Health inspection·July 7, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #28 revealed an admission date of 05/02/24 with diagnoses including diabetes mellitus, hypertension, anxiety, depression, bipolar disorder, and chronic kidney disease. Residents Affected - Few Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required substantial or maximum assistance for activities of daily living (ADLs). On 06/24/25 at 3:01 P.M., an observation of Resident #28's room revealed Resident #28 was laying in bed calling for help and her call light was observed on the floor and out of reach. An interview at the time of observation with Certified Nursing Assistant (CNA) #27 verified Resident #28's call light was on the floor and out of reach. On 06/25/25 at 10:40 A.M., an observation revealed Resident #28 was lying in bed and the call light was not in reach. The call signal light on top of the door was illumined, indicating the residents in the room requested assistance. Licensed Practical Nurse (LPN) #44 entered the room and asked Resident #28 what she needed. Resident #28 replied she needed her call light and wanted to get dressed. LPN #44 retrieved the call light and put it in reach of Resident #28. Resident #28's roommate stated she needed help and had put on the call light. On 06/25/25 at 10:42 A.M., an interview with LPN #44 verified Resident #28's call light was not reach. This deficiency represents non-compliance investigated under Master Complaint Number OH00165594. Based on observation, interview, record review and facility policy, the facility failed to ensure the resident's call light was within reach. This affected three Residents (#6, #28 and #122) out of six residents reviewed for call lights. The facility census was 63. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 06/25/25 with diagnoses including acute respiratory failure, catatonic disorder, dysphagia, major depressive disorder, dependence on respiratory, multiple contractures, dependence on supplemental oxygen, and encephalopathy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 with maximum full dependence on staff for all activities of daily living (ADLs) and hygiene needs. Resident #6 was unable to perform any self-care due to catatonic state and Page 1 of 38 366441 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0558 contractures and uses a pressure pad call light for assistance. Level of Harm - Minimal harm or potential for actual harm Observation on 06/24/25 at 9:30 A.M. revealed pressure pad call light located on the floor and resident was unable to call for assistance. Residents Affected - Few Interview on 06/24/25 at 9:32 A.M. with Certified Nursing Assistant (CNA) #52 verified pressure pad call light on floor. CNA #52 replaced call light next to contracted arm so resident could activate if needed. 2. Review of medical record for Resident #122 revealed an admission date of 06/19/25 with diagnoses including infection of skin and subcutaneous tissue, sepsis, staphylococcus and pseudomonas infections (highly resistant bacterial organisms which require extended antibiotics), morbid obesity, protein-calorie malnutrition, chronic kidney disease, and muscle weakness. Review of MDS dated [DATE] revealed Resident #122 was alert, oriented, appropriate and no behavioral concerns. MDS also revealed Resident #122 required maximum assistance for ADLs, mobility, and hygiene needs due to deconditioning and morbid obesity. Interview and observation on 06/25/25 at 9:11 A.M. revealed Resident #122 complained of having a wet gown and needed to be changed. Resident was unable to reach call light for assistance. Call light was observed to be wrapped around the side of the bed rail near head of bed and out of reach for resident. Interview on 06/25/25 at 9:13 A.M. with CNA #84 verified call light was out of reach for resident. Call light was repositioned and secured on bed within reach for resident. Review of facility policy titled Resident Communication and Call Light Policy revised on 02/24/2023 revealed when resident is in bed or confined to a chair, the call light will be within easy reach. 366441 Page 2 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on record review, observation, and interview, the facility failed to honor resident preferences as ordered by the physician. This affected one resident (#19) out of two reviewed for choices. The facility census was 63. Findings include: Review of the medical record for Specified Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. The assessment indicated Resident #19 required partial or moderate assistance for eating, oral hygiene, and personal hygiene; required substantial or maximum assistance for rolling left and right, sit to lying, and lying to sitting; and was totally dependent on staff for toileting hygiene, showering or bathing self, dressing, and chair/bed to chair transfer. Review of the optional state MDS assessment, dated 04/18/25, revealed Resident #19 required extensive assistance of two staff for bed mobility and total dependence of two staff for transfers. Review of the physician's orders for June 2025 identified orders for crush medications and split in divided amounts with pudding or yogurt only (ordered 12/28/24) and resident to be up before lunch and down after lunch as tolerated (ordered 04/02/25). Review of the progress note dated December 2024 through June 2025 revealed multiple documented instances of Resident #19 refusing his medications. Review of the progress note dated 12/08/24 at 12:12 P.M. revealed Resident #19 refused all morning medications crushed in applesauce because yogurt was unavailable. Review of the progress note dated 12/27/24 at 6:59 P.M. revealed medications were to be crushed and administered with pudding or yogurt. Review of the progress note dated 04/02/25 at 10:28 A.M. revealed Resident #19's representative was in agreement with getting the resident up before lunch and going down after lunch as long as Resident #19 agrees. Review of the progress note dated 04/12/25 at 4:59 A.M. revealed Resident #19 refused his medications and the resident indicated he would take them if the nurse put them in yogurt. On 06/23/25 at 12:45 P.M., an observation of Resident #19's room revealed he was sitting in bed feeding himself a hamburger. On 06/26/25 at 8:51 A.M., an interview with Licensed Practical Nurse (LPN) #45 revealed Resident #19's medications had been administered with applesauce that morning because the facility was out of yogurt. LPN #45 confirmed Resident #19's preference was for medications to be administered with 366441 Page 3 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0561 yogurt instead of applesauce. Level of Harm - Minimal harm or potential for actual harm On 06/26/25 at 9:03 A.M., an interview with Regional Dietary Manager #82 revealed there was yogurt available. Observation at the time of interview revealed a sufficient supply of yogurt in the walk-in refrigerator in the kitchen. Residents Affected - Few On 06/26/25 at 9:05 A.M., an interview with the Director of Nursing (DON) confirmed Resident #19 preferred to take his medications with yogurt instead of applesauce. On 06/26/25 at 10:35 A.M., an interview with the DON confirmed Resident #19 had a physician's order to provide medications in pudding or yogurt only. The DON further revealed there was probably no yogurt in the second floor servery and LPN #45 did not go downstairs to look in the kitchen for yogurt. On 06/30/25 at 12:31 P.M., an observation of Resident #19 revealed he was in bed feeding himself a cheeseburger. On 06/30/25 at 12:40 P.M., an interview with LPN #55 confirmed staff did not get Resident #19 out of bed before lunch. LPN #55 further stated she's not aware of staff ever getting Resident #19 out of bed before lunch in the entire time she had worked at the facility (eight months). LPN #55 verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed on multiple days. LPN #55 also verified there were no documented refusals for Resident #19 getting out of bed. On 07/01/25 at 12:07 P.M., an observation of Resident #19's room revealed he was in bed and Social Services Designee (SSD) #13 was delivering his lunch to him in bed. On 07/01/25 at 12:10 P.M., an interview with SSD #13 confirmed Resident #19 was eating lunch in bed. On 07/02/25 at 12:34 P.M., an observation of Resident #19's room revealed he was in bed feeding himself a cheeseburger. On 07/02/25 at 2:13 P.M., an interview with LPN #44 confirmed Resident #19 had not been out of bed all day, verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed, and LPN #44 said she signed it off as completed because she offered it. LPN #44 claimed Resident #19 refused to get out of bed and confirmed there was no documentation of the refusal. This deficiency represents non-compliance investigated under Master Complaint Number OH00165594. 366441 Page 4 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's self-reported incident (SRI), and interview, the facility failed to conduct a thorough investigation of an allegation of abuse. This affected one resident (#32) out of four reviewed for abuse. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date 04/15/25 with diagnoses including osteomyelitis, clostridium difficile (c-diff), diabetes type II, peripheral vascular disease (PVR), bipolar, chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and was dependent on staff for activities of daily living. Review of the progress note dated 05/12/25 revealed the resident made an accusation about a staff member. Review of the Self-Reported Incident (SRI) 260268 dated 05/12/25 at 10:31 A.M. revealed an allegation of sexual abuse. The Assistant Director of Nursing (ADON) reported to administration that Resident #32 was raped on 05/11/25. The employee was suspended immediately pending investigation. The name of the alleged employee was not listed as a perpetrator. Resident #32 denied being touched inappropriately and stated she was held down gently over the bed and up against the wall. Interview with staff witnesses revealed no pertinent information discovered. Interviews with other staff on duty revealed no additional pertinent information. The SRI was completed on 05/13/25 at 6:25 P.M. The investigation included two employee witness statements completed by a Registered Nurse (RN) #54, and State Tested Nursing Assistant (STNA) #76 who was the suspected perpetrator. There were no additional staff interviews. There was no witness statement from the ADON who reported the allegation. There was an interview statement with Resident #32 conducted by the Administrator and the Director of Nursing (DON). Staff education consisted of an email written by the Business Office Manager (BOM) #3. The email was sent to 102 listed staff plus an additional 78 staff whose names were not listed. The subject line on the email read Resident abuse policy please read, very important. The attachment was a copy of the facility abuse policy. There was no evidence that staff completed the education. Interview on 07/01/25 at 11:44 A.M. with the Administrator stated she interviewed Resident #32 who denied any rape. RN #54 and STNA #76 denied any allegation of rape. The Administrator stated she suspected STNA #76 as the perpetrator because he was the only male who provided care to Resident #32 that night. STNA #76 was in Resident #32's room one time to pull her in bed with RN #54. The Administrator stated since Resident #32 denied the allegation of rape she did not further interview staff. The Administrator verified there were only two staff interviews and there was no evidence that staff completed the training on abuse. The Administrator stated the allegation could have been better investigated. 366441 Page 5 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure notice of transfer and bed hold notice was provided to the resident, and the discharge summary was completed. This affected six Residents #28, # 46, #55, #66 #118, and #119 of eight residents reviewed for hospitalization and discharge. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date 05/02/24 with diagnoses including diabetes type II, puerperal vascular disease (PVR), hypertension, anxiety, depression, and bipolar. The record revealed Resident #28 was sent out to the hospital on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was dependent on staff for activities of daily living. Review of the Immediate Transfer/Discharge, a written discharge notice to the resident/representative dated 05/13/25 revealed that the welfare and needs of the resident cannot be met in the facility due to the urgent medical needs of the resident. There was no evidence that the resident/representative received the written discharge notice. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital, the Immediate Transfer/Discharge Notice is added to the packet of information that goes with the resident to the hospital. Interview with the Administrator on 06/26/25 at 1:15 P.M. verified there was no way to ensure the residents received the written notice. The Administrator stated the facility had identified the transfer discharge notices as a part of Quality Assurance (QA) project. The Administrator stated she had instructed the receptionist to put a copy of the discharge transfer notice in with the hospital paperwork with every person who leaves 911. Interview on 06/26/25 at 1:32 P.M. with Resident #28 stated he had never seen the Immediate Transfer/Discharge form. 2. Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including chronic respiratory failure, quadriplegia, neuromuscular bladder, tracheostomy status. The record revealed Resident #46 was sent to the emergency room on [DATE], 05/16/25, and 05/24/25.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for activities of daily living. Review of the Immediate Transfer/Discharge, the discharge notice to the resident/representative dated 04/10/25, 05/16/25, 05/24/25 revealed the welfare and needs of the resident cannot be met in the facility due to the urgent medical needs of the resident. There was no evidence that the resident/representative received the written notice. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital the Immediate Transfer/Discharge Notice is added to packet of information that goes with the resident.Interview on 06/26/25 at 4:30 P.M. with Resident # 46 stated he had never seen the Immediate Transfer/Discharge form. Interview on 06/26/25 at 1:13 P.M. with Receptionist #9 stated when a resident is sent out to the hospital, the Immediate Transfer/Discharge Notice is added to the packet of information that goes with the resident to the hospital. Interview with the Administrator on 06/26/25 at 1:15 P.M. verified there was no way to ensure the residents received the written notice. The Administrator stated the facility had identified the transfer discharge notices as a part of Quality Assurance (QA) project. The Administrator stated she had instructed the receptionist to put a copy of the discharge transfer notice in with the hospital paperwork with every person who leaves 911. 3. Review of the medical record for Resident #66 revealed an admission date 04/09/25 with diagnoses including respiratory failure, cocaine use, chronic obstructive pulmonary disease (COPD), tracheostomy status a gastrostomy. The record revealed Resident #66 was sent to the emergency room on [DATE]. Further review of the discharge documentation revealed there was no evidence of a bed hold notice or Immediate Transfer/Discharge notice, the written notice to the representative provided 366441 Page 6 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 04/11/25.Interview on 07/02/25 at 1:30 PM with the Administrator verified the Resident #66 did not receive a written notice of transfer or a bed hold notice. 4.Review of the medical record for Resident #119 revealed an admission date 04/09/25 with diagnoses including paroxysmal atrial fibrillation, cancer of the colon, respiratory failure, type II diabetes and ileostomy status. The Resident was discharges on 4/17/25. Further review of the medical record revealed there was no evidence of an Immediate Transfer/Discharge form, a written notice of discharge to the resident/representative. Interview on 07/02/25 at 9:30 A.M. with the Administrator verified there was no evidence of a written discharge notice issued to Resident #119. Review of the facility policy titled Resident discharge/transfer letter policy revised 12/09/24 stated the facility will complete discharge letter appropriately and according to all federal, state and local regulation. 6. Review of the medical record for Resident #55 revealed an admission date of 02/19/25 with diagnoses including cerebral infarction, supraventricular tachycardia, hypertension, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/25, revealed Resident #55 had severely impaired cognition.Review of the physician's orders for Resident #55 identified an order for an appointment for magnetic resonance imaging (MRI) testing on 06/27/25 at 10:00 A.M. (ordered 06/24/25).Review of the progress notes for June 2025 revealed no notes indicating Resident #55 had been transferred or admitted to the hospital.Review of the transfer/discharge assessment, dated 06/27/25, revealed Resident #55 was transferred to the hospital for MRI testing and the bed hold and transfer notices were sent with the resident at the time of transfer. There was no indication that the bed hold and transfer notices were provided to Resident #55's representative.On 06/26/25 at 1:13 P.M., an interview with Receptionist #9 stated the process for when a resident was transferred to the hospital was the immediate transfer/discharge notice was added to the packet that was sent to the hospital with the resident. Review of the certified mail tracking information for the bed hold notice mailed for Resident #55 revealed it was mailed on 06/30/25. There was no evidence that a transfer notice was mailed with the bed hold notice.On 06/30/25 at 4:51 P.M., an interview with the Director of Nursing (DON) stated Resident #55 was sent to the hospital for testing per his sister's request and the hospital kept him for further testing. The DON confirmed there was no note indicating the transfer and said there should have been a progress note. The DON further stated the transfer and bed hold notices were always sent with the residents to the hospital. The DON confirmed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 2.0, indicating severe cognitive impairment, and his sister was notified of the transfer via phone call. On 07/02/25 at 12:49 P.M., an interview with the Administrator confirmed only a bed hold notice was mailed to Resident #55's representative and no transfer notice was provided in writing. 7. Review of medical record for Resident #118 revealed an admission date of 02/13/25 with a diagnoses including acute and subacute endocarditis, methicillin resistant staph aureus (a highly resistant organism), anxiety, obesity, obstructive sleep apnea, hypertension, congestive heart failure, pacemaker, dysphagia, and muscle weakness. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which is indicative of the resident having full cognition. Resident #118 needed partial/moderate assistance with activities of daily living (ADLs) and hygiene needs. Resident used a wheelchair for mobility and was able to self-propel. Review of baseline care plan dated 02/14/25 revealed goals of safety, nutritional status, medication and activities. Review of medical record revealed no discharge summary or discharge planning process was completed by facility as required. Interview with Administrator on 06/30/25 at 1:57 P.M. verified that Resident #118 did not have a discharge summary completed at the facility per requirement.Review of facility policy titled, Resident Discharge/Transfer Letter Policy revised 12/09/24 366441 Page 7 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0628 revealed discharge notices must have the following components: 1. Reason for discharge 2. The effective date of transfer/discharge, 3. The location to which the resident is transferred/discharge. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 366441 Page 8 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Resident Assessment Instrument (RAI) user manual review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate related to wounds. This affected one (Resident #46) of 21 residents reviewed for comprehensive assessments. The facility census was 63. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including chronic respiratory failure, quadriplegia, neuromuscular bladder, and tracheostomy status. Review of the assessment revealed Braden scale for pressure ulcer risk assessments was completed on 11/06/24 indicating Resident #46 was at high risk for pressure ulcer development. There was no evidence of the current Braden assessment. Review of the plan of care dated 05/02/25 revealed Resident #46 had a plan for neuropathic ulcer (a type of ulceration that develops due to nerve damage, commonly found in individuals with conditions like diabetes or spinal cord injuries) to the right foot with risk for complication. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for activities of daily living. Under section M0150 of the assessment revealed the resident was at risk for pressure ulcers and under M1040 had no open lesions on the foot. Review of the physician's wound noted dated 05/25/25 stated the wound the right foot planter aspect was neuropathic. Review of the physician's orders dated June 2025 revealed Resident #46 had a wound dressing order to the right foot planter to cleanse and apply foam cover to the right great toes, dated 04/28/25. Interview on 06/30/24 at 10:20 A.M. with MDS Nurse #11 verified Resident #46 she did not check the box und M1040 other open lesions on the foot. MDS #11 stated she was taught to check the box only if it was related to cancer. MDS Nurse #11 stated neuropathic wounds meet the definition of an open lesion that develops as part of the disease or condition. Review of the RAI manual dated October 2024 stated M1040D Open Lesion(s) Other than Ulcers, Rashes, Cuts. Open lesions that develop as part of a disease or condition and are not coded elsewhere on the MDS, such as wounds, boils, cysts, and vesicles, should be coded in this item. Do not code rashes, abrasions, or cuts/lacerations here. Although not recorded on the MDS assessment, these skin conditions should be considered in the plan of care. Do not code pressure ulcers/injuries, venous or arterial ulcers, diabetic foot ulcers or skin tears here. These conditions are coded in other items on the MDS. 366441 Page 9 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the appropriate Ohio Department of Mental Health and Addiction Services was timely notified of a significant change in a residents Pre-admission Screen (PASRR). The affected one (Resident #20) of three reviewed for PASRR status. The facility census was 63. Findings include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including heart failure, type II diabetes mellitus, major depressive disorder, generalized anxiety disorder and acquired absence of left leg below knee. Review of the 03/27/20 PASRR results for Resident #20 revealed no indications of serious mental illness or developmental disability. Review of the medical record for Resident #20 revealed on 06/01/24 a new diagnosis of bipolar disorder was received. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and receiving antipsychotics. Diagnoses listed included but were not limited to anxiety disorder, depression, bipolar disorder, and psychotic disorder. Review of the nursing progress note dated 05/30/25 revealed Resident #20 was sent to the hospital for a mental status change. Review of the 05/30/25 hospital admission paperwork for Resident #20 revealed he was admitted with left-sided weakness. Resident #20 was noted to have medical history of bipolar disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment. Resident #20 required extensive assistance for activities of daily living and had diagnoses including bipolar disorder, depression, and anxiety disorder. Review of the 06/11/25 PASRR Level II outcome results for Resident #206 revealed approval for nursing facility services related to a diagnosis of bipolar disorder, major depressive disorder and generalized anxiety disorder. Interview on 06/24/25 at 2:40 P.M. with Social Services Designee (SSD) #13 confirmed a PASRR review was completed prior to admission and no additional PASRR was completed until Resident #20 returned from the hospital on [DATE]. SSD #13 confirmed Resident #20 had a diagnosis of bipolar disorder added on 06/01/24, prior to the recent hospitalization, and should have had a PASRR completed as required following the diagnosis on 06/01/24. 366441 Page 10 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure the baseline care plan included person-centered care that included goals to properly care for the resident's specific health and safety concerns and physician orders to prevent decline for Resident #118. This affected one (Resident #118) out of eight residents reviewed for baseline care planning. The facility census was 63. Findings include: Review of the medical record for Resident #118 revealed was admitted to the facility on [DATE] with diagnoses including acute and subacute endocarditis, methicillin resistant staphylococcus aureus (a highly resistant organism), anxiety, obesity, obstructive sleep apnea, hypertension, congestive heart failure, pacemaker, dysphagia, and muscle weakness. Review of the baseline care plan dated 02/14/25 revealed it did not include infection prevention or interventions regarding maintenance and care of peripheral intravascular central catheter (PICC) or care of sternal wound post open heart surgery. Interview on 07/02/25 at 3:00 P.M. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator #6 verified Resident #118's baseline care plan did not include resident specific surgical sternal wound care and infection control interventions for methicillin-resistant staphylococcus aureus (MRSA) (a highly resistant bacteria) which required a six-week course of antibiotics via PICC line. Review of the facility policy titled, Interim/Baseline Care Planning Policy, revised 03/24/25, revealed the facility will develop and implement an interim/baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident. The baseline care plan will include the minimum information necessary to care for a resident including but not limited to: Initial goals based on admission orders, and physician orders etc. 366441 Page 11 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure medical records were accurate. This affected one (Resident #5) of 16 resident medical records reviewed. The facility census was 63.Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/09/16. Diagnoses included but were not limited to schizophrenia, anxiety disorder, obsessive compulsive disorder and osteoarthritis. Review of the 03/31/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed intact cognition and was dependent upon staff for bathing. Review of Resident 5's care plan dated 02/26/24 revealed she is dependent upon staff for bathing. Review of the shower sheets from 04/03/25, 4/07/25, 04/10/25, 04/14/25, 04/17/25, 04/20/25, 04/25/25, 05/06/25, 05/09/25, 05/13/25, 05/15/25, 05/20/25, 05/23/25, 05/27/25, 06/06/25, 06/10/25, and 06/17/25 revealed no evidence the nurse reviewed the shower sheet and no signature. Shower sheets that had documented refusals on 04/07/25, 04/14/25, 04/17/25, 04/20/25, 05/06/25, 05/15/25, and 05/27/25 revealed no evidence of a nursing progress note documenting the refusal or reattempts to offer bathing.Review of the facility provided shower sheet for Resident #5 received on 6/24/25 at 4:06 P.M. dated 06/24/25 revealed a bed bath was given and no nurse signature was found. Review of the facility shower schedule revealed Resident #5's scheduled shower days were Tuesday and Friday on the day shift. Interview on 06/24/25 at 4:34 P.M. with Assistant Director of Nursing (ADON) #8 revealed there is a shower book on each unit with the shower schedule. If a resident refuses, the aide is supposed to tell the nurse, and the nurse is to go to the resident and ask the reason for the refusal and document it in the nursing progress notes. The aide is supposed to give the completed shower sheet to the nurse, and the nurse is to review and sign the shower sheet. The ADON confirmed the above shower sheets provided by the facility were not signed by the nurse and the refusals listed above were not documented in the nursing progress notes. Interview on 06/24/25 at 5:00 P.M. with Resident #5 confirmed no one had offered her a bed bath and had only provided incontinence care. Interview on 06/24/25 at 5:16 P.M. with Certified Nurse Aide (CNA) #80 revealed Resident #5 was scheduled for a shower today but had not had the chance to bathe her due to busyness. CNA #80 confirmed the shower sheets was filled out at the beginning of shift in the morning because she always completes her showers. CNA #80 confirmed she had completed a shower sheet for Resident #5 at the beginning of her shift but had not bathed her and confirmed since she had not bathed her, she was unable to accurately confirm the completed skin check questions. Review of the 09/09/22 revised facility policy called Resident Bath/Showering/Scheduling Policy revealed each resident will be asked about bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive a minimum of two times per week. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet in the electronic record. The nurse will address any findings in the clinical record and appropriate interventions will be initiated. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report the refusal to the charge nurse. The nurse in charge will speak with the resident who refuses to ascertain why and determine if alternative arrangements can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record.Review of the facility form called Bath/Shower sheet revealed the licensed nurse and nursing assistant are to review the shower sheet together. Charge nurse will address the concerns before submitting the form to the Director of Nursing. Residents Affected - Few 366441 Page 12 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

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 record review, observations and interviews, the facility failed to provide meaningful resident-centered activities for Resident #57. This affected one (Resident #57) out of three residents reviewed for activities. The facility census was 63. Residents Affected - Few Findings include: Review of the medical record for Resident #57 revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the current physician's orders revealed no pharmacological intervention for anxiety, agitation, or restlessness. Review of progress notes since admission revealed no evidence of anxiety or restlessness. Review of Resident #57's care plan revealed no evidence of anxiety, agitation, or restlessness addressed. Review of the activities care plan for Resident #57 revealed that she preferred activities that identify with her prior lifestyle. The identified goal was that Resident #57 would express satisfaction with daily routine and leisure activities. The identified interventions were to allow her to express her feelings and to interact with peers that have similar interests. Review of an activity assessment dated [DATE] for Resident #57 authored by Life Enrichment Director (LED) #4 revealed that Resident #57 interacted with team members during care and received a minimum of two visits per week from friends and family resulted in an assessment score of two. Per the facilities assessment a score of two required Resident #57 to receive two one-on-one visits per week. Review of the one-on-one activities visit documentation for Resident #57 provided by LED #4 with the following findings. 04/05/25 Resident #57 made eye contact, 04/19/25 Resident #57 refused, 04/26/25 Resident #57 refused, 05/03/25 Resident #57 made eye contact and verbal sounds, 05/17/25 Resident #57 refused, 05/21/25 Resident #57 made eye contact, verbal sounds and soft music was played, 05/31/25 Resident #57 refused, 06/07/25 Resident #57 refused, 06/21/25 Resident #57 refused, 06/21/25 Resident #57 made eye contact activities held her hand and applied lotion. No other documentation was provided. Visitation records were not signed to verify who provided these activities. During an observation on 06/23/25 at 10:30 A.M. Resident #57 was in bed lying on her left side, an enteral feeding pump was alarming, and the formula was not infusing. During an observation on 06/23/25 at 12:52 P.M. MDS Nurse #11 walked into Resident #57's room. The enteral feeding pump ceased beeping. MDS Nurse #11 verified that the pump was not infusing formula, 366441 Page 13 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0679 that she restarted it and could not say how long the pump was beeping. Level of Harm - Minimal harm or potential for actual harm During an observation 06/24/25 from 8:00 A.M. until 1:13 P.M. revealed Resident #57 lying on her left side without positioning device or pillows to relieve pressure or provide support. No staff members were observed entering Resident #57's room during this observation. Residents Affected - Few An interview on 06/24/25 at 2:43 P.M. with Certified Nursing Assistant (CNA) #58 revealed that the CNAs check and change Resident #57 about every three hours or so. CNA #58 shared that Resident #57 required a Hoyer (mechanical) lift for transfer, but Resident #57 usually wasn't gotten out of bed. CNA #58 was unable to state why they did not get Resident #57 out of bed. An observation on 06/25/25 7:41 A.M. revealed Resident #57 lying on her back with legs bent at the knees without support for legs. Continued observations at 10:00 A.M., 12:30 P.M. and 4:03 P.M. revealed Resident # 57 to be in the same position. An interview on 06/26/25 at 7:52 A.M. LED #4 shared that residents who could not come to activities due to medical reasons or that preferred to stay in their rooms received one-on-one activities in their room. Some examples of one-on-one activities were puzzles, coloring pages, books, conversation, and playing music of the resident's choice. All residents were interviewed to find out what their preferred activities were, and a one-on-one visitation needs assessment was completed for residents that required one-on-one activities. Further shared that for Resident #57 it was more difficult to assess her preferences due to their lack of cognition and meaningful verbalization. We usually do one-on-one activities two to three times a week with her. For activity, we talk to her, she could nod or say yes/no responses. Lastly, she shared that the staff interacted with her while providing care, and she received visits from her husband. On 06/26/25 at 1:49 P.M. an interview with LED #4. verified that handwritten activity assessment that LED #4 provided was not dated or signed. LED #4 was unable to verify when the assessment was completed. Further verified that the handwritten assessment did not match the one in Matrix dated 04/04/25 and that the assessment in Matrix was the most accurate assessment. LED #4 shared that Resident #57 refused activities by frowning if they did not want to participate and was often asleep when activities staff approached them. LED #4 indicated that she did not think that being asleep was the same thing as refusal of the activity but could not verify if Resident #57 was reapproached while awake. An interview on 06/30/25 at10:36 A.M. with the Director of Nursing (DON) revealed that Resident #57 is a mechanical lift for transfers. The DON shared that this information was in Matrix for the CNAs to access. The DON verified that Resident #57 was not on bed rest. It was the expectation that she be dressed in street clothes and out of bed per the resident's wishes, but Resident #57 often did not want to be bothered. The DON further shared that Resident #57 got restless and could only be up in a chair for short periods of time before she became agitated. This deficiency represents non-compliance investigated under Complaint Number OH00165427. 366441 Page 14 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review, and review of the employee handbook, the facility failed to ensure staff performed transfers in a safe manner per physician's orders and re-assess fall risk after a fall occurred. This affected one resident (#19) out of four reviewed for accident hazards. The facility census was 63. Findings include: Review of the medical record for Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking. Review of the physician's orders for Resident #19 identified an order for a mechanical lift for transfers (ordered 10/23/24). Review of the most recent fall risk assessment, dated 10/23/24, revealed Resident #19 had no falls within the previous six months, was completely paralyzed or completely immobilized, and had a score of 0.0 indicating low fall risk. Review of the progress note dated 12/17/24 at 1:38 P.M. revealed Resident #19's roommate notified staff that Resident #19 was on the floor. Resident #19 was found laying on his back to the side of his bed. Resident #19 had no indicators or complaints of pain, answered yes/no questions indicating he was trying to get out of bed, and denied hitting his head. The note dated 12/17/24 at 10:57 P.M. revealed Resident #19 returned to the facility. The note dated 12/19/24 at 1:45 P.M. revealed Resident #19 returned to the facility following a transfer to the emergency room after experiencing a fall on 12/17/24. There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 12/17/24. Review of a video from the in-room camera dated 01/21/25 revealed Resident #19 was laying on the floor beside his bed. After the nurse assessed Resident #19 for injury, the video showed Certified Nursing Assistant (CNA) #60 and CNA #76 getting Resident #19 off the floor by lifting him under his arms. At no point was a mechanical lift used while transferring Resident #19 back into bed. Review of the progress note dated 01/21/25 at 9:30 P.M. revealed Resident #19 had a fall in his room, was assessed with no injuries identified, and the resident had no indicators or complaints of pain. The progress note dated 01/22/25 at 10:03 A.M. revealed the interdisciplinary team (IDT) reviewed Resident #19's fall from 01/21/25. Resident #19 was found on the floor in his room, was unable to state what he was attempting to do, had been in bed prior to the fall, and did not have any injuries after the fall. New interventions included low bed, bed against wall, mat to floor on open side of bed, and perimeter mattress to bed. The progress note dated 01/22/25 at 2:29 P.M. revealed Resident #19's representative was agreeable to the placement of a perimeter mattress. Resident #19's representative stated she did not want Resident #19's bed to be placed against the wall. The progress note dated 01/24/25 at 1:24 P.M. revealed the IDT reviewed the request from Resident #19's representative 366441 Page 15 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0689 that the bed not be placed against the wall. Level of Harm - Minimal harm or potential for actual harm There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 01/21/25. Residents Affected - Few Review of the progress note dated 02/01/25 at 4:15 A.M. revealed Resident #19 was found sitting on the floor next to his bed, there was no apparent injury, and close observation would continue. Review of the IDT note dated 02/06/25 at 11:39 A.M. revealed Resident #19's fall was reviewed, the resident was unable to state what he was doing prior to the fall, no new safety devices were recommended by IDT, and therapy would assess for appropriateness of reacher in regards to ability to use. There was no documentation of a new fall risk assessment after Resident #19 sustained a fall on 02/01/25. Review of a video from the in-room camera dated 01/25/25 revealed CNA #46 and CNA #58 transferred Resident #19 from the bed to an electronic wheelchair utilizing a gait belt. At no point was a mechanical lift used while transferring Resident #19 into his wheelchair. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. The assessment indicated Resident #19 required partial or moderate assistance for eating, oral hygiene, and personal hygiene; required substantial or maximum assistance for rolling left and right, sit to lying, and lying to sitting; and was totally dependent on staff for toileting hygiene, showering or bathing self, dressing, and chair/bed to chair transfer. The assessment indicated Resident #19 had one fall with no injury since the last assessment. Review of the optional state MDS assessment, dated 04/18/25, revealed Resident #19 required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, supervision with setup assist for eating, and total dependence of two staff for toilet use. Review of the physical therapy Discharge summary dated [DATE] revealed Resident #19 required a hoyer mechanical lift for transfers and was dependent on staff for basic mobility. Resident #19 was discharged from physical therapy due to progress ceased. Review of a video from the in-room camera dated 06/15/25 showed two staff members, Certified Nursing Assistant (CNA) #55 and CNA #58, in Resident #19's room during a hoyer mechanical lift transfer. While operating the hoyer mechanical lift to lift Resident #19 out of bed, CNA #55 grabbed her cell phone, propped the phone between her shoulder and her ear, and continued operating the hoyer mechanical lift while talking on the phone. On 06/25/25 at 3:38 P.M., review of the video dated 06/15/25 with the Administrator verified CNA #55 operated the hoyer mechanical lift to transfer Resident #19 while talking on her cell phone. On 06/26/25 at 10:45 A.M., review of the videos dated 01/21/25 and 01/25/25 with the Director of Nursing (DON) verified CNAs #46, #58, #60, and #76 all transferred Resident #19 without utilizing a hoyer mechanical lift. The DON further stated the facility did not have a specific policy or protocol detailing what to do after a fall occurs. On 06/26/25 at 10:50 A.M., an interview with the Administrator stated Resident #19's wife did not want Resident #19 to be transferred via mechanical lift. The Administrator verified Resident #19's 366441 Page 16 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan indicated the resident required a mechanical lift for transfers. The Administrator also reviewed and verified the contents of the videos from 01/21/25 and 01/25/25 at that time. On 06/26/25 at 12:20 P.M., an interview with the DON stated all staff were reporting to her that Resident #19's wife was insistent that staff not utilize a hoyer mechanical lift for transfers because Resident #19's wife wanted him transferred with a gait belt. The DON confirmed therapy had not cleared Resident #19 to be transferred with anything other than a hoyer mechanical lift. On 06/30/25 at 10:22 A.M., an interview with the DON confirmed Resident #19 did not have any new fall risk assessments after experiencing falls. The DON stated after a fall occurs, the IDT reviews the fall and a fall meeting occurs with therapy. The DON further stated no new fall risk assessment was completed that would give a new fall risk score. The DON also confirmed there was no mention of increased fall risk following the falls in January 2025 and February 2025. Review of the facility's employee handbook, dated 01/01/21, revealed the nature of the business of the facility did not allow for personal telephone calls during working hours. The unauthorized use of personal cellular phones or pagers while working in the facility was strictly prohibited and they may be confiscated until the end of the employee's shift. Review of the facility's policy titled Mechanical Lift Policy, dated 01/07/22, revealed a mechanical lift may be used for transferring residents that could not be safely transferred by themselves or with staff assistance. The resident's transfer status would be assessed on admission, quarterly, and as needed with any changes in the resident's transfer ability. Two staff person assist would be required for total body lifts. Any resident who could not be elevated from the floor utilizing contact guard or minimal assist would be lifted from the floor using a mechanical lift only. Review of the facility's policy titled Fall Prevention and Management Policy, dated 08/06/24, revealed residents would be assessed for fall risk on admission, quarterly, and as needed. All falls would be reviewed by the IDT, any new interventions would be implemented, and the care plan would be updated as necessary. The IDT review should include the results of the new fall risk assessment, discussion with the resident and/or any witnessing parties and to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help prevent further falls. This deficiency represents non-compliance investigated under Master Complaint Numbers OH00165594 and Complaint Number OH00165427. 366441 Page 17 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to ensure that colostomy care was provided as ordered and per resident's preference. This affected one resident (Resident #26) out of two residents reviewed for ostomy care. Findings include: Review of medical record revealed that Resident #26 was admitted on [DATE] with diagnosis of heart failure, weakness, polyneuropathy, and major depression. Review of the annual Minimum Data Set (MDS) dated [DATE] Resident #26 was alert and oriented without cognitive impairment. They were dependent upon staff for toilet hygiene, shower and bath, as well as personal hygiene. Resident #26 was always incontinent of bladder and had a colostomy for bowel movements. Review of physician's orders reveal an order dated 01/26/25 to empty the colostomy bag every shift. Report any changes noted such as changes is color of stool, amount of stool, or consistency of stool. Document emptying contents and any changes noted. Review of the comprehensive care plan updated 05/12/25 revealed that per resident's preference empty colostomy pouch, empty all stool, rinse well with water, make sure no stool is left inside the pouch. Reapply the pouch to the wafer. If it remained unclean, replace the pouch with a new one. Review of point of care history for Certified Nursing Assistant (CNA) documentation revealed instructions to the CNA, per Resident's preference, empty colostomy pouch, empty all stool, rinse well with water (make sure no stool left inside pouch) reapply pouch to wafer. If it remained unclean place a new pouch on. The documents provided indicated that the colostomy bag was emptied as follows: 05/27/25 The colostomy pouch was emptied on day shift but not night shift 05/28/25 The colostomy pouch was emptied on both shifts 05/29/25 The colostomy pouch was emptied on both shifts 05/30/25 No evidence that the colostomy pouch was emptied 05/31/25 No evidence that the colostomy pouch was emptied 06/01/25 No evidence that the colostomy pouch was emptied 06/02/25 The colostomy pouch was emptied on day shift but not on night shift 06/03/25 The colostomy pouch was emptied on both shifts 06/04/25 The colostomy pouch was emptied on day shift but not night shift 366441 Page 18 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0691 06/05/25 The colostomy pouch was emptied on night shift but not day shift Level of Harm - Minimal harm or potential for actual harm 06/06/25 The colostomy pouch was emptied on night shift but no day shift 06/07/25 The colostomy pouch was emptied on day shift but not night shift Residents Affected - Few 06/10/25 The colostomy pouch was emptied on both shifts 06/11/25 The colostomy pouch was emptied on day shift but not night shift 06/12/25 The colostomy pouch was emptied on day shift but not night shift 06/13/25 The colostomy pouch was emptied on both shifts 06/14/25 through 06/16/25 There was no evidence that the colostomy pouch had been emptied 06/17/25 The colostomy pouch was emptied on night shift but not day shift 06/18/25 There was no evidence that the colostomy pouch was emptied 06/19/25 The colostomy pouch was emptied on night shift but not on day shift 06/20/25 through 06/23/25 There was no evidence that the colostomy pouch was emptied 06/24/25 The colostomy pouch was emptied on night shift but not on day shift An interview on 06/23/25 at 9:30 A.M. with Resident #26 revealed hey had a colostomy bag that didn't get emptied or cleaned the way it was supposed to. Resident #26 further shared that if the colostomy pouch was not emptied often enough the pressure from gas and fecal matter kept the stoma from draining and that they became experienced nausea. They shared that when the pouch was emptied, the pouch should be taken off the wafer, rinsed and cleaned out. They stated that the CNAs often just open the bottom of the bag and don't clean the pouch out. An interview on 06/24/25 at 02:43 PM with CNA #58 revealed that they only emptied the colostomy pouch if a nurse told them to. CNA #58 reported that they just opened the bottom pouch and emptied it into another bag. Further they shared they received the usual training from the nurse about how to empty Resident #26 colostomy pouch. An observation on 06/25/25 at 03:33 P.M. of Resident #26 revealed their colostomy pouch to be puffed up with large amount of gas and more than half full of feces. Resident #26 revealed her pouch had not been emptied on night shift or day shift this day. An interview on 06/25/25 at 03:49 PM with Assistant Director of Nursing (ADON) #8 revealed Resident #26 was alert, oriented and a reliable source of information. ADON #8 verified that there was no evidence of CNA documentation for emptying the resident's colostomy bag for multiple days and shift and could not verify that the care was provided. This deficiency represents non-compliance investigated under Complaint Number OH00165230. 366441 Page 19 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and interview, the facility failed to provide evidence that enteral tube feedings were administered to prevent weight loss. This affected two residents (#57 and #60) out of three reviewed for tube feeding. The facility also failed to obtain weekly weights as ordered. This affected four residents (#11, #20, #57, and #60) out of six reviewed for nutrition. The facility also failed to provide adequate hydration to prevent dehydration. This affected one resident (#11) out of three reviewed for hydration. The facility census was 63.Actual harm occurred on 06/16/25 when Resident #60, who had severe cognitive impairment and required enteral tube feeding to meet nutritional needs, sustained a 20.6 pound weight loss (in 34 days) as a result of the facility's failure to accurately monitor and record tube feed intakes, obtain weekly weights as ordered, and adjust tube feeding rate timely to prevent further weight loss. On 05/01/25, Resident #60 weighed 207.2 pounds. On 05/07/25 and 05/13/25, Resident #60 weighed 207.0 pounds. On 05/22/25, Resident #60 weighed 197.8 pounds, which was a weight loss of 9.2 pounds (4.4%) in 9 days. On 06/16/25, Resident #60 weighed 186.4 pounds, which was a further weight loss of 11.4 pounds (5.8%) and there was no evidence that the facility had been monitoring Resident #60's weight between 05/22/25 and 06/16/25 or that adjustments had been made to the tube feeding order to prevent further weight loss. The weight loss continued and on 06/19/25 the resident was assessed to sustain an additional weight loss of 7.0 pounds (3.8%) with a recorded weight of 179.4 pounds. Resident #60 sustained a severe weight loss of 13.4% since admission (in 51 days). Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/30/25 with diagnoses including aspiration pneumonia, lung cancer, cerebral infarction, dysphagia, laryngeal cancer, aphasia, and dysarthria. Review of the medical nutritional therapy assessment, dated 05/02/25, revealed Resident #60 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated Resident #60 required 2184 to 2589 calories, 81 to 97 grams of protein, and 2427 to 2832 milliliters (ml) of fluid daily. The nutritional goals included no unplanned significant weight changes, tube feeding formula and flushes as ordered, and weekly weights for four weeks. Review of the nutrition care plan, initiated 05/05/25, revealed Resident #60 was at increased nutritional risk related to gastric tube use, lung and laryngeal cancer, pneumonia, cerebral infarction, dysphagia, hemiplegia, overweight, requiring enteral feedings for nutrition and hydration, and malnutrition. Interventions included but were not limited to: check tube placement prior to medication or tube feeding administration (05/05/25), monitor for complications such as diarrhea, gastric distention, aspiration, and report complications to the physician (05/05/25), monitor labs per orders (05/05/25), monitor need for increased nutritional interventions related to diagnoses, tube feeding, medications, and other listed problems (05/05/25), monitor for signs and symptoms of dehydration such as poor skin turgor, cracked lips, thirst, fever, and abnormal labs (05/05/25), monitor weight per protocol (05/05/25), provide diet as ordered (05/05/25), provide tube feeding as ordered (05/05/25), provide tube feeding and medication flushes as ordered (05/05/25), and report 5% weight loss or gain to the physician and Registered Dietitian (RD) (05/05/25). The nutrition care plan was last reviewed and revised on 05/05/25 at 2:02 P.M. by RD #83.Review of the admission Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #60 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00. The assessment also indicated Resident #60 received 51% or more of daily calories from tube feeding and 501 milliliters (ml) or more of daily fluid from tube feeding.Review of the