Health inspection·June 26, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #42 was admitted on [DATE]. Diagnoses included acute diastolic heart failure, essential hypertension, and osteoarthritis. Residents Affected - Few Review of the MDS assessment, dated 05/16/25, revealed the resident was cognitively intact and required partial/moderate assistance with toileting, showering, lower and upper body dressing, personal hygiene, and applying footwear. Observation on 06/23/25 at 9:27 A.M. revealed Resident #42 in the recliner chair in the resident room and the call light on the floor near the bed. The call light was not within reach. Interview on 06/23/25 at 9:29 A.M. with Resident #42 verified she utilizes her call light. Interview on 06/23/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #284 verified the call light was on the floor and not within reach of the resident. Interview on 06/25/25 at 2:09 P.M. with Licensed Practical Nurse (LPN) #207 verified Resident #42 does utilize her call light. Review of policy, Call Lights: Accessibility and Timely Response, dated 02/11/25, verified staff will ensure the call light is within reach of residents and secured as needed. Based on observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure residents had call lights within reach for use. This affected three (#40, #42, and #45) of three residents observed for call lights within reach. The facility census was 57. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 01/13/25 with diagnoses of anxiety, diabetes mellitus, cerebral vascular accident (CVA) (stroke), viral hepatitis, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #40 revealed he was cognitively impaired and was dependent for all care. Observation on 06/23/25 at 9:45 A.M. of Resident #40 revealed his call light laying on the floor and not within reach. Page 1 of 8 366410 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

F 0558 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #45 revealed an admission date of 02/25/25 with diagnoses of atrial fibrillation, anxiety, and prostate cancer. Review of the quarterly MDS assessment dated [DATE] for Resident #45 revealed he was cognitively impaired. Residents Affected - Few Observation on 06/23/25 at 10:00 A.M. of Resident #45 revealed his call light was draped over call box and not within reach. Interview on 06/23/25 at 10:47 A.M. with Registered Nurse (RN) #295 verified the call light for Resident #40 and Resident #45 were not within reach. RN #295 verified Resident #40 and Resident #45 both utilized their call lights. 366410 Page 2 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

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 medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to notify the physician of medication error. This affected one resident (#54) reviewed for notification to provider of a change. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and prostate cancer. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he does not recall receiving his bedtime medication on 06/23/25. Review of the nursing progress notes for Resident #54 revealed no documentation of physician notification of the missed medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 stated she did not administer Resident #54's bedtime medication on 06/23/25 and did not notify the physician of the omission of the bedtime medication. Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error. 366410 Page 3 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

F 0687 Provide appropriate foot care. 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, observation, staff interview, and review of facility policy, the facility failed to ensure podiatry care services. This affected one (#22) of one resident reviewed for podiatry. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing, type two diabetes mellitus without complications, unilateral primary osteoarthritis, bilateral primary osteoarthritis of hip, chronic systolic (congestive) heart failure, adult failure to thrive, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 06/09/25, revealed the resident was moderately cognitively impaired. Observation on 06/25/25 at 1:58 P.M. revealed Resident #22's left foot toes were long, thick, and curling under the toes. Interview on 06/25/25 at 2:50 P.M. with Licensed Social Worker (LSW) #299 verified there had been no attempts to have Resident #22 on the podiatry list. Interview on 06/25/25 at 4:00 P.M. with the Director of Nursing (DON) verified Resident #22's nails were in need of trimming and would require a podiatrist. Review of policy, Podiatry Services, date implemented 06/25/25, verified residents will receive proper treatment and care within professional standards of practice to maintain mobility and good foot health. Residents requiring foot care who have complicating diseases processes will be referred to qualified professionals such as a podiatrist, doctor of medicine, or doctor of osteopathy. 366410 Page 4 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

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 observation, resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered as ordered. This affected one (#54) resident reviewed for medication error. The facility census was 57. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver, chronic kidney disease, peptic ulcer (ulcer in the lining of the stomach) and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), patoprazole sodium delayed release 40 milligrams (mg) (used for stomach ulcers), rifaximin 550mg (used for cirrhosis of the liver), lactulose oral solution 30 milliliters (ml) (used for elevated ammonia levels from liver disease), and midodrine 5mg (used for low blood pressure to raise the blood pressure). Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he did not recall receiving his bedtime medication on 06/23/25. Review of the Medication Administration Record (MAR) for Resident #54 for 06/23/25 revealed all medications prescribed for bedtime administration were signed off as administered by LPN #205. Review of the video surveillance footage for Resident #54's room from 06/23/25 at 5:13 P.M. until 06/24/25 at 1:25 A.M. revealed no nurse arrived to administer Resident #54's bedtime medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 verified she worked the evening shift on 06/23/25 from 6:00 P.M. until 06/24/25 at 6:30 A.M. and was responsible for providing care to Resident #54. LPN #205 further stated she did not administer the bedtime medication to Resident #54. LPN #205 stated the resident had visitors and she did not want to interrupt the visit and she had already prepared the medication and signed the MAR as administered and meant to go back to Resident #54 to administer the medication after the visitors left but got busy and forgot. Review of the nursing progress notes dated 06/24/25 at 6:00 A.M. documented as late entry for Resident #54 revealed medications were missed. Writer pulled hs (hour of sleep) medications, resident wasn't ready to take them at that time he had visitors. Writer forgot to return with hs medications during the shift. Review of the facility policy titled, Medication Administration, revised 12/24 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state as ordered by the physician. Ensure the six rights of medication administration are followed to include right resident, right drug, right dosage, right route, right time, and right documentation. 366410 Page 5 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

