Health inspection·August 12, 2022

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 observation, record review, and staff interview, the facility failed to timely notify a physician of a resident's significant weight loss. This affected one resident (#55) out of five residents reviewed for nutrition. The facility census was 58. Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, unsteadiness, essential hypertension, other iron deficiency anemias, and morbid obesity due to excess calories. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #55's nutritional care plan dated 05/06/22 revealed Resident #55 was at risk for changes in nutrition. Interventions included review the resident's weights, skin, labs, and intakes routinely and as available and report changes as needed, offer supplements as ordered, offer the diet as ordered by the physician, observe for signs and symptoms of dehydration, offer meal substitutes, encourage the resident to eat and drink, encourage the resident to eat calorically dense foods and encourage the resident to drink all of her fluids when medications are given. Review of Resident #55's weights from 05/01/22 to 08/01/22 revealed Resident #55 weighted 184.2 pounds (lbs.) on 05/01/22, 183.2 lbs. on 05/10/22, 181.4 lbs. on 05/17/22, 182.4 lbs. on 05/31/22, 182.4 lbs. on 06/01/22, 170.0 lbs. on 06/07/22, 170.0 lbs. on 06/16/22, 170.2 lbs. on 06/28/22, 172.9 lbs. on 07/12/22, 160.6 lbs. on 07/26/22 and 159.8 lbs. on 08/01/22. Review of Resident #55's quarterly nutritional screen dated 06/14/22 revealed Resident #55 had a weight loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. Review of Resident #55's quarterly nutritional screen dated 08/02/22 revealed Resident #55 had a loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regiment. The assessment reported Resident #55 was on weekly weights Page 1 of 22 366439 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and had a significant weight loss over the past 30 days. A recommendation of ensure enlive 237 milliliters twice a day was recommended to the physician. Review of Resident #55's progress notes from 07/26/22 to 08/02/22 revealed no documentation that Resident #55's weight loss of 7.11 percent or Resident #55's weight loss of 172.9 lbs. to 160.6 lbs. from 07/12/22 to 07/26/22 was addressed by the dietician or physician, or that interventions were put in place for the weight loss prior to 08/02/22. Additional review revealed no documentation the physician was notified of the weight loss. Telephone interview on 08/04/22 at 10:15 A.M. with Registered Dietician (RD) #800 verified Resident #55 did not receive a weekly weight on 07/19/22 as ordered by the physician. RD #800 also verified Resident #55 had a weight loss of 7.11 percent or 172.9 lbs to 160.6 lbs from 07/12/22 to 07/26/22 and Resident #55 was not assessed for the weight loss and no interventions were put in place until 08/02/22. RD #800 also confirmed the physician was not notified of Resident #55's weight loss of 7.11 percent or 172.9 lbs on 07/12/22 to 160.6 lbs on 07/26/22 until 08/02/22. 366439 Page 2 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide an ongoing activities program. This affected three (Residents #29, #30, and #50) of four residents reviewed for activities. The facility census was 58. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, and dementia with behavioral disturbance. Review of Resident #29's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident activity preferences included group activities, and pet visits. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #29 participated in daily activities. 2. Medical record review revealed Resident #30 admitted to the facility on [DATE] with diagnosis of Parkinson, Alzheimer's disease, muscle weakness, dysphagia, repeated falls, peripheral vascular disease, and abnormal weight loss. Review of Resident #30 admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #30 activity preferences included watching TV in room in afternoon and group activities. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #30 participated in daily activities. 3. Review of the Resident #50s chart revealed Resident #50 admitted to the facility on [DATE] with diagnoses including anxiety disorder, depressive disorder, and dementia, Review of Resident #50's admission Minimum Data Set (MDS) assessment dated [DATE]revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. There were no activity preferences listed on the MDS. Further review of the medical record and review of the Activity Leisure Logs revealed no documentation showing Resident #50 participated in daily activities. Observation on 08/01/22 revealed the facility had five separate houses. Each house was licensed for 12 residents. There were two nurses and eight State Tested Nurse Aides (STNA) present in the facility to care for 58 residents. The STNAs were observed assisting residents with care, cooking, and washing dishes. Review of the posted activity calendar in all facility houses revealed three to four daily planned activities for 08/01/22 through 08/04/22. There were no times listed for the activities except for 366439 Page 3 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0679 church at 2:00 P.M. on 08/03/22. A weekly pet visit was scheduled on Tuesday, 08/02/22. Level of Harm - Minimal harm or potential for actual harm Review of activity calendars provided from 07/10/22 through 