physician's orders for Resident #60 identified orders for NPO (ordered 04/30/25), weekly weights for four weeks (ordered 04/30/25, discontinued 06/03/25), bolus enteral feedings Residents Affected - Few 366441 Page 20 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few of Isosource to infuse 360ml every six hours via enteral tube, flush with 30ml of water after the bolus feed, and record amounts (ordered 04/30/25, discontinued 05/01/25), bolus enteral feedings of Isosource 1.5 to infuse 360ml every six hours via enteral tube for a total of 1440ml of formula providing 2160 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/01/25, discontinued 05/02/25), bolus enteral feedings of Isosource 1.5 to infuse 400ml every six hours via enteral tube for a total of 1600ml of formula providing 2400 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 05/02/25, discontinued 06/19/25), and bolus enteral feedings of Isosource 1.5 to infuse 500ml every six hours via enteral tube for a total of 2000ml of formula providing 3000 calories, flush with 30ml of water after the bolus feed, and record amounts (ordered 06/19/25). Physician's orders for routine tube feeding flushes were separate from the enteral formula orders and were as follows: free water flushing 250ml once daily via peg tube (ordered 04/30/25, discontinued 05/01/25), free water flushing 250ml every six hours via peg tube (ordered 05/01/25, discontinued 05/02/25), free water flushing 300ml every six hours via peg tube (ordered 05/02/25, discontinued 06/19/25), and free water flushing 250ml every six hours via peg tube (ordered 06/19/25). Review of the weights documented in the vitals portion of the electronic health record and on the Medication Administration Record/Treatment Administration Record (MAR/TAR) for Resident #60 revealed the following recorded weights: 207.2 pounds on 05/01/25, 207.0 pounds on 05/07/25, 207.0 pounds on 05/13/25, 197.8 pounds on 05/22/25, 186.4 pounds on 06/16/25, and 179.4 pounds on 06/19/25. There were no recorded weights between 05/22/25 and 06/16/25. Review of the MAR/TAR documentation for Resident #60 for May 2025 through June 2025 revealed the following: - On 05/14/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/15/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 05/16/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/17/25, 900ml of Isosource 1.5 was administered, which provided a daily total of 1350 calories (a deficit of 834 calories from the calculated nutritional needs). It was documented that Resident #60 refused the 12:00 P.M. tube feeding formula administration. - On 05/18/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/19/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/20/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/22/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/23/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/25/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/26/25, 1200ml of Isosource 1.5 was administered, which provided a daily total of 1800 calories (a deficit of 384 calories from the calculated nutritional needs). - On 05/27/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 05/29/25, 700ml of Isosource 1.5 was administered, which provided a daily total of 1050 calories (a deficit of 1184 calories from the calculated nutritional needs). - On 05/30/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 366441 Page 21 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few calories from the calculated nutritional needs). - On 05/31/25, 850ml of Isosource 1.5 was administered, which provided a daily total of 1275 calories (a deficit of 909 calories from the calculated nutritional needs). - On 06/01/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/02/25, 600ml of Isosource 1.5 was administered, which provided a daily total of 900 calories (a deficit of 1284 calories from the calculated nutritional needs). - On 06/03/25, 1100ml of Isosource 1.5 was administered, which provided a daily total of 1650 calories (a deficit of 534 calories from the calculated nutritional needs). - On 06/11/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/12/25, 800ml of Isosource 1.5 was administered, which provided a daily total of 1200 calories (a deficit of 984 calories from the calculated nutritional needs). - On 06/14/25, 1400ml of Isosource 1.5 was administered, which provided a daily total of 2100 calories (a deficit of 84 calories from the calculated nutritional needs). - On 06/15/25, 930ml of Isosource 1.5 was administered, which provided a daily total of 1395 calories (a deficit of 789 calories from the calculated nutritional needs). - On 06/16/25, 1030ml of Isosource 1.5 was administered, which provided a daily total of 1545 calories (a deficit of 639 calories from the calculated nutritional needs). - On 06/20/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs). - On 06/21/25, 1250ml of Isosource 1.5 was administered, which provided a daily total of 1875 calories (a deficit of 309 calories from the calculated nutritional needs). - On 06/23/25, 1000ml of Isosource 1.5 was administered, which provided a daily total of 1500 calories (a deficit of 684 calories from the calculated nutritional needs).Review of the dietary progress note dated 05/26/25 at 3:02 P.M. indicated Resident #60 had sustained a 4.5% weight loss since admission on Isosource 1.5 at 400ml every six hours with 300ml water flushes to provide 2400 calories, 109 grams (g) protein, and 2422ml free fluid. The note indicated the current tube feeding order was meeting Resident #60's nutritional needs and weight maintenance was desirable. The note indicated no changes were made to the tube feeding order and weekly weights would be continued for close monitoring.Review of the weights documented in the vitals portion of the electronic health record and on the MAR/TAR for Resident #60 revealed weekly weights were not obtained as ordered on 05/27/25 and 06/03/25. There was no progress note indicating the physician or RD were notified of the weight loss on 06/16/25.The nurses note dated 06/17/25 at 3:11 P.M. indicated Resident #60 was visited by a physician's assistant (unnamed) that day and new orders were added for Trazadone to address increased restlessness and agitation. There was no mention of weight loss.Review of the dietary progress note dated 06/19/25 at 4:37 P.M. indicated Resident #60 had sustained a significant weight loss of 15% in one month. The note indicated Resident #60 had increased nutritional needs due to a cancer diagnosis and activity levels. The tube feeding order was increased to Isosource 1.5 to infuse 500ml every six hours with 250ml water flushes to provide 3000 calories, 136g protein, and 2528ml free fluid.On 06/30/25 at 9:36 A.M., an interview with RD #83 stated when weight loss occurred, she would make any nutritional recommendations on the following Monday and the expectation was those recommendations would be addressed by Thursday each week (three days later). She also stated re-weights would be obtained to verify the weight loss. On 06/30/25 at 11:27 A.M., an interview with RD #83 stated she had not done the calculations to determine exact amounts, but a significant weight loss would require a large calorie deficit.On 06/30/25 at 3:57 P.M., an interview with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's 366441 Page 22 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few recommendations for any changes because the RD was the expert with weight loss and calculating calories.On 06/30/25 at 4:45 P.M., an interview with the Director of Nursing (DON) verified the documentation on the MAR/TAR indicated Resident #60 did not receive the amount of tube feeding formula that was ordered on numerous days in May 2025 and June 2025.On 07/01/25 at 11:50 A.M., an interview with Regional RD #86 confirmed the documentation indicated the full amount of tube feeding formula was not administered for Resident #60. Regional RD #86 claimed it was just a documentation error, however, she was unable to provide any evidence that the tube feeding formula was administered as ordered. On 07/01/25 at 3:28 P.M., an interview with Regional RD #86 stated RD #83 reviewed the weight change that occurred on 05/22/25, recommended weekly weights to monitor weight trend, and Regional RD #86 confirmed those weekly weights were not obtained after 05/22/25. RD #86 confirmed no changes were made to the tube feeding formula order between 05/02/25 and 06/19/25. Regional RD #86 further stated the way their electronic health records were set up was confusing for the nurses, claiming that was why there were inconsistencies between the physician's orders and the documentation of tube feeding formula administration.On 07/01/25 at 3:53 P.M., an interview with the DON verified the weekly weights were documented as not obtained on the MAR/TAR on 05/27/25 and 06/03/25. The DON was unable to provide a reason why those weights were not obtained.An attempt to interview Physician's Assistant #88 on 07/02/25 was unsuccessful.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record. 2. Review of the medical record for Resident #57 (R #57) revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed R #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the physician's orders revealed no pharmacological intervention for anxiety, agitation or restlessness, and no as needed medication for bowel regime. Further review of the physician's orders for June 2025 for R #57 identified orders for Diabetisource AC at 60 milliliters (ml) per hour for 22 hours to provide 1320ml formula and 1584 calories daily (ordered 03/17/25, discontinued 06/30/25), and Diabetisource AC at 65 ml per hour for 22 hours to provide 1,430ml formula and 1,716 calories daily (order dated 06/30/25).Review of medical nutritional therapy assessment, authored by Registered Dietitian (RD) #83 and dated 04/03/25, revealed R #57 received nothing by mouth (NPO) and required a feeding tube to meet nutritional needs. The assessment indicated the ordered enteral feeding would provide 1,584 calories, 366441 Page 23 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few 79 milligrams (mg) of protein, 1,077 milliliters (ml) of free fluids plus flushes to total 1,977 ml daily. The estimated nutritional needs portion of the assessment was blank and there were no nutritional needs specified. The nutritional goals included tolerance to enteral feedings, no signs or symptoms of dehydration, and no significant weight changes. Review of lab results dated 05/08/25 revealed a basic metabolic panel (BMP) and a complete blood count (CBC) was obtained with results essentially within expected range for diagnosis and no new orders were obtained. Review of the lab results dated 06/05/25 revealed a BMP, CBC and hemoglobin A1C were obtained, and all results were within expected range and no new orders were written. There was no evidence that a Pre-Albumin level was obtained.Review of weights for R #57 revealed a weight loss of 4.8% within 30days. The documented weights were as follows: 152.0 pounds on 05/06/25, 154.2 pounds on 06/09/25, and 146.8 pounds on 06/26/25.Review of the Medication Administration Record (MAR) for R #57 for June 2025 revealed the following: On 06/09/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/11/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/12/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/14/25, 750ml of Diabetisource AC was administered, which provided a daily total of 900 calories (a deficit of 684 calories from what was ordered).On 06/15/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/16/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/17/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/18/25, 810ml of Diabetisource AC was administered, which provided a daily total of 972 calories (a deficit of 612 calories from what was ordered).On 06/19/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/21/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/22/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/23/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/24/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/25/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/26/25, 300ml of Diabetisource AC was administered, which provided a daily total of 360 calories (a deficit of 1224 calories from what was ordered).On 06/27/25, 870ml of Diabetisource AC was administered, which provided a daily total of 1044 calories (a deficit of 540 calories from what was ordered).On 06/28/25, 1260ml of Diabetisource AC was administered, which provided a daily total of 1512 calories (a deficit of 72 calories from what was ordered).On 06/29/25, 660ml of Diabetisource AC was administered, which provided a daily total of 792 calories (a deficit of 792 calories from what was ordered).Review of bowel tracking records for R #57 from 06/20/25 through 06/29/25 revealed no evidence of a bowel movement (BM) on 06/21/25, 06/22/25, 06/23/25, 06/25/25, 06/26/25, 06/27/25, 06/28/25, 06/29/25. There was no evidence of any as needed bowel interventions provided during this interval, just the routine daily dose of Miralax.Review of progress notes since admission revealed no documented evidence of anxiety or restlessness. Review of a progress note dated 06/26/25, authored by RD #83, revealed R #57 had a 4.8% weight loss since 06/09/25 366441 Page 24 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few (17 days). The note indicated R #57 was