Health inspection·August 14, 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 resident, family, staff and certified nurse practitioner (CNP) interviews, record review, and review of the facility policy, the facility failed to timely notify the physician/CNP when physician orders were not completed and pharmacy irregularities on a antibiotic and notify a resident's representative of an incident and a room change involving the resident. This affected two (Residents #1 and #20) of three residents reviewed for notification of change. The facility census was 70. 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment.Review of the physician's orders revealed an order dated 03/31/25 to straight catheterize every six hours for urinary retention four times a day. The procedure was scheduled to be completed at 5:00 A.M., 11:00 A.M., 5:00 P.M. and 11:00 P.M.Review of the progress note for Resident #20 dated 07/21/25 at 2:32 A.M. revealed Licensed Practical Nurse (LPN) #275 documented completed straight catheterization two times with no visible output. The note included the resident was able to urinate on her own and does it every time she was straight catheterized. The note also included this had been a recurrent issue with Resident #20 and her straight catheterization ordered may need to be revised. However, there was no evidence the physician or certified nurse practitioner (CNP) were contacted to report this or discuss the ongoing care needs of the resident related to her urinary status/urinary retention and/or straight catheterization order. A progress note dated 07/27/25 at 10:42 A.M. completed by LPN #511 revealed Resident #20 was to be straight catheterized every six hours for urinary retention. The procedure was not completed; the supplies were pending order. There was no documentation of notification to the physician/CNP the nurse was unable to complete the procedure, and no documentation Resident #20 requested to speak to the CNP on this date (07/27/25)A progress note dated 07/28/25 at 8:44 P.M. completed by Unit Manager (UM) #293 revealed UM #293 was informed by staff the resident placed call to 911 demanding to be sent to the emergency room (ER) related to uncontrolled pain. The note included Resident #20 was assessed by floor nurse, and all vital signs were within normal limits and no other areas of concern noted. Resident #20 continued to demand to go to ER for further evaluation. Call placed to the CNP making the CNP aware and a verbal order was given to transfer Resident #20 to ER for further evaluation. Review of the hospital After Visit Summary dated 07/28/25 revealed the reason for visit was urinary problem. Diagnosis was urinary retention. The summary included: You had an indwelling urinary catheter placed to drain your urine. A basic metabolic panel, complete blood count, urinalysis with microscopic, reflex culture and urine culture were completed. (Results not provided in record).Review of the progress note for Resident #20 dated 07/29/25 at 2:02 A.M. completed by Registered Nurse (RN) #512 revealed Resident #20 returned from the hospital. Resident #20 had a new Page 1 of 21 366419 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling urinary catheter 16 French (16fr)/10cc balloon placed by the hospital for urinary retention. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days.A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions.Interview on 08/06/25 at 1:39 P.M. with Resident #20 revealed staff were supposed to straight catheterize her every four to six hours, but they did not do this. Resident #20 stated staff make excuses and tell her she doesn't need to be straight catheterized because she does urinate. Resident #20 stated sometimes she does urinate and sometimes she doesn't. Resident #20 stated staff provide straight catheterization about three times a day, but she was scheduled four times a day. Resident #20 stated the previous Monday (07/28/25) she had chills, back and abdominal pain, she requested to see the CNP, but she never came. That night she was supposed to be catheterized at 11:00 P.M. but the nurse did not come until 3:00 A.M. She requested several times to see the nurse, but she never came. Resident #20 revealed she was shivering and the abdominal pain continued, she was yelling and still no one came. She called the facility, and no one answered the telephone. Resident #20 stated she became nauseous, needed help, so she called 911. She was then taken to the hospital. Resident #20 stated the ER nurses had to clean her up, and they placed a (urinary) catheter and got 700 cubic centimeters (cc) urine return. The ER physician said she was correct to come to the ER as that was too much urine. Resident #20 stated she received an order for Cipro because she had a UTI that was found from her hospital visit. Resident #20 stated her concern was that she was catheterized last this morning between 4:00 A.M. and 4:30 A.M. and staff have not been in yet to do the next one.Interview on 08/06/25 at 3:15 P.M. with LPN #275 revealed she was Resident #20's primary care nurse. LPN #275 stated she has not straight catheterized her at all today (08/06/25) and was not aware of how frequent Resident #20 need to be straight catharized. LPN #275 referred to the physician orders at the time of the interview and confirmed Resident #20 should be straight catheterized every six hours. Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered.On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the 366419 Page 2 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration.Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it.Interview on 08/07/25 at 11:04 A.M. with LPN #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20.Record review and interview on 08/11/25 at 3:00 P.M. with DON confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders.Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. 2. Record review for Resident #1 revealed a re-admission date of 02/17/16. Diagnosis included vascular dementia with unspecified severity without behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Review of the medical record for Resident #1 face sheet revealed Resident #1 had a representative who was his daughter. The face sheet in the electronic medical record did not have a telephone number available for Resident #1's representative. The medical record revealed Resident #1's representative's telephone number was provided in the hospital record. On 09/11/23, a social services progress note documented the resident representative's telephone number. The progress note dated 04/17/25 completed by Unit Manager #293 revealed Resident #1 received new orders and a telephone call was placed to Resident #1's daughter making her aware of the new orders. Review of the facilities Self-Reported Incident (SRI) revealed on 07/06/25 at 10:38 A.M., a SRI was created by Administrator in Training (AIT) #351. The SRI had allegation of sexual abuse involving Resident #1 and it was witnessed by a staff member. Review of the resident census in Resident #1's electronic medical record revealed Resident #1 resided on the second floor in the same room from 12/14/21 through 07/06/25. On 07/026/25, Resident #1 was transferred to a room on the first floor of the facility. Resident #1's medical record did not have any documentation that Resident #1's responsible party was notified of a sexual abuse incident involving Resident #1 and Resident #1's room change on 07/06/25. Interview on 07/08/25 at 11:59 A.M. with Social Service Designee (SSD) #334 revealed she spoke Resident #1's representative on the telephone about two months ago. SSD #334 stated the telephone number was there on Resident #1's face sheet in the medical record and she was unaware of who took the telephone number off the face sheet. SSD #334 confirmed an incident occurred regarding sexual touching and Resident #1's room was changed on 07/06/25. SSD #334 confirmed Resident #1 did not have any documentation of Resident #1's representative being notified of any occurrence on 07/06/25 and SSD #334 confirmed Resident #1 had a representative in place and Resident #1 was not his own person. Telephone interview on 07/08/25 at 12:16 P.M. with Resident #1's representative revealed the facility staff did not contact her for any incident involving Resident #1 on 07/06/25. Resident #1's representative was unaware Resident #1 moved to the first floor on 07/06/25. Resident #1's representative stated she wanted to be notified of any changes involving Resident #1 and stated she was coming straight to the facility 366419 Page 3 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to obtain additional information about the incident involving Resident #1 on 07/06/25. Interview on 07/08/25 at 3:11 P.M. with Administrator confirmed Resident #1's representative was never notified of the incident on 07/06/25 due to there was no telephone number for her. Review of the facility policy titled Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number OH00167210 (138517). 366419 Page 4 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview the facility failed to ensure Resident #2 received adequate, necessary and timely treatment following a fall with major injury. Actual Harm occurred on 05/20/25 when the facility failed to ensure Resident #2 was provided timely and necessary medical intervention/treatment following a fall. Approximately 12.5 hours after the fall occurred, Resident #2's daughter identified the resident was in excruciating pain. The resident was subsequently transported to the hospital where she was diagnosed with a fractured femur (as a result of the fall) requiring surgical repair. This affected one resident (#2) of three residents reviewed for incidents. The facility census was 70. Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia and senile degeneration of the brain. A plan of care for Resident #2 dated 06/19/23 revealed the resident tended to wander due to cognitive impairment and restlessness. The care plan also identified Resident #2 would hide in closets, wander into other resident's room, would attempt to use their restroom or lay in their bed and/or would attempt to get on the elevator looking for her ride. Interventions included to provide assistance in locating own room and an additional intervention was noted to provide one on one. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impairment. The assessment revealed Resident #2 had no impairment of the upper or lower extremities, was dependent on staff for toileting hygiene, required substantial/maximal staff assistance with chair/bed to chair transfer and required staff supervision or touching assistance for ambulation. A Nursing - Fall Risk Observation/assessment dated [DATE] revealed Resident #2 was at moderate risk for falls. The assessment revealed Resident #2's vision was highly or severely impaired and Resident #2 ambulated without problem and without devices. Review of an Interdisciplinary Team (IDT) note dated 05/20/25 at 5:21 P.M. completed by Unit Manager (UM) #293 revealed the IDT team reviewed Resident #2's fall which occurred on 05/20/25. Resident #2's daughter notified UM #293 Resident #2 was in bed when she arrived, and she attempted to assist the resident out of bed when the resident screamed in pain. The physician was notified, and a verbal order was given to transfer Resident #2 to the emergency department (ED). Upon investigation, UM #293 was notified from Resident #24 that on 05/20/25 at approximately (blank) Resident #24 witnessed Resident #2 lying on the floor in her room at the foot of her bed attempting to pull herself up from the floor using the footboard. Resident #24 [Resident #36 was the actual witness to Resident #2 falling and this was confirmed with the Administrator on 07/09/25 at 3:29 P.M. The facility incorrectly documented the wrong resident in their fall investigation.] Resident [#36] stated she pulled the call light for help and as Resident #2 stood up the Certified Nursing Assistant (CNA) entered the room and escorted Resident #2 back to her room. Review of Resident #2's medical record revealed there was no documentation or assessment on 05/20/25 during night shift. There were no vital signs obtained or a physical assessment at the time of the resident's fall. There was no documentation of any injuries sustained status post fall including an injury to Resident #2's left arm (the daughter identified a treatment on left arm on 05/20/25). Review of the documentation survey report for 05/20/25 revealed Resident #2 was turned and repositioned each shift, but the report did not state how many times Resident #2 was turned and repositioned or provided incontinence care. An interview on 08/07/25 at 8:45 A.M., with CNA #211 revealed she provided Resident #2 incontinence care once in the morning during her day shift and explained she didn't need to reposition the resident, so she was not aware of any pain or injuries. There were no as needed pain medications administered and no pain assessment completed on 05/20/25. Review of the facility Investigation Report for Resident #2 Residents Affected - Few 366419 Page 5 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0684 Level of Harm - Actual harm Residents Affected - Few dated 05/20/25 completed by the Director of Nursing (DON) revealed on 05/20/25, Resident #2 had a witnessed fall with major injury. The report included on 05/20/25 UM #293 revealed Resident #24 reported Resident #2 wandered into her room at 2:30 A.M. Resident #24 yelled out for help and put on her call light when she noticed Resident #2 on the floor. When Resident #2 finally got up, CNA #246 entered the room and took Resident #2 away. CNA #246 reported he escorted Resident #2 back to her room and he did not notice anything unusual. Review of a typed statement completed by the Director of Nursing (DON) dated 05/20/25 revealed CNA #246 reported he answered Resident [#36]'s call light and noticed Resident #2 was in her room. CNA #246 reported he escorted Resident #2 back to her room. CNA #246 reported that he did not notice anything unusual at that time. CNA #246 reported it was not unusual for Resident #2 to wander. The typed report included