Inspection visit

Health inspectionJune 11, 2025

FAIR HAVEN SHELBY COUNTYCMS #36623531 citations on this visit

31 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 31 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure residents were treated with dignity, when staff stood over residents while providing assistance with eating. This affected three (#2, #37, and #41) of three residents reviewed for feeding assistance. The facility census was 62. Findings include: Review of the medical record for Resident #2 revealed and admission date of 11/12/20, with diagnoses of Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a memory problem and cognitive skills were severely impaired. Resident #2 was dependent on staff assistance with all activities of daily living (ADL)s. Review of the care plan dated 12/04/23 revealed the facility will provide and serve meals as ordered and provide adaptive equipment to improve self-feeding skills. Review of the medical record for Resident #37 revealed and admission date of 07/06/20, with diagnoses of Alzheimer's disease with late onset, anorexia, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed the resident has a memory problem, and cognitive skills were severely impaired. Resident #37 was dependent on staff assistance with all ADLs. Review of the care plan dated 07/07/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Review of the medical record for Resident #41 revealed and admission date of 06/16/20, with diagnoses of anorexia, Alzheimer's disease with late onset, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Discharge Return Anticipated MDS, dated [DATE] revealed the resident had a memory problem, and cognitive skills were severely impaired. Resident #41 was dependent on staff assistance with all ADLs. Review of the care plan dated 06/22/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Observation on 06/04/25 at 8:08 A.M., revealed Licensed Practical Nurse (LPN) #290 standing over Resident #37 feeding her. Observation on 06/04/25 at 8:15 A.M., revealed LPN #290 standing over Resident #41 feeding her. Observation on 06/04/25 at 8:16 A.M., revealed Certified Nursing Assistant (CNA) #204 standing over Page 1 of 58 366235 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0550 Resident #2 feeding her Level of Harm - Minimal harm or potential for actual harm Interview on 06/04/25 at 8:20 A.M., with LPN #290 confirmed she was standing over Resident #37 and #41 feeding them breakfast. Interview with LPN #290 confirmed staff should sit down while feeding Resident #37 and #41. Residents Affected - Few Interview on 06/04/25 at 8:20 A.M with CNA #204 confirmed she was standing over Resident #2 feeding her. Interview with CNA #204 confirmed staff should sit down while feeding residents. Review of the undated policy titled Fair Haven Meal Supervision and Assistance, revealed staff should assist with meal feeding as needed to prevent accidents. This deficiency represents the noncompliance investigated under Complaint Number OH00162995. 366235 Page 2 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observations and staff interview, the facility failed to ensure the Survey Book was updated with current surveys and located in an area visible to residents, visitors. This had the potential to affect all 62 residents in the facility. The facility census was 62. Residents Affected - Many Findings include: Observation on 06/03/25 at 8:49 A.M., revealed the Survey Book was located in a corner, by the entrance to the facility, not visible to residents, visitors, or staff members. The Survey Book contained survey information from December 2020. Survey information was not available in the book for surveys completed on 01/21/21, 03/15/21, 03/17/21, 05/13/21, 05/27/21, 06/28/21, 08/16/21, 10/20/22, 12/15/22, 01/17/23, 07/24/23, 09/05/23, 11/13/23, 02/06/24, 02/15/24, 02/26/24, 10/09/24, 11/18/24, 12/30/24, 01/28/25, and 02/04/25. Interview on 06/03/25 at 8:51 A.M., with the Director of Nursing (DON) confirmed the Survey Book was located in a corner, by the entrance to the facility, not visible to residents, visitors, or staff members. Interview also confirmed the Survey Book for residents, visitors and staff to review has not been updated since 12/2020 and survey information was not available in the book for surveys completed on 01/21/21, 03/15/21, 03/17/21, 05/13/21, 05/27/21, 06/28/21, 08/16/21, 10/20/22, 12/15/22, 01/17/23, 07/24/23, 09/05/23, 11/13/23, 02/06/24, 02/15/24, 02/26/24, 10/09/24, 11/18/24, 12/30/24, 01/28/25, and 02/04/25. Interview on 06/09/25 at 5:00 P.M., with the DON confirmed there was not a policy available on Survey Book located or Survey Book update requirements. 366235 Page 3 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 observations, resident and staff interviews, and review of the policy, the facility failed to maintain a homelike environment for the residents. This directly affected two (#28 and #115) of 62 resident rooms observed. The facility census was 62. Findings include: 1. Observation on 06/03/25 at 8:00 A.M., revealed Resident #115 seated in a recliner in her room. The wall to the left, behind the back of the recliner, and to the left of the window, revealed an area round area approximately seven inches, with exposed plaster and a small pile of plaster dust on the floor below it. Interview with Resident #115, at the time of the observation, stated the wall had been like since her admission. 2. Observation on 06/03/25 at 8:55 A.M., revealed both walls in the small hallway leading into the room of Resident # 28 revealed large areas repaired but unpainted to match the wall coloring. Interview on 06/04/25 at 3:10 P.M., with Maintenance #215 revealed he had just finished repairing the walls, and they need sanded and repainted again. Maintenance #215 stated the walls need repaired often. Review of the policy titled Accommodation of Needs and Preference revised March 2020, revealed the facility staff will patch and paint walls between occupancy and updates were completed to damaged room areas as soon as possible. 366235 Page 4 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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, staff interviews, and policy review, the facility failed to ensure medication administered was for an appropriate diagnosis. This affected one (#9) out of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9 had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident #9 was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Resident #9 used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. Review of the monthly Physician Order for June 2025 revealed a start date of 09/17/24 for an order of Quetiapine (Seroquel) 50 milligram (mg) give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and an order for Quetiapine 100 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. Review of the Care Plan dated 01/18/18 revealed Resident #9 was on psychotropic medications including Effexor, Seroquel, Klonopin, Buspar for Anxiety, Psychosis, Bipolar Disorder, dementia with behaviors with interventions to administer medications as ordered, consult with pharmacy, physician to consider dosage reduction when clinically appropriate, and to discuss with physician and family about ongoing need for use of medication. Review of the Pharmacy Reviews dated 06/23/24 through 05/31/25, revealed no recommendations made to discontinue Quetiapine due to improper use for Dementia. Interview on 06/05/25 at 9:43 A.M., with Registered Pharmacist (RPh) #292 stated he does not make recommendations for diagnosis changes on medications. Interview on 06/05/25 at 12:43 P.M., with the Director of Nursing (DON) confirmed Resident #9 is on Quetiapine (Seroquel) 50 mg 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and Quetiapine 100 mg 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. Interview also confirmed dementia is not an appropriate diagnosis for the use of Quetiapine. Review of the undated policy titled, Use of Psychotropic Medication(s), revealed when a psychotropic is used for a diagnosis not indicated, the medication use will be subject to the requirements of 366235 Page 5 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0605 psychotropic medications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366235 Page 6 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the comprehensive assessment was completed accurately to include a diuretic for one (Resident #9) and included falls without injury for one (Resident #40). This affected two (#9 and #40) of five residents reviewed for comprehensive assessments. The facility census was 62. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident # 9 had severe cognitive impairment. Resident used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. There was no diuretic use indicated. Review of the physician orders revealed an order dated 09/17/24 for Furosemide 20 milligram (mg) give one tablet by mouth one time a day related to heart failure. Review of the care plan with a revision date of 06/03/15 revealed Resident #9 was on a diuretic related to hypertension and edema with interventions of administer medications as ordered, physician to review medication for possible dose reduction every three months, monitor for interactions and adverse consequences with other drugs, and report pertinent lab results to the physician. 2. Review of the medical record for Resident #40 revealed an admission date of 05/20/20, with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 has had no falls since admission / entry or reentry or prior assessment without injury. Review of the care plan for Resident #40 revealed a risk for falls with interventions of every two-hour toileting, anti-roll backs on wheelchair, ensure room is free from clutter, and grip strips on floor beside bed. Review of the Unwitnessed Fall report dated 01/15/25 at 3:30 P.M. revealed Resident #40 had a fall without injuries. Review of the Unwitnessed Fall report dated 01/25/25 at 5:50 P.M. revealed Resident #40 had a fall without injuries. Review of the Unwitnessed Fall report dated 03/17/25 at 10:00 P.M. revealed Resident #40 had a fall without injuries. Interview on 06/05/25 at 4:09 P.M. with the Director of Nursing (DON) confirmed the Annual MDS, dated [DATE] for Resident # 9, did not include the use of a diuretic. Interview also confirmed the 366235 Page 7 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0636 Quarterly MDS, dated [DATE] for Resident #40 did not include resident had falls without injuries. Level of Harm - Minimal harm or potential for actual harm Interview on 06/09/25 at 5:00 P.M., with the DON confirmed there is not a policy on a comprehensive assessment being completed accurately. Residents Affected - Few 366235 Page 8 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure the comprehensive care plan was initiated to include contractures. This affected one (#32) of 23 residents reviewed for comprehensive care plans. The facility census was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual MDS dated [DATE] revealed resident was cognitively impaired. Resident #32 is dependent on staff assistance with all Activities of Daily Living (ADLs), except resident does not eat. Review of the care plan dated 03/24/22 revealed had an alteration in musculoskeletal status related to fibromyalgia, muscle spasms, and right below the knee amputation with interventions of Resident #32 will remain free from pain or at a level of acceptable discomfort through the review date. Facility staff will give analgesics as ordered by the physician. Observation on 06/03/25 at 8:26 A.M. revealed Resident #32 laying in bed with right hand contracture noted. No brace or cloth present in resident's right hand. Interview on 06/09/25 at 10:19 A.M., with the Director of Nursing (DON) confirmed Resident #32 does not have a contracture care plan in place. Review of the undated policy titled, Care Plan, revealed each resident will have a comprehensive care plan written that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 366235 Page 9 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure the care plans were updated to reflect the current physician order, change in diagnosis and include interventions. This affected five (#9, #26, #41, #46, and #54) of 23 residents reviewed for care plans. The facility census was 62. Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 09/17/21. Diagnoses include cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively impaired and had impairment of upper extremities. Review of the physician order dated 09/27/24 revealed to gently open right fingers and place a pillow splint in palm with strap over knuckles. Keep in hand at all times, except during hygiene for contracture management. Review of the care plan initiated 11/02/22 revealed to apply the hand splint when in bed and remove in the morning. Interview on 06/09/25 at 8:00 A.M., with Director of Nursing provided verification of the inaccurate care plan, did not address the physician order. Review of the undated policy titled Care Plan Policy, revealed care plans will provide instructions needed to provide effective and person-centers care of the resident that meets professional standards of quality of care. 2. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses that include but not limited to Parkinson's disease, acute kidney failure, hematuria, infection and inflammatory reaction of urethral catheter, urinary retention, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for toileting, dependent for bed mobility and transfers. Resident #26 was coded as having a indwelling catheter, and was incontinent of bowel. Review of the plan of care for Resident #26 dated 10/13/23 revealed use of indwelling supra catheter: urinary retention and hematuria, Interventions include check urinary tubing for kinks every two hours, and as needed (PRN) each shift, monitor and document intake and output as per facility policy, monitor and document for pain and discomfort due to catheter, and monitor/record/report to physician (MD) for signs and symptoms of urinary tract infections. Review of the active June 2025 physician orders for Resident #26 revealed [NAME] oral tablet (Hyoscyamine Sulfate) give 0.125 milligram (mg) by mouth three times a day for bladder spasms dated 05/20/25, change suprapubic catheter 16 French/10 milliliter every four weeks and pro re nata (PRN) dated 10/17/24, provide suprapubic catheter care and cover site with dry dressing twice daily every shift 366235 Page 10 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for protection dated 10/01/24, change urinary drainage bag per facility protocol every night shift every Wednesday for Foley catheter dated 10/02/24, irrigate Foley catheter with normal saline solution to maintain patency as needed for patency and every night shift every Wednesday for patency dated 10/01/24 Review of the physicians consult form dated 04/09/25 revealed the resident went to urologist and supra pubic catheter was changed. Interview and observation completed concurrently on 06/03/25 at 8:30 A.M., with Resident #26 stated he has had the urinary catheter for some time now as he was unable to urinate on his own. Resident #26 states he has spasms related to urinary catheter and follows with urologist. Resident #26 stated sometimes the physician changes it and sometimes the nurses change it. Interview on 06/04/25 at 1:19 P.M., with the Director of Nursing (DON) verified the plan of care did not include the size of the urinary catheter used, irrigation orders, drainage bag changes, dressing changes and medications for bladder spasms and should have. 3. Review of the medical record for Resident #54 revealed an admission on [DATE] with diagnoses including chronic obstructive pulmonary disease, displaced fracture of proximal phalanx of left ring finger, Alzheimer's disease, dementia with severe psychotic disturbances, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed severe cognitive impairment. Resident #54 was not coded with any behaviors. Resident #54 was coded as independent for eating, set up or clean up assistance for toileting, independent for bed mobility and transfers. Resident #54 was coded with fall sustaining a major injury. Review of the plan of care dated 03/25/25 for Resident #54 revealed alteration in musculoskeletal status related to minimally displaced, impacted fracture of left ring finger. Interventions include anticipate and meet needs, ensure call light is within reach and respond promptly to all requests for assistance and give analgesics as ordered. Review of the plan of care for Resident #54 dated 10/13/23 revealed resident was at risk for falls due to confusion, urinary incontinence and psychotropic med use. Interventions include anticipate and meet needs. Review of the fall assessment dated [DATE] revealed Resident #54 was at moderate risks for fall. Review of the fall investigation dated 03/23/25 at 8:00 P.M., for Resident #54 revealed nurse from other unit called to say the resident had fallen. Went to Resident #54 room and resident was sitting on the commode bleeding from skin tears to left thumb and first finger. Resident #54 had bruising to left hand, right palm and thumb. Blood noted on floor beside the bed. Resident #54 was found sitting on the commode by the nursing assistant. Resident #54 stated she used to hands to break the fall. Resident #54 is ambulatory without assist or assistive device. Immediate intervention was documented neurological checks and areas cleaned and steri strips applied. Fall intervention included grip strips next to bed. Review of the fall assessment dated [DATE] revealed Resident #54 was a moderate risk for falls. 