08/13/22 revealed no Bingo was listed as a planned activity. Residents Affected - Few Random observations of residents from 08/01/22 through 08/04/22 from 8:30 A.M. to 4:30 P.M. revealed one activity was presented by a volunteer on 08/03/22 at 2:00 P.M. No other organized planned activities were led or offered by STNAs or other designated staff throughout the facility. Interview on 08/01/22 at 4:38 P.M. the family member of Resident #30, who visits multiple times throughout the week, reported there were no group and/or planned activities for residents. Interview on 08/02/22 at 4:26 P.M. STNA #63 verified the facility has not had an Activity Director since 07/07/22 and no activity staff for the last three years. The STNAs were expected to provide activities as scheduled or alternatives. Activities and any one-on-one activities were to be documented in the Activity Leisure section of the resident's medical electronic record. Interview on 08/03/22 at 8:50 A.M. STNA #89 reported there was not enough time to conduct activities. STNA #89 further reported the facility did not have an Activity Director for over a month and no activity staff. STNA #89 did not have the activity calendar for the current week and was unaware of what activities were scheduled. STNA #89 said daily participation in activities were to be documents in the resident's electronic medical record, for each resident. Interview on 08/03/22 at 11:10 A.M., STNA #26 verified family members have voiced concerns regarding insufficient resident activities. STNA #26 further verified there had been no ongoing activities for over three weeks. Interview on 8/03/22 at 11:45 A.M. STNA #46 verified the facility did not have an Activity Director and there were no designated activity staff to cover each house. STNAs did not have enough time to provide planned activities or one-on-one activities. Observation on 08/03/22 at 1:19 P.M. revealed Resident #30 was sitting in a wheelchair at the dining room table with blocks, which were out of reach from the resident. Resident #30 was not engaged with the blocks and STNA #26, who was present in the area, was not assisting or engaging with the resident. Observation on 08/03/22 from 1:20 P.M. to 2:00 P.M. revealed Resident #50 sitting in a wheelchair at the dining room table without any activity material or engagement. A TV approximately 30 feet away but was not within seeing or hearing distance. The resident was rocking back in forth in the wheelchair, appearing anxious and at times slumped forward with her head on the table. Interview on 08/03/22 at 2:59 P.M. Resident #29 reported she preferred group activities and Bingo was not provided as an activity for several weeks. Resident #29 further stated there was no variety in activities and her preferences were not followed/provided. Resident #29 verified the pet visit scheduled on 08/02/22 did not happen and there was no alternative offered. Interview on 08/03/22 at 3:29 P.M. Diet Tech #31 reported she was filling in as the Activity Director and completed the August activity calendar. The Activity Director position had been vacated for several weeks. Diet Tech #31 verified the facility did not have any activity staff for any of the 366439 Page 4 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0679 facility's houses and STNAs were expected to conduct the ongoing activity program. Level of Harm - Minimal harm or potential for actual harm Observation on 08/08/22 at 10:19 A.M. revealed Resident #30 sitting in a wheelchair at the dining room table with blocks, which were out of reach. Resident #50 was sitting in a wheelchair at the dining room table slumped forward with her head on the table. Residents Affected - Few Interview on 08/08/22 at 10:19 A.M. STNA #89 verified Resident #30 and Resident #50 were not being provided effective and preferred activities due to STNAs not having enough time. Review of the facility policy titled, Engagement and Activity, dated April 2013, revealed the STNAs will print an engagement calendar and store it in the binder for reference. The STNAs are to document resident provided activities in the engagement calendar. 366439 Page 5 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff inteview, and resident interview, the facility failed to provide timely incontinence care. This affected one (Resident #107) of three residents reviewed for incontinence care. The facility census was 58. Findings included: Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence of unspecified artificial knee, chronic pain, atrial fibrillation, and diabetes. Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and reposition frequently. Interview on 08/01/22 at 12:10 P.M. with Resident #107 revealed no staff had offered to change or reposition her since 4:00 A.M. Resident #107 stated she required two staff to change and reposition. The resident stated there was only one staff. Resident #107 stated on occasion she was wet up to her shoulders because there was not been enough staff to change her. Resident #107 stated she was uncomfortable and needed repositioned. Interview on 08/01/22 at 12:32 P.M. with State Tested Nursing Assistant (STNA) #76 confirmed she began working at 7:00 A.M. and had not repositioned or changed Resident #107 since coming to work. STNA #76 stated she was the only staff present to care for Resident #107 and the resident required two staff for incontinence care. Interview on 08/02/22 at 11:14 A.M. with the Director of Nursing revealed it was the expectation of the facility that residents who required incontinence care were checked and repositioned every two hours. The DON revealed staff were expected to request assistance from administrative staff when other staff were not available. This deficiency substantiates Complaint Numbers OH00131398 and OH00134286. 