Health inspection·August 7, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure a resident who developed a pressure ulcer was evaluated for a modification of interventions to prevent further pressure ulcers and to enhance healing. This affected one (Resident #26) of two residents reviewed for pressure ulcers. The facility census was 37. Residents Affected - Few Findings include: Review of Resident #26's medical record revealed diagnoses included Alzheimer's disease, osteoarthritis, weakness, and history of breast cancer. A care plan initiated 04/10/23 indicated Resident #26 was at risk for impaired skin integrity related to fragile skin, incontinence, and impaired mobility. Interventions included providing barrier cream/ointment after each incontinent episode, performing skin assessments as ordered and providing pressure reduction devices if ordered. All of the interventions were dated 04/10/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 was severely cognitively impaired, required extensive assistance of two for bed mobility and did not walk. The MDS indicated Resident #26 was at risk for the development of pressure ulcers. No skin and ulcer injury treatments were indicated. Review of a nursing note dated 07/12/23 at 3:33 A.M. revealed Resident #26 was observed to have redness to the buttocks with a small open area to the sacrum area measuring 3.5 centimeters (cm) x 0.5 cm x 0 cm. The area was cleansed and a foam border dressing was applied. The order was for the treatment to be changed every three days and as necessary until the area resolved. Review of a Braden scale assessment dated [DATE] did not reveal a risk for pressure ulcer development. Review of a wound grid dated 07/13/23 revealed the open area was assessed as a stage II (shallow) pressure ulcer to the sacrum measuring 3.56 cm x 0.5 cm x 0.1 cm with 100% epithelial tissue (thin layer of tissue that covers the body). Review of a wound grid dated 07/27/23 revealed the size of the ulcer had decreased to 2.1 cm x 0.5 cm x 0.1 cm. The wound bed was assessed as 100% epithelial tissue with scant serosanguineous drainage (clear, pale red or pink drainage). On 08/02/23 at 8:27 A.M., Resident #26 was observed sitting in a wheelchair without a pressure relief or pressure redistribution surface. State Tested Nursing Assistant (STNA) #604 transferred Resident #26 to bed and verified there was no device to offer pressure relief in the wheelchair. On 08/02/23 at 12:10 P.M. Resident #26 was sitting in the wheelchair in the dining room for lunch with no pressure relief or redistribution device noted. On 08/02/23 between 1:00 P.M. and 1:30 P.M., the Director of Nursing (DON) was interviewed regarding the lack of pressure relief surfaces in Resident #26's wheelchair. The DON stated pressure relief cushions were provided in accordance with physician orders and Resident #26 did not have an order. The DON was interviewed regarding the development of the pressure ulcer with the interventions that were currently in place (minus the treatment order) and how the facility planned to prevent any further pressure ulcers or decline in the pressure ulcer if interventions were not changed. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366218 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she would review the information but generally any resident with skin breakdown had pressure relief cushions. On 08/03/23 at 1:30 P.M., the DON was interviewed regarding the development of the pressure ulcer and stated she understood the concern that although Resident #26 had been assessed as not having a risk for pressure ulcer development on 07/12/23 she developed a pressure ulcer the same day. Staff should have recognized the interventions that had been in place had not been effective in preventing pressure ulcers and Resident #26 should have been evaluated for further additional interventions which would aid in reducing risk for future pressure ulcers/aid in healing of the current pressure ulcer. A cushion had been applied to the wheelchair after the interview on 08/03/23. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144817. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366218 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management 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, record review and interview, the facility failed to provide adequate pain relief for one (Resident #90) of two residents reviewed for pain. The facility census was 37. Residents Affected - Few Findings include: Review of Resident #90's medical record revealed diagnoses including heart failure, chronic obstructive pulmonary disease, type two diabetes mellitus, and anxiety disorder. An admission nursing assessment dated [DATE] indicated Resident #90 was assessed with an unstageable pressure ulcer (full thickness tissue loss in which actual depth of the ulcer is completely obscured) to the sacrum and suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right heel. Pain was assessed using facial scales with a designation it hurt a little more than a little bit. The location of the pain was listed as the coccyx, sacrum with the pain described as pressure/burning. Nothing was listed for alleviation of pain or worsening of pain. A baseline care plan indicated interventions to monitor for pain and report unrelieved pain as indicated. Review of the August 2023 Medication Administration Record (MAR) revealed Resident #90 had received tramadol 25 milligrams (mg) on 08/01/23 at 5:30 A.M. for pain rated a 10 on a scale of 0-10 that was documented as being ineffective. On 08/01/23 at 9:03 A.M., Resident #90 was able to be heard moaning from her bed into the hall while Licensed Practical Nurse (LPN) #107 was preparing routine medications for administration. Resident #90's medications (no pain medication) were administered at 9:03 A.M. Resident #90 was noted with facial consternation. LPN #107 inquired if Resident #90 was in pain. After Resident #90 verified she was in pain, LPN #107 stated she would see if there was anything she could give Resident #90. LPN #107 returned to the med cart to sign off medications and indicated it was too early for Resident #90 to receive pain medication. The Director of Nursing (DON) had approached on an unrelated matter and LPN #107 asked what time the doctor was supposed to be in to do rounds and the DON indicated she did not have a time. On 08/01/23 at 9:45 A.M., LPN #107 was interviewed regarding the MAR indicating Resident #90 had received the ordered pain medication being administered at 5:30 A.M. which was documented as ineffective and Resident #90 remaining in pain. LPN #107 stated that was why she asked the DON when the physician was supposed to visit so she could have the pain addressed. LPN #107 confirmed she could phoned the physician's office instead of waiting on his visit (time unknown). Further review of the August MAR indicated ultram 50 mg was administered on 08/01/23 at 10:36 A.M. with a pain level of 3 recorded. On 08/01/23 at 11:00 A.M., LPN #107 was followed into Resident #90's room and LPN #107 informed Resident #90 she had a stronger dose of ultram for her and proceeded to raise the head of the bed. Resident #90 moaned and grimaced with the movement. On 08/01/23 at 2:46 P.M., Resident #90 was observed lying in bed with a relaxed facial expression, stating the pain medication helped. Resident #90 verified the pain medication given at 5:30 A.M. had been ineffective and described the pain she had been experiencing as terrible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366218 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Auburn Skilled Nursing and Rehab 451 Valley Road Salem, OH 44460 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's Pain Assessment and Management policy (revised March 2015) revealed a resident's pain was to be assessed routinely as needed for acute pain or significant changes in levels of chronic pain or stable chronic pain. Staff were instructed to observe a resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain included verbal expressions such as groaning, crying, and screaming and facial expressions such as grimacing, frowning, clenching of the jaw. Ask the resident if he/she was experiencing pain. Review the medication administration record to determine how often the individual requested and received pain medication and to what extent the administered medications relieved the resident's pain. Reassess the resident's pain and consequences of pain routinely. If pain had not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Significant changes in the level of a resident's pain and prolonged, unrelieved pain despite care plan interventions were to be reported to the physician or practitioner. Event ID: Facility ID: 366218 If continuation sheet Page 5 of 5