Health inspection·March 18, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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, staff interview, and policy review, the facility failed to ensure preadmission screening was completed for a resident prior to admission to the facility. This affected one (#98) out of five residents reviewed for preadmission screening. The facility census was 145. Residents Affected - Few Findings included: Review of the medical record for Resident #98 revealed an admission date of 10/18/23 with medical diagnoses of diabetes mellitus, anxiety, hypertension, and schizophrenia. Review of the medical record for Resident #98 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/29/24, which indicated Resident #98 was cognitively intact and required supervision with toilet hygiene, bed mobility, and moderate staff assistance with bathing. Review of the medical record for Resident #98 revealed a form titled, Preadmission Screening and Resident Review Results (PASRR) Notice, dated 10/20/23, which indicated Resident #98 had indications of serious mental illness and/or developmental disability and required a Level II evaluation. Further review of the medical record revealed a form titled, Notice of PASRR Level II Outcome, dated 11/03/23, which stated Resident #98 was denied nursing facility services and must remain in the community or return to the community. Interview with Admissions Director #74 confirmed the facility had not completed a PASRR for Resident #98 prior to admission to the facility on [DATE]. Admissions Director #74 also confirmed the Resident #98 required a Level II evaluation which resulted in a denial of stay in the nursing facility. admission Director #74 stated Resident #98 remained in the facility at the time of the denial because he did not have a safe discharge plan. Review of the policy titled, Resident Assessment- Coordination with PASARR program, revised 09/18/23, stated the facility coordinates assessments with PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy stated a PASARR Level I was the initial pre-screening that was to be completed prior to admission. The policy also stated the facility would only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority had determined appropriate for admission. This deficiency represents non-compliance investigated under Complaint Numbers OH00151161 and OH00151159. Page 1 of 14 365209 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interview, and policy review, the facility failed to ensure quarterly care conferences were completed. This affected five (#36, #76, #80, #87, and #122) out of five residents reviewed for care conferences. The facility census was 145. Findings included: 1. Review of the medical record for Resident #36 revealed an admission date of 12/07/22 with medical diagnoses of chronic respiratory failure, emphysema, Guillain-Barre syndrome, dementia, and paraplegic. Review of the medical record for Resident #36 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/03/24, which indicated Resident #36 had moderately impaired cognition and required moderate staff assistance for bed mobility, substantial staff assistance with toilet hygiene and was dependent upon staff for bathing and transfers. Review of the medical record for Resident #36 revealed documentation to support the facility conducted a quarterly care conference on 01/09/23 and 03/12/24. The medical record did not contain documentation to support the facility conducted a quarterly care conference between 01/09/23 to 03/12/24. 2. Review of the medical record for Resident #76 revealed an admission date of 08/17/22 with medical diagnoses of dementia, diabetes mellitus (DM), psychotic disorder with delusions, and atherosclerotic heart disease (ASHD). Review of the medical record for Resident #76 revealed a quarterly MDS, dated [DATE], which indicated Resident #76 had severely impaired cognition and required substantial staff assistance with toilet hygiene and bed mobility, and was dependent upon staff for bathing and transfers. Review of the medical record for Resident #76 revealed documentation to support the facility conducted a quarterly care conference on 04/28/23 and 12/13/23. The medical record did not contain documentation to support the facility conducted a quarterly care conference between 04/23/23 to 12/13/23. 3. Review of the medical record for Resident #80 revealed an admission date of 08/30/23 with medical diagnoses of end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), alcoholic cirrhosis of liver, and ulcerative colitis. Further review revealed a discharge date of 03/04/24. Review of the medical record for Resident #80 revealed a quarterly MDS assessment, dated 12/01/23, which indicated Resident #80 was cognitively intact and required supervision with eating, toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #80 revealed documentation to support the facility conducted a quarterly care conference on 09/20/23. Further review of the medical record revealed no documentation to support the facility conducted a quarterly care conference since 09/20/23. 