366439 Page 6 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to timely monitor and address Resident #55's weight loss and failed to ensure weekly weights were completed as ordered by the physician. This affected one (Resident #55) of five residents reviewed for nutrition. The facility census was 58. Residents Affected - Few Findings include: Medical record review revealed Resident #55 admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, unsteadiness, essential hypertension, other iron deficiency anemias, and morbid obesity due to excess calories. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #55 required supervision with eating. Resident #55 was reported to have a five percent or more weight loss in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regimen. Review of Resident #55's nutritional care plan dated 05/06/22 revealed Resident #55 was at risk for changes in nutrition. Interventions included review the resident's weights, skin, labs, and intakes routinely and as available and report changes as needed, offer supplements as ordered, offer the diet as ordered by the physician, observe for signs and symptoms of dehydration, offer meal substitutes, encourage the resident to eat and drink, encourage the resident to eat calorically dense foods and encourage the resident to drink all of her fluids when medications are given. Review of Resident #55's physician's order dated 04/28/22 and discontinued on 07/07/22 revealed Resident #55 was on a regular diet with regular texture and thin liquids. Review of Resident #55's physician's order dated 05/10/22 and discontinued 07/10/22 revealed Resident #55 was to have weekly weights on Tuesdays for four weeks. Review of Resident #55's physician's order dated 07/07/22 revealed Resident #55 was on a regular diet with pureed texture and mildly thick liquids. Review of Resident #55's physician's order dated 07/12/22 revealed Resident #55 was to have weekly weights on Tuesdays. Review of Resident #55's physician's order dated 08/02/22 revealed Resident #55 was to have ensure enlive advanced therapeutic nutrition shake before meals for breakfast and dinner. Review of Resident #55's weights from 05/01/22 to 08/01/22 revealed Resident #55 weighted 184.2 pounds (lbs.) on 05/01/22, 183.2 lbs. on 05/10/22, 181.4 lbs. on 05/17/22, 182.4 lbs. on 05/31/22, 182.4 lbs. on 06/01/22, 170.0 lbs. on 06/07/22, 170.0 lbs. on 06/16/22, 170.2 lbs. on 06/28/22, 172.9 lbs. on 07/12/22, 160.6 lbs. on 07/26/22 and 159.8 lbs. on 08/01/22. Review of Resident #55's quarterly nutritional screen dated 06/14/22 revealed Resident #55 had a weight loss of five percent or more in the last month or ten percent or more in the last six months 366439 Page 7 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was not on a prescribed weight loss regimen. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. Review of Resident #55's quarterly nutritional screen dated 08/02/22 revealed Resident #55 had a loss of five percent or more in the last month or ten percent or more in the last six months and was not on a prescribed weight loss regiment. The assessment reported Resident #55 was on weekly weights and had a significant weight loss over the past 30 days. A recommendation of ensure enlive 237 milliliters twice a day was recommended to the physician. Review of Resident #55's progress note dated 06/10/22 revealed Resident #55 had a five percent weight change over 30 days. Resident #55 tested positive for coronavirus 2019 (COVID-19) at the end of May and complained of a sore mouth on the lower right side. The dentist was called, and Resident #55 had orajel that she was using in her mouth. The family and physician were notified of the weight change. Review of Resident #55's progress notes from 07/26/22 to 08/02/22 revealed no documentation that Resident #55's weight loss of 7.11 percent or Resident #55's weight loss of 172.9 lbs. to 160.6 lbs. from 07/12/22 to 07/26/22 was addressed by the dietician or physician, or that interventions were put in place for the weight loss prior to 08/02/22. Review of Resident #55's Treatment Administration Record (TAR) dated July 2022 revealed Resident #55 did not receive her weekly weight as ordered on 07/19/22. Telephone interview on 08/04/22 at 10:15 A.M. with Registered Dietician (RD) #800 verified Resident #55 did not receive a weekly weight on 07/19/22 as ordered by the physician. RD #800 also verified Resident #55 had a weight loss of 7.11 percent or 172.9 lbs to 160.6 lbs from 07/12/22 to 07/26/22 and Resident #55 was not assessed for the weight loss and no interventions were put in place until 08/02/22. RD #800 also confirmed the physician was not notified of Resident #55's weight loss of 7.11 percent or 172.9 lbs on 07/12/22 to 160.6 lbs on 07/26/22 until 08/02/22. Observation on 08/04/22 at 12:26 P.M. revealed Resident #55 to be eating pureed corn, pureed macaroni and cheese, and pureed pears independently with a divided plate and spoon. Review of the facility's weights policy and procedure dated 06/26/09 revealed weights will be taken within the comprehensive review period. The following interventions may be put in place if significant weight change occurs: Review of the current diet order, monitor weights weekly, speak with elderly assistants, nurses, and the resident regarding weight changes, monitor the resident at meal times, make recommendations for interventions and updating the care plan and care card with interventions. 