Health inspection·March 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy the facility failed to notify the physician of a change in Resident #71's skin condition. This affected one resident (#71) of two residents reviewed for pressure ulcers. The facility census was 70. Findings include: Review of Resident #71's medical record revealed an admission date of 01/20/25 with a discharge date of 02/24/25, diagnoses included acute respiratory failure, discitis, osteomyelitis of vertebra, encephalopathy, dysphagia, and ileus. Review of Resident #71's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He had three stage two pressure ulcers upon admission. Review of Resident #71's skin observation dated 01/30/25 revealed the resident had shearing to the right and left gluteal fold. Review of Resident #71's progress notes from 01/30/25 to 02/07/25 revealed no evidence the physician was notified of the residents' change in skin condition. Review of Resident #71's skin observation dated 02/08/25 revealed the resident had developed shearing to his coccyx. Review of Resident #71's progress notes from 02/08/25 to 02/10/25 revealed no evidence the physician was notified of the resident's change in skin condition. Review of the policy 'Resident Change in Condition Policy' dated 06/27/24, revealed the licensed nurse would recognize and intervene in the event of a change in condition. The physician will be notified as soon as the nurse has identified the change in condition and the resident is stable. A significant change of condition was a decline or improvement in the residents status that will not normally resolve itself without intervention by staff or implementing standard disease- related clinical intervention, impacts more than one area of the resident's health status, and/or requires interdisciplinary review or revision to the care plan. Page 1 of 16 366299 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interviews and medical record reviews the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected three (#69, #174 and #175) of four reviewed for discharge. The total facility census was 70. Findings Include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, her diagnoses included cirrhosis of liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24 with diagnoses including cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24. Diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of the facility's list of discharged residents' names reported to the Ombudsman for the months of 09/2024,10/2024, 12/2024, 01/2025 and 02/2025 revealed Residents #69 and #175 were not reported as being discharged from the facility. Interview and observation on 03/19/25 at 3:07 P.M. with the Director of Nursing (DON) confirmed Residents #69, #174 and #175 date of discharge was not reported to the Ombudsman. The facility denied having a notification to Ombudsman policy for review. 366299 Page 2 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #53. This affected one resident of six closed records reviewed. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #53's medical record revealed an admission date of 05/21/24 and a discharge date of 12/23/24 with diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia. Review of Resident #53's discharge MDS assessment dated [DATE] revealed it was finalized but not submitted. Review of section 'Z Assessment Administration' revealed all sections of the assessment had been completed on 03/12/25. Review of Resident #53's progress note dated 12/27/25 revealed they had returned from a leave of absence that began on 12/23/25 and reported they were not returning to the facility. Interview on 03/19/25 at 2:05 P.M. with the Director of Nursing (DON) verified the MDS assessment got missed and had not been completed until 03/12/25. 366299 Page 3 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0660 Plan the resident's discharge to meet the resident's goals and needs. 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, interview, and facility policy review the facility failed to obtain a discharge physician order when residents were being discharged from the facility. This affected three (#69, #174, and #175) of four residents reviewed for discharge. The census was 70. Residents Affected - Few Findings include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, diagnoses included cirrhosis of the liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. Review of Resident #69's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits. Review of Resident #69's progress note dated 12/20/24 revealed the resident moved out of the facility when the family came in around 2:15 P.M. to take her home. Discharge summary and a copy of the medication list were provided to the resident. Review of Resident #69's physician orders from 12/01/24 through 12/20/24 revealed there was no discharge order included in the medical record. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24, diagnoses included cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. Review of Resident #174's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive deficits. Review of Resident #174's progress note dated 10/01/24 revealed she was alert and oriented and was discharging home on [DATE]. The nurse went over the medications with the resident and their power of attorney. Review of Resident #174's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24, diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of Resident #175's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #175's progress note dated 09/21/24 revealed the resident was discharged at 2:20 P.M. after reviewing the current medication list and discharge paperwork with the resident and her mother. 366299 Page 4 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #175's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. Interview with the Social Service Designee #42 and Minimum Data Set Coordinator #19 on 3/19/25 at 2:30 P.M. confirmed there was no discharge order obtained when Residents #69 , #174 and #175 were discharged home. Interview on 03/19/25 at 3:07 P.M. interview with the DON confirmed there were no physician orders to discharge residents #69, #174, and #175. Review of the Facility's, Discharge Planning Policy, dated 09/24/2020 revealed a physician order is needed when a resident is discharged and or transferred from the facility. 366299 Page 5 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #4's nails were maintained in a clean manner and at a good length. This affected one resident (#4) of three residents reviewed for activities of daily living (ADL). The facility census was 70. Residents Affected - Few Findings include: Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, and unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. She was dependent for personal hygiene. Review of Resident #4's plan of care dated 03/11/25 revealed she had a self care deficit related to ADL limitation, restlessness and agitation, and her diagnoses. Interventions included monitoring toenails and fingernails with ADL care daily for need of trimming or additional services, and assistance of one staff for personal hygiene. Observation on 03/17/25 at 9:24 A.M. and on 03/20/25 at 11:59 A.M. of Resident #4 revealed the resident had long curved nails that appeared dirty underneath. Interview on 03/20/25 at 11:59 A.M. with Certified Nursing Assistant (CNA) #21 verified the observation. CNA # 21 reported she would ask hospice to cut them when they came in to do her bed bath later. 366299 Page 6 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

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 record review, interview, and facility policy review, the facility failed to ensure physician orders were present for therapy services prior to delivering services to one (#42) of one reviewed for hospice services, and the facility failed to follow practitioner recommendation for vascular surgery consult for one (#35) of one reviewed for non pressure skin condition. The census was 70. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date of 06/29/21, diagnoses included Alzheimer's Disease, dementia, anxiety, bi-polar disorder and a history of falling. Resident #42 admitted to hospice services on 10/31/23 and was a Do Not Resuscitate Comfort Care (DNR-CC). Observation on 03/18/25 at 11:30 A.M. revealed Resident #42 was in bed, and Certified Occupational Therapist Aide (COTA) #102 was present and revealed she had just finished working with Resident #42 to improve her sitting position in her wheelchair. Resident #42 appeared to be very restless with involuntary head and hand control, COTA #42 explained the sessions are about forty minutes long and she has seen little improvement. Review of the Hospice Interdisciplinary Team (IDT) Comprehensive Assessment and Plan of Care Update Report from 01/17/25 to 03/17/25 revealed Resident #42's health had declined in the last two weeks cognitively and physically. Morphine (opioid) for pain had increased from two times a day to three times a day, involuntary head and hand movement continues. Resident #42 sleeps 20 to 24 hours a day and requires total care for activities of daily living, bed baths are provided due to poor trunk control. The plan did not include orders for any type of rehabilitation services. Review of the Occupational Therapy notes from 03/04/25 to 03/18/25 revealed Resident #42 received a total of eight therapy sessions. Review of the Hospice Physician Order Report from 01/17/25 to 03/19/25 revealed there was no order for physical or occupational therapy to evaluate or treat. Review of Resident #42's physician notes from 01/01/25 to 03/19/25 revealed there was no physician order for occupational therapy to treat Resident #42 for increased trunk control to utilize a wheel chair while out of bed. Review of the Resident #42 plan of care dated 12/23/24 did not include occupational or physical therapy services as being included in the care of Resident #42. Review of Resident #42 nurses progress notes from 2/2/25 to 3/10/25 revealed no indication the medical director and or the hospice physician were notified to obtain an order for Resident's #42 to receive occupational therapy. Interview with the Director of Nursing (DON) on 03/19/25 at 8:47 A.M. confirmed she was unaware that Occupational Therapist/Aide had been seeing the resident for chair positioning. Interview with the Director of Nursing and the Rehab Director #107 on 03/19/25 at 1:30 P.M. confirmed Resident #42 had been evaluated and treated by the occupational therapist with no physician order 366299 Page 7 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from hospice or her primary care physician. The DON verified the hospice agency Registered Nurse or physician should have been notified to obtain therapy orders for Resident #42. Review of the facility Hospice Care Policy , dated 05/24/23 revealed the hospice assumes responsibility for determining the appropriate course for hospice care, including the determination to change the level of care services provided. 