4. Review of the medical record for Resident #87 revealed an admission date of 01/04/23 with 365209 Page 2 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical diagnoses of stage IV pressure ulcer, severe protein calorie malnutrition, chronic obstructive pulmonary disease, malignant tumor of stomach and status post colostomy. Review of the medical record for Resident #87 revealed a significant change Minimum Data Set (MDS), dated [DATE], which indicated Resident #87 was cognitively intact and was dependent upon staff for toilet hygiene and transfers, required substantial assistance for bathing and moderate assistance for bed mobility. Review of the medical record for Resident #87 revealed documentation to support the facility conducted a quarterly care conference on 02/07/23 and 02/21/24. Review of medical record contained no documentation to support the facility conducted a care conference between 02/07/23 to 02/21/24. 5. Review of the medical record for Resident #122 revealed an admission date of 03/31/23 with medical diagnoses of DM, dementia, HTN, anxiety, and depression. Review of the medical record for Resident #122 revealed a quarterly MDS, dated [DATE], which indicated Resident #122 had moderately impaired cognition and required moderate staff assistance with bathing, supervision with toileting hygiene, and was independent with transfers. Review of the medical record for Resident #122 revealed documentation to support the facility conducted a quarterly care conference 05/31/23 and 12/13/23. Review of the medical record revealed no documentation to support the facility conducted a quarterly care conference from 05/31/23 to 12/13/23. Interview on 03/18/24 at 8:00 A.M. with Social Service Director (SSD) #86 confirmed the medical records for Residents #36, #76, #80, #87, and #122 did not contain documentation to support the facility conducted or offered to conduct quarterly care conferences. Review of the facility policy titled, Comprehensive Care Plans, revised 09/18/23, stated the comprehensive care plans would be prepared by the interdisciplinary team (IDT) which would include, but not limited to Social Service designee, a registered nurse, a nurse aide, member of the food and nutrition service staff, and the resident and the resident's representative. The policy stated the comprehensive care plans would be reviewed and revised by the interdisciplinary team (IDT) after each comprehensive and quarterly MDS assessment. This deficiency represents non-compliance investigated under Complaint Number OH00151159 and OH00151161. 365209 Page 3 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital documentation, review of a fall investigation, observations, staff interviews, and policy review, the facility failed to provide adequate assistance and supervision while a resident was sitting on the side of the bed, to prevent the resident from falling. This resulted in Actual Harm when Resident #06 was left unassisted on the side of the bed and the resident had an avoidable fall off the bed. Resident #06 sustained fractures of the femur and humerus which required surgical intervention. The affected one (#06) out of three residents reviewed for falls. Additionally, the facility failed to provide adequate supervision to Resident #91 while he smoked, which placed the resident at risk for more than minimal harm. This affected one (#91) of three resident reviewed for smoking. The facility census was 145. Findings included: 1. Review of the medical record for Resident #06 revealed an admission date of 08/29/22 with medical diagnoses of depression, congestive heart failure, anxiety, and dementia. Review of the medical record for Resident #06 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/06/24 which indicated Resident #06 was severely cognitively impaired and was dependent for toilet hygiene, oral care and bathing and required substantial/maximum staff assistance with transfers and going from lying to sitting on the side of the bed. Review of the medical record for Resident #06 revealed Fall Risk assessments, dated 12/21/23 and 02/13/24 which indicated Resident #06 was at high risk for falls. Review of the medical record for Resident #06 revealed an Activities of Daily Living (ADL) care plan which indicated Resident #06 needs assistance with ADL's due to weakness, impaired cognition, and impaired mobility. Interventions included provide staff assistance with bed mobility. Further review revealed Resident #06 was at risk for falls related to dementia with poor safety awareness, agitation, anxiety, and weakness. The interventions included to provide staff assistance with bed mobility as needed and elevated perimeter mattress. Review of the medical record for Resident #06 revealed a nurse progress note dated 02/13/24 at 9:30 A.M. which indicated the nurse was notified by State Tested Nursing Assistant (STNA) #03 that Resident #06 was lying on the floor next to the bed and complained of bilateral knee pain and left shoulder pain. The note stated STNA #03 reported Resident #06 was sitting on the side of the bed for morning care and the STNA turned to reach for Resident #06's dentures when she fell off the side of the bed. Further review of the medical record revealed a nurse progress note, dated 02/14/24 at 3:43 A.M. which stated Resident #06 was admitted to the hospital for a distal femoral fracture. Review of the facility fall investigation for Resident #06 revealed on 02/13/24 the nurse