often restless, anxious and, per nursing staff, often rolled onto her tubing causing the infusion of formula to occlude. There were no other notes between 01/09/25 and 06/26/25 to indicate R #57 rolled onto her tubing causing the tube feed formula to stop infusing. Review of the progress note dated 07/01/25 at 8:43 P.M. indicated R #57 was transferred to an acute care hospital due to unrelieved brown emesis.An observation on 06/23/25 at 10:30 A.M. revealed that R #57 was in bed lying on her left side, the enteral feeding pump was alarming, and the formula was not infusing. A bag of Diabetisource AC was hanging on a pole and was attached to the infusion pump. The formula bag was labeled with a date of 06/23/25 without a time. Continued observation of R #57's room revealed no staff were present on the unit and no staff entered R #57's room until 12:52 P.M., approximately two hours and 22 minutes after the tube feed was first observed alarming.An observation on 06/23/25 at 12:52 PM revealed MDS nurse #11 walked into R #57 room. The enteral feeding pump ceased beeping. MDS nurse #11 verified that the pump was not infusing formula, that she restarted it and could not say how long the pump was beeping.A continuous observation on 06/24/25 from 8:00 A.M. until 1:13 P.M. revealed R #57 lying on her left side, not laying on enteral tubing. No staff members were observed entering R #57's room at any point during this observation.An observation on 06/25/25 07:41 A.M. revealed R #57 lying on her back with legs bent at the knees, not laying on enteral tubing. Further observations at 10:00 A.M., 12:30 P.M. and 4:03 P.M. revealed R #57 was in the same position.An interview on 06/24/25 at 02:43 P.M. with Certified Nursing Assistant (CNA) #58 revealed that R #57 was checked and changed about every 3 hours. CNA #58 was unable to state when she was last in the room. CNA #58 shared that they had twelve residents to care for all of which were located on the same hallway.An interview on 06/30/25 at 10:23 A.M. with the Director of Nursing (DON) revealed that when R #57's enteral feeding pump beeped then the nurses went down to the resident's room, readjusted the pump and/or tubing, and restarted the pump. The DON stated the pump would be occluded for a minimal time, not a significant amount of time. The DON indicated that she did not know how long a pump would have to be off to cause significant weight loss. The DON verified the documentation on the MAR of less than the ordered amount of enteral feeding. Regarding the lack of bowel movements, the DON stated that the MDS nurse brought a report to morning meeting and identified all residents that had no BM in three days or greater. That information was given to the nurses on the floor for follow-up. Once the information was given to the nurse, the alerts were cleared from the electronic health record system and no further information was tracked. An interview on 06/30/25 at 11:27 A.M. with RD #83 confirmed the documentation in the MAR was less than the ordered amount of tube feeding formula. RD #83 indicated that she would have to do calculations but that a significant weight loss in 30 days would require a large calorie deficit.An interview on 06/30/25 at 03:06 P.M. with Licensed Practical Nurse (LPN) #55 revealed that occasionally the tubing on R #57's feeding pump got kinked. The pump beeped but was not as loud as an IV pole and that R #57's room was two-thirds of the way down the hall away from the nurse's station, so it could not be heard at the nurse's station. LPN #55 Further shared that the second floor had two nurses assigned to split the all the residents on the second floor. Each nurse assigned to a hall also had to split another hall for medication administration and could not hear anything that occurred on the other hall. Further shared that Resident #57 used to move about and pull the whole pump and pole over when they were first admitted but doesn't do that anymore.An interview on 06/30/25 at 3:57 P.M. with Medical Director (MD) #87 stated the facility probably notified Physician's Assistant #88 of weight changes because the facility usually only notified MD #87 of bigger things. MD #87 said he would just follow the RD's recommendations for any changes because the RD was the expert with weight loss and calculating calories. MD #87 366441 Page 25 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few indicated that he expected lab chemistry to be monitored and to include pre-Albumin levels.Review of the facility's policy titled Dietary Enteral Nutrition Care, dated 06/02/20, revealed upon initiation of enteral feeding, the RD would conduct an assessment that included a calculation of the individual's energy, protein, and fluid requirements, as well as any potential medication interactions. If there was an existing enteral nutrition order, a comparison would be made between the individual's requirements and the physician ordered enteral formula and free fluid flush. The RD or designee would monitor weight, skin conditions, labs, physical symptoms, and tolerance to feeding. The nursing staff would communicate any concerns to the physician and RD regarding changes in condition such as weight loss, diarrhea, nausea, vomiting, bloating, gas, and high residual levels. Review of the facility's policy titled Resident Weight Policy, dated 12/12/23, revealed weights would be obtained routinely in order to monitor nutritional health over time. Each resident's weight would be determined upon admission to the facility, weekly for four weeks after admission, and monthly or more often if risk was identified, or as ordered. Nursing was responsible for obtaining weights. After the first four weeks, the resident review committee would determine the need for continued weekly weights. Weights would be recorded in the electronic health record.Review of the facility's policy titled Bowel Tracking Protocol, dated 03/12/24, revealed bowel movements were documented by nurse aides in the electronic medical record. If the resident had not had a bowel movement for 3 full days (72 hours), and in the absence of other resident-specific orders, the nurse would determine if laxatives were indicated based on the resident's bowel habits and patterns. Step 1: Milk of Magnesia 30 ml at bedtime the evening after 72 hours without a bowel movement (BM) ; Step 2: If no BM by 10:00 A.M. the following day, give bisacodyl suppository 10 mg PR; Step 3: If no BM by the next morning, contact provider for further orders.3. Review of the medical record for Resident #11 revealed an admission date of 04/17/25. Diagnoses included but were not limited to epilepsy, unspecified fracture of right and left pubis, fracture of right tibia, poly osteoarthritis, and repeated falls. Review of the 06/16/25 Minimum Data Set (MDS) for Resident #11 revealed a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. Resident #11 was noted to be independent for self-care, eating and dependent for toileting, bathing, dressing and wheeling 150 feet. Resident #11 was not noted to be on a therapeutic diet and was noted to have significant weight loss and was not on a physician prescribed weight loss program. Review of the 04/17/25 physician order for Resident #11 revealed an order to obtain weight upon admission and then weekly for four weeks once a day on Tuesdays.Review of the facility weight recording form from 04/14/25 revealed a weight for Resident #11 but was not dated as being another date other than 04/14/25 since resident was not at the facility on 04/14/25. Review of the admission progress note for Resident #11 revealed no listed admission weight. Review of the 04/21/25 care plan for Resident #11 revealed increased nutrition and hydration risk related to epilepsy, fracture of pubis, muscle weakness, obesity, diuretic use and potential for fluid related weight fluctuations. Interventions listed were to encourage compliance with diet guidelines, encourage resident to dine in the dining room, monitor dietary intake, monitor lab values per orders, monitor need for increased nutritional intervention related to diagnosis, medication and listed problems, monitor weight per protocol, offer alternate food is less than 50 % of meals, and encourage adequate fluid intake.Review of the facility weight recording form from 04/21/25, 04/28/25, for Resident #11 revealed no weight recorded. Review of the nursing progress note date 04/20/25 timed at 1:59 P.M. for Resident #11 revealed a burning sensation when voiding, and order for a urinalysis (UA) and a urine culture and sensitivity (C &S) test were obtained. Review of the nursing progress note dated 04/21/25 at 3:24 P.M. for Resident #11 revealed an order for Macrobid 100 milligrams (mg) by mouth twice daily for 366441 Page 26 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0692 Level of Harm - Actual harm Residents Affected - Few seven days for symptoms of a urinary tract infection.Review of the 04/22/25 lab results for Resident #11 revealed they were completed and a request with an order to repeat the labs on 04/29/25.Review of the facility weight recording form from 05/01/25 (monthly weights) for Resident #11 was 150.8 # and a reweight was requested but not completed. No weight was recorded in the medical record.Review of the facility weight recording form from 05/12/25 and 05/20/25 for Resident #11 revealed no weight recorded. Review of the medical record for Resident #11 revealed a weight on 04/21/25 of 173.2# and 06/16/25 of 164.4 pounds (#) and no additional weights recorded. Weight loss from 4/21/25 to 06/16/25 was 8.8# which was a 5 percent loss.Review of the labs recorded on 04/29/25 for Resident #11 revealed the physician requested no new orders. Review of the 05/12/25 nursing pro[TRUNCATED] 366441 Page 27 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and facility policy review, the facility failed to ensure pain medications were administered timely to ensure effective pain management. This affected one resident (#120) out of eight residents reviewed for medication administration. The facility census was 63. Residents Affected - Few Findings include: Review of medical record for Resident #120 revealed an admission date of 04/15/25 with diagnoses including pathological fractures, malignant neoplasm's of bone, malignant neoplasm of bladder, protein-calorie malnutrition, urostomy, and need for assistance with personal care. Review of Resident #120's Minimum Data Sheet (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Resident #120 required moderate assistance for upper body activities of daily living (ADLs) and maximum assistance for lower body and mobility needs. Resident #120 also needed maximum assistance for toileting and hygiene needs. Review of care plan dated 05/01/25 revealed Resident #120 had chronic pain related to cancer and fractures. Interventions included the administration of pain medications per physician order and evaluate the effectiveness. Review of Resident #120's physician orders dated 04/15/25 revealed Morphine Extended Release 15 milligrams was ordered to be a scheduled medication administered twice daily from 7:00 A.M. to 11:00 A.M. and from 7:00 P.M. to 11:00 P.M., not as needed. Review of Resident #120's Medication Administration Record (MAR) revealed the resident did not receive any scheduled morphine doses on 04/15/25 or 04/16/25 in the morning as required. Resident #120 received one dose of Acetaminophen 325 milligrams on 04/16/25 at 6:58 A.M. for a pain score of four and a follow-up pain assessment of four with no relief. Further review of the MAR noted Resident #120 received the first dose of scheduled Morphine on 04/16/25 during the evening between 7:00 P.M. and 11:00 P.M. Further review of Resident #120's medical record revealed no documented evidence of new interventions for pain management while Resident #120 was awaiting his Morphine ER medication and while the Acetaminophen medication was ineffective. Interview with Licensed Practical Nurse (LPN) #19 on 06/24/25 at 1:45 A.M. verified the pharmacy delivers twice daily. She stated the facility also kept a variety of frequently used medications and antibiotics in stock to use if resident medications were unavailable. Those were kept in the medication storage room. Interview with LPN #23 on 06/24/25 at 2:00 P.M. revealed if there was a stat order, the pharmacy could make an emergency drop of the medication. If something was not available, the Omnicare Pharmacist would reach out to other sites for availability or notify physician of possible replacement. Interview with LPN #23 on 06/24/25 at 2:35 P.M. verified that pharmacy dropped off medications twice daily, once at 5:00 P.M. and another during the night. 366441 Page 28 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing (DON) on 06/30/25 at 10:20 A.M. verified the missing medication in the MAR and further verified that Resident #120 did not receive his scheduled pain medication as ordered. Review of facility policy titled, Pain Management Policy revised on 01/08/25 revealed the facility will assess for pain and/or potential for pain in order for the resident to reach and maintain his/her highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of facility policy titled Pharmacy: Delivery and Receipt of Routine Deliveries revised on 08/01/24 revealed if an item ordered by the facility is not received, the facility staff should check for a pharmacy communication slip indicating the reason a medication was not delivered. Facility should also contact pharmacy and document any delivery discrepancies. This deficiency represents noncompliance investigated under Complaint Numbers OH00163252 and OH00165427. 