/24, Ziprasidone (antipsychotic) 80 mg one tablet by mouth twice daily for paranoid schizophrenia, Resident #16's medical record did not have evidence have a GDR attempt for the two antipsychotic medications (Perphenazine and Ziprasidone) nor rationales why a GDR would be contraindicated. Interview with the Director of Nursing (DON) on 06/18/25 at 3:10 P.M. verified there were no attempts a GDR was attempted for the use of the two antipsychotic medications (Perphenazine and Ziprasidone) nor was there rationale why a GDR would be contraindicated for Resident #16 Page 1 of 3 365932 365932 06/18/2025 Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure a resident who had abnormal heart rate received timely care and services. This affected one (Resident #37) of two residents reviewed for change of condition. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #37 revealed an admission date of 11/19/2020. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and chronic pain. Review of the nursing progress note dated 04/19/25 at 1:09 P.M. created by Licensed Practical Nurse (LPN) #202 revealed the nurse was putting the vital signs in the medical record for Resident #37 when noticing a heart rate was documented on the paper as 23 beats per minute (bpm) (normal was 60 to 100 bpm). LPN #202 went to recheck the resident's pulse to make sure it was not actually 23 bpm. The resident's heart rate was fluctuating back and forth from 23 to 25 bmp. LPN #202 called the physician to report the findings and the physician instructed to send Resident #37 to the emergency room. Interview on 06/18/25 at 3:30 P.M. with the Director of Nursing (DON) confirmed any abnormal vital sign results including a pulse of 23 should be reported to the nurse immediately for immediate assessment. The DON confirmed Resident #37's low heart rate was not reported to the nurse in a timely manner. 365932 Page 2 of 3 365932 06/18/2025 Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff interviews, and review of facility policy, the facility failed to ensure privacy curtains were in place around commodes in the communal bathroom for residents to utilize for privacy when toileting. This had the potential to affect the 22 residents (#1, #2, #5, #6, #9, #14, #17, #18, #19, #22, #26, #27, #33, #34, #35, #36, #38, #39, #45, #54, #59, and #64) who resided on the 300 hall and 400 hall and were identified by the facility as utilizing the communal bathrooms. The facility census was 67. Findings include: Observation on 06/17/25 at 10:30 A.M. revealed residents residing on the 300 hall did not have private bathrooms present in their rooms and had to utilize a communal bathroom for toileting. The bathroom contained two commodes which had tracks on the ceiling to place a curtain to pull around the commodes for privacy when in use. No curtains were in place on the tracks to pull for privacy. Interview with Certified Nursing Assistant (CNA) #241 at the time of the observation confirmed the residents residing on the 300 hall had to utilize the communal bathroom for toileting. CNA #241 confirmed the door to the bathroom did not lock and there were not any curtains in place on the tracks above the commodes for residents to pull for privacy when using the bathroom. Observation on 06/18/25 at 2:20 P.M. revealed residents residing on the 400 hall did not have private bathrooms present in their rooms and had to utilize a communal bathroom for toileting. The bathroom contained two commodes which had tracks on the ceiling to place a curtain to pull around the commodes for privacy when in use. One curtain was hanging from one of the tracks but the curtain on the second track was not present. Interview with the Director of Nursing (DON) at the time of the observation confirmed the residents on the 400 hall had to utilize the communal bathroom for toileting. The DON confirmed the door to the bathroom did not lock and one of the curtains was not in place on the track for residents to pull for privacy when using the bathroom. The DON confirmed curtains should be present on the tracks around all commodes in common bathrooms. Review of the facility policy titled Resident Rights, revised 12/2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. 365932 Page 3 of 3