was notified by STNA #03 that while performing morning care, Resident #06 fell off the side of the bed when the STNA went to reach for Resident #06's dentures. Review of the medical record revealed a hospital physician progress note, dated 02/19/24, which documented Resident #06 was admitted to hospital on [DATE] after having an unwitnessed fall. The note stated Resident #06 had a left periprosthetic distal femur fracture and nondisplaced fracture of the 365209 Page 4 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0689 left medial humerus. The note documented Resident #06 underwent open reduction internal fixation of left femur on 02/15/24. Level of Harm - Actual harm Residents Affected - Few Interview on 03/14/24 at 1:05 P.M. with STNA #31 stated she routinely provided care to Resident #06 prior to her fall when Resident #06 resided on the dementia unit. STNA #31 stated Resident #06 required two persons assistance with bed mobility because of poor stability and lack of safety awareness prior to her fall on 02/13/24. Interview on 03/14/24 at 1:35 P.M. with STNA #03 confirmed she was the STNA providing care for Resident #06 on 02/13/24 when Resident #06 fell off the side of the bed. STNA #03 stated she left Resident #06 sitting on the side of the bed without any physical support while she turned and took a few steps away from the bed to wash Resident #06's dentures in the sink. STNA #03 stated she left Resident #06 on the side of the bed for just a few seconds before she fell. Review of the facility policy titled, Fall Management, revised June 2023, revealed the purpose of the policy was to prevent injuries related to falls and a care plan would be developed at the time of admission with specific care plan interventions to address each resident's risk factors. 2. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, type 2 diabetes mellitus, centrilobular emphysema, major depressive disorder, nicotine dependence, disorganized schizophrenia, and vascular dementia with other behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/24, revealed Resident #91 had memory problems, with staff interview completed. The assessment revealed the resident's cognitive skills for daily decision making was moderately impaired with decisions poor, cues/supervision required. The resident required moderate/partial assistance with one staff assistance for bed mobility, dressing, toileting and transfers. Review of Care Plan revealed Resident #91 is a smoker and staff to assist/supervise resident who going out to smoke. Observation on 03/07/24 at 4:28 P.M. revealed eight residents, including Resident #91, outside smoking without supervision, no staff member present. Observations of the facility Smoking Policy hanging on exit door to smoking area revealed all residents will be monitored while smoking. Interview on 03/07/24 at 4:32 P.M. with Memory Care Coordinator (MCC) #19 confirmed there were eight residents outside smoking without supervision. MCC #19 stated there are some residents who can smoke independently. MCC #19 confirmed Resident #91 was outside smoking without supervision and that he requires supervision while smoking. Interview with MCC #19 confirmed nurses give Resident #91 his cigarettes when asked even though he is a supervised smoker. Review of Smoking Policy dated September 2022 revealed residents that meet the criteria to smoke independently will be allowed to do so within the guidelines. Residents that require supervision to smoke: C. Supervision must be provided to residents during smoking times. Smoking materials (cigarettes and lighter) are kept and distributed by staff. This deficiency represents non-compliance investigated under Complaint Number OH00151871. 365209 Page 5 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure resident's nutritional needs were met as care planned. This affected five (#9, #43, #87, #201 and #202) of eight residents reviewed for weight changes. The facility census were 145. Residents Affected - Some Findings include: 1. Review of the medical record review for Resident #9 revealed an admission date of 05/11/23 with diagnosis of type 2 diabetes mellitus with ketoacidosis without coma, asthma, chronic obstructive pulmonary disease, unspecified, bipolar disorder, current episode depressed, severe, with psychotic features, difficulty in walking, and major depressive disorder severe with psychotic symptoms. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/08/24 revealed Resident #9 was cognitively intact and was dependent with all activities of daily living (ADL's). Review of the Care Plan for Resident #9 revealed resident is at risk for complications related to hypoglycemia or hyperglycemia, hypothyroidism, fluid imbalance. Resident #9 also presents with potential for nutritional risk. Registered Dietician to follow and make diet changes, weights as ordered/indicated, notify physician of significant weight changes. Review of Resident #9 weights revealed on 08/03/23 a weight of 123.0 and on 02/06/24 a weight of 104.8 = 14.80% loss in six months. There was no documentation the physician or resident contact was notified of the significant weight change. There was also no new interventions implemented. 