366441 Page 29 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, review of resident council meeting minutes, review of dining council minutes, the facility failed to ensure palatable meals were being provided. This affected three residents (Resident #11, #30 and #45) and had the potential to affect 56 residents receiving food from the kitchen (except Residents # 6, #44, #51, #55, #57, #60, and #218 whom the facility identified as nothing by mouth). The facility census was 63. Residents Affected - Some Findings include: Review of the food committee meeting minutes dated 01/21/25 revealed the following concerns: -an unidentified resident stated the Salisbury steak was bad -residents are asking for more juice options to be added to the juice cart at meals. Review of the food committee meeting minutes dated 02/25/25 revealed the following concerns: -rice is cooked too long and hard to chew -residents requested fresh fruit with meals -residents requested no more vegetable lasagna -residents reported getting sour milk with meals -residents reported kitchen not making enough food and are told they are not allowed to request more -Resident #50 stated on 02/22/25's lunch tray they only got spinach and bread with no meat -Residents requested if the dining room can be served first so their food is still hot when they are served Review of the 03/18/25 resident council meeting minutes revealed to see attached dining concerns, but the facility was unable to provide evidence of the food committee minutes for 03/18/25. Review of the 04/22/25 food committee meeting minutes revealed the following concerns: -the resident wanted things added to the food to make it taste better not just Stouffer's food -dietary staff need to read meal tickets better to ensure accuracy Review of the 05/20/25 food committee meeting minutes revealed the following concerns: -snacks are left at the nurses' desk, but when residents request a snack there are none left -Resident #37 reported not getting his double portions as requested 366441 Page 30 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/23/25 at 11:48 A.M. with Resident #11 revealed sometimes she gets foods she dislikes even though she has requested not to receive them. Observation on 06/25/25 at 11:40 A.M. with [NAME] #26 revealed the following temperatures: stuffed peppers 176 Fahrenheit (F), ground beef tips 170 F, pureed beef roast 183 F, beef patty 182 F, pureed cauliflower 168 F, cauliflower 185 F, mashed potatoes 175 F, gravy 185 F, burgers 185 F, chicken noodle soup 185 F, chicken breast 167 F, and noodles 180 F, and pureed bread 172 F. Lunch tray service began at 11:55 P.M. in the first floor serving station and finished at 12:18 P.M. The tray serving cart was delivered to first floor rooms starting at 12:20 P.M. The lunch tray pass finished at 12:31 P.M. The lunch test tray was completed with Regional Dietary Manager #82 and Dietitian #83 at 12:32 P.M. Temperatures of the test tray were as follows: Stuffed pepper 139 F, mashed potatoes 116 F, mixed vegetables 113 F, milk 49 F, and coffee 140 F. Interview following the temperatures with Dietitian #83 revealed the mashed potatoes and mixed vegetables were warmish but could be warmer for preference. Interview on 06/25/25 at 2:26 P.M. with Resident #30 revealed lunch was okay today but is frequently cold and has reported it previously. Interview on 06/25/25 at 2:29 P.M. with Resident #45 revealed she frequently receives cold meals and just doesn't eat them. Review of the 08/28/19 revised facility policy called; Food Temperatures Policy revealed hot foods should be palatable at the time of delivery. This deficiency represents non-compliance investigated under Complaint Number OH00165427. 366441 Page 31 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of shower documentation and interviews, the facility failed to ensure accurate and complete bathing documentation was completed as required for four residents (Residents #5, #19, #33 and #57) of four residents reviewed for activities of daily living. The facility census was 63. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 12/09/16. Diagnoses included but were not limited to schizophrenia, anxiety disorder, obsessive compulsive disorder and osteoarthritis. Review of the 03/31/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed intact cognition and was dependent upon staff for bathing. Review of Resident 5's care plan dated 02/26/24 revealed she is dependent upon staff for bathing. Review of the shower sheets from 04/03/25, 4/07/25, 04/10/25, 04/14/25, 04/17/25, 04/20/25, 04/25/25, 05/06/25, 05/09/25, 05/13/25, 05/15/25, 05/20/25, 05/23/25, 05/27/25, 06/06/25, 06/10/25, and 06/17/25 revealed no evidence the nurse reviewed the shower sheet and no signature. Shower sheets that had documented refusals on 04/07/25, 04/14/25, 04/17/25, 04/20/25, 05/06/25, 05/15/25, and 05/27/25 revealed no evidence of a nursing progress note documenting the refusal or reattempts to offer bathing.Review of the facility provided shower sheet for Resident #5 received on 6/24/25 at 4:06 P.M. dated 06/24/25 revealed a bed bath was given and no nurse signature was found. Review of the facility shower schedule revealed Resident #5's scheduled shower days were Tuesday and Friday on the day shift. Interview on 06/24/25 at 4:34 P.M. with Assistant Director of Nursing (ADON) #8 revealed there is a shower book on each unit with the shower schedule. If a resident refuses, the aide is supposed to tell the nurse, and the nurse is to go to the resident and ask the reason for the refusal and document it in the nursing progress notes. The aide is supposed to give the completed shower sheet to the nurse, and the nurse is to review and sign the shower sheet. The ADON confirmed the above shower sheets provided by the facility were not signed by the nurse and the refusals listed above were not documented in the nursing progress notes. Interview on 06/24/25 at 5:00 P.M. with Resident #5 confirmed no one had offered her a bed bath and had only provided incontinence care. Interview on 06/24/25 at 5:16 P.M. with Certified Nurse Aide (CNA) #80 revealed Resident #5 was scheduled for a shower today but had not had the chance to bathe her due to busyness. CNA #80 confirmed the shower sheets was filled out at the beginning of shift in the morning because she always completes her showers. CNA #80 confirmed she had completed a shower sheet for Resident #5 at the beginning of her shift but had not bathed her and confirmed since she had not bathed her, she was unable to accurately confirm the completed skin check questions. Review of the 09/09/22 revised facility policy called Resident Bath/Showering/Scheduling Policy revealed each resident will be asked about bathing preferences upon admission (type of bath, preferred days and times). Each resident will be scheduled to receive a minimum of two times per week. When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet in the electronic record. The nurse will address any findings in the clinical record and appropriate interventions will be initiated. If the bath/shower cannot be given or the resident refuses, the nursing assistant will promptly report the refusal to the charge nurse. The nurse in charge will speak with the resident who refuses to ascertain why and determine if alternative arrangements can be made. If the resident continues to refuse, the charge nurse will document the resident's refusal in the medical record.Review of the facility form called Bath/Shower sheet revealed the licensed nurse and nursing assistant are to review the shower sheet together. Charge nurse will address the concerns before submitting the form to the Director of Nursing. 2. Review of the medical record for Resident #33 admitted on [DATE] with diagnosis of diabetes mellitus 366441 Page 32 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some type 2, and obstructive reflux uropathy. Review of Resident #33's MDS admission assessment dated [DATE] revealed Resident #33 was alert and oriented without cognitive impairment and was dependent upon staff for ADLs. Resident #33 was noted to have an indwelling urinary catheter and was continent of bowel. Review of Resident #33's shower sheets for April 2025 through June 2025 revealed the resident received showers on 04/05/25, 04/16/25, 05/07/25, 05/24/25, 05/28/25, 05/31/25, 06/04/25. 06/14/25, 06/18/25, 06/21/25. 06/25/25, 06/27/25, and on two additional dates for which the dates are illegible on the shower sheets. No other evidence was provided of showers being given for Resident #33.An interview on 06/26/25 at 2:25 P.M. with ADON #8 revealed that the facility did not have all the documentation for Resident #33's showers for the months of April, 2025, May 2025, and June 2025. ADON #8 confirmed she had requested unnamed staff members to complete and sign shower sheets for the missing dates where there is no record of a shower being given. 3. Review of the medical record for Resident #57 revealed an admission date of 01/09/25 with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus.Review of the MDS quarterly assessment dated [DATE] revealed Resident #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressingReview of Resident #57's shower sheets provided by ADON #8 included shower sheet for the following dates 4/21/25, 4/24/25, 5/2/25, 5/6/25, 5/9/25, 5/13/25, 6/20/25 that were blank except for the nurse's signature at the bottomAn interview on 06/30/25 at 03:21 P.M. with LPN #55 verified that shower sheets provided for 4/21/25, 4/24/25, 5/2/25, 5/6/25, 5/9/25, 5/13/25, and 6/20/25 were blank except for room number, date and nurse signature. The forms contained no evidence of documentation on whether a shower or bed bath had been given or was refused on these dates. 4. Review of the medical record for Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking.Review of the MDS quarterly assessment, dated 04/18/25, revealed Resident #19 had severely impaired cognition. Review of Resident #19's shower sheets for April 2025 through June 2025 revealed 22 out of 26 shower sheets were not reviewed or signed by a licensed nurse, which the form indicated was required, and the shower sheet for 05/05/25 was completely blank.Review of the physician's orders for June 2025 identified orders for resident to be up before lunch and down after lunch as tolerated (ordered 04/02/25).Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for 06/02/25 through 07/02/25 for Resident #19 revealed the order for getting Resident #19 out of bed before lunch and putting him back down after lunch was signed as completed daily. There were no refusals documented.On 06/23/25 at 12:45 P.M., an observation of Resident #19's room revealed he was sitting in bed feeding himself a hamburger.On 06/24/25 at 4:41 P.M., an interview with ADON #8 verified the shower sheets were not completed in their entirety and stated she had educated the nurses multiple times previously about reviewing and signing the shower sheets.On 06/30/25 at 12:31 P.M., an observation of Resident #19 revealed he was in bed feeding himself a cheeseburger. On 06/30/25 at 12:40 P.M., an interview with Licensed Practial Nurse (LPN) #55 confirmed staff did not get Resident #19 out of bed before lunch. LPN #55 further stated she's not aware of staff ever getting Resident #19 out of bed before lunch in the entire time she had worked at the facility (eight months). LPN #55 verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed on multiple days. LPN #55 also verified there were no documented refusals for Resident #19 getting out of bed.On 07/01/25 at 12:07 P.M., an 366441 Page 33 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observation of Resident #19's room revealed he was in bed and Social Services Designee (SSD) #13 was delivering his lunch to him in bed. On 07/01/25 at 12:10 P.M., an interview with SSD #13 confirmed Resident #19 was eating lunch in bed.On 07/02/25 at 12:34 P.M., an observation of Resident #19's room revealed he was in bed feeding himself a cheeseburger.On 07/02/25 at 2:13 P.M., an interview with LPN #44 confirmed Resident #19 had not been out of bed all day, verified she signed the MAR/TAR as completed for getting him out of bed despite staff not getting him out of bed, and LPN #44 said she signed it off as completed because she offered it. LPN #44 claimed Resident #19 refused to get out of bed and confirmed there was no documentation of the refusal.This deficiency represents non-compliance investigated under Master Complaint Number OH00165594. 366441 Page 34 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