Resident [#36] reported to UM #293 that she observed Resident #2 lying on the floor at the foot of the bed around 2:30 A.M.; Resident #[#36] reported she yelled out for help and put on her call light when she noticed resident on the floor. Resident [#36] reported Resident #2 was attempting to get up off the floor using the footboard of the bed. Resident [#36] reported when she finally got up, CNA #246 entered the room and took her away. Review of Hospital #401's after visit summary for Resident #2 dated 05/20/25 at 4:42 P.M. revealed Attending Physician #403 the resident had been seen in a freestanding emergency department with no inpatient services. Resident #2 came from the nursing home after an unwitnessed fall overnight last night. Documentation included Resident #2 provided no history here but had significant pain in her left hip when she moved around in bed. Resident #2 was evaluated emergently. X-ray imaging showed a femoral neck fracture. Resident #2 was then transferred to Hospital #402's emergency department for further evaluation and care. Hospital #402's after visit summary for Resident #2 from a hospitalization 05/20/25 to 05/23/25 revealed a principal diagnosis of left displaced femoral neck fracture. The resident underwent surgical intervention; an open treatment of femoral fracture proximal end neck internal fixation or prosthetic replacement (left). Review of a physician progress note dated 07/04/25 completed by Physician #352 revealed Resident #2 fell at the facility on 05/20/25. The resident was found lying on the floor of her room at the foot of the bed attempting to pull herself up by the footboard. A Certified Nursing Assistant (CNA) was able to assist Resident #2 back to bed. When Resident #2's daughter came to the facility to visit, the daughter tried to assist Resident #2 up out of bed, but Resident #2 screamed out in pain with facial grimacing and refused to move. Resident #2 was sent to the emergency department for a workup. The hospital determined Resident #2 suffered a displaced fracture at the base of the neck of the left femur. She underwent left hemiarthroplasty on 05/21/25. Interview on 07/09/25 at 1:41 P.M. with UM #293 revealed on 05/20/25 when UM #293 began in the morning, Resident #2's daughter was already at the facility and said something was wrong with Resident #2. The daughter reported when she moved the resident, Resident #2 yelled. UM #293 went into the room to assess Resident #2, and Resident #2 was lying on her right side in the fetal position. UM #293 turned her on her left side, Resident #2 cried out in pain. UM #293 called the nurse practitioner (NP) who said to transfer the resident to the hospital. Resident #2 was transported to the hospital around 10:00 A.M. Interview on 07/09/25 at 2:30 P.M. with the DON confirmed there was no documentation when Resident #2 left the facility and/or evidence an investigation was completed to determine how Resident #2 had a fractured femur. Interview on 08/06/25 at 2:10 P.M. with Resident #2's daughter who was Resident #2's responsible party, revealed she visited her mom daily in the afternoon and prior to visiting her mom, she would sign in at the front desk on the visitor log. When she arrived, her routine included first taking her mom to the bathroom. The daughter revealed on 05/20/25 when she arrived to visit, Resident #2 was lying in bed. When she attempted to assist her mom, her mom began 366419 Page 6 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0684 Level of Harm - Actual harm Residents Affected - Few screaming in pain. Resident #2's daughter reported she went to the nurse and reported her mom was unable to get up and walk and just moving made her scream in pain. Resident #2's daughter reported she insisted her mom be sent to the hospital and reported she thought her mom must have had a fall because there was also a dressing on her left arm dated 05/20/25 (There was no documentation of a dressing). Resident #2's daughter revealed the staff told her later (unable to recall when) that her mom had wandered into someone's room, fell down, broke her hip, walked on it, and then they assisted her back to bed. Resident #2's daughter revealed There was no way my mom could have walked on it, just moving it made her scream in pain. The resident's daughter revealed it was then another 45 minutes to an hour before the facility transferred the resident to the hospital. Review of the sign in visitor log dated 05/20/25 revealed Resident #2's daughter arrived on 05/20/25 at 2:55 P.M. This shows evidence of the time the daughter arrived, she was sent to the hospital after that. A telephone interview on 08/06/25 at 6:33 P.M. with LPN #277 revealed she was Resident #2's primary charge nurse on 05/20/25 during the day shift. LPN #277 revealed she was on her lunch break (did not recall the time) when she received a call from UM #293 indicating Resident 2's daughter was there and Resident #2 was in pain. LPN #277 stated she gave Resident #2 her medications that morning when the resident was in bed. LPN #277 didn't know how CNA #211 changed her, but Resident #2 did not get out of the bed. UM #293 wanted LPN #277 to write a statement saying she fell on her day shift and the LPN refused to write one. LPN #277 revealed Resident #2 did not appear to be in pain that morning, but she did not have to move her. Interview on 08/07/25 at 8:22 A.M. with Resident #36 revealed she recalled a resident coming into her room. Resident #36 stated a female resident fell, didn't know who the female resident was, it had occurred a couple months ago around twilight time, before morning. Resident #36 stated it looked like the resident was dancing, fell, the man picked her up, she walked out, then she didn't know what happened. Resident #36 confirmed when she saw the resident in her room, she turned her call light on and yelled for help. The man that came in was staff. Interview on 08/07/25 at 8:45 A.M. with CNA #211 revealed she was Resident #2's primary CNA on 05/20/25. CNA #211 stated on the morning of 05/20/25, CNA #211 fed Resident #2 in bed. Resident #2 was usually up wandering but did lay down for naps throughout the day. However, Resident #2 did not get up at all on that day. CNA #211 stated she was on lunch break when Resident #2 was transferred to the hospital. CNA #211 stated she changed Resident #2 that morning, and she did not seem like she was in pain, she was lying in a fetal position, which was not her usual as she would wander typically, and was on her side. CNA #211 stated she didn't have to straighten Resident #2's legs out to provide incontinence care. CNA #211 confirmed she provided incontinence care that morning only and confirmed she was Resident #2's primary CNA on that day. CNA #211 revealed Resident #2 didn't scream until her daughter straightened her legs out. Resident #2 did not get up at all that day. CNA #211 stated Resident #2 did usually get up on night shift and walked around during the day but didn't on 05/20/25. Review of the facility policy titled, Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status. The nurse would notify the resident's attending physician or physician on call when there had been a (an) accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/emotional/mental condition. This deficiency represents non-compliance investigated under Complaint Number 2581344. This is an example of continued non-compliance from the survey dated 06/25/25. 