2. Review of the medical record review for Resident #43 revealed an admission date of 12/28/22 with diagnoses of acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, dependence on respirator [ventilator] status, shortness of breath, other abnormalities of breathing, carrier or suspected carrier of methicillin resistant staphylococcus aureus, personal history of other diseases of the respiratory system, and anxiety. Review of the quarterly MDS 3.0 assessment, dated 12/19/23 revealed Resident #43 is cognitively intact and requires extensive assistance for bed mobility, dressing, toileting, personal hygiene, and bathing. Resident requires total dependence for transfers. Review of the Care Plan for Resident #43 revealed resident presents with potential for nutritional risk related to diet as ordered. Resident will not exhibit significant weight change. Registered dietician to evaluate and make diet change recommendations. Weight as ordered / indicated, notify the physician of significant weight changes. Review of Resident #43's weights revealed on 04/27/23 a weight of 826.5 and on 10/04/23 a weight of 661.0, a 20.02 % weight loss. Review of the progress notes revealed no documentation that physician or Resident #43's contact was notified of the significant weight change. There was no documentation of any assessment/interventions. 3. Review of the medical record review for Resident #87 revealed an admission date of 01/04/23 with diagnosis pressure ulcer of sacral region, stage 4, unspecified severe protein-calorie 365209 Page 6 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some malnutrition, chronic obstructive pulmonary disease, malignant carcinoid tumor of the stomach, paroxysmal atrial fibrillation, and acquired absence of left leg above knee. Review of the quarterly MDS 3.0 assessment, dated 02/01/24 revealed Resident #87 cognition intact. Resident with multiple pressure areas. Resident with impairment to lower extremity on one side. Resident dependent for toileting hygiene, dressing lower extremities, transfers, and personal hygiene. Review of the Care Plan for Resident #87 revealed resident presents with potential for nutritional risk related to diet as ordered. Resident refuses weights at times. Registered dietician to evaluate and make diet change recommendations. Weight as ordered / indicated, notify the physician of significant weight changes. Review of weights in medical record revealed the last weight on Resident #87 was on 12/02/23. Review of progress notes revealed no documentation on resident refusal of being weighed. Review of the Weight Entry logs revealed resident was not weighed for January, February or through March 13, 2024. Weight on 03/14/24 revealed a weight of 225.6 and 223.6, which resulted in a 28.6 pound weight gain or 14.67% weight gain. Interview on 03/13/24 at 2:12 P.M. with the Registered Dietician (RD) #12 revealed all residents are to be weighed monthly and any residents who are on a physician's order to be weighed should be weighed per physician's orders. Interview with RD #12 confirmed Resident #87 has not been weighed since December 2023 and had not refused according to the weight logs. Interview also confirmed the physician and family had not been notified. Interview also confirmed the nurses are responsible for contacting the physician for weight changes. 4. Review of the medical record review for Resident #201 revealed an admission date of 04/20/23 with diagnosis anoxic brain damage, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia, dependence on respirator [ventilator] status, and tracheostomy status. Review of the quarterly MDS 3.0 assessment, dated 01/26/24 revealed Resident #201 cognitive skills for daily decision making was moderately impaired. Resident was dependent for toileting hygiene, shower/bathing, personal hygiene and transfers. Review of the Care Plan for Resident #201 revealed resident presents with potential for nutritional risk related to diet as ordered. Registered dietician to evaluate and make diet change recommendations. Weight as ordered / indicated, notify the physician of significant weight changes. Resident has impaired skin integrity with multiple wounds. Supplements as ordered. Review of weights for Resident #201 revealed a weight on 06/09/23 of 189.0 and on 01/16/24 163.0, a 13.76% weight loss. Interview on 03/13/24 at 2:12 P.M. with the RD #12 revealed all residents are to be weighed monthly and any residents who are on a physician's order to be weighed should be weighed per physician's orders. Interview with RD #12 also confirmed Resident #201 had a weight loss, her tube feed had been attempted to be adjusted up and resident was not able to tolerate it. Interview with RD #12 also confirmed there was no recommendation for IV parental nutrition, she was on protein two times daily and 365209 Page 7 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the family was refusing hospice services. Interview with RD #12 also confirmed the nurses are responsible for contacting the physician for weight changes and there was no documentation that that occurred. 