366439 Page 8 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, resident interviews, and review of facility policy, the facility failed to provide sufficient staffing to meet the needs of the residents. This affected one (Resident #107) and had the potential to affect twelve residents (#207, #47, #46, #156, #206, #111, #106, #107, #45, #108, #40 and #31) who resided in House #15. The facility census was 58. Findings included: During initial tour of the facility on 08/01/22 from 8:15 A.M. through 9:20 A.M. revealed the facility had five separate homes. Each home was licensed for twelve residents. There were two nurses, Licensed Practical Nurse (LPN) #92 and Registered Agency Nurse (RN) #120 and eight State Tested Nurse Aides (STNA) (#8, #9, #35, #38, #46, #52, #76, and #82) present in the facility to care for 58 residents residing in the five houses. Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence of unspecified artificial knee, chronic pain, atrial fibrillation, and diabetes. Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Further review of the MDS revealed the resident revealed the resident was occasionally incontinent of bowel and bladder. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and repositioned frequently. Interview on 08/01/22 at 12:10 P.M. with Resident #107 revealed no staff who had offered to change or reposition her since 4:00 A.M. The Resident #107 stated she required two staff to change and reposition her. The resident stated there was only one staff member. Resident #107 stated there have been days when she was wet up to her shoulders because there was not enough staff. Resident #107 stated she was uncomfortable and needed repositioned. Interview on 08/01/22 at 12:32 P.M. with State Tested Nursing Assistant (STNA) #76 confirmed she began working at 7:00 A.M. and had not repositioned or changed Resident #107 since coming to work. STNA #76 stated she was currently the only direct care staff in House #15 and the resident required two staff for incontinence care. Interviews on 08/04/22 from 7:53 A.M. with STNA #6 and #89 revealed the facility did not have sufficient staff to provide the care and services needed for the residents. STNA #6 stated there are multiple residents who require two people for repositioning and transfers. Interview on 08/04/22 at 10:44 A.M. with Director of Nursing confirmed the facility expectation for the STNAs included resident care, cooking, cleaning, and laundry. The DON stated the night shift 366439 Page 9 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleans the common area and does the laundry. The first shift STNAs responsibilities included cooking, serving, and providing care and services for the residents. The DON revealed it was the responsibility of the STNAs to ask for help from administrative staff if needed. The DON stated the goal was two STNAs were to be assigned to each home. The DON confirmed there were homes with only one STNA to care for the twelve residents. The DON further reported the expectation was if residents required incontinence care, they were checked and respositioned every two hours. Review of the facility Resident Council Meeting Minutes dated 03/29/22 revealed residents voiced concerns related to only one STNA working in a house per shift. Review of the facility policy titled, Scheduling Guidelines Consistent Assignments, dated 01/23/08 revealed the facility must maintain appropriate staffing levels in each home. The policy revealed consistent assignments are essential to the quality and care of the elders. Further review revealed two STNAs per house and two nurses per neighborhood (five homes) were to be scheduled on day shift and afternoon/evening shift and one STNA and one nurse on night shift. This deficiency substantiates Complaint Numbers OH00134286, OH00132632, and OH00131398. 366439 Page 10 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and review of personnel files, the facility failed to ensure an annual performance review was completed for State Tested Nursing Assistant (SNTA) #2. This affected one (STNA #2) of two STNAs reviewed for annual performance reviews. This had the potential to affect all residents at the facility. The facility census was 58. Residents Affected - Few Findings include: Review of State Tested Nursing Assistant (STNA) #2's personnel file revealed a date of hire on 02/10/20. Review of the STNA's file revealed no annual performance review was contained in the file. Interview on 08/04/22 at 8:02 A.M. with Business Office Manager #84 confirmed the facility was not able to provide evidence an annual performance review was completed for STNA #2. 366439 Page 11 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify the reason for the use of as needed (PRN) narcotic pain medications and provide other interventions prior to the administration of pain medications for one (#22) of six residents reviewed for unnecessary medications. