Health inspection·May 21, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified when a medication was unavailable for administration. This affected one (#57) of three residents reviewed for physician notification. The facility census was 96. Findings include: Review of Resident #57's medical record revealed an admission date of 10/07/24 with diagnoses including Parkinson's disease, hypertension (HTN), hyperlipidemia, hypothyroidism, major depressive disorder, anemia, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #57 was cognitively intact. Review of a physician order, dated 10/07/24, revealed Resident #57 had an order for trihexyphenidyl hydrochloride (HCl) (used to treat movement problems caused by Parkinson's disease), two milligrams (mg) to be administered orally (PO) two times per day. Observation on 05/19/25 at 7:00 A.M. of medication administration with Licensed Practical Nurse (LPN) #527 revealed trihexyphenidyl HCl was not administered to Resident #57. Concurrent interview with LPN #527 verified trihexyphenidyl HCI was not administered to Resident #57 due to the medication being unavailable. LPN #527 stated she would request the medication from the pharmacy and would administer it if it came in. Review of the Medication Administration Record (MAR) revealed Resident #57 was not administered either of the two ordered doses of trihexyphenidyl HCl on 05/19/25. Further review of Resident #57's medication record revealed no evidence the physician was notified that trihexyphenidyl HCl was unavailable for administration on 05/19/25. Interview on 05/21/25 at 9:10 A.M. with the Director of Nursing (DON) verified the prescribing physician was not notified that trihexyphenidyl HCl was unavailable for administration to Resident #57 on 05/19/25. Review of the facility policy titled, Notification of Changes, dated 10/02/22, revealed the facility promptly informed the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Page 1 of 25 365976 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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. Based on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure bedding was maintained in a clean and sanitary manner. This affected one (#16) resident reviewed for soiled bedding. The facility census was 96. Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/01/23. Diagnoses included Parkinson's disease, chronic kidney disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed Resident #16 was mildly cognitively impaired and required supervision for bathing. Observation on 05/18/25 at 10:30 A.M. of Resident #16's bedding revealed several light brown streaks on the fitted sheet of the bed and a dark brown spot on the bed pad. Concurrent interview with Resident #16 revealed her sheets had not been changed in a while and stated they were dirty. Observation on 05/19/25 at 9:40 A.M. of Resident #16's bedding revealed the sheets remained with the same brown streaks on the fitted sheet. Concurrent interview with Resident #16 confirmed her sheets had not been changed. Observation on 05/20/25 at 9:29 A.M. of Resident #16's bedding revealed the bedding remained dirty and unchanged. Interview on 05/20/25 at 10:07 A.M. with Registered Nurse (RN) #509 verified the light brown streaks on the fitted sheet and the dark brown spot on the bed pad on Resident #16's bedding. Review of the facility policy titled, Homelike Environment, revised February 2021, revealed residents were provided a safe, clean, comfortable and homelike environment. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, to include a clean bed and bath linens that are in good condition. 365976 Page 2 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure valid indications for the use of mobility restricting devices. This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. Residents Affected - Few 1. Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. Review of the Elopement Risk Assessment, dated 04/04/25, revealed Resident #3 had no history of elopement in the last six months and was identified as not being an elopement risk. Review of the care plan, dated 06/01/22, revealed Resident #3 was risk for wandering/elopement, with no specific diagnosis or reasoning for the wandering/elopement risk was identified. Interventions included WanderGuard to the left ankle and check its placement every shift. Review of the physicians orders revealed an order dated 02/05/24 to check placement of the WanderGuard (a medical device to help prevent residents, especially those at risk of wandering, from leaving secure areas within a facility) every shift daily and an order dated 03/08/24 to check WanderGuard function daily. Further review of the medical record revealed no documentation to support the use of a WanderGuard for Resident #3. Observation of Resident #3 on 05/20/25 at 9:45 A.M. revealed Resident #3 was sitting in her room watching television. Resident #3 presented with no observable restlessness or any indications that she was exit seeking. 2. Review of Resident #56's medical record revealed an admission date of 09/21/18. Diagnoses included Alzheimer's disease, schizophrenia, dementia, and major depressive disorder. Review of the MDS 3.0 assessment, dated 02/06/25, revealed Resident #56 was severely cognitively impaired, required one person assistance for completing ADLs, and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #56's admission to the facility revealed the facility had never identified the resident as having wandering behaviors. Review of the Elopement Risk Assessment, dated 04/17/25, revealed Resident #56 had no history of elopement in the last six months and was identified as not being an elopement risk. Further review of previous Elopement Risk Assessments revealed Resident #56 had not been identified as being at risk for elopement since 11/16/23. Review of the physician orders revealed an order initiated on 02/05/24 to check placement of the WanderGuard every shift daily and an order dated 09/01/23 to check WanderGuard function daily. 