2. Review of Resident #35's medical record revealed an admission date of 11/21/24 with diagnoses including depression, dysphagia, peripheral vascular disease (PVD), type two diabetes mellitus, hemiplegia, chronic diastolic heart failure, gastric ulcer, and atherosclerosis of native arteries of bilateral legs. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had moderately impaired cognition. Review of Resident #35's physician note dated 12/12/24 revealed a recommendation to follow up with vascular surgery related to Peripheral Vascular Disease (PVD). Review of Resident #35's Certified Nurse Practitioner (CNP) notes dated 12/18/24, 12/26/24, 01/22/25, 02/04/25, 02/11/25, and 02/19/25 revealed a recommendation to follow up with vascular surgery related to PVD. Review of Resident #35's physician note dated 03/13/25 revealed a recommendation to follow up with vascular surgery related to PVD. Observation on 03/17/25 at 9:08 A.M. of Resident #35 revealed both of his feet were a dark purple color. Interview on 03/17/25 at 9:08 A.M. with Resident #35 revealed the hospital had wanted him to see a vascular doctor but that had not happened yet. Interview on 03/18/25 at 2:10 P.M., 2:14 P.M. and 5:05 P.M. with the Director of Nursing (DON) verified the physician and CNP notes had indicated follow up with vascular surgery but that had not occurred. She reported his hospital notes indicated he was not appropriate for vascular surgery and she would follow up with the CNP to ensure they were aware. She verified they had been documenting this for months and it had gone unaddressed. 366299 Page 8 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor Resident #4 and Resident #20's use of a splint. This affected two residents (#4 and #20) of two residents reviewed for limited range of motion. The facility census was 70. Findings include: 1. Observation on 03/17/25 at 12:01 P.M. revealed a splint in Resident #4's room. Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #4's occupational therapy discharge evaluation dated 02/28/25 revealed a discharge recommendation to tolerate a left elbow splint for six hour intervals. Review of Resident #4's medical record from 02/28/25 to 03/16/25 revealed no indication resident #4 was using a splint. Review of Resident #4's physician order dated 03/17/25 revealed an order to wear a left elbow brace for four to six hours a day as tolerated. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified there was no tracking or monitoring for Resident #4's splint in the medical record. 2. Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 10/30/24 revealed the resident was to wear left resting hand splint six hours as tolerated at bedtime with hygiene and skin check prior to donning. Review of Resident #20's medical record from 10/30/24 to 03/18/25 revealed no indication that the left resting hand splint was being applied. Observation on 03/18/25 at 8:25 A.M. revealed Resident #20's left hand was contracted into a tight fist. 366299 Page 9 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/18/25 at 8:25 A.M. with Resident #20 revealed she had a splint for her left hand she was supposed to wear daily but staff did not always provide it. Interview on 03/18/25 at 9:47 A.M. with the DON she verified they had not been tracking or monitoring when Resident #20 was using her splint. She reported the resident was noncompliant, but verified there was no evidence of this. 366299 Page 10 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place and falls were documented for one (#11) of two residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #11's medical record revealed an admission date of 03/04/22, diagnoses included dementia, major depressive disorder, epilepsy, other chronic pain, paroxysmal atrial fibrillation, fracture of one rib on left side (12/03/24), and glaucoma. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #11's plan of care dated 02/14/25 revealed she was at risk for falls related to her diagnoses, history of falls, lack of coordination, and impaired mobility. Interventions included but were not limited to removing regular socks from her room and providing non-skid socks, maintaining the call light in reach, and nonskid socks. Review of Resident #11's medical record revealed no documentation related to a fall which occurred on 03/16/25. Review of the post huddle form dated 03/16/25 revealed Resident #11 had been found sitting in the door way of her bedroom with her walker back beside her recliner. Observation on 03/17/25 at 9:20 A.M. and 11:05 A.M. revealed Resident #11 was wearing regular socks, not non-skid socks. Observation on 03/19/25 at 8:45 A.M. and 9:40 A.M. revealed Resident #11 lying in bed. Her call light was out of reach, it was laced through her bedside table drawer and hanging out the far side of the drawer. Interview on 03/19/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #96 verified Resident #11's call light was out of reach. Resident #11 would have to sit up on the side of the bed to get to the call light. LPN #96 reported the resident had a fall on 03/16/25 Interview on 03/19/25 at 10:25 A.M. with the Director of Nursing (DON) verified the fall on 03/16/25 had not been documented in the progress notes. A post fall huddle form had been completed that was not part of the medical record. Review of the policy titled Fall Prevention and Management Policy dated 12/09/19 and last revised on 08/06/24 reveaeld: Residents will be assessed for fall risk[s] on admission, quarterly, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. Individualized interventions will be implemented based on this assessment and care planned accordingly. 366299 Page 11 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview, medical record review, and facility policy review the facility failed to ensure an indwelling foley catheter was inserted correctly and monitored after insertion. This had the potential to affect one (#24) of two reviewed for catheter care. The census was 70. Findings include: Review of the medical record for Resident #24 revealed an admission date of 08/08/24 with sever cognitive deficits. Diagnoses included hypertensive chronic kidney disease, depression, overactive bladder, neuromuscular dysfunction of bladder and anxiety. Review of Resident #24 nurses progress notes revealed on 10/22/24 at 6:41 P.M. the nurse changed her catheter with 22 french (FR) 10 cc balloon, because the resident was found playing in her stool, pulling her catheter, and having spasms. The nurse followed the sterile technique protocol. When the procedure was completed Resident #24 was resting in her bed. Review of Resident #24 progress notes on 10/23/24 at 10:11 A.M. the nurse was notified by the Certified Nursing Assistant (CNA) that the resident did not have any urine output overnight. Resident #24 was examined, and it was determined her catheter was inserted in the incorrect area. A new 22 FR 10 cc balloon catheter was inserted with urine coming present after insertion. Review of Resident #24's documentation of urine out put from 10/22/24 at 6:41 P.M. to 10/23/24 at 10:11 A.M. revealed no documentation indicating she had any urine output for sixteen hours. An interview on 03/18/25 at 11:30 A.M. with CNA #93 confirmed they are to monitor residents' urine output when they have an indwelling catheter inserted, if they have any problems, they are to report them to the nurse taking care of the resident. Interview on 03/19/24 at 3:00 P.M. with the Director of Nursing (DON) it was confirmed standard nursing practice was to record resident urine out put at least every eight hours. DON verified Resident #24's catheter was not monitored or changed in the sixteen hours when the catheter was inserted incorrectly into Resident #24 on 10/22/24. Review of the Facility's ,Urinary Catheterization and Removal Procedure, (Female) dated 04/24/07 and last revised on 11/06/24 revealed: If a catheter is mistakenly placed in the vagina repeat the entire procedure with another sterile catheter. Pinch catheter when flow of urine ceases (do not remove more than 1000 ml at once) hold catheter in place. The catheter is to remain in place to measure the total amount of urine. 366299 Page 12 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

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 record review, resident interview, and staff interview, the facility failed to maintain availability of ordered pain management medications for one resident (Resident #33) out of two residents reviewed for pain management. The facility census was 70. Residents Affected - Few Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cellulitis of right lower limb, dysphagia, tracheostomy, acute pancreatitis, acute myocardial infarction, depression, squamous cell carcinoma of skin, anxiety disorder, obstructive sleep apnea, hypertension, atrial fibrillation, and chronic congestive heart failure. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact with mild depression. Resident #33 received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications with indications noted. Review of physician's orders revealed Resident #33 had an order for a Fentanyl patch (opioid) 100 micrograms (mcg) per hour to be changed every 72 hours. Patch placement to be monitored every shift. Resident #33 also had an order for Oxycodone (opioid) 5 mg every four hours as needed for pain. Interview on 03/17/25 at 9:54 A.M. with Resident #33 revealed the resident had some level of pain all the time. Resident #33 stated he has a Fentanyl patch that is changed every three days. Resident #33 stated he recently went 10 - 12 days without the patch because there was a problem getting the prescription refilled. Review of the March 2025 medication administration