Health inspection·September 14, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record review, interview and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed within the 14 day allotted time period following the assessment reference date (ARD). This affected seven residents (#6, #7, #10, #13, #19, #22, #32) of 25 sampled residents. The facility census was 35. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 01/16/20 with the latest readmission of 12/18/20 with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, hypertension, morbid obesity, obstructive sleep apnea, hyperlipidemia, osteoarthritis, chronic pain and congestive heart failure. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/24/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed 2. Review of the medical record for Resident #13 revealed an initial admission date of 07/12/21 with the diagnoses including calcaneal spur, hypertension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease and vitamin D deficiency. Review of the resident's MDS list revealed a comprehensive MDS assessment with the ARD date of 07/12/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed 3. Review of the medical record for Resident #19 revealed an initial admission date of 04/28/22 with the latest readmission of 11/03/22 with diagnoses including vascular dementia, depression, hypertension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease and hearing loss. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 08/07/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed Page 1 of 10 365998 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of the medical record for Resident #32 revealed an initial admission date of 10/20/22 with diagnoses including acute and chronic respiratory failure, cerebral infarction, chronic kidney disease, hypertension, hyperlipidemia, osteoarthritis, anxiety disorder, atrial fibrillation, COVID-19 and edema. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/30/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed 5. Review of the medical record for Resident #7 revealed an initial admission date of 07/31/23 with the diagnoses including generalized muscle weakness, repeated falls, depressive disorder, vertigo, dizziness and giddiness, presence of cardiac pacemaker, hypertension, hypothyroidism, hyperlipidemia, rheumatoid arthritis and muscle wasting and atrophy. Review of the resident's MDS list revealed a comprehensive MDS assessment with ARD 08/25/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed 6. Review of the medical record for Resident #22 revealed an initial admission date of 05/19/23 with the latest readmission of 08/30/23 with the diagnoses including traumatic subdural hemorrhage, COVID-19, vascular dementia with anxiety and mood disorder, diabetes mellitus, acute and chronic respiratory failure, hypertension, hyperlipidemia, heart failure, hypothyroidism, chronic obstructive pulmonary disease, asthma, gastro-esophageal reflux disease and old myocardial infarction. Review of the resident's MDS assessment list revealed a quarterly MDS assessment with an assessment reference date of 08/25/23 still in progress and incomplete. Review of the resident's MDS assessment list revealed a discharge assessment with ARD date of 08/28/23 still in progress and incomplete Review of the resident's MDS assessment list revealed an entry MDS assessment with the ARD of 08/30/23 still in progress and incomplete. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed 7. Review of the medical record for Resident #6 revealed an initial admission date of 06/22/19 with the most recent readmission of 01/11/23 with the diagnoses including COVID-19, pneumonia, acute and chronic respiratory failure, dysphagia, generalized muscle weakness, acute pulmonary edema, major depressive disorder, diabetes mellitus, hypertension, retention of urine, angina pectoris, hypertension, gout, hypothyroidism and disorders of bladder. Review of the resident's MDS list revealed a quarterly MDS assessment with ARD 07/27/23 still in progress and incomplete. 365998 Page 2 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not completed Review of the facility policy titled, MDS Completion and Submission Timeframes, dated 07/17 revealed the facility will conduct and submit resident assessments in accordance with current and federal and state submission timeframes. 365998 Page 3 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure one resident's quarterly Minimum Data Set (MDS) assessment was transmitted to the required state agency. This affected one resident (#17) of 25 sampled residents. The facility census was 35. Residents Affected - Few Findings Include: Review of the medical record for Resident #17 revealed an initial admission date of 04/20/22 with the diagnoses including hyperlipidemia, anemia, pain, gastro-esophageal reflux disease and [NAME] cell carcinoma. Review of the resident's MDS list revealed a quarterly MDS assessment with the ARD date of 07/14/23 not transmitted to the required state agency. On 09/13/23 at 3:23 P.M., interview with the Director of Nursing (DON) verified the MDS was not transmitted to the state agency as required. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated 07/17 revealed the facility will conduct and submit resident assessments in accordance with current and federal and state submission timeframes. 365998 Page 4 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, pharmacy recommendation review, interview, and facility policy review, the facility failed to ensure two residents (#5, #18) pharmacy recommendations were addressed by the physician. This affected two of five residents reviewed for unnecessary medications. The facility census was 35. Findings include: 1. Review of the medical record for Resident #5 revealed an initial admission date of 10/04/22 with the latest readmission of 04/10/23 with the diagnoses including COVID-19, hypertension, pneumonia, major depressive disorder, major depressive disorder, suicidal ideations, traumatic subdural hemorrhage, frontal lobe and executive function deficit following cerebral infarction, seizures, atrial fibrillation, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease (GERD) and arthritis. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the plan of care dated 10/14/22 revealed the resident had GERD related to medication use. Interventions included give medications as ordered, monitor/document side effects and effectiveness, avoid lying down for at least one hour after eating, keep head of bed elevated, encourage to stand/sit upright after meals, monitor vital signs as ordered and record and obtain and monitor lab/diagnostic work as ordered, report results to physician and follow up as indicated. Review of the pharmacy recommendation dated 07/27/23 revealed the pharmacist recommended tapering the medication Reglan 5 mg twice daily with an end goal to discontinue the medication. Further review of the recommendation revealed the physician had not addressed the recommendation. Review of the monthly physician orders for September 2023 identified orders dated 01/24/23 Omeprazole 20 mg by mouth daily for GERD, 01/31/23 Reglan 5 mg by mouth before meals and at bedtime for gastroparesis. On 09/14/23 2:49 P.M., interview with the Director of Nursing (DON) verified the recommendation had not been addressed by the physician. 2. Review of the medical record for Resident #18 revealed an initial admission date of 09/15/17 with the latest readmission of 08/09/22 with diagnoses including low back pain, hypothyroidism, hypertension, urinary incontinence, major depressive disorder, chronic pulmonary edema, diabetes mellitus, gastro-esophageal reflux disease, COVID-19, acute and chronic respiratory failure, dependence on supplemental oxygen, zoster, dysphagia, delusion disorder, mood disorder, dementia, bipolar disorder, chronic obstructive pulmonary disease, cervical disc degeneration, absolute glaucoma, heart failure, cardiomegaly, constipation and osteoarthritis. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the plan of care dated 10/29/17 revealed the resident used psychotropic medications 365998 Page 5 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to major depressive disorder, paranoia, delusions, bipolar disorder and dementia. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness, consult with pharmacy, and/or physician to consider dosage reduction when clinically appropriate and provide non-pharmacological interventions. Review of the monthly physician orders for September 2023 identified orders dated 10/13/22 Risperdal 0.25 mg by mouth daily. Review of the pharmacy recommendation dated 11/15/22 revealed the pharmacist recommended a fasting lipid panel (FLP) due to no record of one on the resident's chart in the past 12 months. The recommendation was not signed or reviewed by the physician. Review of the medical record revealed the FLP had not been obtained. On 09/13/23 at 1:01 P.M., interview with the Director of Nursing (DON) verified the pharmacy recommendation for the FLP was not addressed as well as the FLP not being completed. Review of the facility policy titled, Medication Regimen Review, last revised 08/17/23 revealed the facility should encourage the physician or other responsible parties receiving the medication regimen review (MRR) and the Director of Nursing to act upon the recommendation contained in the MRR. The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any action has been taken to address it. 365998 Page 6 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure one resident's (#5) antihypertensive medications were held when the resident's pulse was below the physician ordered parameter. This affected one of five residents reviewed for unnecessary medications. The facility census was 35. Residents Affected - Few Findings Include: Review of the medical record for Resident #5 revealed an initial admission date of 10/04/22 with the latest readmission of 04/10/23 with the diagnoses including COVID-19, hypertension, pneumonia, major depressive disorder, major depressive disorder, suicidal ideations, traumatic subdural hemorrhage, frontal lobe and executive function deficit following cerebral infarction, seizures, atrial fibrillation, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease and arthritis. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the plan of care dated 10/07/22 revealed the resident had an altered cardiovascular status related to atrial fibrillation, hypertension, hyperlipidemia, edema and orthostatic hypotension. Interventions included administer medications as ordered, encourage low fat, low salt intake, monitor edema, monitor blood pressure via orthostatic blood pressure method per orders and monitor vital signs as ordered, notify the physician of any abnormal findings. Review of the monthly physician orders for September 2023 identified orders dated 01/24/23 for Metoprolol Tartrate 25 mg with the special instructions to give one tablet by mouth twice daily for hypertension and hold if systolic blood pressure (SBP) is less than 110 or pulse less than 60. Review of the resident's Medication Administration Record (MAR) for June 2023 revealed on 06/05/23, 06/12/23, 06/15/23 and 06/28/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. Review of the resident's Medication Administration Record (MAR) for July 2023 revealed on 07/07/23, 07/08/23, 07/09/23, 07/11/23 and 07/12/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. Review of the resident's Medication Administration Record (MAR) for September 2023 revealed on 09/08/23 the resident was administered the medication Metoprolol 25 mg by mouth despite the fact the resident's pulse was less than 60. On 09/14/23 at 8:52 A.M., interview with the Director of Nursing (DON) verified the medication was administered despite the fact the resident's pulse was below the physician ordered parameter of 60. 