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed an admission date of 01/06/18. Diagnoses included fracture of unspecified pubis, chronic obstructive pulmonary disease, neuropathy, anxiety disorder, urinary incontinence, chronic pain, and hyponatremia. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of Resident #22's plan of care dated 05/11/22 revealed the resident was at risk for pain related to poly-osteoarthritis, neuropathy, and decreased mobility. Interventions included topical pain medications, range of motion, and administer pain medications as ordered. Review of Resident #22's physician order dated 07/26/22 revealed an order for the narcotic pain medication oxycodone hydrochloride (HCL) tablet 10 milligrams (mg) every four hours PRN for pain. Review of Resident #22's narcotic sheet for the PRN oxycodone HCL 10mg revealed the medication was removed on the following dates and times: On 08/01/22 at 7:05 A.M., at 10:55 A.M., 2:40 P.M., 5:45 P.M., and at 11:00 P.M. by Licensed Practical Nurse (LPN) #92. On 08/02/22 at 12:00 A.M., (one hour later from the 08/01/22 11:00 P.M. dose), 10:00 A.M., and 2:30 P.M. by Agency Registered Nurse (RN) #99. On 08/02/22 at 5:40 P.M., 8:50 P.M., and 11:00 P.M. by LPN #92. Review of Resident #22's Medication Administration Record (MAR) for 08/01/22 revealed the oxycodone HCL was only documented as administered to the resident at 7:01 A.M. and 10:57 A.M. with no reason for the administration documented. Review of the MAR for 08/02/22 revealed no oxycodone HCL 10mg tablets were administered. The medical record contained no documentation of the reason the oxycodone HCL 10 mg was removed from the narcotic storage for administration to Resident #22 on 08/01/22 and 08/02/22. The record did not address if other pain interventions were utilized prior to administration. Interview on 08/04/22 at 1:25 P.M. with the Director of Nursing (DON) confirmed discrepancy between the resident's MAR and the narcotic record. The DON confirmed, per the documentation, the MAR indicated the resident was not administered the oxycodone HCL each time the oxycodone HCL was removed from the narcotic drawer. 366439 Page 12 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to verify a resident's (Resident #55) identity prior to medication administration, resulting in Resident #55 being given another resident's medication. This resulted in actual harm when Resident #55 had a subsequent episode of vomiting and lethargy, leading to the resident being transferred to the emergency room. Additionally, the facility failed to administer pain medication in a timely manner and as ordered by the physician for Resident #107. This affected two (Residents #55 and #107) of six residents reviewed for medication administration. The facility census was 58. Residents Affected - Few Findings included: Medical record review for Resident #55 revealed the resident admitted to the facility on [DATE] with diagnoses including vascular disorder of intestine, chronic kidney disease, essential hypertension, other iron deficiency anemias, unspecified asthma, dyspnea, nonrheumatic mitral valve stenosis, aphasia, asthma, and arthropathy. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #55 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the facility's undated incident submission summary revealed on 05/29/22, Resident #55 was administered the wrong medication by agency staff. The agency staff member was going in order of rooms and failed to verify Resident #55's name and room number with staff. At approximately 10:30 A.M., Resident #55 was given aspirin, calcium, Aricept, doxycycline, iron, gabapentin, lisinopril, Namenda, Protonix, multivitamin, Profenone, zinc and vitamin D. After the wrong medication was administered, Resident #55 presented with vomiting. The agency nurse contacted the physician who gave orders to send the resident to the emergency room. The nurse also contacted Resident #55's representative and Resident #55 left the facility for the hospital at 11:30 A.M. On 05/29/22 at approximately 12:21 P.M., the facility contacted the emergency room, and the emergency room nurse returned the call and reported Resident #55 was fine and lethargic. Resident #55 also still had episodes of vomiting but was stable. Resident #55 returned from the hospital on [DATE] at 8:10 P.M. Review of the progress note dated 05/29/22 revealed Resident #55 was out to the hospital and should be closely monitored and charted on every shift for three days. Per the hospital, the resident was in stable condition. Review of the late entry progress note dated 05/31/22 revealed Resident #55 was administered the wrong medication. The nurse was educated on medication administration and asking facility staff for proper resident identification if unable to determine. The physician and family were notified. Resident #55 returned from the emergency room at 8:10 P.M. with vital signs within normal limits and lungs clear with a moist cough noted. Resident #55 continued on coronavirus quarantine until asymptomatic. Resident #55 denied pain or discomfort. No further emesis noted. All parties were aware. Telephone interview on 08/04/22 at 1:30 P.M. with the Director of Nursing (DON) revealed she received a call from the previous Administrator on 05/29/22. The Administrator informed the DON Resident #55 was administered another resident's medications. Resident #55 received Aspirin 81 milligrams (mg), calcium plus vitamin D 600mg, Aricept 10 mg, doxycycline 100mg, iron 325 mg, vitamin D 25 366439 