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 observations, interviews, and record reviews the facility failed to follow enhanced barrier precautions as indicated during care for Resident #46, Resident #33, and #5. This affected one resident (#46) of three reviewed for pressure ulcers, one resident (#33) of three reviewed for catheter use, and one resident (#5) out of four reviewed for incontinence. The facility also failed to ensure staff performed hand hygiene during medication pass. This affected six residents (#23, #29, #48, #52, #61, and #130) out of eight observed for medication administration. The facility also failed to ensure staff followed contact precautions when entering Resident #12's room. This affected one resident (#12) of one reviewed for contact precautions. The facility census was 63.Findings include:1. Review of the medical record for R #5 admitted [DATE] with diagnosis overactive bladder, schizophrenia, and anxiety disorder. R #5 was alert and oriented without cognitive impairment. R #5 was dependent upon staff for performance of all activities of daily living (ADLs) including toileting, hygiene, bathing, dressing and bed mobilityReview of MDS for R #5 revealed that they were always incontinent of bowel and bladder and were dependent upon staff for toileting hygiene. Review of Care plan for R #5 revealed that they were to have incontinence care provided after each episode of bowel and bladder incontinence and that they preferred to have a liner insert in their brief.Review of current physicians' orders for R #5 revealed that they were checked and changed every two hours and as needed due to incontinence. An observation on 06/26/25 at 08:10 A.M. revealed LPN #47 and CNA #70 performed incontinence care for R #5. Observed LPN #47 and CNA #70 using towels, one end wet and one end dry, to clean, rinse and dry resident. After the incontinence care was completed, CAN #70 did not apply a new liner to R #5 brief and did not remove her gloves prior to touching the clean sheets, blanket, pillow, and the overbed table. An interview on 06/26/25 at 8:20 A.M. CNA #70 verified that she did not remove her gloves prior to touching clean linen and surfaces. Further CNA #70 shared that she was using towels instead of wash clothes to perform incontinence care because she only had 3 wash clothes for her entire floor. They stated that R #5 is supposed to have a liner in her brief, but she did not replace it because they didn't have any. An observation on 06/26/25 at 08:44 AM with Laundry Aide #42 revealed a supply of clean linen including wash clothes in the main supply closet adjacent to the laundry. The door was unlocked and accessible to staff. 2. Review of the medical record for R #33 admitted on [DATE] with diagnosis of diabetes mellitus type 2, and obstructive reflux uropathy. R #33 was alert and oriented without cognitive impairment and dependent upon staff for activities of daily living including care of an indwelling urinary catheter. Review of Physicians' orders revealed an order dated 09/27/24 For enhanced barrier precautions (EBP). According to CDC guidelines EBP is an approach of targeted gown and glove use during high contact resident care activities. EBP are applied (when Contact Precautions do not otherwise apply) to residents with any wounds or medical indwelling devices, regardless of infection. Review of care plan revealed R #33 had and indwelling urinary catheter due to obstructive uropathy with a goal of catheter care to manage indwelling catheter appropriately without signs and symptoms of infection or urethral trauma. There was no evidence of EBP mentioned in the care plan. An observation on 06/23/25 at 10:55 AM revealed R #33 lying in bed with an indwelling urinary catheter collection bag lying on the floor and no privacy cover on the bag. EBP posting was not visible outside R #33 rooms to alert staff to use appropriate personal protective equipment (PPE). Continued observations on 06/24/25 at 8 AM and 12:05 PM, 06/25/25 at 2:32 PM, and O6/26/25 at 10 AM revealed that posting remained absent outside R #33 room. Indwelling catheter bag was off the floor, attached to the bed frame below their bladder with privacy cover during these observations. An observation on 06/26/25 at 10:35 AM Residents Affected - Some 366441 Page 35 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed CNA #70 performed AM care including shaving, changing bed linens and emptying an indwelling urinary catheter bag. CNA #70 preformed hand hygiene and donned gloves without donning a gown prior to performing care. CNA emptied the urinary drainage bag for 1450 milliliters (ml) of pale urine. An interview on 06/26/25 at 11:11 AM with CNA #70 verified that she did not wear a gown while providing care and that she did not know she was supposed to. Further verified that the urinary drainage bag was very full of urine, not able to flow freely from the bladder into the bag and was backed up into the tubing. CNA shared that the bag was over full when she came on shift and was not emptied by the previous shift. At interview on 06/26/25 at 1:06 PM with ADON/infection control preventionist #8 verified the physicians' order for EBP and that there were no visible posting for R #33 to alert staff to use EBP while giving care. Further shared that staff should be donning gowns and gloves while providing care due to the use of an indwelling urinary catheter. 3. Record review of Resident #33 (R #33) revealed an admission date of 09/24/21 with diagnoses including diabetes mellitus, Review of the physician order dated revealed Resident #33 had an order to check their blood sugar before each meal.An observation 06/25/25 08:00 AM revealed that LPN #44 exited R #33 room with a glucometer and placed it on the med cart without a barrier while she donned gloves and got bleach wipes out of the medication cart. She proceeded to pick up the glucometer and wipe it with the bleach wipe, wrap the glucometer in a bleach wipe, then place it into a disposable cupAn interview with LPN #44 revealed that she had taken a blood sugar reading for R #33 and placed the glucometer on her medication cart while they got out the supplies to disinfect the glucometer. LPN #44 further shared that they should have used a barrier beneath the glucometer before placing it on the medication cart. Review of CMS guidelines for disinfection of a multi-use glucometer revealed the guidance to use a barrier (e.g., clean paper towel) under the glucometer when testing on surfaces like overbed tables and medication carts to prevent contamination. 3. Review of the medical record for Resident #46 revealed an admission date 8/15/24 with diagnoses including lupus, congestive heart failure, venous insufficiency, type II diabetes, acute kidney failure, and systemic inflammatory response.Review of the MDS quarterly assessment dated [DATE] revealed Resident #46 had intact cognition and was dependent on staff for ADLs. The assessment identified Resident #46 had four venous ulcers. Observation on 06/24/25 at 3:04 P.M. of Resident #46's wound care with LPN #19 revealed LPN #19 gathered supplies and walked into Resident #46's room. Prior to entering the room there was a sign posted next to the door with two stop signs that stated Enhanced Barrier Precaution, everyone must wear gloves and a gown for wound care. There was a cart filled with PPE and supplies. LPN #19 proceeded to walk into the room without any gown or gloves. LPN #19 washed his hands, donned gloves, and completed Resident #46 wound dressing as ordered. LPN #19 removed his gloves, washed his hands, and walked out of the room. Interview on 06/24/24 at 3:45 P.M. with LPN #19 verified he did not don a gown and gloves prior to entering the room. LPN #19 stated Resident #46 did not have a wound infection that required him to wear a gown. Review of Center for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDROs) dated 04/02/24, nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO. The use of gown and gloves for high contact resident care activities is indicated, when contact precaution do not otherwise apply, for nursing home resident with wounds and or indwelling medical devices regardless of MDRO colonization as well as for resident with MDRO infection or colonization. 4. Observation on 06/24/25 at 7:31 A.M. during medication administration revealed LPN #23 opened the locked medication cart and pulled the medication cards and bottles for Resident #23. LPN #23 then placed each prescribed medication dose into the 366441 Page 36 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication cup. LPN #23 then signed off medications in the electronic medical record and proceeded directly to administer pulled medications to Resident #23. LPN #23 did not perform hand hygiene prior to accessing medications, prior to administering medications to Resident #23, or after contact with Resident #23 and the environment. Additionally, LPN #23 was subsequently observed to administer medications to Residents #48 and #130 without performing any hand hygiene between each resident's medication administrations. Interview with LPN #23 on 06/24/25 at 8:00 A.M verified she had not performed hand hygiene as required. Observation on 06/24/25 at 8:05 A.M. revealed LPN #19 did not perform hand hygiene prior to administering Residents #52, #61, and #29 their medications. LPN #19 was not observed performing hand hygiene prior to, after, or between resident medication administration. Interview with LPN #19 on 06/24/25 at 8:25 A.M. verified that he had forgotten to perform hand hygiene before, between, and after resident care as required.Interview with the Director of Nursing (DON) on 06/24/25 at 12:05 P.M verified that all staff were to follow the facility medication administration policy and complete hand hygiene before and after administering medications, and prior to next resident contact. A follow up interview with the DON at 1:35 P.M. revealed the DON provided evidence of hand hygiene re-education and competency validation provided to both LPN #19 and LPN #23 after the prior interview. Review of the facility policy titled Hand Hygiene/Handwashing Policy revised 02/28/25 revealed hand hygiene is the most important component for preventing the spread of infection. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water immediately before touching a patient and after touching a patient or the patient's immediate environment. 6. Review of the medical record for Resident #12 revealed an admission date of 09/16/20 and re-admission date of 06/19/25. Current diagnoses included chronic kidney disease, colostomy status, hypertension, resistance to specified beta lactam antibiotics, and need for assistance with personal care.Review of the care plan, revised 04/07/25, revealed Resident #12 was at-risk for infection related to positive for carbapenem-resistant Enterobacteriaceae (CRE), need for contact isolation indefinitely, and cannot have a roommate. Interventions included providing isolation precautions as ordered (initiated 04/16/24).Review of the physician's orders for Resident #12 identified an order for contact isolation precautions (ordered 06/23/25).On 06/23/25 at 12:20 P.M., an observation of Resident #12's room revealed a sign by the door indicating contact isolation precautions indicating all staff must don a gown and gloves prior to entering the room, a cart of personal protective equipment was positioned outside the room, and red isolation waste bins were just inside the door to the room. On 06/24/25 at 8:11 A.M., an interview with the Director of Nursing (DON) stated Resident #12 was on contact isolation precautions due to CRE in his urine. The DON stated Resident #12 returned from the hospital on [DATE] and the order for isolation precautions was not re-started until 06/23/25, four days after re-admission. The DON said there was a delay in reinstating the contact isolation order because she did not have a chance to review the ancillary orders until four days after he returned from the hospital. On 06/24/25 at 8:35 A.M., an observation of Resident #12's room revealed Activities Director #4 entered Resident #12's room without applying any PPE, proceeded to set up his meal tray, moved his bedside table into position, and left the room three minutes after entering the room. Activities Director #4 did not perform hand hygiene before going in the room or after leaving the room. An interview at the time Activities Director #4 left Resident #12's room confirmed she did not apply any PPE because she was unaware he was on any precautions. Activities Director #4 confirmed there was a contact isolation sign outside Resident #12's room, and she further stated she was just delivering his meal tray. Activities Director #4 verified the contact isolation sign posted outside the door did not specify that PPE was only to be applied for hands on care. On 06/24/25 at 8:46 A.M., an interview with 366441 Page 37 of 38 366441 07/07/2025 Seven Hills Health & Rehab Center 819 Rockside Road Seven Hills, OH 44131

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Social Services Designee (SSD) #13, who was seated at the nurses station, stated all isolation signs were color coded and staff were supposed to read the signs prior to entering the room. She further stated all PPE indicated on the sign should be donned prior to entering the room.On 06/24/25 at 9:48 A.M., an interview with the DON stated gloves should be on the PPE cart outside Resident #12's room.On 06/24/25 at 9:49 A.M., an observation with the DON of the PPE cart outside Resident #12's room verified there were no gloves on the cart.Review of the facility's policy titled Transmission-Based Precautions and Isolation Policy, dated 05/19/25, revealed contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the patient or the patient's environment. Personal protective equipment recommended included gloves, gowns, limiting transportation and movement of the resident outside the room, using disposable care equipment when able or resident dedicated equipment if disposable is not available, cleaning rooms daily with a focus on frequently touched surfaces, and single room placement when available. 366441 Page 38 of 38