365976 Page 3 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/20/25 at 10:15 A.M. of Resident #56, with the Director of Nursing (DON) present, revealed Resident #56 was laying back in her tilt-n-space wheelchair (reclining wheelchair) looking around in a common area. Resident #56 presented with no distress or repetitive movements/phrases that would indicate possible exit seeking behaviors. Interview with the DON on 05/20/25 at 11:00 A.M. confirmed the medical records for both Resident #3 and Resident #56 lacked indications for the use of the WanderGuard device. Review of the facility policy titled, Restraint Free Environment, dated 05/20/25, revealed it was the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibited the use of physical or chemical restraints for discipline or convenience and limited restraint use to circumstances in which the resident had medical symptoms that warrant the use of such restraints. This deficiency represents non-compliance investigated under Complaint Number OH00163154. 365976 Page 4 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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 medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#15) of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, revised 03/08/24, revealed Resident #15 used psychotropic medications. Interventions included administering medications as ordered and monitoring for side effects and effectiveness, and monitoring and reporting as needed side effects and adverse reactions of medication. Review of Resident #15's active physician orders for May 2025 revealed an order for buspirone (anti-anxiety medication) 7.5 milligram (mg) oral tablet, give one tablet by mouth two times per day for major depressive disorder; lorazepam (benzodiazepine medication used to treat anxiety) 0.5 mg oral tablet, give one tablet by mouth two times per day related to anxiety disorder; lorazepam 0.5 mg oral tablet, give 0.25 mg one time per day for anxiety disorder; and sertraline (anti-depressant medication) 50 mg oral tablet, give one tablet by mouth one time per day for major depressive disorder. Review of the Medication Administration Records (MAR) from 03/01/25 through 05/20/25 revealed Resident #15 received sertraline once daily from 03/01/25 through 04/14/25 and 04/18/25 through 05/20/25. The resident received buspirone twice per day from 03/01/25 through 04/14/25 and 04/14/25 through 05/19/25. Resident #15 also received lorazepam twice per day from 03/01/25 through 04/14/25 and 04/18/25 through 05/19/25. Further review of the medical record revealed no evidence Resident #15 was monitored for any specified behaviors or for efficacy related to the three medications from 03/01/25 through 05/20/25. In addition, there was no evidence the resident was monitored for adverse effects from the medications from 05/01/25 through 05/20/25. Interview on 05/20/25 at 5:45 P.M. with the Director of Nursing (DON) verified there was no evidence Resident #15 was monitored on a regular basis for behaviors, efficacy, and adverse effects for psychotropic medication use. Review of the facility policy titled, Use of Psychotropic Medication, undated, revealed the resident's response to psychotropic medications, including the presence/absence of adverse consequences, would be documented in the resident's record, and the resident's symptoms would be clearly identified and documented. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, revealed when medications were prescribed for behavioral symptoms, documentation would 365976 Page 5 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0605 include potential underlying causes of the behavior, specific target behaviors and expected outcomes, monitoring for efficacy and consequences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365976 Page 6 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to complete timely Minimum Data Set (MDS) assessments following a significant change. This affected one (#91) of one resident reviewed for hospice services. The facility identified five residents receiving hospice services. The facility census was 96 Residents Affected - Few Findings include: Review of Resident #91's medical record revealed an admission date of 11/11/24. Diagnoses included dementia, insomnia and neck fracture. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/13/25, revealed Resident #91 was severely cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs). The MDS did not indicate Resident #91 received hospice services. Review of the physician orders revealed an order dated 04/29/25 to consult a local hospice provider for potential admission for Resident #91. Further review of the medical record revealed Resident #91 elected hospice services on 05/01/25, with a diagnosis of senile degeneration of the brain. Additional review of the MDS assessments from 05/01/25 through 05/19/25 revealed no evidence that a significant change MDS was completed upon Resident #91's election of hospice services. Interview on 05/19/25 at 1:30 P.M. with the Director of Nursing (DON) verified a significant change MDS was not completed within 14 days of Resident #91 electing hospice services. 