366235 Page 11 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the discontinued orders for Resident #54 revealed an order for physical therapy evaluation and treat dated 03/24/25, an order dated 03/27/25 for physical therapy to include thirty sessions in 6 weeks to include therapeutic exercises, therapeutic activity, neurological reeducation for gait training, manual techniques and modalities as needed. an order to apply bunny tape to ring finger and middle finger and wrap around left hand due to swelling and healing for fracture dated 03/25/25 and radiology (X-ray) of left hand due to pain and swelling from fall dated 03/24/25. Review of the progress note dated 03/24/25 at 5:06 P.M. for Resident #54 revealed nurse from another unit brought resident over in chair from other hall way with a skin tear on upper left forearm. Resident is unsure what happened and is worried about what happened to her left hand/fingers. Resident is complaining of pain, Tylenol was administered. Resident also took wrap off of left hand/wrist and tape off fingers. Nurse called and left a voice mail for physician to call back to make aware of situation, and also to get something stronger for pain. Director of Nursing (DON) aware and power of attorney notified. Review of the progress notes dated 03/24/25 at 5:22 P.M. revealed nurse also offered resident ice through out the day for swelling of Left hand and fingers. Resident has refused ice due to not liking the cold or feeling of having ice on her. Observation on 06/03/25 at 10:06 A.M., of Resident #54's room revealed grip strips applied to floor on the side of the bed that is closest to the bathroom. Interview on 06/09/25 at 5:00 P.M., with DON verified the fall interventions were not on the care plan and should have been. Review of the undated policy titled Care Plan Policy, undated, stated each care plan will be reviewed and updated after each quarterly and comprehensive assessment. 4. Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9 had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident #9 was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident #9 was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Resident #9 used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. Review of the care plan with a revision date of 02/04/25 revealed Resident #9 was on prophylactic antibiotic therapy with interventions of administer medication as ordered, monitor for side effects, and report pertinent lab results to physician. Review of the monthly physician orders for June 2025 revealed Resident #9 was not currently taking an antibiotic. Further review of the physician orders revealed an order dated 03/29/25 for Cipro (antibiotic) Oral Tablet 500 milligrams (mg) one tablet two times a day for urinary tract infection (UTI) for 20 administrations. 366235 Page 12 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record for April 2025 revealed Cipro Oral Tablet 500 mg administration was completed on 04/08/25. Interview on 06/05/25 at 4:09 P.M., with the Director of Nursing (DON) confirmed Resident #9 was not on an antibiotic and care plan is inaccurate. Residents Affected - Some 5. Review of the medical record for Resident #41 revealed an admission date of 6/16/20 with diagnoses of anorexia, Alzheimer's disease with late onset, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Discharge Return Anticipated Minimum Data Set, dated [DATE] revealed Resident #41 had severe cognitive impairment. Resident was dependent on staff assistance with all ADLs. Review of the care plan dated 01/16/21 revealed Resident #41 was at risk for bowel elimination problems related to decreased mobility, and history of constipation. Further review revealed the care plan was not revised to include fecal Impaction. Review of the progress note dated 05/14/25 at 6:00 A.M., revealed Resident #41 found with dark brown liquid emesis. Abdomen slightly firm, bowel sounds noted in all four quadrants. Review of the progress note dated 05/14/25 at 2:40 P.M., revealed the physician examined Resident #41 and ordered resident to be sent to the emergency room for evaluation. Review of the progress noted dated 05/17/25 at 8:37 P.M., revealed Resident #41 returned from the hospital after being admitted to the hospital with fecal impaction, manually removed while at the hospital, and a urinary tract infection (UTI). Review of the care plan dated 01/16/21 revealed Resident #41 was at risk for bowel elimination problems related to decreased mobility, and history of constipation. Further review revealed the care plan was not revised to include fecal Impaction. Review of hospital record for 05/14/25 through 05/17/25 revealed resident was seen in the emergency room on [DATE] after having an emesis and then became unresponsive. Emergency notes revealed resident had abnormal urine and dehydration. Resident was started on IV fluids and IV Rocephin and admitted to the hospital. Examine revealed resident's abdomen was distended. Lab results showed urinary tract infection, bowel dilatation and possible stool in rectum. Resident discharged back to the skilled nursing facility on 05/17/25 with diagnosis of fecal impaction in the rectum, constipation, dementia, and urinary tract infection. Review of the facility tasks for bowel continence revealed on 05/08/25, Resident #41 had a medium bowel movement, on 05/09/25 had a small bowel movement, 05/10/25 had two small bowel movements, 05/11/25 had a small bowel movement, 05/12/25 had a small, medium, and large bowel movement, 05/13/25 resident did not have a bowel movement, and on 05/14/25 resident had a small and medium bowel movement. All bowel movements documented were of soft texture. Review of the Medication Administration for Resident #41 record for May 2025 revealed resident did not receive any medications for constipation. Interview on 06/09/25 at 10:19 A.M., with the DON confirmed Resident #41's care plan was not 366235 Page 13 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0657 updated to include the new diagnoses of fecal impaction and UTI. Level of Harm - Minimal harm or potential for actual harm Review of the undated policy titled, Care Plan, revealed each resident will have a comprehensive care plan written that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Residents Affected - Some 366235 Page 14 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and policy review, the facility staff failed to sign out narcotics when administered. This affected seven (#4, #7, #11, #20, #22, #26, and #43) of 62 residents in the facility randomly observed during medication cart review. The facility census was 62. Residents Affected - Some Findings include: Observation on 06/04/25 at 12:59 P.M., of Sycamore Hall medication cart with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 milligram (mg) one (1) tablet signed out during cart inspection and Oxycodone 5 mg 1 tablet signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg 1 tablet signed out during cart inspection. Observation on 06/04/25 at 1:05 P.M., of Sycamore Hall medication cart with RN #262 revealed Resident #7's Lorazepam 0.5 mg count sheet revealed 11 tablets remaining, medication card shows 10 tablets present. Interview on 06/04/25 at 1:05 P.M., with RN #262 confirmed Resident #7's Lorazepam 0.5 mg and Oxycodone 5 mg was signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg was signed out during cart inspection. RN #262 confirmed Resident #7's Lorazepam 0.5 mg count sheet revealed 11 tablets remaining and there was only 10 tablets left on the medication card. RN #262 also revealed it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. RN #262 stated the narcotic count was correct at the start of the shift. Observation on 06/04/25 at 3:19 P.M., with Licensed Practical Nurse (LPN) #201 of Walnut Lane medication cart revealed Resident #20 Alprazolam 0.5 mg 1 tablet signed out during cart inspection, Resident #4's Pregabalin 100 mg 1 tablet signed out during cart inspection, Resident #11's Tramadol 50 mg 1 tablet signed out during cart inspection, Resident #22's Tramadol 50 mg 1 tablet signed out during cart inspection, and Resident #43's Hydrocodone / APAP 5/325 mg 1 tablet signed out during cart inspection. Interview on 06/04/25 at 3:29 P.M., with LPN #201 confirmed she failed to sign out Resident #20 's Alprazolam 0.5 mg, Resident #4's Pregabalin 100 mg, Resident #11's Tramadol 50 mg, Resident #22's Tramadol 50 mg, and Resident #43's Hydrocodone / APAP 5/325 mg, until during cart inspection. LPN #201 stated it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. Interview also confirmed the narcotic count was correct at the start of the shift. Interview on 06/04/25 at 2:40 P.M. with the Director of Nursing (DON) confirmed it is the expectation of the facility that all narcotics are signed of at the time of the narcotic being pulled out of the medication cart. Interview also confirmed RN #262 has been pulled off the floor. Review of the undated policy titled, Medication Administration Systems And Scheduled Medication Administration Times, revealed all medications are safely and accurately administered and documented by appropriately trained and authorized personnel in accordance with applicable state and federal regulations. 366235 Page 15 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 medical record review, staff interview, observations and policy review, the facility failed to ensure dependent residents were provided personal hygiene. This affected two (#26 and #45) residents reviewed for activities of daily living (ADL). The facility census was 62. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses that include but not limited to Parkinson's disease, syncope and collapse, pacemaker, bulbous pemphioid, orthostatic hypotension, acute kidney failure, infection and inflammatory reaction of urethral catheter, urinary retention, anxiety disorder, atria fibrillation, bradycardia, depression, hypertension, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for oral hygiene, dependent for toileting, dependent for shaving, dependent for bed mobility and transfers. Resident #26 was not coded for any rejection of care or behaviors. Review of the plan of care for Resident #26 dated 09/14/23 and last revised on 12/12/23 revealed resident had impaired activities of daily living (ADL) self performance related to sepsis, urinary tract infections, acute kidney injury, Parkinson's, urinary retention, hematuria, anxiety, atrial fibrillation, bradycardia, chronic kidney disease, dementia, and depression. Interventions include assess/record self-care status changes, boost very high calorie as ordered, ensure that call light is kept within reach, magic cup as ordered, monitor need for consultation and provide treatment as ordered: physical and occupation therapy, oral care at least daily and as needed (PRN), provide adaptive/safety equipment: wheelchair, report significant changes in ADL status to physician, showers one to two times per week and PRN, transfer using Hoyer lift. Review of Resident #26 Kardex (electronic document for residents patient details and care plans) was silent for any information related to shaving. Observation on 06/02/25 at 12:07 P.M., of Resident #26 revealed resident had facial hair and had not been recently shaved. Review of the Current Care Record for Resident #26 revealed staff signed personal hygiene as completed on 06/02/25 at 3:55 A.M., 1:59 P.M., and 9:59 P.M. Observation and interview on 06/03/25 at 8:26 A.M., with Resident #26 stated he was not shaved yesterday and would like to be shaved today. Resident #26 reported that his face is itchy. Interview on 06/02/25 at 4:30 P.M. with Licensed Practical Nurse (LPN) #200 verified Resident #26 did not appear to have been shaven today and would ask staff to complete task. LPN #200 verified resident was not able to shave himself and was dependent on staff. Observation on 06/09/25 at 4:00 P.M. of Resident #26 revealed resident had not been shaven recently. 366235 Page 16 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the Current Care Record for Resident #26 revealed staff signed personal hygiene as completed on 06/09/25 at 2:07 A.M. and 7:38 A.M. Interview with Resident #26 at 06/09/25 at 4:03 P.M. states that he was not shaved on his neck area and that is the part that is very itchy. Residents Affected - Few Interview on 06/09/25 at 4:45 P.M. with LPN #238 verified the hair on his neck and some areas on his face appeared to be longer than other areas of his face. LPN #238 stated she would have staff assist with shaving as he is unable to do that part of his care independently. 2. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses that include cardiac arrhythmia, asthma, dementia with behaviors, psychotic disorder with delusions, Alzheimer's disease with late onset, major depressive disorder with severe psychotic symptoms, type two diabetes, and persistent mood disorder. Review of the quarterly Minimum Data Set assessment dated [DATE], for Resident #45 revealed severe cognitive impairment. Resident #45 was coded with other behavioral symptoms not directed towards others occurring 1-3 days in the assessment period. Resident #45 requires set up or clean up assistance for eating, dependent for toileting and transfers, maximal assistance for bed mobility and personal hygiene. Review of the plan of care for Resident #45 dated 05/04/22 and revised on 05/17/22 revealed resident had impaired ADL self performance related to bradycardia, atria fibrillation, anemia, weakness, arthritis and dementia. Interventions included anticipate and meet needs in a timely manner, assess and record self care status changes, oral care daily, showers one to two times a week and transfers with stand up lift. Observation on 06/02/25 at 10:32 A.M. of Resident #45 revealed resident had facial hair growth and was not shaved recently. Review of the electronic Kardex for Resident #45 was silent for any staff direction related to shaving. Review of the Current Care Record for Resident #45 revealed personal care task was signed as completed on 06/02/25 at 2:33 A.M., 11:44 A.M., and 8:25 P.M. Interview on 06/02/25 03:46 P.M., with LPN #426 verified Resident #45 appeared to have not been shaven. LPN #426 verified Resident was dependent on staff for shaving. Request for facility policy related to shaving was requested during the survey and not provided for review. 