record (MAR) revealed Resident #33 was without a Fentanyl patch from 03/09/25 until 03/14/25. Progress note dated 03/06/25 at 12:58 P.M. Registered Nurse (RN) #47 documented this nurse called the pharmacy for a refill on resident's Fentanyl 100 mcg/hr patch. Per the pharmacy, we need a new prescription to fill this medication. Physician was documented as being called and a new prescription was requested to be sent to the pharmacy so the medication could be refilled. Progress note dated 03/14/25 at 10:22 A.M. RN #30 documented Fentanyl patch was delivered the pervious shift, this nurse placed patch on this morning on left upper extremity. Interview on 03/19/25 at 7:37 A.M. with RN #47 confirmed when the last Fentanyl patch in stock was placed on 03/06/25, RN #47 placed a call to the pharmacy to reorder the medication for Resident #33. The pharmacy informed RN #47 there were no more refills on the prescription and a new prescription was required to refill the medication. RN #47 then placed a request on the physician's medication refill voice mail requesting a new prescription be sent to the pharmacy for Resident #33. Interview on 03/19/25 at 12:20 P.M. with Director of Nursing (DON) confirmed there was no Fentanyl patch placed on Resident #33 as the facility did not obtain a current order from the physician from 03/09/25 until the morning of 03/14/25. 366299 Page 13 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0698 Provide safe, appropriate dialysis care/services 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 interview and record review the facility failed to ensure pre and post dialysis assessments were completed for Resident #20. This affected one resident (#20) of one resident reviewed for dialysis. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's plan of care dated 02/21/25 revealed the resident required dialysis three times a week and the facility provided transportation. Her chair time and location for dialysis were provided. Interventions included noon meal provided by facility prior to dialysis, assessing for fluid excess, assuring medications are administered before and after dialysis as ordered, diet as ordered, monitor intake and output, monitor laboratory work, monitor weight, notify physician of weight changes or fluid volume excess, and report changes in neurological status. Review of Resident #20's physician orders revealed an order dated 01/16/25 indicating she was to go to dialysis on Monday, Wednesday, and Friday's. Review of Resident #20's pre and post dialysis assessments from 02/03/25 to 03/14/25 revealed on 02/03/25 the pre assessment was not fully completed, on 02/05/25 the facility did not complete a pre-assessment, on 02/07/25 and 02/10/25 the pre assessment was not fully completed, on 02/12/25 neither pre or post assessment was completed, on 02/17/25 the pre assessment was not fully completed and dialysis did not complete the post assessment, on 02/19/25 and 02/24/25 the pre assessment was not fully completed, on 02/26/25 the pre assessment was not fully completed and dialysis did not complete a post assessment, on 02/28/25 the pre assessment was not fully completed, on 03/05/25 neither the pre or post assessment was completed, on 03/07/25 and 03/10/25 the pre assessment was not fully completed, on 03/12/25 neither the pre or post assessment was completed, on 03/14/25 the pre assessment was not fully completed and the post assessment was not completed by dialysis. Interview on 03/19/25 at 9:22 A.M. with the Director of Nursing (DON) verified pre and post dialysis assessments were not being completed with every dialysis treatment. 366299 Page 14 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #20's medication was held as ordered by the physician This affected one resident (#20) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 01/03/25 revealed an order for Enulose (Lactulose) (osmotic laxative) 30 milliliters (ml) three times a day. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) for heart rate below 60 beats per minute. Review of Resident #20's physician order dated 03/06/25 revealed an order to hold the morning dose of Lactulose and metoprolol on dialysis days. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Enulose was not held prior to dialysis on 03/10/25, 03/14/25, or 03/17/25. Metoprolol was not held prior to dialysis on 03/10/25 and 03/14/25. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her medication was not held according to the physician orders. 366299 Page 15 of 16 366299 03/20/2025 Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011

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 interview and record review the facility failed to follow medication parameters for one (#20) of five reviewed for unnecessary medication. The facility census was 70. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) or heart rate below 60 beats per minute. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Metoprolol was not held for a systolic blood pressure below 110 mmHg on 03/10/25 when her blood pressure was 106 over 67 mmHg. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her Metoprolol was not held according to the orders/parameters. 366299 Page 16 of 16