365976 Page 7 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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. Based on record review, observation and staff interview the facility failed to ensure residents care plans were an accurate representation of current resident conditions This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. Findings include: Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. Review of the Elopement Risk Assessment, dated 04/04/25, revealed Resident #3 had no history of elopement in the last six months and was identified as not being an elopement risk. Review of the care plan dated 06/01/22 revealed Resident #3 was identified at risk for wandering/elopement. No specific diagnosis or reasoning for the elopement risk was identified. Interventions included a WanderGuard to the left ankle and to check placement every shift. Observation of Resident #3 on 05/20/25 at 9:45 A.M. revealed Resident #3 was sitting in her room watching television. Resident #3 presented with no observable restlessness or any indications that she was exit seeking. 2. Review of Resident #56's medical record revealed an admission date of 09/21/18. Diagnoses included Alzheimer's disease, schizophrenia, dementia and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 02/06/25, revealed Resident #56 was severely cognitively impaired, required one person assistance for completing ADLs, and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #56's admission to the facility revealed the facility had never identified the resident as having wandering behaviors. Review of the Elopement Risk Assessment, dated 04/17/25, revealed Resident #56 had no history of elopement in the last six months and was identified as not being an elopement risk. Further review of the previous Elopement Risk Assessments revealed Resident #56 had not been identified as an elopement risk since 11/16/23. Review of the care plan dated 8/26/22 revealed Resident #56 was at risk for elopement due to understanding and recognizing her surroundings. Observation of Resident #56, with the Director of Nursing (DON) present, on 05/20/25 at 10:15 A.M. revealed Resident #56 was laying back in her tilt-n-space (reclining wheelchair) looking around in a common area. Resident #56 presented with no distress or repetitive movements/phrases that would indicate possible exit seeking behaviors. 365976 Page 8 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DON on 05/20/25 at 11:00 A.M. verified Resident #3 and Resident #56's care plans did not accurately reflect the current elopement risks for Resident #3 and Resident #56. Review of the facility policy titled, Elopements and Wandering Residents, dated 11/01/17, revealed the interdisciplinary team would evaluate the unique factors contributing to risk in order to develop a person-centered care plan. 365976 Page 9 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were provided assistance with oral hygiene. This affected one (#89) of one resident reviewed for oral hygiene. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record revealed Resident #89 was admitted to the facility on [DATE]. Diagnoses included lack of coordination, unsteadiness on feet, hypertension (TN), gastro-esophageal reflux disease (GERD), glaucoma, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #89 was cognitively intact. The resident required supervision/touching assistance for oral hygiene. Review of the plan of care dated 10/21/24 revealed Resident #89 had an activities of daily living (ADLs) self-care performance deficit. Interventions included providing all necessary equipment to complete oral care and setting up and assisting as needed. Further review of Resident #89's medical record revealed no evidence the resident was specifically assisted with oral care on a regular basis. An observation on 05/18/25 at 9:22 A.M. of Resident #89 revealed the resident had their natural teeth. There was a line of buildup along the gumline of both their upper and lower teeth and a visible film over their teeth. An interview on 05/18/25 at 9:23 A.M. with Resident #89 revealed the resident needed help with brushing her teeth. Resident #89 reported if she asked staff to help her brush her teeth she was sure that they would. Resident #89 reported staff were so busy that she felt bad asking for help. Resident #89 reported she had been used to brushing her teeth three times per day prior to coming into the facility, but that she was unsure of the last time her teeth were brushed. Resident #89 reported staff did not offer to assist her with brushing her teeth. An observation on 05/19/25 at 10:33 A.M. revealed Resident #89's teeth appeared the same as the previous observation. The resident still had the layer of film and buildup over her teeth. An observation on 05/20/25 at 11:59 A.M. of Resident #89, with Certified Nursing Assistant (CNA) #556, verified the resident's teeth had buildup and were in need of being brushed. During the observation, Resident #89 stated to CNA #556 that she knew her teeth were pretty bad and she would really like to brush her teeth more often but knew that the aides were busy. CNA #556 stated they felt bad and would come back to assist the resident with brushing their teeth in a little while. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00163154. 