366235 Page 17 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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** Based on observation, medical record review, staff interview, and review of the policy, the facility failed to ensure a Resident #46 reviewed for activities of daily living, had a hand splint applied as ordered. The facility further failed to ensure wound assessments were completed for a non pressure sore for Resident #40. This affected two (#40 and #46) of 21 residents reviewed for quality of care. The facility census was 62. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 09/17/21. Diagnoses include cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively impaired and had impairment of upper extremities. Review of the physician order dated 09/27/24 revealed to gently open right fingers and place a pillow splint in palm with strap over knuckles. Keep in hand at all times, except during hygiene for contracture management. Review of the care plan initiated 11/02/22 revealed to apply the hand splint when in bed and remove in the morning. Observations on 06/02/25 from 8:30 A.M. to 3:00 P.M., on 06/03/25 from 9:30 A.M. to 2:45 P.M., on 06/04/25 from 9:00 A.M. to 2:00 P.M., and on 06/09/25 at 8:20 A.M., revealed Resident #46 had no splint applied to his right hand. The hand was in a contracture position. Interview on 06/09/25 at 8:20 A.M., with Licensed Practical Nurse (LPN) #201 revealed the hand splint was not in Resident #46's hand. Review of the policy titled Brace Care (Care of Resident with Brace) policy and Procedure, dated 03/07/18, revealed a resident with a brace will receive appropriate care and monitoring. Apply the brace as prescribed at the prescribed time. 2. Review of the medical record for Resident #40 revealed an admission date of 05/20/20, with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident #40 was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident #40 required set-up assistance with oral hygiene and bathing. Resident #40 required partial assistance with transfers. Resident #40 required substantial assistance with dressing and personal hygiene. Resident #40 did not have a pressure ulcer or a venous ulcer. Review of the physician orders dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical) apply to second left toe topically daily pain / swelling / 366235 Page 18 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0684 redness until healed. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 02/05/25 revealed Resident #40 had a reddened, painful and edematous area to the left second toe needing monitoring with interventions of encourage good nutrition and hydration in order to promote healthier skin, Gentamycin cream as ordered, follow facility protocols for treatment of injury Residents Affected - Few Review of the progress notes revealed no documentation related to wound on Resident #40's left second toe. Further review of the medical record revealed no assessments, including wound measurements, appearance, interventions or treatments. Observation on 06/05/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #201 revealed an unopened scabbed wound approximately 1.5 centimeter (cm) long x 0.8 cm wide to resident's left second toe. Interview with LPN #201, at the time of the observation, confirmed the wound should be measured on the weekly assessment, and should be documented in the nurse's process notes, but she is not sure if it is. Interview also confirmed Resident #40 is not seen by the Wound Nurse Practitioner. Interview also confirmed she is not sure of what the policy says. Interview on 06/05/25 at 12:43 P.M., with the Director of Nursing confirmed there are no wound assessments completed for Resident #40's left 2nd toe. Interview also confirmed it is the expectation of the floor nurses to assess wounds weekly and document any changes including size of the wound. Review of the policy titled, Wound Care Policy, dated 07/19/15, revealed any impairment in skin will be assessed and documented. The scheduled nurse will assess the wound each shift until the wound is healed. 366235 Page 19 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 medical record review, staff interview, nurse practitioner interview, observations and policy review, the facility failed to ensure identified wounds were assessed, measured and documentated on discovery and pressure relieving devices were in place. This affected three (#1, #13, and #49) of three residents reviewed for pressure ulcers. The facility census was 62. Residents Affected - Few Findings include: 1. Medical record review for Resident #13 revealed an admission on [DATE], with diagnoses including but not limited to heart failure, methicillin resistant staphylococcus aureus, local infection of the skin, Alzheimer's disease, major depressive disorder, dementia, abnormal weight loss, corns and callosities, peripheral vascular disease, hammer toes, atrial fibrillation, chronic obstructive pulmonary disease, stress incontinence and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed intact cognition. Resident #13 is independent for eating, dependent for toileting, dependent for bed mobility, and dependent for transfers. Resident #13 was coded as having a pressure injury, formal assessment and clinical assessment for risk determination revealed resident was at risk. Resident #13 was coded with one unstageable pressure ulcer not present on admission. Review of the plan of care dated 05/06/25 revealed Resident #13 had edema to right knee and ankle with interventions to include administer medications as ordered, elevate legs when in bed and chair, monitor laboratory tests and report significant assessment dated to physician. Review of the plan of care for Resident #13 revealed impaired activities of daily living related to weakness, mobility impairment and dementia, non compliance, and anxiety. Interventions to include anticipate and meet needs, assess/record self care status changes, boost very high resource as ordered, call light within reach, Megace as ordered, pro-stat as ordered, wheelchair, and transfers with Hoyer lift. Review of the plan of care for Resident #13 dated 05/11/17 revealed resident refuses medication at times related to panic disorder, paranoia, agitation and anxiety. Interventions include allow resident to make decisions about treatment regime, to provide sense of control, educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Review of the plan of care for Resident #13 dated 05/20/25 revealed pressure ulcer to right heel (stage 3) with interventions that include administer treatments as ordered, monitor for effectiveness, blue boots to bilateral heels, consult with wound nurse, monitor dressing every shift, monitor nutritional status and record intake, monitor and report to physician changes in skin status, appearance, color wound healing, signs and symptoms of infection, wound size and stage, pressures reduction for bed and chair. Review of the Braden scale for predicting pressure sore risk completed on 05/08/25 for Resident #13 revealed resident was at risk with a score of 15. Review of the monthly physicians orders for June 2025, for Resident #13 revealed a treatment to right heel. Cleanse with normal saline and pat dry. Apply medihoney and silicone foam dressing daily to 366235 Page 20 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right heel wound dated 05/30/25; an order for Wound/Burn Dressing External Gel apply to affected area topically as needed for wound daily; blue boots to bilateral feet to prevent further breakdown to heels every shift when in bed dated 05/16/25, skin prep to left heel for prevention of breakdown every day dated 05/17/25, Pro-Stat Oral Liquid (promotes wound healing supplement) give 30 milliliters by mouth two times a day dated 02/28/25, and weekly skin assessment with shower every night shift every Friday for weekly skin check dated 10/04/24. Review of the progress note dated 05/15/25 at 10:03 P.M., for Resident #13 revealed physician was notified that resident somewhat lethargic tonight, not her normal self, vitals assessed. Resident noted to have a low grade temperature, along with low oxygen saturation. Resident #13 was given Tylenol, and oxygen applied via nasal cannula at two liters per minute. Review of the progress note dated 05/15/25 at 10:20 P.M. for Resident #13 revealed resident family was notified of Resident #13 change in condition. Review of the progress notes for Resident #13 dated 05/16/25 at 5:04 P.M. revealed the right heel with an open area with scab. Zero redness to peri wound and zero drainage. Silicone dressing applied and cover with Kerlix everyday until healed. Left heel soft and pink. Skin prep to heel everyday was ordered. Bilateral boots to feet when in bed. Resident's representative was notified of areas and new orders. Review of the progress notes for Resident #13 dated 05/16/25 at 5:28 P.M. revealed the physician was notified of areas and nursing interventions in place. Review of the progress notes for Resident #13 dated 05/17/25 at 2:45 P.M. revealed the physician was notified of right foot edema, redness, and warm to the touch. Review of the wound nurse practitioner initial wound evaluation dated 05/29/25 for Resident #13 revealed resident had one pulse edema to right lower leg and foot, weakness, and confusion. Wound to right posterior heel was assessed and staged a pressure ulcer Stage 3 with measurements of 0.6 centimeters (cm) x 0.7 cm x 0.2 cm. Wound description was documented as initially covered with yellow slough and draining small to moderate amount of serosanguinous drainage. Sharp debridement of the majority of the slough. No acute signs and symptoms of infections and palpable pulses to the right lower extremities. Review of the progress note for Resident #13 dated 05/29/25 at 2:59 P.M. revealed Resident #13 consented to seeing wound clinician from local hospital and was seen today for area on right heel. New orders to apply medi-honey and silicone foam daily to right heel wound. Wound assessed and staged a pressure ulcer Stage 3 with measurements of 0.6 centimeters (cm) x 0.7 cm x 0.2 cm. Wound description was documented as initially covered with slough and was able to remove the majority of the slough with sharp debridement, no acute signs and symptoms of infections and palpable pulses to the right lower extremities. Observation on 06/03/25 at 7:22 A.M., of Resident #13 revealed resident in bed with night clothing on, appears to be sleeping, dressing to right foot in place clean and dry, and blue pressure reducing boots in place. Interview on 06/03/25 at 3:57 P.M., with Director of Nursing (DON) verified the nurse that found the open area did not document any measurements in the electronic health record and should have. DON 366235 Page 21 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further states that she was just seen by the wound nurse and will have potentially a photo of what the wound looks like. DON stated they did not know what the wound was initially due to the location of the wound was not over a bony prominence. DON stated the resident had been sleeping in her easy chair per her preference until she had a short illness and has just been recently sleeping in her bed. Additionally, the DON stated that she makes rounds with the wound nurse practitioner weekly and area to right heel is improving. Observation on 06/05/25 09:30 A.M., of Resident #13 sitting in her wheelchair with pressure reduction cushion in place to seat of chair. Resident #13 had non skid socks on bilateral feet with observable dressing to right foot. Interview on 06/05/24 at 10:00 A.M., with Nurse Practitioner (NP) #425 for wound care stated she was notified to visit Resident #13 related to wound to right foot and determined it was a stage three due to the circular shape of the wound. NP #425 verified the wound was not in a usual location for pressure ulcer development as it was located laterally on the heel and not over a bony prominence. NP #425 stated the wound is healing without signs and symptoms of infection and could be related to the sleeping arrangements prior to her recent illness. NP #425 stated the wound was considered unavoidable. 2. Medical record review for Resident #49 revealed an admission dated 02/10/25, a discharge on [DATE] and a readmission on [DATE], with diagnoses including chronic embolism and thrombosis of deep veins of left lower extremity, methicillin resistant staphylococcus aureus infection, fracture of superior rim of pubis, urinary track infection, cerebral infarction, acute kidney failure, chronic myeloproliferative disease, depression, hypothyroidism. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #49 revealed moderately impaired cognition. Resident #49 required set up or clean up assistance for eating, dependent for toileting, maximal assistance for bed mobility, and dependent for transfers. Resident #49 was coded at risk for developing ulcers and has one unstageable pressure ulcer no present on admission. Resident #49 was coded with infection on the foot. Review of the Care Area assessment dated [DATE] revealed unstageable pressure ulcer to right heel with current methicillin-resistant staphylococcus aureus (MRSA) infection. Antibiotic therapy as ordered and isolation precautions in place. Resident #49 has bruising to Left elbow, left antecubital space, left hand as noted on admission assessment. Resident #49 requires assistance with bed mobility as triggered above and is frequently incontinent of bladder and bowel. Resident #49 receives Eliquis which can increase risk for bleeding and bruising and Remeron to stimulate appetite. Review of the plan of care for Resident #49 dated 02/10/25 revealed resident had a fall with fracture to the pubic [NAME] on the superior and inferior rim that was non-operatable. Review of the plan of care for Resident #49 revealed Infection of right heel wound dated 05/13/25. Interventions include administer antibiotic as per medical doctor (MD) orders, maintain universal precautions when providing resident care, monitor temperature/pulse as clinically indicated, monitor/document/report to MD signs and symptoms of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. Review of the plan of care for Resident #49 dated 02/12/25 revealed resident is at risk for skin 366235 Page 22 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breakdown/pressure area formation related to recent pubic [NAME] fracture with limited mobility, chronic leukemia, hypertension, acute kidney failure, long-term use of anticoagulants Interventions included medications as ordered, blue boot to left foot when in bed or chair, educate resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, encourage and/or assist to turn and reposition frequently, evaluate/record changes in skin status, follow facility policies for the prevention of skin breakdown, minimize pressure to bony prominence, pad with appropriate device or pillows, monitor nutritional status, serve diet as ordered, monitor intake and record, pressure reduction devices for bed/chair and provide wound care clinician as needed. Review of the admission progress note dated 02/10/25 for Resident #49 revealed no skin issues were documented. Review of the Braden scale for Resident #49 dated 02/10/25 for Resident #49 revealed resident was at risk for the development of pressure ulcers. Review of the progress note dated 02/17/25 at 8:46 A.M. for Resident #49 revealed care given and staff noted a purple discoloration to right heel. Skin prep ordered everyday to bilateral heels as a preventative measure for breakdown and blue boots to bilateral feet when in bed. Review of the active physician orders for Resident #49 revealed Doxycycline Hyclate Oral Tablet 100 milligram (mg) give 1 tablet by mouth two times a day for heel wound