5. Review of the medical record review for Resident #202 revealed an admission date of 11/30/22 with diagnosis acute metabolic acidosis, adult failure to thrive, hypo-osmolality and hyponatremia, type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oropharyngeal phase, vitamin d deficiency, unspecified, polyneuropathy, unspecified, essential (primary) hypertension, pure hypercholesterolemia, unspecified, major depressive disorder, single episode, unspecified, hyperlipidemia, unspecified, suicidal ideation's, muscle weakness (generalized), repeated falls, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS 3.0 assessment, dated 11/19/23 revealed FR #202 was cognitively impaired, cognitive skills for daily decision making was moderately impaired. Resident was dependent for toileting hygiene, shower/bathing, personal hygiene and required substantial / maximal assistance for transfers. Review of the Care Plan for Resident #202 revealed resident presents with potential for nutritional risk related to diet as ordered. Registered dietician to evaluate and make diet change recommendations. Weight as ordered / indicated, notify the physician of significant weight changes. Review of weights on Resident #202 revealed a weight on 07/05/23 of 121.0 and on 01/02/24 94.0 which is a 21.31% weight loss. Review of progress notes for Resident #202 revealed no documentation present that family or physician was notified of a significant weight change. Interview on 03/13/24 at 2:12 P.M. with the RD #12 confirmed there is no documentation that the physician and resident representative was notified on Resident #202 was notified of the significant weight change. Review of the Resident Weight Monitoring Policy dated September 2022 revealed all residents will be weighed at admission and routinely thereafter. A weight report will be generated monthly and reviewed by the DM, RD, DNS and MDS for significant changes. A significant weight change is defined as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. The resident's physician and family / guardian will be notified of any verified significant weight change. Resident's with verified significant weight change will be followed by the IDT in the Risk Nutrition meeting. If the resident declines to be weighed, documentation will be made in the EMR that the weight was not taken. This deficiency represents non-compliance investigated under Complaint Numbers OH00151871 and OH00151239. 365209 Page 8 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of personnel records, review of training documents and staff interviews, the facility failed to ensure that nursing staff had the competencies and skill set to perform their job regarding care for residents with ventilators. This had the potential to affect four (#39, #43, #45 and #48) residents on ventilators. Facility census was 145. Findings include: Review of employee chart for Licensed Practical Nurse (LPN) #77 LPN revealed a hire date of 02/05/24. A pre-employment background check was completed. LPN #77's nursing license was active. Review of training record for LPN #77 revealed a Relias training record showed she completed Infection Control, Respecting Diversity in the Workplace, and Teepa Snow: PAC Skills Make a Difference. No other training documentation available. Review of employee chart for LPN #17 revealed a hire date of 12/20/23. A pre-employment background check was completed. LPN #17's nursing license was active. Review of training record for LPN #17 revealed a Relias training record showed training complete for Communication and Conflict Skills, Electrical Safety the Basics, Ethics and Corporate Compliance, Fire Safety for Ohio Healthcare Facilities, HIPPA: Basic Self-Paced, Infection Control: Basic Concepts Self-Paced, Liquid Oxygen Safety, Lockout/Tagout Procedures, Preventing Hospital readmission: What Wound You Do, Respecting Diversity in the Workplace Self-Paced, Respiratory Protection Program, Safe Guarding Resident Rights in Nursing Facilities Self-Paced, Teepa Snow: PAC Skills Make a Difference - Chapter 1: Positive Approach Techniques and Medication Administration: Nebulizer. No other training documentation available. Review of employee chart for LPN #115 revealed a hire date of 07/14/21 as an State Tested Nursing Assistant (STNA( then transitioned to an LPN 12/08/23. A pre-employment background check was completed. STNA registry is still active and LPN #115's nursing license was active. Review of training completed for LPN #115 revealed all the new hire orientation courses were complete except Communication and People with Dementia, Electrical Safety: The Basics, Hazardous Chemicals: SDS and Labels Self-Paced, Lockout / Tagout Procedures, Preventing Adverse Reactions to Dementia Care, Teppa Snow: Dementia Care Provisions: Chapter 5 The Brain Tour, Teppa Snow: PAC Skills Make a Difference Chapter Three - Skills Practice Demonstrations, and Medication Administration: Nebulizer. No other training documentation available. Interview on 03/05/24 at 1:55 P.M. with, LPN #17 revealed she has worked at the facility approximately four to five months. LPN #17 reports she works all units if needed including the vent unit but has not had any documented formal training to work on the vent unit. LPN #17 reports her training consisted of just following another nurse to learn vents and the unit. Interview with LPN #17 also revealed she has not had any on the floor skills checkoff list since hired. Interview on 03/05/24 at 2:14 P.M. with LPN #115 revealed she worked here as an STNA, then was hired as