365976 Page 10 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Residents Affected - Few Review of the five-day Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, dated 08/28/18, revealed Resident #15 was at risk for constipation related to decreased mobility and medication side effects. Interventions included following the facility bowel protocol for bowel management and recording bowel movement pattern. Review of Resident #15's active physician orders for May 2025 revealed an order dated 04/17/25 for Oxycodone (opioid medication) five milligram (mg) oral capsule, give one capsule by mouth every six hours as needed for pain. Review of the Medication Administration Record from 04/17/25 through 05/19/25 revealed Resident #15 received Oxycodone on 11 occasions. Review of Resident #15's bowel tracking record from 04/21/25 through 05/19/25 revealed there were only two documented bowel movements within this timeframe. Interview on 05/20/25 at 5:45 P.M. with the Director of Nursing (DON) verified Resident #15's bowel movements had not been tracked per the plan of care and, subsequently, it could not determined whether the facility's bowel protocol needed to have been implemented. Review of the facility policy titled, Bowel Protocol, undated, revealed in the event a resident did not have a bowel movement for three consecutive days, the facility was to give as-needed medications, followed by contacting the physician if needed. Based on resident interview, medical record review, staff interview and review of the facility policy, the facility failed to ensure surgical wound treatments were completed as physician ordered. This affected one (#303) of one resident reviewed for non-pressure ulcer wound care. Additionally, the facility failed to track bowel movements to identify the need to implement the facility's bowel protocol. This affected on (#15) of one resident reviewed for bowel protocol. The facility census was 96. Findings include: Review of the medical record for Resident #303 revealed an admission date of 05/15/25 with diagnoses of malignant neoplasm of the brain and surgical aftercare following surgery for the nervous system. Review of the admission assessment dated for 05/15/25 for Resident #303 revealed she was alert and oriented to person, place, and time. Review the current physician orders for May 2025 revealed Resident #303 had an order to clean the scalp incision with half strength peroxide, pat dry, apply Aquaphor ointment, and leave open to air, 365976 Page 11 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0684 twice a day. Level of Harm - Minimal harm or potential for actual harm Review of the Treatment Administration Record (TAR) for Resident #303 revealed on 05/18/25 and 05/19/25, the night shift scalp incision treatment was not documented as completed. Residents Affected - Few Interview on 05/18/25 at 2:30 P.M. with Resident #303 revealed her scalp incision was the result of brain cancer and she had to have a skull cap created as the cancer consumed the bone of her skull and the surgeon took a skin graft from her leg to create the skin for her scalp. Resident #303 stated no wound care had been provided for the incision to her scalp since her admission three days ago. Interview on 05/19/25 at 3:57 P.M. with Registered Nurse (RN) #590 verified the missing nursing initials on the TAR on 05/18/25 and 05/19/25 night shift, which indicated the treatments were not completed as physician ordered. Review of the facility policy titled, Wound Treatment Management, revised November 2022, revealed wound treatments would be provided in accordance with the physician orders and treatments would be documented on the TAR or in the electronic medical record. 365976 Page 12 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of optometry (vision) notes, and staff interview, the facility failed to ensure residents received routine eye care timely. This affected one (#35) of one resident reviewed for vision care. The facility census was 96. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/13/23. Diagnoses included metabolic encephalopathy, type two diabetes mellitus (DM2), hepatic encephalopathy, dysphagia, need for assistance with personal care, respiratory disorders, hypertension (HTN), depression, obstructive sleep apnea (OSA), and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 03/09/25, revealed Resident #35 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. Review of an optometry note, dated 11/13/23, revealed Resident #35 was seen by the optometrist for an examination (exam). The resident had complaints of blurred vision in both eyes, which was getting worse. New eyeglasses were ordered. Further review revealed Resident #35 was to continue care with her primary care physician (PCP) to control blood sugars (BS), repeat dilated fundus exam (dilates the pupil to allow the back of they eye to be seen more clearly) in six to nine months to determine if a referral to a retinal specialist for further treatment was needed, and a comprehensive exam was due on 11/13/24. Review of an optometry note, dated 01/24/24, revealed Resident #35 was seen by the optometrist due to the new bifocals from November 2023 may have been lost and needed replaced. Further review revealed Resident #35 was to follow-up with the optometrist on 11/13/24 for a priority comprehensive examination. Further review of Resident #35's medical record revealed no evidence the resident received any optometry follow-up after the visit on 01/24/24. Interview on 05/20/25 at 11:27 A.M. with Director of Social Services (DSS) #598 verified Resident #35 had not been seen by optometry since 01/24/24 and confirmed the resident was past due for an exam. 365976 Page 13 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