366419 Page 7 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure wound care was completed as per the physician orders for one resident, Resident #57 of three residents reviewed for wound care. The facility census was 70.Findings include:Record review for Resident #57 revealed an admission date of 10/23/23. Diagnoses included multiple sclerosis, sepsis, chronic osteomyelitis, colostomy, neuromuscular disfunction of the bladder, pressure ulcer stage IV (Full thickness loss with exposed bone, tendon or muscle), and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57 had impairment on one side of the upper extremity and both sides of the lower. Resident #57 was dependent on staff for all activities of daily living (ADL). Resident #57 was at risk for pressure ulcers, had one stage IV pressure ulcer and one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). Review of the physician orders for Resident #57 revealed on 05/23/25, an order for the right dorsum foot to cleanse right dorsum foot with Dakin's 0.25% solution, blot dry, apply calcium alginate with silver, ABD and kerlix. Change daily and as needed every day shift for wound management. Observation 07/08/25 at 4:30 P.M. revealed Wound Care Nurse (WCN) #292 and Unit Manager (UM) #293 were going to provide wound care for Resident #57. WCN #292 and UM #293 confirmed the date on the dressing to Resident #57's wound on the right foot was dated 07/06/25 the initials were [Licensed Practical Nurse (LPN) #283]. Observation after removal of the dressing revealed the old dressing had a heavy drainage and foul odor. The tissue surrounding the edges of the wound bed was white/emaciated. The appearance and odor was verified by WCN #292. Record review of the nursing staff assignment sheets and timecards and interview on 07/09/25 at 9:00 A.M. with the Administrator and UM #293 confirmed LPN #283 worked at the facility on 07/06/25. LPN #283 did not work on 07/07/25 or 07/08/25. The Administrator and UM #293 confirmed LPN #283 completed the dressing change on 07/06/25 and the dressing change was not completed again until 07/08/25. Review of the facility's undated policy titled Wound Care revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Dress the wound and mark tape with initials, time, and date and apply to dressing. This deficiency represents non-compliance investigated under Complaint Number OH00167210 (1381513). Residents Affected - Few 366419 Page 8 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, record review, review of a facility Self-Reported Incident (SRI) report, facility policy review and interview, the facility failed to provide residents who have wandering and/or sexual aggressive behaviors with adequate supervision. This affected two residents (#1 and #2) and the potential to affect three residents (#23, #41, and #70) who the facility identified to be independently mobile, confused and residing in the same hall as Resident #1. Findings included:Record review for Resident #2 revealed an admission date of 06/11/19 with diagnoses including dementia and senile degeneration of the brain. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status Score (BIMS) of one indicating Resident #2 was severely cognitively impaired. Resident #2 required the use of a wheelchair for mobility and stated Resident #2 did not wander during the review period.A care plan dated 06/11/19 and revised 07/07/25 revealed Resident #2 was at risk for falls due to impaired mobility, impaired balance, unsteady gait at times, fracture of unspecified part of neck of left femur. Interventions included physical therapy to evaluate and treat dated 05/23/25 and to offer the resident to lay in bed after all meals dated 06/06/25. A care plan dated 05/02/23 revealed Resident #2 had potential for impaired vision as evidenced by diagnosis of glaucoma. Interventions included to encourage to wear glasses. A care plan dated 06/19/23 included Resident #2 tended to wander due to cognitive impairment and restlessness. The care plan included Resident #2 may wander into other resident's room, will attempt to use their restroom or lay in their bed. Interventions included aid in locating own room (last revised 04/12/23) and to provide one-on-one as needed (last revised 07/31/25).Review of Resident #2 progress notes and medical record from 01/01/25 through 07/29/25 revealed no written evidence that the resident exhibited any type of sexual behaviors. Review of a facility SRI created 07/06/25 revealed an allegation of sexual abuse involving Resident #1 and #2 was reported to the State Survey Agency. Resident #1 with Resident #1's penis out and Resident #2 sucking on it. Review of a facility Witness Statement dated 07/06/25 (untimed) and signed by Certified Nursing Assistant (CNA) #217 revealed CNA #217 was taking Resident #1's roommate into his room from the dining room. When CNA #217 entered Resident #1's room, Resident #1 was lying in bed with just a shirt on and Resident #2 had her head down near Resident #1's private area. Resident #1 had his hand on her (Resident #2's) arm and head as Resident #2's mouth was on his (Resident #1's) private area. The statement included CNA #217 immediately secured each resident and informed the nurse. Review of a facility Witness Statement dated 07/06/25 (untimed) and signed by Licensed Practical Nurse (LPN) #283 revealed she was called down to the room and saw Resident #1 with his hand over his private part looking shocked. LPN #283 observed CNA #217 attempting to move Resident #2 who was being combative at the time. LPN #283 assisted CNA #217 removing Resident #2 from the room. Observation on 07/08/25 at 9:23 A.M. revealed Resident #2 was eating breakfast in the dining room using her fingers only. An attempt to interview Resident #2, revealed the resident rambled incoherently unrelated to the conversation. An interview with Unit Manager #293 at the time of the observation revealed Resident #2 was unable to answer questions appropriately or make independent decisions. The unit manager revealed Resident #2 had dementia, could walk but also used a wheelchair. Resident #2 had poor vision and ate all her meals in the dining room. Interview on 07/08/25 at 3:51 P.M. with CNA #211 stated Resident #2 can walk, the staff try to keep her in her wheelchair, but she walks. CNA #211 stated when she arrived at work in the morning on 07/06/25, Resident #2 was wandering the hallway, and she used her hands to feel around. CNA #211 denied trying to redirect Resident #2 to sit in a chair or go to her own room on 07/06/25 and the reason provided 366419 Page 9 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was that this was her usual behavior. Interview on 07/08/25 between 3:52 P.M. and 4:00 P.M. with CNA #216 and CNA #238 revealed Resident #2 was able to ambulate and frequently wandered in other residents' rooms.Interview on 07/09/25 at 1:10 P.M. with Physical Therapy Assistant (PTA) #501 confirmed she worked with Resident #2 in therapy. PTA #501 revealed Resident #2 was not safe to ambulate independently.Interview with MDS Nurse #510 on 07/31/25 at 12:49 P.M. stated the resident's plan of care interventions were considered active if the intervention was still listed on the care plan after the revision date. MDS Nurse #510 verified Resident #2's care plan stated to provide Resident #2 1:1 supervision. Interview on 08/12/25 at 4:15 P.M. with Administrator revealed the care plan with 1:1 supervision for Resident #2 was from a previous incident and should have been removed, it was no longer active and discontinued out of the care plan today.2. Record review revealed Resident #1 had a re-admission date of 02/17/16 with diagnoses including vascular dementia with unspecified severity without behavioral disturbances, psychotic disturbances, mood disturbances and urinary incontinence. Review of a care plan dated 05/15/23 revealed Resident #1 had a history of inappropriate sexual behavior at times related to cognitive impairment. Interventions included to provide supervision in social gatherings/recreation programs and staff to minimize any close interaction with female residents. An additional care plan initiated 07/19/24 revealed Resident #1 demonstrated socially inappropriate behaviors: inappropriately touching staff. Interventions included psychological counseling for psych/behavior management.Interview on 07/08/25 at 12:22 P.M. with CNA #233 revealed she worked with Resident #1. CNA #233 stated Resident #1 was sexually inappropriate, especially when staff changed him. Resident #1 would grab at staff; CNA #233 stated they tried to re-direct Resident #1, move his hand but he would not listen. Interview with the Administrator on 07/08/25 between 1:35 P.M. and 3:11 P.M. stated the incident occurred in Resident #1's room while he was in bed. During the interview, the Administrator stated Resident #2 was the perpetrator, not Resident #1. However, no additional information was provided as to how this conclusion was reached. Interview on 07/08/25 at 5:07 P.M. with CNA #233 revealed at the end of May (2025), she was cleaning Resident #1's buttocks due to him being incontinent. CNA #233 turned him over on his side and while she was washing him, Resident #1 began masturbating. CNA #233 also reported Resident #1 tries to touch CNA #233 inappropriately. The CNA stated other CNAs had also reported Resident #1's sexual inappropriateness, but the facility had done nothing to address Resident #1's behavior. A telephone interview on 07/09/25 at 9:26 A.M. with CNA #217 revealed on 07/06/25, she was bringing Resident #1's roommate from the dining room to his room. As CNA #217 walked through the door, CNA #217 saw Resident #1 was lying in bed, Resident #1 had Resident #2 by the arm and had his hand on Resident #2's head/back of her neck making it go up and down on his penis. The CNA stated she observed Resident #1 being forceful with Resident #2 and Resident #2 was trying to move to leave, as she was not sexual at all. CNA #217 told Resident #1 to let Resident #2 go, he was still holding her, then he let her go. The CNA stated Resident #2 was blind, but she moved right away from Resident #1 once Resident #1 released his hands from her. CNA #217 stated she yelled, and LPN #283 came into Resident #1's room. Interview on 07/09/25 at 10:07 A.M. with LPN #283 revealed on 07/06/25 in the morning, she was down the hall coming out of a different room when she heard CNA #217 call for her. LPN #283 entered Resident #1's room and saw CNA #217 moving Resident #2 away from Resident #1. Resident #2 was confused. When LPN #283 walked into Resident #1's room, Resident #1 was in bed sitting straight up with a hospital gown on and his hand over his private part. LPN #283 stated Resident #2 would not be forceful with anyone if she walked into a resident room. Interviews on 07/08/25 between 12:48 P.M. and 12:55 P.M. with CNA #238, CNA #216, and Activity Director #203 revealed Resident #1 participated in activities and frequently sat in the dining room. CNA 366419 Page 10 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0689 Level of Harm - Minimal harm or potential for actual harm #238, #216 and Activity Director #203 revealed Resident #1 never required supervision. The facility identified Residents #23, #41, and #70 who resided on the same hall as Resident #1 and were independently mobile and had cognitive impairments. This deficiency represents non-compliance investigated under Control Number OH00167346 (1381517). This is an example of continued non-compliance from the survey dated 06/25/25. Residents Affected - Some 366419 Page 11 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview with resident, facility staff, pharmacy staff and nurse practitioner the facility failed to implement a comprehensive and individualized plan of treatment for Resident #20 to ensure the resident was catheterized timely and as ordered for urinary retention and provided timely and necessary treatment for a urinary tract infection (UTI). Actual harm occurred on 07/28/25 when Resident #20 demanded to be transferred to the emergency room for uncontrolled pain. The resident was subsequently treated for urinary retention and a UTI. Prior to the hospitalization, the resident had physician orders to be straight catheterized for urine retention every six hours; however, this was not being completed as ordered. Following the hospital treatment the facility failed to administer Resident #20's oral antibiotics per the physician orders and continued not to straight catheterize as ordered resulting in the need for intravenous medications. This affected one resident (#20) of three residents reviewed for UTIs. The census was 70. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, UTI, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. Record review revealed the facility had not developed/implemented a plan of care for Resident #20 for the care and treatment for urinary retention or history of urinary tract infections. Review of the physician's orders revealed an order dated 03/31/25 to straight catheterize every six hours for urinary retention four times a day. The procedure was scheduled to be completed at 5:00 A.M., 11:00 A.M., 5:00 P.M. and 11:00 P.M. Review of the progress note for Resident #20 dated 07/21/25 at 2:32 A.M. revealed Licensed Practical Nurse (LPN) #275 documented completed straight catheterization two times with no visible output. The note included the resident was able to urinate on her own and does it every time she was straight catheterized. The note also included this had been a recurrent issue with Resident #20 and her straight catheterization ordered may need to be revised. However, there was no evidence the physician or certified nurse practitioner (CNP) were contacted to report this or discuss the ongoing care needs of the resident related to her urinary