until 06/12/25, dated 05/30/25; an order dated 05/28/25 for Pro-Stat Oral Liquid give 30 milliliters (ml) by mouth three times a day for due to wound on right heel, an order dated 05/23/25, an order for right heel cleanse with normal saline (ns) and pat dry. Apply Silver Alginate to wound only. Cover with Silicone bordered foam and wrap with kerlix, every day, and moon boot to right foot when in bed or chair very shift for right heel wound dated 03/13/25. Review of the Braden scale dated 05/12/25 for Resident #49 revealed resident was at moderate risk for the development of pressure ulcers. Review of the admit/ readmit screener assessment dated [DATE] for Resident #49 revealed right heel pressure ulcer without any measurements. Review of the hospitalization for Resident #49 dated 05/12/25 revealed resident was treated for a deep vein thrombosis and refused any follow up treatment. Right heel wound was cultered and tested positive for MRSA infections. Facility wound NP also followed Resident #49 at the hospital. Review of the Current Care for Resident #49 revealed resident is being assisted with turning and repositioned every shift. Observation on 06/04/25 at 9:31 A.M. with Registered Nurse (RN) and Resident #49 during wound dressing change to right heel revealed old dressing was removed and the wound was cleaned with normal saline. Observation of the wound revealed open area to posterior heel measuring approximate 7 centimeters (cm) x 5 cm by 0.3 cm, wound bed beefy red granulating tissue with small areas of green adherent slough. Pressure relieving mattress was in place and resident had blue moon boots on as ordered. Interview on 06/05/24 at 10:00 A.M., with Wound NP #425 states Resident #49 was a previous patient at the facility. Resident #49 diagnoses with myloproliferative neoplasic leukemia and underwent 366235 Page 23 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chemotherapy and then went into hospice care. Resident #49 fell at home and was hospitalized with inoperatable fractures and returned to the facility in February for skilled services in an attempt to return home with hospice services. Wound NP states the resident refused all interventions for treatment at the hospital for DVT and was returned to the facility. Wound NP #425 stated the current wound to her right heel was unavoidable in her opinion due to her overall health complexities. Interventions have been in place on each visit as ordered and she has no concerns related to the care and treatment of the heel wound. Interview on 06/05/24 at 3:10 P.M., with the Director of Nursing verified the wound when found by the facility staff in February was not measured and documentated as it should have been. Review of the facility policy titled Skin Care Prevention dated 09/12/09, revealed all residents will have full body skin assessments completed on admission and readmission. Weekly skin assessments will be conducted 3. Review of the medical record for Resident #1 revealed an admission date of 10/29/15, with diagnoses of Alzheimer's disease, peripheral vascular disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 required set-up assistance with eating and was dependent on staff assistance with all other activities of daily living, including dressing. Resident #1 was at risk for developing pressure ulcers. Review of the physician orders revealed an order dated 10/01/24 for blue boots (pressure relieving devices) to bilateral lower extremities every shift for pressure reduction while in bed. Review of the care plan dated 10/29/15 revealed Resident #1 was at risk for skin breakdown and pressure area formation related to decreased mobility with an intervention of blue boots while in bed. Further review of the care plan dated 04/13/25 revealed Resident #1 had a blanchable purple area to the right heel and needs monitoring with interventions of monitor / document location, size and treatment of skin injury. Report abnormalities to the physician. Observation on 06/03/25 at 6:36 A.M. revealed Resident #1 was asleep in bed. Blue heel lift boots were laying in resident's wheelchair. Observation on 06/03/25 at 2:05 P.M. revealed Resident #1 was asleep in bed. Blue heel lift boots were laying in resident's wheelchair. Interview on 06/03/25 at 2:07 P.M., with Registered Nurse (RN) #252 confirmed Resident #1 was in bed and did not have her blue boots on all day while in bed. Interview also confirmed Resident #1 should have had blue heel boots on while in bed. Review of the policy titled, Skin Care Prevention Protocol Policy dated 09/12/09, revealed the facility will identify residents with a high risk of developing pressure sores and will implement interventions to prevent the occurrence of pressure sores. 366235 Page 24 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to ensure the correct liquid nutritional liquid tube feeding supplement was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively impaired and was dependent on staff assistance with all activities of daily living (ADLs), except resident did not eat. Resident used a peg tube for feeding. Review of the care plan dated 03/23/22 revealed resident was tube feeding dependent with interventions to change feed container and tubing every 24 hours and resident was dependent on staff for tube feeding and water flushes. See physician orders for current feeding orders. Review of the physician order dated 04/22/25 revealed an order for Peptamen Oral Liquid (Nutritional Supplements) give 83 milliliters (ml) an hour via Peg-Tube every shift for weight monitoring. Observation on 06/03/25 at 8:25 A.M. revealed Resident #32 tube feeding machine on and running 83 ml of a tan substance her hour via Peg-Tube. Bag has the date of 06/03/25 but is not labeled with the actual contents in the peg tube feeding bag. A bottle of Peptamen Oral Liquid 1.5 kcals (Nutritional Supplements) was sitting on bedside table. Observation on 06/04/25 at 12:44 P.M. revealed the unlabeled tube feeding was still running and a bottle of Peptamen Oral Liquid 1.5 kcals (Nutritional Supplements) was sitting on bedside table. Interview on 06/04/25 at 12:44 P.M. with Registered Nurse (RN) #262 confirmed Resident #32 tube feed bag was not labeled with what the contents in the bag was. Interview confirmed the bag is to be labeled with what the contents are. RN #262 confirmed the physician order for Peptamen Oral Liquid (Nutritional Supplements) give 83 ml via Peg-Tube every shift for weight monitoring was what should be in the tube feed bag that wasn't labeled. RN #262 confirmed Resident #32's tube feeding as Peptamer 1.5. kcals. Interview also confirmed the physician's order was for Peptamen Oral Liquid (Nutritional Supplements) give 83 ml via Peg-Tube every shift for weight monitoring. Interview confirmed Resident #32 is not receiving what the physician order says. Interview also confirmed there are three different Peptamen formulas available and that the current Peptamer 1.5. kcals does not match the physician's order dated 04/22/25. Interview also confirmed the physician should have been contacted for order clarification and had not been contacted. Interview on 06/09/25 at 10:19 A.M. with the Director of Nursing (DON) confirmed Resident #32 tube feeding order should match what was administered. Review of the undated policy titled, Medication Administration, revealed all medications will be checked for the right dose. 366235 Page 25 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure tube feeding container was labeled with what solution was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility censes was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 ,with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and was dependent on staff assistance with all activities of daily living (ADLs), except resident did not eat. Resident used a peg tube for feeding. Review of the care plan dated 03/23/22 revealed resident was tube feeding dependent with interventions to change feed container and tubing every 24 hours and resident was dependent on staff for tube feeding and water flushes. See physician orders for current feeding orders. Review of the physician order dated 04/22/25 revealed an order for Peptamen Oral Liquid (Nutritional Supplements) give 83 ml an hour via Peg-Tube every shift for weight monitoring. Observation on 06/03/25 at 8:25 A.M., revealed Resident #32 tube feeding machine on and running 83 ml of a tan substance her hour via Peg-Tube. The tube feeding bag had the date of 06/03/25, with out a label with the actual contents of the peg tube feeding bag. Interview on 06/04/25 at 12:44 P.M., with Registered Nurse (RN) #262 confirmed Resident #32 tube feed bag was not labeled with what the contents in the bag was. RN #262 confirmed the bag is to be labeled with what the contents are. RN #262 confirmed the physician order for Peptamen Oral Liquid (Nutritional Supplements) give 83 ml via Peg-Tube every shift for weight monitoring was what should be in the tube feed bag that wasn't labeled. Interview on 06/09/25 at 10:19 A.M., with the Director of Nursing (DON) confirmed Resident #32 tube feeding bag should be labeled with what the bag contains. The DON confirmed there is not a policy on labeling a tube feeding bag. 366235 Page 26 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 the medical record review, staff interviews, and policy reviews, the facility failed to address complaints of pain when reported. Additionally, the facility failed to monitor the effectiveness of routine pain medication. This affected one resident (#12) of two residents revealed for pain management. The facility census was 62. Residents Affected - Few Findings include: Medical record review for Resident #12 revealed an admission on [DATE], with diagnoses including but not limited to heart failure, atrial fibrillation, hearing loss, peripheral vascular disease, insomnia, chronic kidney disease, rheumatoid arthritis, dementia, hypertension, osteoarthritis, anxiety disorder, and congestive heart failure. Review of the Annual Minimum Data Set assessment dated [DATE] for Resident #12 revealed resident was cognitively intact. Resident had no behaviors. Resident was independent with eating, dependent with toileting, supervision for bed mobility and transfers. Resident #12 received routine pain medication. Resident #12 reported pain in the last five days, frequency of pain reported almost constantly, pain frequently effecting sleep, pain rarely or not at all interfering with day to day activities and pain intensity was rated seven on a scale of one to ten. Review of the plan of care for Resident #12 dated 07/29/21 revealed resident was at risk for pain related to rheumatoid arthritis, osteoarthritis and bilateral lower extremities wounds. Interventions included anticipate need for pain relief and respond promptly to any complaint of pain, evaluate the effectiveness of pain interventions after initiation or administration, provide, monitor for effectiveness of, and document, non medication interventions for pain prior to administration of analgesics. Review of the active physician orders for Resident #12 revealed an order dated 03/13/25, for prednisone oral tablet five milligrams (mg) give one tablet by mouth one time a day for arthritis; an order dated 09/17/2024, for diclofenac gel (pain relieving gel) apply to bilateral knees topically as needed for pain three times a day; an order dated 09/17/24, for rolamine salicylate 10 percent cream apply to affected areas topically as needed for pain twice daily as needed; an order dated 09/17/24, for lidocaine four percent patch over the counter apply to right shoulder topically two times a day for arthritis pain, apply patch in am in remove patch at bedtime; an order dated 09/17/24, for tramadol 50 mg give one tablet by mouth four times a day for pain; and an order dated 09/17/2024, for Tylenol 325 milligrams, give 1 tablet by mouth four times a day for pain and give two tablet by mouth every six hours as needed for pain. Review of the pain assessment dated [DATE] at 1:00 P.M., for Resident #12 revealed resident had pain in the last five days, that pain was constant in the last five days, that pain made it hard for the resident to sleep and resident rated the pain as a seven on a scale of one to ten. Review of the progress notes for Resident #12 dated 04/11/25 was silent for any documentation for pain management. Review of the Medication Administration Record for Resident #12's month of April 2025 revealed resident was not provided with any as needed pain medications on 04/11/25. 366235 Page 27 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Treatment Administration Record for Resident #12's the month of April 2025 revealed resident was not provided with any as needed topical creams on 04/11/25. Interview on 06/02/25 at 10:50 A.M., with Resident #12 stated she has had arthritis for years and her hands especially just ache at times. Resident #12 reports that pain is manageable, but have had periods in the past that my hands just ache and pain medications do not help. Resident #12 reported that facility staff do not routinely ask her if she is having pain. Interview on 06/05/25 at 11:01 A.M., with Licensed Practical Nurse (LPN) #217 stated the medication administration record does not have a place to document routine pain monitoring. LPN #217 stated she will ask the patient if they are having any pain and will document the level of pain identified by the patient when an as needed (prn) medication has been administered, but can not document that without PRN administration. Interview on 06/09/25 at 10:30 A.M., LPN #426 stated the facility does not document any pain effectiveness on a routine basis, only when a PRN medication has been given. Interview on 06/09/25 at 3:45 P.M., with Director of Nursing (DON) verified at the time of the pain assessment conducted on 04/11/25 at 1:00 P.M., no as needed pain medication was administered. Additionally, the DON verified the facility does not routinely monitor for pain on a daily bases. Review of the undated policy titled Pain Management Policy, stated under number seven: facility staff will reassess resident's pain management for effectiveness and or adverse consequences. This deficiency represents the noncompliance investigated under Complaint Number OH00162889. 366235 Page 28 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure daily nurse staffing was posted daily and readily available for residents and visitors at any given time. This had the potential to affect all 62 residents. The facility census was 62. Residents Affected - Many Findings include: Observation on 06/03/25 at 8:46 A.M., with the Director of Nursing (DON) revealed the Nurse Staffing Posting was not posted as required. Interview on 06/30/25 at 8:47 A.M., with the DON confirmed Nurse Staffing is usually posted in the employee breakroom daily. The DON confirmed there was not any Nurse Staffing posted and when posted it is in the employee breakroom, not a prominent area readily accessible to residents, staff, and visitors. Interview on 06/09/25 at 5:00 P.M., with the DON confirmed there is not a policy available for Nurse Staffing posting. 366235 Page 29 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interviews, the facility failed to ensure the care plan was followed for dementia treatment when the facility failed ensure medications being used was for dementia and an attempt to reduce the use of psychoactive medication was made. This affected one (#9) of four residents reviewed for dementia care. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set assessment, dated 03/09/25 revealed had severe cognitive impairment. Resident had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Review of the Physician Order dated 09/17/24 revealed an order for Quetiapine 50 milligram (mg) give one (1) tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation, an order for Quetiapine 100 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation, an order for Venlafaxine Extended Release (XR) 75 mg 1 capsule by mouth one time a day related to major depressive disorder, single episode, unspecified, an order for Buspirone 10 mg tab give 2 tablet by mouth two times a day related to anxiety disorder, unspecified; bipolar disorder, unspecified , an order for Galantamine Extended Release (ER)16 mg give 1 capsule by mouth one time a day related to unspecified dementia, unspecified severity, with agitation, and an order for Clonazepam 1 mg give 1 tablet by mouth two times a day related to anxiety disorder, unspecified and give 1 tablet by mouth every 4 hours as needed for anxiety/behaviors related to anxiety disorder, unspecified; bipolar disorder. Review of the Care Plan dated 01/18/18 revealed resident was on psychotropic medications including Effexor, Seroquel, Klonopin, Buspar for Anxiety, Psychosis, Bipolar Disorder, dementia with behaviors with interventions to administer medications as ordered, consult with pharmacy, and attempt to reduce the use of psychoactive medication. Review of the Pharmacy Reviews dated 06/23/24, 07/31/24, 08/31/24, 09/30/24, 10/31/24, 11/30/24, 12/31/24, 02/28/25, 03/31/25, 04/30/25, and 05/31/25, revealed no recommendations made to reduce the use of psychoactive medications. Interview on 06/05/25 at 9:43 A.M. with Registered Pharmacist (RPh) #292 confirmed he does not make medications reduction requests for residents who are being seen by a psychiatrist due to the physician is not cooperative and the medical director does not address them if the resident is being seen by a psychiatrist. 366235 Page 30 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/05/25 at 12:43 P.M. with the Director of Nursing (DON) confirmed the pharmacist did not make recommendations for gradual dose reductions due to feeling the physician is not cooperative. Interview also confirmed the care plan dated 01/18/18 revealed an attempt wound be made for gradual dose reductions on psychotropic Interview on 06/05/25 at 2:20 P.M. with Licensed Social Worker (LSW) #208 confirmed the care plan does not accurately reflect the residents dementia treatment and does not include all of the resident's medications for dementia treatment to include Galantamine Extended Release (ER)16 mg for unspecified dementia, unspecified severity with agitation. Interview on 06/09/25 at 5:00 P.M. with the Director of Nursing confirmed there is not a policy available to medications and dementia care. 366235 Page 31 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, observations, staff interviews, review of medication inserts, and policy review, the facility failed to ensure medication were administered per physician orders and medications were documented when administered. This affected 16 (#4, #6, #7, #11, #15, #17, #18, #22, #26, #31, #32, #35, #43, #53, #61, and #115) of 62 residents in the facility. The facility census was 62. Findings include: Observation on 06/04/25 at 12:59 P.M. of Sycamore Medication Cart Narcotic Count Sheets with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's Oxycodone 5 mg narcotic count sheet was off by one, one table signed out at time of observation. Resident #26's Alprazolam 0.5 mg narcotic count sheet was off by one, one tablet signed off at time of observation. Interview on 06/04/25 at 1:05 P.M., with Registered Nurse (RN) #262 confirmed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's Oxycodone 5 mg narcotic count sheet was off by one, one table signed out at time of observation. Resident #26's Alprazolam 0.5 mg narcotic count sheet was off by one, one tablet signed off at time of observation. RN #262 confirmed Resident #7 Lorazepam 0.5 mg tablet is one tablet short, the count sheet says 11, the card shows 10. RN #262 confirmed that all narcotics are to be signed out of the narcotic log sheets when the medications are pulling from the narcotic drawer. Interview confirmed she did not follow the procedure to sign the narcotic out on the narcotic log when she pulled the narcotics on this date. Observation on 06/04/25 at 1:09 P.M., with RN #262 of Sycamore Medication Cart revealed a COVID-19 test with an expiration date of 04/25/24. Latanoprost 0.005% for Resident #53 that was opened and not dated when opened or when expired. Latanoprost 0.005% and Artificial Tears for Resident #35 that was opened and not dated when opened or when expired. Antacid / Anti-gas Liquid 400 mg for Resident #32 with an expiration date of 05/2025. Stock Nitroglycerin 0.4 mg tablets with an expiration date of 10/2024. Interview on 06/04/25 at 1:15 P.M., with RN #262 confirmed Sycamore Medication Cart had a COVID-19 test with an expiration date of 04/25/24. Latanoprost 0.005% for Resident #53 that was opened and not dated when opened or when expired. Latanoprost 0.005% and Artificial Tears for Resident #35 that was opened and not dated when opened or when expired. Antacid / Anti-gas Liquid 400 mg for Resident #32 with an expiration date of 05/2025. And stock Nitroglycerin 0.4 mg tablets with an expiration date of 10/2024. Interview also confirmed medications should be discarded when expired. Interview on 06/04/25 at 2:40 P.M. with the Director of Nursing (DON) confirmed it is the expectation of the facility that all nurses sign out narcotics when pulled from the narcotic drawer and sign the medication administration record when given. Observation on 06/04/25 at 3:19 P.M. with Licensed Practical Nurse (LPN) #201 of Walnut Lane medication cart revealed Resident #20 Alprazolam 0.5 mg 1 tablet signed out during cart inspection, Resident #4 Pregabalin 100 mg 1 tablet signed out during cart inspection, Resident #11 Tramadol 50 mg 1 tablet signed out during cart inspection, Resident #22's Tramadol 50 mg 1 tablet signed out during 366235 Page 32 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0755 cart inspection, and Resident #43 Hydrocodone / APAP 5/325 mg 1 tablet signed out during cart inspection. Level of Harm - Minimal harm or potential for actual harm Interview on 06/04/25 at 3:29 P.M. with LPN #201 confirmed she failed to sign out Resident #20 Alprazolam 0.5 mg 1 tablet during cart inspection, Resident #4 Pregabalin 100 mg 1 tablet during cart inspection, Resident #11 Tramadol 50 mg 1 tablet during cart inspection, Resident #22 Tramadol 50 mg 1 tablet during cart inspection, and Resident #43 Hydrocodone / APAP 5/325 mg 1 tablet during cart inspection. Interview also revealed it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. Interview also confirmed the narcotic count was correct at the start of the shift. Residents Affected - Some Observation on 06/04/25 at 3:32 P.M. with LPN #201 of Walnut Lane Medication Cart revealed a bottle of A Reds with an expiration date of 03/2025 was present in the cart, observation also revealed Resident #6's Lispro Insulin 100 units / ml was opened and not dated when opened, Resident #15's Sodium Chloride 5% eye drops was opened and not dated when opened, Resident #18's Brimodine 0.2% eye drops was opened and not dated when opened, Resident #18's Timolol 0.5% eye drops was opened and expired on 04/07/25, Resident #22's Novolog 100 units / ml expired 05/29/25, Resident #31's Lantus Insulin 100 units / ml expired 05/29/25, and Resident #31 Albuterol 0.83%/ml expired 12/2024. Interview on 06/04/25 at 03:36 P.M. with LPN #201 confirmed a bottle of Areds with an expiration date of 03/2025 was present in the cart, Resident #6's Lispro Insulin 100 units / ml was opened and not dated when opened, Resident #15's Sodium Chloride 5% eye drops was opened and not dated when opened, Resident #18's Brimodine 0.2% eye drops was opened and not dated when opened, Resident #18's Timolol 0.5% eye drops was opened and expired on 04/07/25, Resident #22's Novolog 100 units / ml expired 05/29/25, Resident #31's Lantus Insulin 100 units / ml expired 05/29/25, and Resident #31 Albuterol 0.83%/ml expired 12/2024. Interview also confirmed all of the expired medications and the medications not labeled in the Walnut Lane Medication Cart were active and still in use. Observation on 06/04/25 at 7:31 A.M. with LPN #290 revealed Resident #61 was administered Aspirin Enteric Coated (EC) 81 mg 1 tablet. Physician order was for Aspirin 81 mg 1 tablet. Observation also revealed Trelegy Eilipta 200-62.5-25mcg 1 puff was administered by having Resident #61 take a deep breath prior to administering, then had the resident to inhale the medication, LPN #290 did not advise resident to hold the medication in prior to exhaling. LPN #290 did not advise Resident #61 to rinse and spit after the inhalation of Trilogy Elipta 200-62.5-25 mcg. Observation on 06/04/25 at 7:43 A.M. with LPN #290 revealed Resident #17 was administered Aspirin EC 81 mg 1 tablet. Physician order was for Aspirin Chewable 81 mg 1 tablet. Observation on 06/04/25 at 8:42 A.M. with LPN #201 revealed Resident #115 was administered Farxiga 10 mg 1 tablet. Physician order was for Farxiga 5 mg 1 tablet. Observation also revealed Vitamin C 500 mg 1 tablet was administered. The physician order was for Vitamin C 1000 mg 1 tablet. Interview on 06/04/25 at 9:55 A.M. with LPN #201 confirmed Resident #115 was administered Farxiga 10 mg 1 tablet and the physician order was for Farxiga 5 mg 1 tablet. Interview also confirmed Resident #115 was administered Vitamin C 500 mg 1 tablet and the physician order was for Vitamin C 1000 mg 1 tablet. Observation and interview at 9:55 A.M. with LPN #201 confirmed the Farxiga pharmacy box for Resident #115 read Farxiga 5 mg on the label, but the tablets inside the box were labeled Farxiga 10 mg 366235 Page 33 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0755 tablets. Level of Harm - Minimal harm or potential for actual harm Interview on 06/04/25 at 10:06 A.M. with LPN #290 confirmed she administered Resident #61 Aspirin Enteric Coated 81 mg 1 tablet and that the physician order was for Aspirin 81 mg 1 tablet. Residents Affected - Some Interview on 06/04/25 at 10:17 A.M. with LPN #290 confirmed she administered Resident #17 Aspirin Enteric Coated 81 mg 1 tablet and that the physician order was for Aspirin 81 mg 1 tablet. Review of the undated titled, Medication Administration revealed all medications are safely and accurately administered and documented. Review of the Trelegy Ellipta important safety information at trelegy.com/copd/why-trelegy-for-copd revealed TRELEGY can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using TRELEGY to help reduce your chance of getting thrush. 366235 Page 34 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 medical record review, observations, staff interviews, and policy review, the facility failed to ensure antibiotic use was necessary for one (#40) and failed to make recommendations for appropriate medication use for one (#9) This affected two (#9 and #40) of six residents reviewed for medication regimen review. The facility census was 62. Findings include: 1. Review of the medical record of Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy. Review of the Annual Minimum Data Set (MDS) assessment reveled resident had severe cognitive impairment, had no behaviors exhibited or listed. Resident was independent with bed mobility, required set-up assistance with eating, required substantial assistance with oral hygiene and ambulation, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Resident used high risk drug classes of antipsychotics, antianxiety, antidepressant, and anticonvulsants. Review of the physician orders revealed an order dated 09/17/24 for Quetiapine 50 milligram (mg) give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. An order dated 09/17/24 for Venlafaxine Extended Release (ER) 75 mg give 1 capsule by mouth one time a day related to major depressive disorder, single episode, unspecified. An order dated 09/17/24 for Quetiapine 100 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. An order dated 09/17/24 for Buspirone 10 mg tab give 2 tablet by mouth two times a day related to anxiety disorder, unspecified; bipolar disorder, unspecified. An order dated 09/17/24 for Galantamine ER 16 mg capsule give 1 capsule by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and an order dated 09/17/24 for Clonazepam 1 mg tab give 1 tablet by mouth two times a day related to anxiety disorder, unspecified and give 1 tablet by mouth every 4 hours as needed for anxiety/behaviors related to anxiety disorder, unspecified; bipolar disorder, unspecified. Review of the care plan with a revision date of 01/18/18 revealed resident on psychotropic medications Effexor, Seroquel, Klonopin, Buspar for Anxiety, Psychosis, Bipolar Disorder, dementia with behaviors with interventions of will attempt to reduce the use of psychoactive medication after quarterly review and consultation with physician and consult with pharmacy, physician to consider dosage reduction when clinically appropriate. Review of the Pharmacy Reviews dated 06/23/24, 07/31/24, 08/31/24, 09/30/24, 10/31/24, 11/30/24, 12/31/24, 02/28/25, 03/31/25, 04/30/25, and 05/31/25, revealed no recommendations made to reduce the use of psychoactive medications. Interview on 06/05/25 at 9:43 A.M. with Registered Pharmacist (RPh) #292 confirmed he does not make recommendations for diagnosis changes on medications and does not make medications reduction requests for residents who are being seen by Guidestar due to the physician is not cooperative and the 366235 Page 35 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0756 medical director does not address them. Level of Harm - Minimal harm or potential for actual harm Interview on 06/05/25 at 12:43 P.M. with the Director of Nursing (DON) confirmed the pharmacists did not make recommendations for gradual dose reductions for Resident #9 due to feeling the physician is not cooperative. Interview also confirmed the Resident #9 is on Quetiapine 50 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and Quetiapine 1000 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. Residents Affected - Few 2. Review if the medical record of Resident #40 revealed an admission date of 05/20/20, with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed Resident #40 was cognitively intact. Resident was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident required set-up assistance with oral hygiene and bathing, required partial assistance with transfers, and required substantial assistance with dressing and personal hygiene. Review of the physician order dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % apply to second left toe topically one time a day for pain / swelling / redness every day until healed. No pharmacy recommendations were received for dose reduction or discontinuation for Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical). Apply to second left toe topically one time a day for pain/swelling/redness apply gentamicin cream to second left toe every day (QD) till healed. Observation on 06/05/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #201 revealed a scabbed wound approximately 1.5 centimeter (cm) long x 0.8 cm wide to resident's left second toe. Interview on 06/05/25 at 11:34 A.M. with LPN #201 confirmed a scabbed wound to Resident #40's left second toe. Interview also confirmed she applies the Gentamicin Sulfate External Cream 0.1 % daily. Interview on 06/05/25 at 11:36 A.M. with Registered Nurse (RN) Infection Preventionist (IP) #283 confirmed if the wound on Resident #40's second toe is scabbed over, Gentamicin Sulfate External Cream 0.1 % use is not appropriate. RN #283 verified there is no recommendations by the pharmacist evaluate the use of Gentamicin. Review of the undated policy titled, Monthly Drug Regiment Review Policy, revealed the residents shall have there medication regimens reviewed monthly by the consulting pharmacist. The audit will alert nursing and physicians of discrepancies in utilization and compatibility of resident medication regimens. 