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, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents identified to smoke were assessed for safety. This affected one (#68) of one resident resident identified by the facility as a smoker. The facility census was 96. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, depression, hypertension, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/01/25, revealed Resident #68 was cognitively intact. The resident required partial/moderate assistance from staff when wheeling 50 or 150 feet once seated in their wheelchair. Review of the plan of care, dated 09/11/24, revealed Resident #68 was a daily smoker, had been informed of the facility non-smoking status, and would abide by smoking off of facility property at all times. Interventions included the receptionist in the front of the building would hold the resident's cigarettes. An interview on 05/19/25 at 7:27 A.M. with Resident #68 revealed the resident was unaware of an assessment completed by the facility to determine whether the resident was considered safe to smoke or to handle a lighter or cigarettes safely. Observation on 05/19/25 at approximately 2:30 P.M. revealed Resident #68 obtained their smoking materials from the receptionist at the front desk and propelled themselves off of the facility property via sidewalk to smoke. An interview on 05/20/25 at 8:43 A.M. with Licensed Practical Nurse (LPN) #529 revealed the facility was a non-smoking facility and Resident #68 was the only resident in the facility who smoked. LPN #529 reported Resident #68 went off of facility property to smoke. LPN #529 reported they were unsure if the resident had ever been assessed for safety when smoking. LPN #529 verified the receptionist kept Resident #68's cigarettes and lighter, and supplied them to Resident #68 whenever they wanted to smoke. An interview on 05/20/25 at 9:34 A.M. with the Director of Nursing (DON) verified the facility was considered a non-smoking facility and Resident #68 was the only resident residing in the facility who smoked. The DON verified the facility was aware Resident #68 was a smoker when they admitted to the facility. The DON verified Resident #68 had never been assessed to determine whether they were safe to smoke or to have a lighter and cigarettes. The DON also verified the resident was not assessed on a regular basis for safety when smoking and subsequently the facility would not necessarily know if the resident had a decline resulting in them becoming unsafe to smoke. Interview on 05/21/25 at 6:59 A.M. with Licensed Social Worker #598 verified the facility did not complete any type of assessment to verify Resident #68 was safe to smoke unsupervised or to handle a lighter and cigarettes. 365976 Page 14 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Resident Smoking, dated 10/24/22, revealed residents who smoked would be further assessed using the Resident Safe Smoking Assessment to determine whether or not supervision was required for smoking, or if a resident was safe to smoke at all. The policy also stated if at any time the facility changed their policy to prohibit smoking, it would inform residents of this upon admission. Residents Affected - Few 365976 Page 15 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic kidney disease, panic disorder, seizures, schizophrenia, anxiety, migraine, low back pain, pain in the right leg, and pain in the right hip. Residents Affected - Few Review of the MDS assessment, dated 03/31/25, revealed Resident #30 was cognitively intact. Review of the active physician orders for May 2025 revealed an order dated 05/14/25 for Vancomycin (antibiotic medication) intravenous (IV) solution 1250 milligrams/250 milliliters (mg/ml), use 1250 ml IV one time per day for cellulitis for 10 days. The scheduled time for the medication to be administered was 9:00 A.M. Observation on 05/20/25 at 12:12 P.M. revealed Resident #30 was sitting up on the side of their bed. The resident was receiving Vancomycin IV via a midline catheter at the time of observation. A pole located next to the resident's bed contained a pump with medication administration settings. A bag containing fluid/medication was attached to a vial which contained fluid/medication via tubing. The bag containing medication read to infuse 1250 ml via IV over 90 minutes at 167 ml per hour daily. Further observation of the settings revealed the Vancomycin was being infused at 250 ml per hour, rather than at 167 ml per hour. Observation on 05/20/25 at approximately 12:15 P.M. with Licensed Practical Nurse (LPN) #529 verified the Vancomycin was being infused at 250 ml per hour, rather than at 167 ml per hour. LPN #529 reported they were unsure about the timing or why the medication was being administered at the wrong rate because Resident #30's assigned nurse, who began administering the medication, was on lunch break. Continued observation on 05/20/25 at 12:17 P.M. revealed the IV pump located in Resident #30's room began beeping and the screen read upstream occlusion. Registered Nurse (RN) #508 entered the room and stated the IV medication was complete and they would get Resident #30's nurse. LPN #529 then entered the room and disconnected the IV antibiotic from Resident #30's IV port. LPN #529 flushed the IV port, disposed of the IV antibiotic and tubing in the trashcan in the resident's room, and left the room. Interview on 05/20/25 at 12:24 P.M. with LPN #545 verified she