365998 Page 7 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected one resident (#3) of five residents reviewed for unnecessary medications. The facility census was 35. Findings include: Record review of Resident #3 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: human metapneumovirus, muscle weakness, difficult ambulation, anxiety, depression, atherosclerosis, asthma, OA, sepsis, unspecified dementia with psychotic disturbance, sepsis, hypertension, hyperlipidemia, and constipation. This resident is currently alert to name only with a Brief Interview for Mental status(BIMS) score of three on the most recent Minimum Data Set(MDS) assessment completed on 05/08/23, indicating severe cognitive impairment. Review of physician orders revealed this resident is receiving the following medications: Seroquel 25mg 1 tablet by mouth daily for unspecified dementia with psychotic disturbance. Review of the FDA Black Box Warning for the medication Seroquel revealed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Seroquel is not approved for the treatment of patients with dementia-related psychosis. Interview with the Administrator on 09/13/23 at 11:12 A.M. verified that an inappropriate diagnosis of unspecified dementia with psychotic disorder is being used for the use of Seroquel. 365998 Page 8 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a resident with timely dental care and services. This affected one resident (#27) of one resident reviewed for dental services. The facility census was 35. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed an admission date of 04/28/22 with diagnoses including urinary retention, obstructive and reflux uropathy, type two diabetes mellitus and congestive heart failure. Review of the admission nursing assessment dated [DATE] revealed Resident #27 had his own teeth with caries and broken teeth. Review of the nursing progress notes revealed on 08/24/22 nurse documented Resident #27 went to dentist appointment this A.M. The resident returned with a referral to an oral surgeon related to pacemaker and high risk for complications. The referral was sent to a Facial Surgeon. Review of the plan of care dated 09/08/22 revealed Resident #27 had oral and or dental health problems. The interventions included to coordinate arrangements for dental care and transportation as needed or ordered, provide oral and dental care two times daily and as needed, administer medication as ordered, and monitor for and document any side effects and effectiveness of the medication. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had slightly cognitive impairment with a Brief Interview Mental Status of 12. Resident #27 required assistance with all activities of daily living. Resident #27 had problems with chewing and no mouth or facial pain. A note dated 10/19/22 at 12:06 P.M. a referral was faxed to the University of Cincinnati Oral Surgery and an appointment was scheduled on 01/23/23 at 2:00 P.M. at [NAME] Hospital in Cincinnati. A note dated 01/23/23 at 1:18 P.M. revealed Resident #27 had appointment scheduled at [NAME] Hospital in Cincinnati for consult for teeth extraction. Transport services was to arrive at 11:00 A.M. for a 2:00 P.M. appointment however, did not arrive until 11:30 A.M. At 12:05 P.M. a staff member from the transport services messaged the facility requesting the facility to call [NAME] Hospital and ensure resident would be seen with a 2:30 P.M. arrival time. The hospital stated they would accommodate Resident #27 with a 2:30 P.M. arrival time. The transport services dispatch was notified of the accomodation, and called [NAME] Hospital stating Resident #27 would not be arriving until around 3:00 P.M. At that time [NAME] Hospital was not able to accommodate the late arrival time and and the transport was canceled. [NAME] Hospital dental office called the facility to reschedule the appointment for 02/09/23 at 10:00 A.M. A note dated 02/09/23 at 7:05 A.M. the resident left the facility via Medcare transportation and returned at 1:50 P.M. with follow up appointment scheduled for 06/23/23. A note dated 06/22/23 at 1:33 P.M. the facility had called transport company on 06/16/23 to schedule pick up for appointment. Medcare (transport company) stated they could not transport that early in the morning. Another transport service, Portsmouth Ambulance, was called and stated they did not have a truck in that area that could do the transport. On 06/20/23 the facility contacted Medcare 365998 Page 9 of 10 365998 09/14/2023 Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transport who stated they could do the transport with a pick up of 10:00 A.M. The facility contacted [NAME] Hospital and the appointment could not be moved due to being fully booked. The dental appointment for extraction was rescheduled for 11/15/23 at 1:30 P.M. at [NAME] Hospital in Cincinnati. No documentation related to transport for service scheduled 11/15/23 at 1:30 P.M. Review of the physician orders September 2023 indicated Resident #27 had an appointment on 11/15/23 at 1:30 P.M. with [NAME] Hospital in Cincinnati. Review of the documentation by the State Tested Nursing Assistants (STNA) in the medical record revealed Resident #27 received oral care two times daily but refused at times. An observation on 09/11/23 at 1:22 P.M. of Resident #27 revealed he had poor dental hygiene with caries noted. An interview on 09/11/23 at 1:22 P.M. with Resident #27 revealed he had oral pain at times and was not sure when he last saw a dentist. An interview on 09/14/23 at 12:00 P.M. with the Director of Nursing (DON) revealed the facility had a van for transportation and outings, however, Resident #27 was not able to go far away in the van as he needed ambulance transport due to his medical conditions. Review of the facility policy titled Dental Services dated 12/16 did not address timeliness of care and services or transportation. 365998 Page 10 of 10