Inspection·January 4, 2024

F 0695 Review of the SWA assessment dated [DATE], revealed Resident #166 had a BIMS score of 13 that indicated she was alert and oriented to person, place, and time. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 12/21/23 revealed Resident #166 was on two liters of oxygen. Residents Affected - Few Review of the physician orders dated 12/24/23 revealed an order for oxygen therapy per protocol routinely. Review of the medical record, reflecting occupational therapy (OT), revealed Resident #166 was on two liters of oxygen but was increased to three liters during OT activity for safety and comfort. Resident #166 complained of being weak and winded. Observation and interview on 01/02/24 at 9:50 A.M. with Resident #166 revealed she had been in the facility for three weeks for therapy due to being out of breath. Observation revealed Resident #166 was sitting in a recliner with a nasal canula in place with the oxygen tubing connected to a bottle of sterile water affixed to the wall. Observation revealed the oxygen tubing and sterile water were undated. Resident #166 revealed she was unsure of when the oxygen tubing and sterile water was last changed. Interview with Registered Nurse (RN) #804 on 01/02/24 at 11:04 A.M. verified and confirmed Residents #7, #69, and #166 oxygen tubing and sterile water were undated. RN #804 revealed she was not sure when the tubing was changed out, but staff waited until the containers were empty. RN #804 revealed she could not indicate when the last time the oxygen tubing and sterile water were changed due to no documentation and no tracking system in place. Interview on 01/03/24 at 1:55 P.M. with State Tested Nurse Assistants (STNAs) #811 and #819 revealed Residents #7, #69, and #166 all wore oxygen during their stay in the hospital. STNAs #811 and #819 revealed Resident #7 wore her oxygen only at night. STNAs #811 and #819 were unaware when the oxygen tubing and sterile water were changed. Interview on 01/03/24 at 2:10 P.M. with the Administrator verified the above findings. Interview with the Administrator revealed oxygen tubing and sterile water were changed every Sunday, but staff did not document the changes, there were no physician orders to change the sterile water or oxygen tubing, and it was not in their policy to do so. Interview with the Administrator revealed there was a form to document and track the changing of oxygen tubing on Sundays, but staff did not utilize it and she was unable to provide any history of utilization. Interview with the Administrator revealed there was no way to verify the time and date oxygen and tubing was changed. Review of the facility document titled PCA task List revealed the facility had a form to document and track new oxygen tubing on Sundays. The form was blank. Review of the facility document titled Oxygen Administration, Long-Term Care, revised 12/11/23, revealed the facility had a policy in place for implementation of oxygen. Review of the policy revealed staff would verify the physician order, complete the administering protocol, and document the procedure. Review of the facility document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366405 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wooster Community Hospital Snf 1761 Beall Avenue Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected one resident (#67) out of five residents reviewed for unnecessary medications. The facility census was 14. Findings include: Review of Resident #67's medical record revealed the resident was admitted on [DATE] with diagnoses including encephalopathy, left hemiparesis, hemorrhagic stroke, and debility. Review of Resident #67's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment, no behaviors were noted, and the resident was dependent for activities of daily living (ADL). Review of Resident #67's physician orders revealed an order dated 01/01/24 for quetiapine fumarate (antipsychotic medication) 25 milligrams (mg) give one tablet by mouth once a day. Review of the current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview on 01/02/23 at 3:50 P.M. with Administrator revealed that quetiapine fumarate was ordered for Resident #67 related to anxiety, and that quetiapine fumarate is not an antianxiety medication. The Administrator also verified that there was no documented evidence from the nursing staff that Resident #67 had signs or symptoms of anxiety or restlessness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366405 If continuation sheet Page 3 of 3