Page 13 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0760 Level of Harm - Actual harm Residents Affected - Few micrograms (mcg), gabapentin 300 mg, lisinopril 5 mg, Namenda 10 mg, Protonix 40 mg, multivitamin and zinc 50 mg that were not prescribed to her. The DON stated the nurse who administered the wrong medications was an agency nurse, but she could not recall her name. The DON stated the agency nurse was going room to room passing medications and did not realize she was in the wrong room. The DON stated Resident #55 had episodes of vomiting after receiving the wrong medication and was sent to the emergency room. The DON reported Resident #55's representatives were contacted. The DON reported she started medication administration audits after the incident and educated the facility's staff. The DON also reported she notified the agency where the agency nurse was employed, of the incident. The DON educated the nurse that made the medication error but did not put in place, any education for other agency nurses or staff that worked in the facility stating, It's the agencies job to educate their staff. Attempted interview on 08/09/22 at 2:05 P.M. with Staffing Agency #801 was unsuccessful. Review of the facility's medication administration procedure revised 11/09/21 revealed residents are identified before medications are administered. Methods of identification include checking the photograph attached to the medical record, ask the resident to say or spell his or her name, and verify the resident's identification with other community personnel if necessary. 2. Review of Resident #107's medical record revealed an admission date of 07/17/22. Diagnoses included pneumonia, hypertension, osteoarthritis, cardiomegaly, gout, presence of unspecified artificial knee, chronic pain, atrial fibrillation, and diabetes. Review of Resident #107's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and dressing. The resident was totally dependent with two-person assist for toileting and personal hygiene. The resident required supervision with set-up for eating. Review of Resident #107's plan of care dated 07/17/22 revealed the resident had a self-care deficit related to multiple diagnoses. The plan of care identified the resident was at risk for skin breakdown. Interventions included turn and repositioned frequently. The plan of care revealed the resident was at risk for pain with interventions to administer medications as ordered. Review of Resident #107's physician order dated 07/22/22 revealed an order for Lyrica 75mg to be administered three times daily (8:00 A.M., 5:00 P.M. and 9:00 P.M.) for pain. Observation on 08/01/22 at 11:59 A.M. revealed Resident #107 was administered the Lyrica 75mg, which was ordered to be administered at 8:00 A.M. Interview on 08/01/22 at 12:10 P.M. Resident #107 reported she did not receive her morning medications until almost noon. Interview on 08/01/22 at 12:34 P.M. with Licensed Practical Nurse (LPN) #92 confirmed the resident's Lyrica was ordered to be administered at 8:00 A.M. LPN #92 confirmed she did not administer the medication timely. LPN #92 revealed she had an admission earlier in the morning which made her medication administration times late. Interview on 08/01/22 at 1:05 P.M. with the Certified Nurse Practitioner (CNP) #325 revealed she 366439 Page 14 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0760 was at the facility every Monday and Thursday. The CNP #325 revealed late medication administration was a, common occurrence. Level of Harm - Actual harm Residents Affected - Few Interview on 08/02/22 at 10:44 A.M. with the Director of Nursing confirmed it was the facility's expectation to administer resident's medications within one hour prior or one hour after the scheduled medication ordered time. Review of the facility policy titled, Medication Administration Procedures, revised 11/09/21 revealed medications are administered within one hour before or one hour after scheduled times. 366439 Page 15 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, the facility failed to properly label insulin medication. This affected two (Residents #13 and #21) and had the potential to affect 10 residents (#13, #21, #206, #41, #29, #48, #4, #49, #43, #40) who received insulin at the facility. The facility census was 58. Findings include: Observation and interview on 08/03/22 at 11:23 A.M. revealed the medication cart located in House #17 contained two opened, unnamed, multi-use vials of insulin. Neither vial was labeled with a resident's name or the date it was opened. Agency Registered Nurse (RN) #101 confirmed the Lantus 100 units per milliliter (ml) belonged to Resident #13 and the Humalog 100 units per ml belonged to Resident #21. Further observation revealed both bottles were open and approximately half empty. RN #101 confirmed neither insulin vial was labeled with an open-dat and neither insulin vial was in a pharmacy bag or box with the name, order or open date. RN #101 verified all insulin was required to have the opened date written on the vial or container. Review of Resident #13's medical record revealed an admission date of 01/14/21. Diagnoses included diabetes, chronic congestive heart failure, and unspecified dementia. Review of Resident #13's physician orders revealed an order for Insulin Glargine Solution 100 unit per milliliter (ml) with directions to inject 22 units subcutaneously at bedtime for diabetes. Review of Resident #21's medical record revealed and admission date of 04/03/20. Diagnoses included diabetes, morbid obesity, dementia and major depressive disorder. Review of Resident #21's physician orders revealed no active orders Humalog 100 unit per ml as identified by RN #101. Interview on 08/04/22 at 10:11 A.M. with the Director of Nursing confirmed the expectation of the facility was all multi-use medications were labeled with the date the product was opened. Review of the facility's policy titled, Medication Administration Procedure, dated 11/09/21 revealed the policy did not address the labeling of insulin or multi-use medications. 