status/urinary retention and/or straight catheterization order. A progress note dated 07/27/25 at 10:42 A.M. completed by LPN #511 revealed Resident #20 was to be straight catheterized every six hours for urinary retention. The procedure was not completed; the supplies were pending order. There was no documentation of notification to the physician/CNP the nurse was unable to complete the procedure, and no documentation Resident #20 requested to speak to the CNP on this date (07/27/25) A progress note dated 07/28/25 at 8:44 P.M. completed by Unit Manager (UM) #293 revealed UM #293 was informed by staff the resident placed call to 911 demanding to be sent to the emergency room (ER) related to uncontrolled pain. The note included Resident #20 was assessed by floor nurse, and all vital signs were within normal limits and no other areas of concern noted. Resident #20 continued to demand to go to ER for further evaluation. Call placed to the CNP making the CNP aware and a verbal order was given to transfer Resident #20 to ER for further evaluation. Review of the hospital After Visit Summary dated 07/28/25 revealed the reason for visit was urinary problem. Diagnosis was urinary retention. The summary included: You had an indwelling urinary catheter placed to drain your urine. A basic metabolic panel, complete blood count, urinalysis with microscopic, reflex culture and urine culture were completed. (Results not provided in record). Review of the progress note for Resident #20 366419 Page 12 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0690 Level of Harm - Actual harm Residents Affected - Few dated 07/29/25 at 2:02 A.M. completed by Registered Nurse (RN) #512 revealed Resident #20 returned from the hospital. Resident #20 had a new indwelling urinary catheter 16 French (16fr)/10cc balloon placed by the hospital for urinary retention. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Review of the medication administration record from 08/01/25 to 08/06/25 revealed Cipro was to be administered at 9:00 P.M. and 9:00 A.M. for seven days and it was to start on 08/02/25 at 9:00 P.M. On 08/02/25 at 9:00 P.M., the number nine was documented in the timeframe, which indicated to see the nurses' notes. From 08/02/25 through 08/06/25 for the scheduled dose at 9:00 P.M. the boxes all documented a number nine. The MAR indicated Resident #20 received the Cipro on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only (three of 10 doses documented as administered). However, review of the pharmacy delivery manifest with the Director of Nursing (DON) on 08/06/25 revealed Resident #20's Cipro had never been delivered to the facility (indicating the three doses documented as administered were not actually administered to Resident #20). On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. An order was also provided for Enhanced Barrier Precautions - use gown and gloves for high contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care for any device including trach, central line, tube feeding and catheter. Interview on 08/06/25 at 1:39 P.M. with Resident #20 revealed staff were supposed to straight catheterize her every four to six hours, but they did not do this. Resident #20 stated staff make excuses and tell her she doesn't need to be straight catheterized because she does urinate. Resident #20 stated sometimes she does urinate and sometimes she doesn't. Resident #20 stated staff provide straight catheterization about three times a day, but she was scheduled four times a day. Resident #20 stated the previous Monday (07/28/25) she had chills, back and abdominal pain, she requested to see the CNP, but she never came. That night she was supposed to be catheterized at 11:00 P.M. but the nurse did not come until 3:00 A.M. She requested several times to see the nurse, but she never came. Resident #20 revealed she was shivering and the abdominal pain continued, she was yelling and still no one came. She called the facility, and no one answered the telephone. Resident #20 stated she became nauseous, needed help, so she called 911. She was then taken to the hospital. Resident #20 stated the ER nurses had to clean her up, and they placed a (urinary) catheter and got 700 cubic centimeters (cc) urine return. The ER physician said she was correct to come to the ER as that was too much urine. Resident #20 stated she received an order for Cipro because she had a UTI that was found from her hospital visit. Resident #20 stated her concern was that she was catheterized last this morning between 4:00 A.M. and 4:30 A.M. and staff have not been in yet to do the next one. Interview on 08/06/25 at 3:15 P.M. with LPN #275 revealed she was Resident #20's primary care nurse. LPN #275 stated she has not straight catheterized her at all today (08/06/25) and was not aware of how frequent Resident #20 need to be straight catharized. LPN #275 referred to the physician orders at the time of the interview and confirmed Resident #20 should be straight catheterized every six hours. Observation on 08/06/25 at 3:35 P.M. revealed LPN #275 was walking down the hall. LPN #275 stated Resident #20 was just straight catheterized and got 500 cc of urine out. UM #293 was present and stated LPN #275 went in Resident #20's room at 11:00 A.M. to straight catheterized her and Resident #20 was not in her room so the next catheter would not be due until 5:00 P.M. anyway. Interview on 08/06/25 at 3:40 P.M. with the 366419 Page 13 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0690 Level of Harm - Actual harm Residents Affected - Few DON revealed if a resident had treatment due and was not in their room, the nurse would go back when the resident returned to do the treatment. The DON stated Resident #20 had been getting straight catheterized prior to the hospital visit. The hospital placed an indwelling urinary catheter in. The indwelling urinary catheter was discontinued due to Resident #20 did not have the appropriate diagnosis for an indwelling catheter and the straight catheterize order was continued. Review of Resident #20's Medication Administration Record (MAR) with the DON confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Interview on 08/06/25 at 4:32 P.M. with Resident #20 and with the DON present revealed LPN #275 never offered to straight catheterization her today (08/06/25) until a few minutes ago and she got over 500 cc out. Resident #20 stated to the DON she was upset she had not been getting her Cipro like she was supposed to, and it started later than it was supposed to. Interview on 08/06/25 at 4:34 P.M. with LPN #275 with the DON present confirmed she administered Resident #20 her Cipro this morning and the Cipro was prepackaged by the pharmacy in the medication cart. Observation revealed the DON checked the medication cart with Resident #20's prepackaged medications, and confirmed Resident #20 did not have any Cipro present in any of the prepackaged medications or any other location of the medication cart. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview and observation on 08/07/25 at 10:14 A.M. with Resident #20 revealed the resident was lying in bed crying. Resident #20 stated she hurt, CNP #514 was just in to see her a few minutes ago and gave new orders. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could 366419 Page 14 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0690 Level of Harm - Actual harm Residents Affected - Few do it. Interview on 08/07/25 at 11:04 A.M. with LPN #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20. Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt. Record review and interview on 08/11/25 at 3:00 P.M. with DON confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. Review of the facility policy titled, Catheter Care Urinary revised August 2022 revealed the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician. This deficiency represents non-compliance investigated under Complaint Number 2581344 and Complaint Number 2574277. 366419 Page 15 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