a nurse. Interview with LPN #115 revealed she had two or three days training as a nurse before being placed on the floor alone. LPN #115 reports she was also sent to the vent unit to work. LPN #115 reports she has not received enough training and that she is not comfortable working on the vent unit due to lack of training and has not any on the floor skills checkoff list since hired. LPN #115 reports she has asked for more training but has not received it. 365209 Page 9 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/18/24 at 2:28 P.M. with Infection Preventionist #91 revealed all new hires have three courses to complete within the first two weeks of employment and another 17 that must be completed within their 1st thirty days. Interview with Infection Preventionist #91 also confirmed the courses are listed on the Assignments list in Relias. Interview with Infection Preventionist #91 also confirmed there is no documentation showing any staff has been trained on any other training in the building, including training for care of residents on ventilators. Interview with Infection Preventionist #91 also confirmed that newly hired nurses follow another nurse, and that nurse would train the new nurse on any processes or procedures completed while on that hall or unit that day, there is no documented proof of what they are trained on and if they are competent. Interview on 03/18/24 at 2:39 P.M. with Regional Nurse Consultant #59 confirmed there is not a policy for training new employees or expectations for training employees when new treatment or care protocols arise. The facility confirmed there are currently four (#39, #43, #45 and #48) residents on ventilators. This deficiency represents non-compliance investigated under Complaint Number OH00151871 and OH00151329. 365209 Page 10 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of Hospice documentation, interviews with facility staff, Hospice provider and pharmacy representative, and policy review, the facility failed to ensure staff were able to access medications from the facility's electronic medication dispenser (Ebox). This affected one (#203) out of four reviewed for medication administration. Facility census was 145. Findings included: Review of the medical record for Resident #203 revealed an admission date of [DATE] with medical diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, and spinal stenosis. Review of the medical record revealed Resident #203 enrolled into Hospice care on [DATE] and expired on [DATE]. Review of the medical record for Resident #203 revealed an annual Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #203 had severely impaired cognition and required substantial staff assistance for eating and bathing and was dependent for toileting hygiene, bed mobility, and transfers. Review of the medical record for Resident #203 revealed a nurse progress note, dated [DATE] at 11:30 P.M., which stated nurse was unable to get blood pressure reading on resident and heart rate was 48. The note indicated that the Hospice nurse was contacted, and the Hospice nurse advised the nurse to administer evening medications (crushed/diluted with water, use syringe) and that she was on the way to assess the resident. Further review revealed a nurse's note, dated [DATE] at 1:23 A.M., which stated the on-call Nurse Practitioner was contacted for an order for comfort medications (morphine sulfate and Ativan) for the resident. Further review revealed a progress note, dated [DATE] at 3:58 A.M. that Resident #203 had expired. Review of the medical record for Resident #203 revealed physician orders, dated [DATE] for lorazepam intensol oral concentrate 2 milligram (mg) per milliliter (ml), give 0.5 ml by mouth every two hours as needed, an order for morphine sulfate 100 mg per 5 ml by mouth every 2 hours as needed. Review of the Medication Administration Record (MAR) for February 2024 revealed neither medication was administered. Review of Hospice documentation for Resident #203 revealed the Hospice nurse was contacted by the facility nurse on [DATE] at 11:22 P.M. notifying her of Resident #203's decline in health status. Review of the Hospice notes revealed the Hospice nurse notified the facility nurse to obtain orders for morphine sulfate and lorazepam for Resident #203. Further review of the notes revealed on [DATE] at 12:29 A.M. the Hospice nurse arrived at the facility and assessed Resident #203. A Hospice note dated [DATE] at 1:10 A.M. stated the facility nurse was not able to obtain the medications from the Ebox and were awaiting a code from the facility pharmacy to access the Ebox. The documentation revealed the Hospice nurse contacted the Hospice Medical Director and requested an order for the medications be sent to the local pharmacy so the Hospice nurse could pick the medications up and deliver to the facility for faster patient intervention. The note continued to indicate the Director of Nursing (DON) was contacted and gave approval for medications to be picked up by Hospice nurse at the local pharmacy. Further review of the Hospice documentation revealed a note, dated [DATE] at 2:53 A.M. stated a text was received from facility DON which stated the medications had been retrieved from the 365209 Page 11 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ebox. The