366439 Page 16 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation, and interview, the facility failed to provide food portions and menus as approved by a Registered Dietitian. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings Include: Review of the facility's approved menu dated 08/01/22 for House #15's lunch meal revealed the following was to be served: Six ounces (oz) of spaghetti with meatballs, four oz of broccoli, four oz of cottage cheese with peaches, one slice of garlic bread and a beverage. Observation on 08/01/22 at 12:40 P.M. revealed Resident #207 was served five slices of peaches, less than one cup of chicken noddle soup, and one slice of bread with butter. Interview on 08/01/22 at 12:41 P.M. Resident #207 reported the lunch portion was, not much food for anyone. Resident #207 stated the portion sizes were dependent upon which State Tested Nurse Aide (STNA) or how many STNAs were working. Resident #207 also verified menus were not followed. Observation and interview on 8/01/22 at 1:15 P.M. revealed Resident #206 was serviced five slices of peaches, less than one cup of chicken noodle soup, and one slice of break. Resident #206 verified the food served and reported she had not requested a substitute. Resident #206 reported there was not enough time for staff to prepare meals on most days and there was only one STNA working to prepare meals and care for residents. Interview on 8/01/22 at 1:18 P.M. Household Assistant (HA) #77 reported she prepared lunch and did not follow a menu, but prepared the meal with foods found in the storage room. HA #77 verified she did not use measuring utensils when serving lunch. HA #77 did not have approval from a Registered Dietician (RD) to make food substitutions and did not log substitutions. HA #77 further verified she did not follow recipes when preparing meals, but utilized the meal guideline reference sheet found in the STNA notebook of menus. HA #77 reported broccoli was listed on the lunch menu for 08/01/22 and she did not prepare broccoli or any other vegetable for lunch. Interview on 08/01/22 at 12:27 P.M. with STNA #46 (working in House #14) revealed the menu changed from a hamburger to a tuna noodle casserole, with no vegetables because groceries were not delivered as planned. STNA #46 did not use a recipe and did not use measuring utensils when serving. STNA #46 verified she was the only STNA working in the house and had little time to prepare a full meal. STNA #46 reported she did not have approval from a RD to make food substitutions and did not log substitutions. Interview on 08/02/22 at 10:35 A.M. with STNA #11 (working in House #16) revealed she was the only STNA working to prepare meals and care for 12 residents. STNA #11 verified the menu was not followed as many foods were not delivered and recipes were not provided. STNA #11 further stated measuring utensils were not utilized to follow listed portion sizes and there were no measuring utensils even available for use. STNA #11 reported she did not log food substitutions. Observation and interview on 08/03/22 at 8:50 A.M. with STNA #89 (working in House #16) revealed breakfast served was a croissant roll with eggs, cheese, and bacon, despite the menu listing one egg, 366439 Page 17 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some two slices of bacon, one cup of cereal, and two slices of toast. STNA #89 stated she did not follow a recipe and used five slices of bacon for 12 residents. STNA #89 stated a RD did not review, provide, or approve recipes or meal substitutions. STNA #89 further verified she did not measure portions per the menu and she, eyeballs, the amount of food she thinks the resident will accept. Interview on 08/03/22 at 11:06 A.M. with HA #77 (working in House #19) revealed the menu listed the following to be served for lunch: Applesauce, ham salad, croissant, and broccoli salad. HA #77 stated none of the ingredients were available and she was substituting the meal with hotdog's, baked beans, potato salad or potato chips. HA #77 stated a RD had not approved the substitution and it was not logged. HA #77 reported she did not know what portion sizes were required and verified she did not have measuring utensils available for use. Observation and interview on 08/03/22 at 11:20 A.M. with STNA #19 (working in House #15) revealed the planned meal was supposed to be four oz of pulled pork sandwich, green beans, pasta salad, and a fruit cup, but she was serving a baked chicken croissant, green beans with potato, fruit cocktail, and pudding. STNA #19 verified she came up with the baked chicken croissant recipe herself and it was not written down. STNA #19 was not measuring the chicken mixture when preparing the croissant. STNA #19 stated she was putting enough in the croissant so