366235 Page 36 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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 record review, observation, and staff interviews, the facility failed to ensure antibiotic use was appropriate after a wound closed. This affected one (#40) of five reviewed for unnecessary medications. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident required set-up assistance with oral hygiene and bathing. Resident required partial assistance with transfers. Resident required substantial assistance with dressing and personal hygiene. Resident did not have a pressure ulcer or a venous ulcer. Review of the physician orders dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical) apply to second left toe topically daily pain / swelling / redness until healed. Review of the care plan dated 02/05/25 revealed Resident #40 had a reddened, painful and edematous area to the left second toe needing monitoring with interventions of encourage good nutrition and hydration in order to promote healthier skin, Gentamycin cream as ordered, follow facility protocols for treatment of injury Review of the progress notes revealed no documentation related to a wound on Resident #40's left second toe. Observation on 06/05/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #201 revealed an unopened scabbed wound approximately 1.5 centimeter (cm) long x 0.8 cm wide to resident's left second toe. Interview on 06/05/25 at 11:34 A.M. with LPN #201 confirmed a scabbed wound to resident's left second toe. Interview also confirmed Gentamicin Sulfate External Cream 0.1 % is applied daily. LPN #201 confirmed the wound should be measured on the weekly assessment, and should be documented in the nurse's progress notes, but she is not sure if it is. LPN #201 confirmed Resident #40 is not seen by the Wound Nurse Practitioner. LPN #201 confirmed she is not sure of what the policy says about wound documentation and discontinuing the Gentamicin Sulfate External Cream 0.1 % since the wound is scabbed over. LPN #201 confirmed the physician order dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % says applied daily until healed. Interview on 06/05/25 at 11:36 A.M. with Registered Nurse (RN) Infection Preventionist (IP) #283 confirmed if the wound on Resident #40's second toe is scabbed over; antibiotic cream use is not appropriate. 366235 Page 37 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medication record review, observations, staff interviews, and policy review, the facility failed to ensure a medication error rate was below 5%. A total of 34 opportunities were observed with five errors for a error rate of 14.71%. This affected three (#17, #61, and #115) of four residents observed for medication administration. The facility census was 62. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 05/06/25, with diagnoses of acute on chronic diastolic (congestive) heart failure, dementia, old myocardial infarction, and essential (primary) hypertension. Review of the physician orders revealed and order dated 05/22/25 for Aspirin Oral Tablet Chewable 81 milligram (mg) give 1 tablet by mouth one time a day for old myocardial Infarction. Observation on 06/04/25 at 7:43 A.M. of medication administration with Licensed Practical Nurse (LPN) #290 revealed Aspirin Enteric Coated (EC) 81 mg one tablet was administered. Interview on 06/04/25 at 10:17 A.M., with LPN #290 confirmed Resident #17 was administered Aspirin EC 81 mg one tablet. Interview also confirmed Aspirin Chewable 81 mg one tablet was what the physician order was for. Interview confirmed the medication given was a medication error. 2. Review of the medical record for Resident #61 revealed an admission date of 04/29/25, with diagnoses of angina pectoris, essential (primary) hypertension, pulmonary embolism, dementia, and chronic obstructive pulmonary disease. Review of the physician orders revealed an order dated 04/30/25 for Aspirin Oral Capsule 81 mg give 1 tablet by mouth one time a day related to personal history of pulmonary embolism and Trelegy Ellipta 200-62.5-25 microgram (mcg) Inhaler 1 puff daily. Observation on 06/04/25 at 7:31 A.M. of medication administration with LPN #290 revealed Aspirin EC 81 mg 1 tablet administered and Trelegy Ellipta 200-62.5-25 microgram (mcg) Inhaler 1 puff via LPN #290 instructing Resident #61 to take a deep breath prior to administering the medication. Resident #17 held the inhaler in her hand, took a puff and exhaled immediately. LPN #290 took the Trelegy Ellipta 200-62.5-25 mcg Inhaler and exited the room. Interview on 06/04/25 at 7:58 A.M. with LPN #290 confirmed she did not instruct Resident #61 to inhale one puff of Trelegy Ellipta 200-62.5-25 mcg Inhaler and hold in for a few seconds prior to inhaling. Interview also confirmed she did not have Resident #61 to rinse and spit after using the Trelegy Ellipta 200-62.5-25mcg inhaler. Interview also confirmed the Trelegy Ellipta 200-62.5-25 mcg Inhaler contains a steroid which requires a resident to rinse and spit after administration. Interview on 06/04/25 at 10:06 A.M. with LPN #290 confirmed Resident #51 was administered Aspirin EC 81 mg one tablet. Interview also confirmed Aspirin Chewable 81 mg one tablet was what the physician order was for. Interview confirmed the medication given was a medication error. 3. Review of the medical record for Resident #115 revealed an admission date of 02/18/25 with diagnosis of chronic kidney disease, type 2 diabetes, and anxiety. 366235 Page 38 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician orders revealed an order dated 03/26/25 for Farxiga Oral Tablet 5 mg give 1 tablet by mouth one time a day related to type 2 diabetes mellitus without complications. Review of the physician orders also revealed an order dated 02/18/25 for Ascorbic Acid Oral Tablet 1000 mg give 1 tablet by mouth one time a day for supplement. Observation on 06/04/25 at 8:42 A.M. with LPN #201 of medication administration for Resident #115 revealed Farxiga 10 mg 1 tablet and Ascorbic Acid Oral Tablet 500 mg 1 tablet administered Interview on 06/04/25 at 9:54 A.M. with LPN #201 confirmed Acid Oral Tablet 500 mg 1 tablet administered and the order was for Acid Oral Tablet 1000 mg 1 tablet. Interview confirmed the medication given was a medication error. Interview on 06/04/25 at 9:55 A.M. with LPN #201 confirmed Farxiga 10 mg 1 tablet was administered and the order was for Farxiga 5 mg 1 tablet. Interview confirmed the medication given was a medication error. Review of the undated policy titled, Medication Administration Systems and Scheduled Medication Administration Times Policy and Procedure, revealed all medications are safely and accurately administered and documented. 366235 Page 39 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure prescription medication was stored in a locked secured location and not within reach of the residents. In addition, the facility failed to ensure medications were labeled for opening, labeled for expiration, disposed of when expired and stored only with medications. This had the potential to affect all 62 residents in the facility who received medications. The facility census is 62. Findings include: 1. Review of the medical record for Resident #26 revealed an admission on [DATE], with diagnoses that include but not limited to Parkinson's disease, syncope and collapse, pacemaker, bulbous pemphioid, orthostatic hypotension, acute kidney failure, anxiety disorder, atrial fibrillation, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for oral hygiene, dependent for toileting, dependent for shaving, dependent for bed mobility and transfers. Review of the plan of care for Resident # 26 revealed impaired activities of daily living (ADL) self performance related to sepsis, Parkinson's disease, anxiety, and dementia. Interventions include assess/record self-care status changes, administer boost very high calorie as ordered, ensure that call light is kept within reach, monitor need for consultation and provide treatment as ordered for therapy, provide adaptive/safety equipment with wheelchair and report significant changes in ADL status to physician. Review of the active physician orders for Resident #26 revealed an order for ketoconazole 2% shampoo apply to scalp topically every night, every Tuesday and Friday for dry scalp. Observation on 06/03/25 at 8:15 A.M., of a bottle of ketoconazole shampoo with label from facility pharmacy in Resident #26 bathroom. Interview on 06/03/25 at 8:22 A.M. with Registered Nurse (RN) #262 verified the medicated shampoo should not be in the room but locked up in the treatment cart. 2. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses that include cardiac arrhythmia, asthma, dementia with behaviors, psychotic disorder with delusions, Alzheimer's disease with late onset, major depressive disorder with severe psychotic symptoms, type two diabetes, and persistent mood disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] for Resident #45 revealed severe cognitive impairment. Resident #45 requires set up or clean up assistance for eating, dependent for toileting, maximal assistance for bed mobility and dependent for transfers. Review of the plan of care for Resident #45 revealed has impaired cognitive function, decision 366235 Page 40 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many making skills, memory and recall impairments, impaired thought process related to dementia. Interventions include administer medication as ordered, monitor for side effects, anticipate and meet needs in a timely manner, avoid constant noise. distractions, use calendars' clocks and other items that establish and confirm orientation. Review of the active physician orders for Resident #45 revealed an order for Desonide 0.05% cream apply to face topically every shift for dermitis dated 09/04/24 and an order for Ketoconazole 2% shampoo apply daily to scalp topically every night shift, on Wednesday, Friday and Sunday for seborrheic dermatitis dated 04/04/24. Observation on 06/02/25 at 10:32 A.M., of a two bottles of medication for Resident #45. Bottles were labeled with the facility pharmacy label and identified as Desonide 0.05% cream apply to face topically every shift for dermatitis and Ketoconazole 2% shampoo apply daily to scalp topically every night shift on Wednesday, Friday and Sunday for seborrheic dermatitis. Both bottles observed in Resident #45's bathroom contained warning labels to contact poison control if ingested. Interview on 06/02/25 at 3:46 P.M., with Licensed Practical Nurse (LPN) #217 verified the two bottles of medication located in the bathroom of Resident #45 should not be in the room unsupervised removed it LPN #217 verified that she did not put it in the room and that the resident was the night shift shower. Review of the undated policy titled, Storage of Medication, stated drugs and biologicals shall be stored in a safe, secure and orderly manner. 3. Observation on 06/04/25 at 12:40 P.M. of the Sycamore Medication Room with Registered Nurse (RN) #262 revealed there were two residents who are no longer in the facility, personal medications in the cabinet, that needed to be sent home with the resident's family. Observation also revealed the medication refrigerator contained three yogurts, a pudding cup, a bottle of coffee, and multiple supplements. There was a vial of Tuberculin solution in refrigerator with a delivery date of 01/13/25. The Tuberculin solution was opened, with no date documented when it was opened. Interview on 06/04/25 at 12:45 P.M. with RN #262 confirmed the Sycamore Medication Room had two residents who are no longer in the facility, personal medications in the cabinet, that needed to be sent home with the resident's family. Interview also confirmed the medication refrigerator contained three yogurts, a pudding cup, a bottle of coffee, and multiple supplements. Interview also confirmed there was a vial Tuberculin solution in the refrigerator with a delivery date of 01/13/25 and the Tuberculin solution was opened, with no date documented when it was opened. Interview also confirmed that the refrigerator was a medication refrigerator and should not have food items in the refrigerator. Observation on 06/04/25 at 1:09 P.M. with RN #261 of the Sycamore Medication Cart revealed a COVID-19 Test with an expiration date of 04/25/24, Resident #53 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Artificial Tears, opened not labeled with a date opened or expiration date from when it was opened, Resident #32 Antacid / Antigas Liquid 400 mg with a expiration date of 05/2025, and stock Nitroglycerin 0.4 mg with an expiration date of 10/2024. Interview on 06/04/25 at 1:15 P.M. with RN #261 confirmed a COVID-19 Test with an expiration date 366235 Page 41 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of 04/25/24, Resident #53 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Artificial Tears, opened not labeled with a date opened or expiration date from when it was opened, Resident #32 Antacid / Antigas Liquid 400 mg with a expiration date of 05/2025, and stock Nitroglycerin 0.4 mg with an expiration date of 10/2024 was on the Sycamore Medication Cart and still actively in use. Interview on 06/04/25 at 2:46 P.M. with the Director of Nursing (DON) confirmed night shift nurses are supposed to check the medications refrigerator nightly to ensure it is clean and only contains medications but expects all nurses to check it as well. Review of the undated policy titled, Storage of Medication policy, revealed no discontinued, outdated, or deteriorated drugs or biologicals are available for use in this facility. All such drugs are destroyed. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station. Mediations must be stored separately from food and must be labeled drugs. Food and Drinks (except those to be used for patient drug administration assistance) should not be stored or placed in/on the med cart. 366235 Page 42 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, review of the facility menu, and review of the policy, the facility failed to ensure all residents received a balanced and nutritious meal. This had the potential to affect six residents (#01, #02, #19, #31, #26, and #53) who receive a pureed diet and did not receive bread or the desert, as well as all of the residents, who did not receive the desert. Resident #28 was identified as not receiving anything by mouth and is not affected. The facility census was 62. Findings include: Observation on 06/04/25 at 10:00 A.M. revealed [NAME] #237 preparing the pureed foods. No bread was added to the beef patty, nor the roasted zucchini. Review of the menu served on 06/04/25 included beef pepper patty, mashed potatoes, roasted zucchini, choice of roll, and cherry crisp. Observation on 06/04/25 from 11:27 A.M. to 1:20 P.M., revealed [NAME] #265 served the meals and was assisted by Dietary Manager (DM) #214 preparing the trays for delivery. The meal consisted of a beef pepper patty, mashed potatoes with gravy, roasted zucchini, a dinner roll, margarine, and cherry crisp. As the meals were being plated for the residents receiving a pureed diet, no bread was added to the plate. No pureed desert was noted in any of the serving dishes. Neither DM #214, nor [NAME] #265 placed the desert, cherry crisp, onto any of the trays to be delivered to the units as well as to the residents eating in the dining room. No margarine was placed on the trays. Observation at 11:50 A.M. of the dining room revealed no margarine on any of the tables with residents seated. At 12:16 P.M., surveyor questioned Food Service Worker (FSW) #274 if any of the residents in the dining had been served the desert or had been offered margarine. FSW #274 replied no, and entered the kitchen and began dishing out the desert and grabbed a handful of margarine tubs to offer to the residents. FSW #274 verified a few of the residents had already left the dining room after finishing their meal. Interview at 1:20 P.M. with [NAME] #265 and DM #214 provided verification the desert had not been served with the room trays nor to the residents in the dining room before FSW #274 dished the desert and served it to the remaining residents. They both also stated pureed bread is not served as it is unappealing and none of the residents eat it. [NAME] #265 and DM #214 verified margarine should be on the carts, but when checked the carts did not have any on it. Review of the undated policy titled Menus, revealed menus shall provide a variety of foods and indicate standard portions. This deficiency represents non-compliance investigated under Complaint Number OH00162995. 