was assigned to Resident #30 and had started the resident's Vancomycin administration. LPN #545 reported they had turned on the IV pump which asked to verify the patient, LPN #545 verified it was Resident #30, and that was how the rate of infusion was determined. LPN #545 verified they did not double-check to ensure the medication was being infused at the correct rate. LPN #545 also verified the medication was ordered to be given at 9:00 A.M. over a period of 90 minutes. LPN #545 verified that even if the medication had been started at 10:00 A.M., it would have been completed by 11:30 A.M. and it was not. LPN #545 reported they were unsure of what time they began administering the medication, as they did not sign the medication administration record until the medication was completely given. Observation on 05/20/25 at 12:51 P.M. with LPN #545 verified the vial of Vancomycin attached to the bag of fluid, placed in the resident's trashcan during the observation at 12:17 P.M. and used to infuse the IV antibiotic on 05/20/25, was full. LPN #545 reported the bottle was empty when they began infusing the medication but they had been having issues when preparing the medication. LPN #545 365976 Page 16 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verified staff should check to ensure all medication was administered before disconnecting an IV. LPN #545 verified there was no way to know exactly how much Vancomycin Resident #30 received on 05/20/25. Review of the facility policy titled, Intravenous Therapy, dated 10/24/22, revealed when residents were receiving IV therapy, staff were directed to ensure the IV pump was programmed accurately and turned to the appropriate rate as ordered. Review of the facility policy titled Medication Administration, dated 12/20/24, revealed staff were to follow the six rights of medication administration which included the right dosage and the right time. Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (#57 and #30) of four residents reviewed for medication administration. The facility census was 96. Findings include: Review of Resident #57's medical record revealed an admission date of 10/07/24 with diagnoses including Parkinson's disease, hypertension (HTN), hyperlipidemia, hypothyroidism, major depressive disorder, anemia, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #57 was cognitively intact. Review of a physician order, dated 10/07/24, revealed Resident #57 had an order for trihexyphenidyl hydrochloride (HCl) (used to treat movements related to Parkinson's disease), two milligrams (mg) to be administered orally (PO) two times per day related to Parkinson's disease. Observation on 05/19/25 at 7:00 A.M. of medication administration with Licensed Practical Nurse (LPN) #527 revealed trihexyphenidyl HCl was not administered to Resident #57. Concurrent interview with LPN #527 verified trihexyphenidyl HCI was not administered to Resident #57 due to the medication being unavailable. LPN #527 stated she would request the medication from the pharmacy and would administer it if it came in. Review of the Medication Administration Record (MAR) revealed Resident #57 was not administered either of the two ordered doses of trihexyphenidyl HCl on 05/19/25. Review of a nursing progress note dated 05/19/25 at 8:15 A.M., and authored by LPN #527, revealed med (medication) was ordered. Interview on 05/21/25 at 9:10 A.M. with the Director of Nursing (DON) verified neither ordered dose of two mg trihexyphenidyl HCl was administer to Resident #57 on 05/19/25. Review of the facility policy titled, Medication Administration, dated 12/30/24, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician. 365976 Page 17 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and maintenance record review, the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 96. Findings include: Observation on 05/19/25 at 10:05 A.M. of the large industrial ice machine on the Rosewood unit, with Director of Maintenance (DOM) #600, revealed the inside of the machine had noticeable mold-like built up on the bottom of the machine and other areas throughout the machine. Multiple areas of the machine had large orange, rust-like areas. Concurrent interview with DOM #600 confirmed the findings and stated the ice machine was often used by staff and residents for various uses, such as filling water pitchers. Review of the ice machine maintenance records revealed the machine was last serviced on 02/14/24 and had no upcoming maintenance scheduled. 365976 Page 18 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to maintain the dumpster area in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 96. Residents Affected - Many Findings include: Observation on 05/20/25 at 8:30 A.M. of the outside dumpster area revealed numerous cardboard boxes, gloves, food scraps and six alcoholic beverage cans on the ground, outside of the dumpster. Interview on 05/18/25 at 8:45 A.M. with [NAME] (CK) #257 verified the debris located on the ground, around the dumpster. 365976 Page 19 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, staff interview and review of facility policy, the facility failed to maintain complete documentation of care provided for residents. This affected four (#14, #95, #301, and #35) of four residents reviewed for activities of daily living (ADLs). The facility census was 96. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/05/18. Diagnoses included atherosclerotic heart disease of native coronary artery, atrial fibrillation (a. fib), unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, spinal stenosis, hypertension (HTN), major depressive disorder, anxiety, history of falling, unsteadiness on feet, generalized muscle weakness, and respiratory disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #14 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. The resident required assistance with hygiene. Review of the facility shower schedule revealed Resident #14 was scheduled to receive showers twice a week, every Tuesday and Saturday. Review of the shower sheets from February 2025 through 05/21/25 revealed no documentation of showers provided for Resident #14 on 02/04/25, 02/08/25, 02/11/25, 02/18/25, 02/22/25, 03/04/25, 03/08/25, 03/11/25, 03/22/25, 04/05/25, 04/08/25, 04/12/25, 04/15/25, 04/19/25, 04/29/25, 05/09/25, 05/10/25, 05/13/25, and 05/17/25. Interview on 05/21/25 at 11:17 A.M. with the Director of Nursing (DON) verified Resident #14's showers were not documented as completed. 2. Review of the medical record for Resident #95 revealed an admission date of 03/03/25. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM2), generalized muscle weakness, dysphagia, hemiplegia and hemiparesis, acute and chronic respiratory failure, mild cognitive impairment, lack of coordination, unsteadiness on feet, HTN, aphasia, and obstructive and reflux uropathy. Review of the Medicare 5-Day MDS assessment, dated 03/06/25, revealed a BIMS score of 03, indicating Resident #9 was severely cognitively impaired. The resident required substantial/maximal (staff) assistance with personal hygiene. Review of the facility shower schedule revealed Resident #95 was scheduled to receive showers twice a week, on Tuesdays and Fridays. Review of the shower sheets from March 2025 through 05/20/25 revealed no documentation of showers provided for Resident #95 on 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/18/25, 03/21/25, 03/25/25, 03/28/25, 04/01/25, 04/08/25, 04/15/25, 04/18/25, 04/22/25, 04/25/25, 04/29/25, 05/02/25, 05/06/25, 05/09/25, 05/13/25, 05/16/25, and 05/20/25. 365976 Page 20 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 05/21/25 at 11:17 A.M. with the DON verified Resident #95's showers were not documented as completed. 3. Review of the medical record for Resident #301 revealed an admission date of 03/03/23. Diagnoses included obesity, DM2, HTN, anemia, major depressive disorder, fibromyalgia, anxiety, respiratory disorders, muscle weakness, need for assistance with personal care, and spina bifida. Review of the most recent quarterly MDS assessment, dated 04/08/25, revealed a BIMS score of 14, indicating Resident #301 was cognitively intact. The resident required assistance with personal hygiene. Review of the facility shower schedule revealed Resident #301 was scheduled to receive showers twice a week, on Mondays and Thursdays. Review of the shower sheets from February 2025 through April 2025 revealed no documentation for showers completed for Resident #301 on 02/17/25, 02/20/25, 03/10/25, 03/13/25, 03/17/25, 03/27/25, 03/31/25, 04/03/25, 04/14/25, 04/24/25, and 04/28/25. Interview on 05/21/25 at 11:17 A.M. with the DON verified Resident #301's showers were not documented as completed. 4. Review of the medical record for Resident #35 revealed an admission date of 06/13/23. Diagnoses included metabolic encephalopathy, type two diabetes mellitus (DM2), hepatic encephalopathy, dysphagia, need for assistance with personal care, respiratory disorders, hypertension (HTN), depression, obstructive sleep apnea (OSA), and osteoarthritis. Review of the MDS assessment, dated 03/09/25, revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating Resident #35 was moderately cognitively impaired. Review of the Activities of Daily Living (ADL) Incontinence Care documentation from February 2025 through 05/01/25 revealed no documentation for incontinence care provided for Resident #35 on 02/02/25, 02/04/25, 02/06/25, 02/10/25, 02/11/25, 02/14/25, 02/15/25, 02/17/25, 02/19/25, 02/20/25, 03/01/25, 03/05/25, 03/08/25, 03/09/25, 03/11/25, 03/14/25, 03/16/25, 03/18/25, 03/19/25, 03/20/25, 03/22/25, 03/22/25, 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/29/25, 03/30/25, 04/02/25, 04/03/25, 04/04/25, 04/07/25, 04/08/25, 04/09/25, 04/11/25, 04/12/25, 04/13/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/25/25, 04/27/25, 04/30/25, 05/01/25, 05/02/25, 05/03/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/10/25, 05/11/25, 05/13/25, 05/14/25, 05/15/25, 05/16/25, 05/18/25, 05/20/25, and 05/21/25. Interview on 05/21/25 at 11:17 A.M. with the DON verified the incontinence care provided for Resident #35 was not documented in the resident's medical record. Review of the facility policy titled, Documentation in Medical Record, dated 04/03/25, revealed each resident's medical record shall contain an accurate representation of the resident and include enough information to provide a picture of the resident's progress through completed, accurate, and timely documentation. 