it could be folded. Upon insistence of the surveyor, the meat mixture measured two oz, not four oz as listed on the menu for the protein portion. Observation and interview on 08/03/22 at 12:19 P.M. with STNA #6 (working in House #16) revealed she was serving Spaghetti O's, mixed fruit, peanut butter sandwich, and mixed berry pie for lunch. STNA #6 was unaware of required portion sizes and reported she did not have any measuring utensils for use. Review of the planned menu for House #15 dated 08/03/22 revealed the supper meal was to consist of hearty vegetable soup, a roll, pears, and a cookie. There was no entry on the substitution log for baked spaghetti. Interview on 8/04/22 at 8:30 A.M. family member of Resident #156 (in House #15) revealed the supper meal on 08/03/22 consisted of baked spaghetti, applesauce, and no vegetable. Interview on 08/04/22 at 08:47 A.M. Resident #107 verified supper on 08/03/22 had no vegetables served. Interview on 08/04/22 at 10:52 A.M. STNA #38 (working in House #17) verified substitutions of meals were not documented on the substitution logs. Review of substitution logs of Houses #14, #15, #16, #17 and #19 for January 2022 through August 2022 revealed no food substitution entries. Review of Resident Council Meeting Minutes dated 07/27/21 and 10/26/21 revealed Resident #49 reported there were a lot of menu substitutions and the menu was not followed a lot of the time. Review of the Food Substitution Guideline Reference Sheet dated 03/20/20 revealed like foods were to be substituted for like foods. Review of facility policy titled, Food Substitution Log Use, dated 07/21/22 revealed food is 366439 Page 18 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some substituted in an appropriate, healthy, and safe way. Food will be replaced with the respective food group, the diet technician will be notified of the change to the day's menu, the change will be written on the menu substitution log. Review of the facility policy titled, Family Style Meal Service Policy and Procedure, dated May 2013 revealed the nurse aide will plate food with the appropriate serving portion. 366439 Page 19 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interviews, review of manufacture directions, and review of facility policy, the facility failed to store foods in a safe and sanitary manner. This had the potential to affect all 58 residents who received food from the kitchen. The facility census was 58. Findings include: Observation on 08/01/22 at 8:30 A.M. with Diet Technician #31 revealed the following concerns in House #16's kitchen. 1. Two containers of unidentifiable food, unlabeled and undated. 2. Three quarters of a chocolate pie in a pie pan uncovered and undated. 3. Opened potato salad, undated. 4. Container of opened applesauce, undated. 5. Open container of pineapple undated. 6. Container of opened chicken broth, undated. 7. No thermometer in reach of the refrigerator. 8. An undated pan of partially served brownies. Observation on 08/01/22 at 8:45 A.M. with Diet Technician #31 revealed the following concerns in House #17's kitchen: 1. 366439 Page 20 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0812 Container of opened applesauce, undated. Level of Harm - Minimal harm or potential for actual harm 2. Container of opened beef broth with expiration date of 07/27/22. Residents Affected - Many 3. Undated open container of cranberry juice. 4. No thermometer in reach of the freezer 5. Package of bread with expiration date of 07/31/22. Observation on 08/01/22 at 9:05 A.M. with Diet Technician #31 revealed following concerns in House #19's kitchen: 1. No thermometer in reach of the refrigerator or freezer 2. Container of opened beef broth with expiration date of 07/28/22. 3. Open containers of sour cream and cottage cheese, undated. 4. Container of opened applesauce, undated. Observation on 08/01/22 at 9:20 A.M. with Diet Technician #31 revealed following concerns in House #15's kitchen: 1. No thermometer in reach of the refrigerator. 2. Container of opened chicken broth with expiration date of 07/20/22. 3. 366439 Page 21 of 22 366439 08/12/2022 Otterbein Union Township 1114 Neighborhood Drive Batavia, OH 45103

F 0812 Cheese spread, undated. Level of Harm - Minimal harm or potential for actual harm 4. Open and partially used sour cream, undated. Residents Affected - Many 5. Bagged potatoes stored on the floor in the dry storage area. 6. Two bags of unidentifiable food unlabeled and undated. Observation on 08/01/22 at 9:30 A.M. with Diet Technician #31 revealed following concerns in House #14's kitchen: 1. Container of opened applesauce, undated. 2. Open container of ham salad, undated. 3. No thermometer in reach of the refrigerator. 4. Bag of several unidentifiable containers with food undated and unlabeled. Interview on 08/01/22 at 9:30 A.M. Diet Technician #31 verified all above observations. Interview on 08/09/22 at 1:20 P.M. Registered Dietitian (RD) #800 verified opened foods should be labeled with a date of when the product was opened and needed to be discarded within four to seven days of the open date. Review of facility policy titled, Food Storage Policy and Procedure, dated May 2013, revealed food should be covered, dated, and labeled with the month and day which it was opened and used by four to seven days after the food was opened/prepared. Food containers are stored at least six inches off the floor. 366439 Page 22 of 22