366235 Page 43 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to ensure the kitchens were maintained in a clean and sanitary condition and foods were stored in a manner to avoid contamination and spoilage. The facility also failed to ensure the dishes were sanitized when using the dishwasher. Furthermore, the facility failed to maintain the ice machines in the smaller kitchen areas in a sanitary manner. This had the potential to affect all residents but one (#32) who received foods prepared in the kitchens. The facility census was 62. Findings include: A tour of the kitchen on 06/02/25, beginning at 8:20 A.M. and ending at 8:50 A.M., revealed the floors were dull with many food particles scattered everywhere. The aluminum hand sink is stained brown and no covered trash bin was near. Food particles were noted on most surfaces, the sugar bin had dried food splatters on the exterior and a paper bag of sugar with a scoop inside the bin. The oatmeal and flour bins also had dried food splatters on the exterior. The floors and walls in the back portion of the kitchen, near the walk-in refrigerators, have a buildup of splatters. A prep table to the right of the right-hand walk-in refrigerator had a moderate sized splatter of, what appeared to be ketchup, dried on the side. A cart with shelves, located near the back entrance, had a gallon bottle of vanilla extract without a lid. On the same set of shelves were various other, non-food items, and a container of powered oven cleaner. The right-hand walk-in refrigerator had approximately 20 dishes of fruit without a date, and the floors were scattered with various items and dried food splatters. In the left-hand walk-in refrigerator were five packages of meats, bologna, ham, sliced beef, and sliced turkey, without opened dates, as well as two boxes of hot dogs, opened and with dates, and a metal container of chicken cordon bleu was on a shelf without a date. The floor was strewn with numerous items and dried food splatters. The top shelf was either rusty or coated with food particles. The walk-in freezer floor was splattered with dried food particles. A bag of dried macaroni, opened and undated, was noted in the dry food storage area. The hot box was splattered with dried food particles on the interior. The sanitization log for the dishwasher, hanging beside the dishwasher, was dated 08-2024. No log was located for the three-compartment sink sanitization levels. A chemical check of the sanitization level in the dishwasher, performed by [NAME] #265, revealed no reaction on the strip while the unit was in operation. All of the previous findings were verified at the time of discovery with [NAME] #265. While speaking with Dietary Manager (DM) #214, the exterior surfaces of the oven, the deep fryer, and the range were noted to be covered with dried food particles and a large build-up of grease. DM #214 revealed the convection oven surfaces require a special cleaning agent and she is awaiting the delivery of that. She verified the surfaces could have been wiped with a regular cleaning agent. DM #214 stated would get a hold of the contracted company regarding the sanitization of the dishwasher. A second observation at 9:20 A.M., revealed the dishwasher was still being used. At this time this surveyor verified the facility was going to stop using the dishwasher until checked by the contracted company to ensure sanitization levels are being reached. Observation on 06/04/25 at 8:45 A.M., of the kitchen in the skilled nursing section revealed three 366235 Page 44 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0812 small bowls, upside down, in a dishwasher tray. Food particles were also noted in the tray. Level of Harm - Minimal harm or potential for actual harm Interview at the time, with FSW #274, revealed the bowl were clean and verified the bowls were being used for the breakfast meal and verified the presence of the food particles. The drain continued to have a thick film of scum. Residents Affected - Many Review of the undated policy titled Food Storage, revealed cleaning compounds are stored in separate storage areas. Review of the undated policy titled Food Storage Policy, revealed all opened, refrigerated foods were to be tightly sealed and labeled with the open date and product name. All products in the dry storage area were to be labeled with the opened date. Review of the undated policy titled Sanitation, revealed the food service are shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas, and dining rooms are to kept clean and free of insects. Dumbwaiters are to sanitized between use. Review of the policy titled Fair Haven [NAME] County Home Dishwashing Policy undated, revealed sanitizer testing should be completed three times a day, before every meal. Observation on 06/02/25 at 2:12 P.M., revealed the Arbor Hall ice machine at the far end of dining room observed with whitish brown build up down front of ice machine by the water and ice dispenser, and whitish / brown buildup on the flat section above the ice dispenser. A yellowish white blanket was observed on floor in front of the ice machine with dirt like residue present. Another towel was noted under the ice machine. The overflow tray was observed to be full of liquid. Interview on 06/02/25 at 2:20 P.M. with Registered Nurse (RN) #252 confirmed she only knows how to get ice or water out of it. Interview confirmed she doesn't know when it is cleaned or how to get the water tray out of it. Interview on 06/02/25 at 2:22 P.M. with Maintenance Employee #215 confirmed the ice machine in Arbor Hall at the back of the dining room was dirty and needed cleaned. The interview confirmed there was a whitish brown buildup down front of ice machine by the water and ice dispenser, and whitish / brown buildup on the flat section above the ice dispenser. Interview also confirmed a yellowish white blanket was on floor in front of the ice machine with dirt like residue present and another towel was under the ice machine. Interview also confirmed that the overflow tray had white rough looking material on it, and the bottom had black substance that rubbed off when rubbed with a cloth. Interview confirmed the white built up substance is calcium buildup from the iron water the facility uses. Observation on 06/04/25 at 10:12 A.M. revealed the ice machine at the back of Arbor Hall continues with whitish brown buildup down front of ice machine, with whitish / brown buildup on the flat section above the ice dispenser. Yellowish white blanket on floor in front of the ice machine with dirt like residue present. Review of the undated policy titled, Sanitation, revealed the food service area shall be maintained in a clean and sanitary manner. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. 366235 Page 45 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the policy, the facility failed to ensure the refrigerator used by family to store foods brought in from outside for residents was maintained in a clean manner. This had the potential to affect 44 (#03, #04, #05, #06, #07, #08, #10, #11, #12, #13, #15, #16, #18, #20, #21, #22, #23, #26, #28, #30, #31, #33, #34, #35, #36, #38, #40, #42, #43, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #57, #59, #115, #116, #165, and #215) of 44 residents who utilized the refrigerator The facility census was 62. Residents Affected - Some Findings include: Observation on 06/02/25 at 2:34 P.M. revealed four plastic dishes in the resident refrigerator, located in the lounge area near room [ROOM NUMBER], without dates, one plastic dish dated 04/30/25, and one small dish of salsa dated 04/15/25. The floor of the refrigerator was covered in food particles. Interview at the time of discovery with Certified Nursing Assistant (CNA) #258 revealed all of the food dishes belonged to Resident #12, and verified the presence of the food particles on the floor of the refrigerator. Observation on 06/04/25 at 2:30 P.M. revealed the dishes were still in the refrigerator but now had dates, but all were past the three days specified in the policy. Review of the policy titled Sanitary Outside Food Policy updated August 2017, revealed any food brought in for the residents must be labeled with the resident's name and the date it was brought in. All perishable food will be removed after the third day of arrival in the facility. 366235 Page 46 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on observation and staff interview, the facility failed to ensure a full-time Licensed Nursing Home Administrator was available at least sixteen hours weekly. This had the potential to affect all 62 residents in the facility. The faciltiy census was 62. Findings include: Observation on 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25 and 06/09/25, from 8:00 A.M. through 5:00 P.M. revealed no Licensed Nursing Home Administrator (LNHA) available. Interview on 06/09/25 at 10:35 A.M., with the Director of Nursing (DON) confirmed there was not an active LNHA working in the facility. Interview also confirmed the current LNHA #6468 has been on medical leave since 05/21/25 and has not been in the facility since 05/21/25. Interview also confirmed she was not aware of a policy related to LNHA coverage and she was not aware of the regulation requiring a LNHA in the facility at least sixteen hours weekly. 366235 Page 47 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to have a comprehensive Quality Assurance Performance Improvement Program (QAPI). This had the potential to affect all 62 residents in the facility. Residents Affected - Many Findings include: Record review on 06/09/25 at 5:20 P.M. of the current QAPI information available revealed no current program information available. QAPI book available had no program information present. The book contained meeting information from November 2024. There was no participation documented in the book. Interview on 06/09/25 at 5:20 P.M. with the Director of Nursing (DON) at the time of observation confirmed no current program information available. Interview confirmed the QAPI book available had no program information present. The book contained meeting information from November 2024. There was no participation documented in the book. 366235 Page 48 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) took action and investigated underlying causes and factors contributing to problems. This had the potential to affect all 62 residents in the facility. Findings include: Record review on 06/09/25 at 5:20 P.M. of the current QAPI information available revealed actions or investigations have been completed for problems. The QAPI book contained no documents with actions taken or investigations to find underlying causes for problems in the facility. meeting information from November 2024. There was no participation documented in the book. Interview on 06/09/25 at 5:20 P.M., with the Director of Nursing (DON) at the time of observation confirmed no current investigations or actions being taken for current problems. 366235 Page 49 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) committee met on a regular basis. This had the potential to affect all 62 residents in the facility. Residents Affected - Many Findings include: Record review on 06/09/25 at 5:20 P.M. revealed there was no current QAPI committee meeting information available. The QAPI book had meeting information available for November 2024. Interview on 06/20/25 at 5:20 P.M. with the Director of Nursing (DON) at the time of the observation confirmed there was no information available of QAPI meetings being held since November 2024. 366235 Page 50 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, observation, review of the Sani-Cloth Bleach wipes container instructions, review of glucometer manufacture's recommendations, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to ensure hand hygiene was completed during a pressure ulcer dressing change for Resident #49; failed to ensure recommendations for enhanced barrier precautions (EBP) were initiated for Resident #26; failed to ensure gloves were worn during assistance with food for Resident #17 and #56; and failed to ensure glucometer was properly cleaned for Resident #115. This affected four residents (#17, #26, #49, and #56), with the potential to affect a limited number of resident who received assistance with meals, glucometer checks or were on enhanced barrier protection. The census was 62. Residents Affected - Some Findings included 1. Medical record review for Resident #49 revealed an admission assessment dated [DATE] with diagnoses including methicillin resistant staphylococcus aureus infection (MRSA), fracture of superior rim of pubis, urinary track infection, cerebral infarction, chronic myeloproliferative disease, depression and hypothyroidism. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #49 revealed moderately impaired cognition. Resident #49 required set up or clean up assistance for eating, dependent for toileting, maximal assistance for bed mobility, and dependent for transfers. Resident #49 was coded with one unstageable pressure ulcer. Resident #49 was coded with infection on the foot. Review of the Care Area assessment dated [DATE] for Resident #49 revealed an unstageable pressure ulcer to R heel with current MRSA infection. Antibiotic therapy as ordered and isolation precautions in place. Resident #49 requires assistance with bed mobility, frequently incontinent of bladder and bowel and receives blood thinners which can increase risk for bleeding and bruising. Review of the plan of care for Resident #49 revealed an infection of the right heel wound dated 05/13/25. Interventions include administer antibiotic as ordered, maintain universal precautions when providing resident care, monitor temperature/pulse as clinically indicated, monitor/document/report signs and symptoms of delirium including changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. Review of the active physician's orders for Resident #49 revealed an order dated 05/30/25 for Doxycycline Hyclate oral tablet 100 milligram (mg) give 1 tablet by mouth two times a day for heel wound until 06/12/2025; an order dated 05/23/25 for right heel, cleanse with normal saline (ns) and pat dry, apply silver alginate to wound only, cover with silicone bordered foam and wrap with kerlix. change dressing daily; and moon boot to right foot when in bed or chair every shift for right heel wound dated 3/13/2025. Observation on 06/04/25 at 9:31 A.M., with Registered Nurse (RN) #262 complete right heel dressing change for Resident #49. RN #262 donned personal protective equipment just inside the door. RN #262 advised the resident what task she was going to complete and assessed for pain prior to dressing initiation. Bedside table was cleaned and clean barrier was applied to surface, dressing supplies were 366235 Page 51 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some opened and arranged on table with packaging under each item. RN #262 removed the blue moon boot from resident right heel and used pillow used to elevated right heel. RN #262 unwrapped kerlix from right heel, removed old dressing using normal saline to soak areas of silver nitrate from wound, dressing removed. RN #262 placed dressing into gloved hand and removed glove over dressing discarding both items into a bag on the resident's bed. RN #262 donned new gloves from supply table and cleansed wound to right heel with normal saline. RN #262 applied silver alginate to wound bed, covered with silicone bordered dressing. Dressing was dated with correct date and initialed by nurse. Interview on 06/04/25 at 9:52 A.M. with RN #262 verified she removed the old dressing, placing it in a gloved hand and discarded both items. RN#262 verified she did not complete hand hygiene before cleansing and applying the new dressing and should have. 2. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses including Parkinson's disease, acute kidney failure, hematuria, infection and inflammatory reaction of urethral catheter, urinary retention, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for toileting, dependent for bed mobility and transfers. Resident #26 was coded as having a indwelling catheter, and was incontinent of bowel. Review of the plan of care for Resident #26 dated 10/13/23 revealed use of indwelling supra catheter: urinary retention and hematuria, Interventions include check urinary tubing for kinks every two hours, and as needed (PRN) each shift, monitor and document intake and output as per facility policy, monitor and document for pain and discomfort due to catheter, and monitor/record/report to physician (MD) for signs and symptoms of urinary tract infections. Review of the active physician orders for Resident #26 revealed [NAME] oral tablet (Hyoscyamine Sulfate) give 0.125 mg by mouth three times a day for bladder spasms dated 05/20/25; change suprapubic catheter 16 French/10 milliliter every four weeks and PRN dated 10/17/24; provide suprapubic catheter care and cover site with dry dressing twice daily every shift for protection dated 10/1/24; change urinary drainage bag per facility protocol every night shift every Wednesday for Foley catheter dated 10/2/2024; irrigate Foley catheter with normal saline solution to maintain patency as needed for patency AND every night shift every Wednesday for patency dated 10/1/2024. Observation on 06/02/25 12:04 P.M. of Resident #26 door frame facing hallway contained a small yellow square without any directions/signage of what it meant. Directly inside the room was observed a small three drawer chest with personal protective equipment in each drawer and alcohol based hand gel on the top of the unit. The area did not have any directions to see the nurse prior to entrance to the rooms with the yellow squares on them. Interview with Resident #26 concurrently requested assistance from staff to be pulled up in chair. Observation on 06/02/25 at 12:07 P.M. revealed Licensed Practical Nurse (LPN) #217 and Certified Nurse Assistant (CNA) #209 enter the room and both staff members donned gloves prior to pulling the resident up in his wheelchair. LPN #217 and CNA #209 removed gloves, discarded them into garbage bin before exiting the room. Interview on 06/02/25 at 12:15 P.M. with Resident #26 stated staff only have to wear a gown when the are caring for his catheter. Resident #26 unable to recall receiving any education regarding why 366235 Page 52 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the staff wear them and when they are supposed to where them. Resident #26 stated staff usually wear gloves but has not seen gowns in a long time. Interview on 06/02/25 at 12:21 P.M. with LPN #217 verified that she or the CNA assisting with positioning did not wear gowns as they were just pulling him up in his chair and did not provide any direct care to the resident. Interview on 06/09/25 at 01:05 P.M. with Registered Nurse (RN) #283 stated the facility has an enhanced barrier precaution (EBP) policy in place. RN #283 stated a small yellow square outside of the room on the door frame alerts staff of that care to the specified resident requires personal protective equipment (PPE) for staff when providing care. RN #283 verified the square did not contain any guidance for staff or visitors of the specific actions to take or precautions needed to follow to care or have contact with resident. RN #283 further verified rooms did not have any instruction to see the nurse prior to entering rooms with the yellow squares. RN #283 had a large binder that contained the Centers of Disease Control one sheet signage regarding EBP, but stated the facility was concerned they would violate the residents protected health information. RN #283 stated she was unaware of any education given to residents and visitors in regarding to the meaning or instructions regarding the EBP policy. Interview on 06/09/25 at 2:25 P.M. with the Director of Nursing (DON), verified the facility uses the yellow squares on the doors to alert staff and do not have any signage to alert visitors to see the nurse prior to visiting residents with the identified yellow squares on the door frames. Review of the facility policy titled Enhanced Barrier Precautions, dated 04/01/24 stated signage is posted at all nurse's stations explaining EBP and notification of which residents require EBP. Rooms will have a marker outside the residents room as a way to alert staff that they require EBP. Review of the CDC website (cdc.gov) for long term care facilities state the implementation of EBP should include posting clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves), signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves, make PPE including gowns and gloves, available immediately outside of the resident room, ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room), position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room, incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education, and provide education to residents and visitors. 3. Review of the medical record for Resident #17 revealed an admission date of 05/06/25 with diagnoses of acute on chronic diastolic congestive heart failure and dementia. Review of the care plan dated 05/12/25 revealed resident had a nutrition problem with intervention of provide and serve diet as ordered. Observation on 06/02/25 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #207 unwrapped Resident #17's cookie with her bare hands, without gloves and placed the cookie on the resident's meal tray. 4. Review of the medical record for Resident #56 revealed an admission date of 02/04/25 with 366235 Page 53 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Level of Harm - Minimal harm or potential for actual harm diagnoses of lumbago with sciatica, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the care plan for Resident #56 dated 02/17/25 revealed resident had a nutrition problem with intervention of provide and serve diet as ordered. Residents Affected - Some Observation on 06/02/25 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #207 unwrapped Resident #56's cookie with her bare hands, without gloves and placed the cookie on the resident's meal tray. Interview on 06/02/25 at 12:39 P.M. with CNA #207 confirmed she opened and removed Resident #17 and Resident #56's cookies with her bare hands, without gloves and placed them on their meal trays. Interview also confirmed she did not know she could not touch resident's food with her bare hands. Review of the undated policy titled, Food Handling and Serving, revealed gloves are required to be worn when handling ready-to-eat foods. 5. Review of the medical record for Resident #115 revealed an admission date of 02/18/25 with diagnosis of type 2 diabetes, anxiety, and chronic kidney disease. Review of the Quarterly MDS dated [DATE] revealed resident was cognitively intact. Resident #115 require set- up assistance with toileting hygiene and personal hygiene. Resident was independent with all other activities of daily living. Review of the physician order dated 02/18/25 revealed an order for Accu-Check before meals (AC) and at bedtime (HS) four times daily for diabetes. Observation on 06/04/25 at 8:42 A.M. revealed Licensed Practical Nurse (LPN) #201 remove the Glucometer One Care from her scrub shirt right pocket. LPN #201 continued into Resident #115's room. LPN #201 washed her hands, applied gloves, cleaned Resident #115's finger with alcohol wipes and proceeded to check Resident #115's finger stick blood sugar with the Glucometer One Care she had removed from her scrub shirt pocket. LPN #201 removed her gloves, placed the Glucometer One Care on top of her medication cart and washed her hands. After washing her hands, LPN #201 picked up Glucometer One Care and placed it inside the medication cart. Interview on 06/04/25 at 9:00 A.M. with LPN #201 confirmed she did not clean the glucometer before using in on Resident #115. LPN #201 confirmed she had cleaned the glucometer prior to sticking it into her scrub top pocket with Sani-Cloth Bleach wipes. LPN #201 confirmed the Glucometer One Care should not have been placed onto the medication cart after use or placed inside the medication cart after use without using a Sani-Cloth bleach wipe. LPN #201 proceeded to clean the Glucometer One Care at this time with the Sani-Cloth bleach wipes, with an expiration dated of 08/2025, at the nurse's station. Interview on 06/05/25 at 12:43 P.M. with the DON confirmed it is the expectation of the nurses to clean the Glucometer One Care after each use with an approved Sani-Cloth bleach wipe. Review of the Sani-Cloth Bleach wipes container revealed an expiration date of August 2025 revealed instructions to wait 4 minutes after cleaning to use. 366235 Page 54 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of the undated Glucometer One Care manual revealed to disinfect the Glucometer One Care apply protective disposable gloves, remove an EPA-registered disinfecting wipe from its container, carefully wipe the outside of the meter avoiding saturating the test strip dock , data port or battery section. Discard the used disinfecting wipe. Allow the meter to remain wet according to the recommended contact time of the manufacturer of the disinfecting wipe. Allow the meter to dry completely. Residents Affected - Some Please note that there are commercially available EPA-registered disinfecting wipes, 1:10 quaternary/alcohol wipes and bleach wipes from a variety of manufactures to clean and disinfect the One-Care Pro meter. o PDI Super Sani-Cloth Germicidal Disposable Wipes o PDI Sani-Cloth Bleach Germicidal Disposable Wipes o Clorox Healthcare Bleach Germicidal Wipes Review of the undated policy titled,Glucometer Disinfecting, revealed the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 366235 Page 55 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure a resident receiving antibiotics was being tracked and monitored for use. This affected one (#40) of 8 reviewed for infection control. The census was 62. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident required set-up assistance with oral hygiene and bathing. Resident required partial assistance with transfers. Resident required substantial assistance with dressing and personal hygiene. Resident did not have a pressure ulcer or a venous ulcer. Review of the physician orders dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % (Gentamicin Sulfate (Topical) apply to second left toe topically daily pain / swelling / redness until healed. Review of the care plan dated 02/05/25 revealed Resident #40 had a reddened, painful and edematous area to the left second toe needing monitoring with interventions of encourage good nutrition and hydration in order to promote healthier skin, Gentamycin cream as ordered, follow facility protocols for treatment of injury Review of the progress notes revealed no documentation related to a wound on Resident #40's left second toe. Observation on 06/05/25 at 11:30 A.M. with Licensed Practical Nurse (LPN) #201 revealed an unopened scabbed wound approximately 1.5 centimeter (cm) long x 0.8 cm wide to resident's left second toe. Interview on 06/05/25 at 11:34 A.M. with LPN #201 confirmed a scabbed wound to resident's left second toe. Interview also confirmed Gentamicin Sulfate External Cream 0.1 % is applied daily. LPN #201 confirmed the wound should be measured on the weekly assessment, and should be documented in the nurse's progress notes, but she is not sure if it is. LPN #201 confirmed Resident #40 is not seen by the Wound Nurse Practitioner. LPN #201 confirmed she is not sure of what the policy says about wound documentation and discontinuing the Gentamicin Sulfate External Cream 0.1 % since the wound is scabbed over. LPN #201 confirmed the physician order dated 02/06/25 revealed an order for Gentamicin Sulfate External Cream 0.1 % says applied daily until healed. Interview on 06/05/25 at 11:36 A.M. with Registered Nurse (RN) Infection Preventionist (IP) #283 confirmed if the wound on Resident #40's second toe is scabbed over; antibiotic cream use is not appropriate. Interview also confirmed she does not have Resident #40 on the infections / antibiotic log for Gentamicin Sulfate External Cream 0.1 % and has not assessed the wound to determine proper use of the antibiotic. Interview also confirmed the Infection Report Form Society for Healthcare 366235 Page 56 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0881 Epidemiology of America ([NAME]) is to be completed by the IP on all residents on antibiotics. Interview also confirmed she did not complete the Infection Report Form ([NAME]) for Resident #40. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366235 Page 57 of 58 366235 06/11/2025 Fair Haven Shelby County 2901 Fair Road Sidney, OH 45365

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review, the facility failed to maintain a pest-free environment. This had the potential to affect all residents (except Resident #32) who receive food served from the kitchen. The facility census was 61. Residents Affected - Many Findings include: Observation on 06/02/25 at 10:50 A.M. revealed a moderate amount of gnats flying around the juice and soda dispensing machine located in the serving area of the dining room on the skilled nursing unit. Interview on 06/02/25 at 10:55 A.M. with Food Service Worker #274 revealed the gnats have been there for quite some time. A subsequent observation on 06/04/25 at 11:00 A.M. revealed the gnats to still be present. Review of the undated policy titled Integrated Pest Management, revealed the facility will follow guidelines for preventative procedures for pest management. 366235 Page 58 of 58

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Citations

31 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0577GeneralS&S Cno actual harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
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.
0605GeneralS&S Dpotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0636GeneralS&S Dpotential for harm
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0732GeneralS&S Cno actual harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0744GeneralS&S Dpotential for harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0813GeneralS&S Epotential for harm
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
0865GeneralS&S Fpotential for harm
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0803GeneralS&S Fpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0925GeneralS&S Fpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0658GeneralS&S Epotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0867GeneralS&S Fpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0868GeneralS&S Fpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0837GeneralS&S Fpotential for harm
F837 - Governing body
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

FAQ · About this visit

Common questions about this visit

What happened during the June 11, 2025 survey of FAIR HAVEN SHELBY COUNTY?

This was a inspection survey of FAIR HAVEN SHELBY COUNTY on June 11, 2025. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at FAIR HAVEN SHELBY COUNTY on June 11, 2025?

Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to easily view the nursing home's survey results and communicate with advocate agencies."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 11, 2025