F 0755 Sign MAR after administration. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error. Residents Affected - Few 366410 Page 6 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review, and review of the facility policy the facility failed to ensure significant medications were administered as ordered. This affected one (#54) resident reviewed for significant medication error. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/14/25. Diagnoses included congestive heart failure (CHF), diabetes mellitus type II, cirrhosis of the liver with ascites (fluid build up in the abdomen from a failing liver), chronic kidney disease, and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed he was cognitively intact. Review of the current physician orders from 06/25 for Resident #54 revealed he was ordered the following medication for bedtime: lantus insulin 12 units subcutaneously (subQ) (used to control diabetes mellitus), rifaximin 550mg (used for cirrhosis of the liver), lactulose oral solution 30 milliliters (ml) (used for elevated ammonia levels from liver disease), and midodrine 5mg (hold for systolic blood pressure (BP) above 130 millimeters of Mercury (mmHg) (used for low blood pressure to raise the blood pressure). Review of the care plan initiated 04/25 for Resident #54 revealed he was care planned for liver disease related to liver cirrhosis, bruise and bleed easily, and have a history of ascites. Interventions in place included medications as ordered for liver cirrhosis and ascites. Review of the hospital records for Resident #54 from his most recent hospitalization from 06/11/25 through 06/15/25 revealed his diagnoses for admission were altered mental status and abnormal laboratory results. Further review of the hospital records revealed an ammonia level of 103 micromoles per liter (Umol/L) (normal 18-72). Further review of the hospital medical record revealed Resident #54's mentation was altered and with treatment of elevated ammonia level with lactulose, the mentation of Resident #54 improved and the ammonia level also improved to 56Umol/L (within normal range of 18-72). Interview on 06/24/25 at 9:09 A.M. with Resident #54 stated he does not recall receiving his bedtime medication on 06/23/25. Review of the Medication Administration Record (MAR) for Resident #54 for 06/23/25 revealed all medications prescribed for bedtime administration were signed off as administered. Further review of the MAR revealed Resident #54 had a blood pressure reading of 101/63 mmHg and should have received the midodrine 5mg for hypotension according to the parameters to only hold midodrine 5mg for a systolic blood pressure greater than 130mmHg. Review of the video surveillance footage for Resident #54's room from 06/23/25 at 5:13 P.M. until 06/24/25 at 1:25 A.M. revealed no nurse arrived to administer Resident #54's bedtime medication. Interview on 06/24/25 at 4:29 P.M. with Licensed Practical Nurse (LPN) #205 verified she worked the evening shift on 06/23/25 from 6:00 P.M. until 06/24/25 at 6:30 A.M. and was responsible for 366410 Page 7 of 8 366410 06/26/2025 St Clare Commons 12469 Five Point Road Perrysburg, OH 43551

F 0760 Level of Harm - Minimal harm or potential for actual harm providing care to Resident #54. LPN #205 further stated she did not administer the bedtime medications to Resident #54. LPN #205 stated the resident had visitors and she did not want to interrupt the visit and she had already prepared the medication and signed the MAR as administered and meant to go back to Resident #54 to administer the medication after the visitors left but got busy and forgot to go back and administer the bedtime medication. Residents Affected - Few Review of the nursing progress notes dated 06/24/25 at 6:00 A.M. documented as late entry for Resident #54 revealed medications were missed. Writer pulled hs (hour of sleep) medications, resident wasn't ready to take them at that time he had visitors. Writer forgot to return with hs medications during the shift. Review of the facility policy titled, Adverse Consequence and Medication Errors, revised 04/14 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors include omission-a drug is ordered but not administered. The attending physician is notified promptly of any significant error. Review of the facility policy titled, Medication Administration, revised 12/24 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state as ordered by the physician. Ensure the six rights of medication administration are followed to include right resident, right drug, right dosage, right route, right time, and right documentation. Sign MAR after administration. 366410 Page 8 of 8