365976 Page 21 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility infection tracking records, staff interview and review of the facility policy, the facility failed to ensure residents met infection criteria prior to the initiation of antibiotics. This affected 27 (#10, #11, #12, #18, #19, #24, #25, #26, #27, #30, #37, #40, #48, #50, #56, #62, #63, #64, #66, #69, #71, #75, #82, #88, #89, #102, and #301) of 27 residents reviewed for antibiotic stewardship. The facility census was 96. Residents Affected - Some Findings include: Review of the facility infection tracking records from 12/01/25 through 01/31/25 revealed the facility utilized McGeer's (set of clinical and laboratory findings used to assist in identifying infections requiring antibiotic treatment) criteria to determine appropriate antibiotic usage. Further review revealed the following residents were ordered antibiotics without being reviewed to determine whether the McGeer's criteria for antibiotic use was met: • Resident #66, with an admission date of 09/12/23, was ordered ceftriaxone for a bladder infection on 12/02/24. • Resident #10, with an admission date of 10/10/24, was ordered levofloxacin for a bladder infection on 12/02/24. Resident #10 was also ordered Bactrim for a bladder infection on 01/20/25. • Resident #19, with an admission date of 05/15/24, was ordered doxycycline for a skin infection on 12/02/24. • Resident #25, with an admission date of 02/09/23, was ordered Maxipime for a bladder infection on 12/04/24. • Resident #56, with an admission date of 09/21/18, was ordered Bactrim for a bladder infection and cephalexin for a surgical wound on 12/07/24. Resident #56 was also ordered doxycycline for skin and surgical infections on 12/12/24, and was ordered doxycycline for an elbow infection on 01/16/25. • Resident #75, with an admission date of 06/23/22, was ordered doxycycline for a wound infection on 12/10/24. • 365976 Page 22 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0881 Level of Harm - Minimal harm or potential for actual harm Resident #37, with an admission date of 02/07/24, was ordered cefdinir for a bladder infection on 12/12/24, and was ordered Invanz for a bladder infection on 01/08/25. Resident #37 was also ordered levofloxacin for a bladder infection on 01/09/25. • Residents Affected - Some Resident #88, with an admission date of 10/01/24, was ordered cephalexin for a bladder infection on 12/14/24. • Resident #102, with an admission date of 04/06/23, was ordered cefuroxime for a bladder infection on 12/18/24. • Resident #40, with an admission date of 05/27/18, was ordered doxycycline for a skin infection on 12/21/24. • Resident #27, with an admission date of 12/23/24, was ordered Bactrim for a post-surgical intervention on 12/26/24. Resident #27 was also ordered clindamycin for a post-surgical intervention on 01/03/25. • Resident #26, with an admission date of 03/31/23, was ordered cephalexin for a bladder infection on 01/02/25. • Resident #64, with an admission date of 09/01/21, was ordered doxycycline on 01/03/25 for an infection of the leg, and was ordered Invanz for a bladder infection on 01/22/25. • Resident #71, with an admission date of 06/07/21, was ordered cefdinir for a bladder infection on 01/03/25. • Resident #69, with an admission date of 05/21/22, was ordered cephalexin for a skin infection on 01/06/25. • Resident #62, with an admission date of 12/17/24, was ordered amoxicillin for a bladder infection on 01/11/25. Resident #62 was also ordered Invanz for a bladder infection on 01/30/25. 365976 Page 23 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0881 • Level of Harm - Minimal harm or potential for actual harm Resident #63, with an admission date of 08/28/24, was ordered cefadroxil for a bladder infection on 01/14/25. Residents Affected - Some • Resident #301, with an admission date of 03/03/23, was ordered doxycycline for a lung infection on 01/15/25. • Resident #24, with an admission date of 11/22/23, was ordered doxycycline for a lung infection on 01/21/25. • Resident #48, with an admission date of 07/21/23, was ordered cephalexin for a bladder infection on 01/27/25. • Resident #89, with an admission date of 10/18/24, was ordered doxycycline for a skin infection on 01/28/25. • Resident #12, with an admission date of 01/26/22, was ordered Macrobid for a bladder infection on 01/29/25. • Resident #82, with an admission date of 09/23/23, was ordered doxycycline for blisters on their back on 01/29/25. • Resident #11, with an admission date of 07/03/19, was ordered doxycycline for a lung infection on 01/30/25. • Resident #30, with an admission date of 02/27/21, was ordered doxycycline for a lung infection on 01/30/25. • Resident #50, with an admission date of 12/05/24, was ordered Rocephin for a bladder infection on 01/31/25. 365976 Page 24 of 25 365976 05/21/2025 Providence Care Center 2025 Hayes Avenue Sandusky, OH 44870

F 0881 • Level of Harm - Minimal harm or potential for actual harm Resident #18, with an admission date of 10/10/21, was ordered doxycycline for methicillin-resistant staphylococcus aureus of an unknown origin on an unknown date in January 2025. Residents Affected - Some Interview on 05/21/25 at 8:12 A.M. with Registered Nurse (RN) #590, identified as the facility's infection preventionist, confirmed the facility utilized McGeer's criteria as part of their antibiotic surveillance program and further verified the above residents were ordered antibiotics without the facility determining whether residents met McGeer's infection criteria for antibiotic usage. RN #590 reported the facility was supposed to ensure all residents who were prescribed antibiotics met McGeer's criteria but she did not have time to complete the process for any residents in the months of December 2024 or January 2025. Review of the facility policy titled, Antibiotic Prescribing Practices, dated 03/01/23, revealed antibiotic use protocols were implemented as a part of the facility's antibiotic stewardship program for the purpose of optimizing the treatment of infections and reducing adverse events associated with antibiotic use. 365976 Page 25 of 25