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 record review and interviews with staff and pharmacy, the facility failed timely respond and act upon the pharmacy's notification regarding irregularity with a new order to start an antibiotic. This affected one (#20) of one resident reviewed for pharmacy services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond. Medication Cipro had a drug interaction with (medication) tizanidine. Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic. The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax. The pharmacy also calls the nurses who need to update the physician with the pharmacy information. The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it. This was an incidental finding discovered during the course of the complaint investigation. 366419 Page 16 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

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, interviews with resident, staff and Certified Nurse Practitioner (CNP), record review, review of insulin administration guidelines, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected four (#7, #11, #20, and #68) of six residents reviewed for medication administration. The facility census was 70.Findings included: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions. Review of the medication administration record from 08/01/25 to 08/06/25 revealed Cipro was to be administered at 9:00 P.M. and 9:00 A.M. for seven days and it was to start on 08/02/25 at 9:00 P.M. On 08/02/25 at 9:00 P.M., the number nine was documented in the timeframe, which indicated to see the nurses' notes. From 08/02/25 through 08/06/25 for the scheduled dose at 9:00 P.M. the boxes all documented a number nine. The MAR indicated Resident #20 received the Cipro on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only (three of 10 doses documented as administered). However, review of the pharmacy delivery manifest with the Director of Nursing (DON) on 08/06/25 revealed Resident #20's Cipro had never been delivered to the facility (indicating the three doses documented as administered were not actually administered to Resident #20). Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M. The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only. Interview on 08/06/25 at 4:32 P.M. with Resident #20 and with the DON present revealed Resident #20 stated to the DON she was upset she had not been getting her Cipro like she was supposed to, and it started later than it was supposed to. Interview on 08/06/25 at 4:34 P.M. with LPN #275 with the DON present confirmed she administered Resident #20 her Cipro this morning and the Cipro was prepackaged by the pharmacy in the medication cart. Observation revealed the DON checked the medication cart with Resident #20's prepackaged medications, and confirmed Resident #20 did not have any Cipro present in any of the prepackaged medications or any other location of the medication cart. Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify. The pharmacy never received the response, so they never sent the Cipro. The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered. On 08/07/25 there was an order by CNP Residents Affected - Some 366419 Page 17 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days. Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration. 2. Record review for Resident #11 revealed an admission date of 02/02/24. Diagnosis included type two diabetes mellitus (DM) with unspecified complications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact, and had medically complex conditions including type two DM with unspecified complications. Resident #11 received injections daily. Review of the care plan for Resident #11 dated 01/11/25 revealed Resident #11 required hypoglycemic medication related to diabetes/hyperglycemia. Interventions included to administer medications as ordered. Review of the physician's orders for Resident #11 included Lantus Solostar subcutaneous solution pen-injector 100 units per milliliter (ml) (Insulin Glargine) inject 15 units subcutaneously two times a day for DM type two. Observation on 08/06/25 at 8:31 A.M. of medication administration with Licensed Practical Nurse (LPN) #275 revealed LPN #275 administered Lantus Solostar to Resident #11 via pen injector. LPN #275 did not prime the pen injector prior to dialing up 15 units and administering the insulin. Interview on 08/06/25 at 8:44 A.M. with LPN #275 stated she did not know what priming the insulin pen meant and confirmed she did not prime the insulin pen. Review of the undated pamphlet for Lantus insulin titled Using the Solostar Pen revealed insulin pens contain multiple doses of insulin; a new needle will be used for each injection; insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; Screw the pen needle onto the insulin pen; Dial two units by turning the dose selector clockwise, push the plunger and watch to see that at least one drop appears; then turn the dose selector to ordered dose. 3. Record review for Resident #7 revealed an admission date of 11/11/24. Diagnosis included type two diabetes mellitus (DM) with hyperglycemia and diabetic autonomic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, and had medically complex conditions, DM and required injections daily. Review of the care plan dated 04/21/25 revealed Resident #7 had a diagnosis of DM and was at risk for complications. Interventions included blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters. Review of the physician orders for Resident #7 revealed an order dated 08/05/25 for Humalog injection solution inject as per sliding scale. If 71-150 = zero units, 151-200 = two units, 201 - 250 = four units, 251 - 300 = six units, 301 - 350 = eight units, 351 to 400 =10 units subcutaneously three times a day for DM. Inject zero to 10 units subcutaneously with meals per sliding scale. Observation and interview on 08/06/25 at 9:32 A.M. revealed Licensed Practical Nurse (LPN) #275 assessed Resident #7's blood sugar via fingerstick while Resident #7 was lying in bed. The breakfast tray next to Resident #7 was empty and all the food was consumed. Resident #7 confirmed she ate all her breakfast about an hour ago. Resident #7's blood sugar results was 460. LPN #275 confirmed she should have checked the blood sugar before Resident #7 ate her meal and verified she did not because she was on another hall passing medications. Unit Manager (UM) #293 instructed LPN #275 to hold the insulin until CNP was notified. UM #293 called the CNP for insulin orders, told CNP blood sugar results but never told the CNP the results were obtained after Resident #7 ate 100% of breakfast. UM #293 confirmed she never told CNP that the results were obtained after breakfast and stated the CNP knows what time breakfast was. Interview on 08/06/25 at 9:50 A.M. with Certified Nursing Assistant (CNA) #220 revealed she served the breakfast trays to residents on Resident #7's hall at 8:00 A.M. Interview on 08/06/25 at 9:44 A.M. with CNP #514 revealed blood sugars should be check before meals. CNP #514 stated she wants to know the blood sugar before the resident's eat and staff should have let me 366419 Page 18 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #7 already ate her breakfast and said that was important information to know. CNP #514 verified UM #293 never notified her Resident #7 ate her breakfast prior to the blood sugar results. CNP 3514 stated she didn't want a hypoglycemic reaction so she needed to know information to give correct orders. 4. Record review for Resident #68 revealed an admission date of 04/10/23. Diagnoses included chronic atrial fibrillation and hypertension (HTN). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact and had hypertension. Review of the physician orders for Resident #68 revealed an order dated 07/28/25 for metoprolol succinate extended release 24 hour 25 milligrams (mg) give one tablet by mouth one time a day for HTN hold for a heart rate of less than 60 beats per minute or a systolic blood pressure of less than 100. The order under status revealed pending order signature. Review of the Medication Administration Record (MAR) for Resident #68 revealed the metoprolol was not administered in July 2025 or 08/01/25 to 08/11/25. Resident #68's last blood pressure documented in the medical record was dated 07/28/25 at 9:54 A.M. and was 140/88. The last pulse documented was 06/03/25 and was 72. Interview with the Director of Nursing (DON) on 08/11/25 at 3:25 P.M. confirmed staff did not monitor Resident #68's blood pressure or pulse and she was also unable to find the documentation for the pulse and blood pressure daily for Resident #68. DON confirmed the medication metoprolol was not administered to Resident #68 per the order. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she wrote the order on 07/28/25 for Resident #68 to receive metoprolol succinate extended release 25 mg one time a day. CNP #514 revealed the medication should have started after she ordered it and she was never notified by any staff the medication was never initiated. The medication had a dual purpose for the blood pressure and the heart rate so both the heart rate and blood pressure needed monitored prior to medication administration. Review of the facility policy titled Medication Administration dated 11/2017 revealed to administer the medications as ordered; the physician shall be notified of held medications. This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number 1381508 (OH00167560). 366419 Page 19 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, the facility failed to timely obtain a urinalysis ordered by the physician/certified nurse practitioner (CNP). This affected one (#20) of one resident reviewed for laboratory services.Findings included: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) during stay, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. On 08/07/25 there was an order by Certified Nurse Practitioner (CNP) #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days and a urinalysis. Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered. And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered. Interview on 08/07/25 at 11:04 A.M. with Licensed Practical Nurse (LPN) #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20. Record review and interview on 08/11/25 at 3:00 P.M. with Director of Nursing (DON) confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25. The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory. The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders. Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered. This was an incidental finding discovered during the course of the complaint investigation. Residents Affected - Few 366419 Page 20 of 21 366419 08/14/2025 Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087

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 observation, resident and staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff wore personal protective equipment (PPE) for a resident on Enhanced Barrier Protection (EBP). This affected one (#20) of one resident reviewed for infection control. The facility census was 70. Findings include: Record review for Resident #20 revealed an admission date of 07/20/24. Diagnoses included Parkinson's disease and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter. Review of the physician orders for Resident #20 revealed an order dated 03/31/25 to straight catheterize every six hours or urinary retention four times a day for urinary retention; an order dated 08/01/25 for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a urinary tract infection (UTI) for seven days; and an order dated 08/04/25 for EBP use gown and gloves for high contact resident care including dressing,, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes and care of any device including trach, central line, tube feeding and catheter. Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. UM #350 assisted Resident #20 back to bed and repositioned her legs. Neither LPN #518 nor UM #350 donned an isolation gown. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt. LPN #518 then provided peri care for Resident #20. Resident #20 stated when staff straight catheterized her, they never wear isolation gowns. UM #350 stated nurses would only wear an isolation gown if the resident had an infection Interview on 08/07/25 at 12:21 P.M. with DON revealed staff should wear Personal Protective Equipment (PPE) for wound care, peri care, indwelling catheter, or when providing care for a specific reason. DON confirmed staff should wear an isolation gown when providing hands on care for Resident #20. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) revised February 2021 revealed EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents. EBP refers to an infection control intervention designed to reduce the transmission of MDRO's during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that are unable to be covered or contained. Indwelling medical devices include urinary catheters. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This was an incidental finding discovered during the course of the complaint investigation. Residents Affected - Few 366419 Page 21 of 21