hospice documentation indicated the DON informed the Hospice Clinical Director (CD) #195 that the Ebox spring gets stuck and facility staff needed education. Interview via phone on [DATE] at 1:00 P.M. with Hospice Clinical Director (CD) #195 confirmed Resident #203 received their Hospice services and stated an internal investigation was completed into the events that occurred on [DATE] and [DATE] regarding Resident #203. CD #195 confirmed the Hospice nurse for Resident #203 was contacted on [DATE] at 11:22 P.M. by facility staff because of a decline in Resident #203's health status. CD #195 stated the Hospice nurse recommended the facility obtain an order for morphine sulfate and lorazepam from the facility physician. CD #195 stated the order for the medications were obtained but the facility was not able to obtain the medications from the Ebox. CD #195 confirmed the facility had requested two different access codes to the Ebox on [DATE]. CD #195 stated the pharmacy was not provided with a reason for the need for the second code. CD #195 stated the facility were not able to access the morphine sulfate or lorazepam medication for Resident #203 as recommended by Hospice nurse from the facility Ebox so the medications had to be sent stat by the pharmacy to the facility. CD #195 stated she had communicated with the facility DON via text messages which stated the facility staff had trouble getting into the Ebox due to the spring gets stuck and staff needed education on how to properly open the Ebox. Interview on [DATE] at 2:00 P.M. with the facility pharmacy's Director of Quality #190 stated the pharmacy received a call on [DATE] around midnight requesting authorization codes for the Ebox so the nurse could obtain medications for Resident #203. Director of Quality #190 stated the pharmacist received a call on [DATE] at 2:29 A.M. requesting a different authorization code to access the Ebox and then another call on [DATE] at 3:02 P.M. to cancel the codes and to send the medications stat. Director of Quality #190 state the pharmacy documentation did not contain information related to why the second access code was requested and were not aware of any issues with the Ebox not opening properly. Interview on [DATE] at 3:00 P.M. with DON stated she received a call on [DATE] in the middle of the night from the Hospice nurse who stated the facility staff could not get the morphine sulfate or lorazepam medication for Resident #203 out of the Ebox and the staff needed a new access code. DON stated the pharmacy provided the facility with another access code and the nurse was eventually able to the medications from the Ebox. DON stated the Ebox drawers get stuck at times and staff just need to press on the shelf or move it around a little bit to get the shelf to open. DON confirmed Resident #203 expired prior to receiving any comfort medications recommended by the Hospice nurse or as ordered by the physician on [DATE]. Review of the facility policy titled, Medication Administration, revised [DATE], stated medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with profession standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number OH00151159. 365209 Page 12 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

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 record review, observations, staff interview and review of a facility policy, the facility failed to ensure staff used the appropriate personal protective equipment (PPE) while in a residents room who was in isolation. This affected one (#43) of three residents reviewed for infection control. The facility census was 145. Residents Affected - Few Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnosis acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, dependence on respirator (ventilator), carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA), and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/19/23, revealed Resident #43 cognition is intact. Review of the quarterly MDS 3.0 assessment, dated 09/27/23, revealed Resident #43 required extensive assistance for bed mobility, dressing, toileting, personal hygiene, and bathing and total dependence for transfers. Review of Care Plan revealed Resident #43 revealed resident has MRSA in Sputum, and in contact isolation. Observation on 03/05/24 at 2:41 P.M. revealed Respiratory Therapist #306, revealed the staff member was in Resident #43's room. RT #306 was observed standing up next to Resident #43's head of the bed, without any PPE on talking to Resident #43. The signage outside of Resident #43's room indicated the resident was to be on contact isolation and that a gown and gloves must be worn in the room. A cart was available right outside of the room with clean gowns and gloves. Observation also revealed RT #306 did not wash or sanitize her hands prior to exiting the room. Interview on 03/05/24 at 2:43 P.M. with RT #306, confirmed she was in Resident #43's room which was an isolation room without any PPE on. Interview with RT #306 confirmed she removed her PPE and continued to stay in the room and just talk to the resident. Interview with RT #306 also confirmed the sign outside the room was for contact isolation and that a gown and gloves were required while in the room. Interview with RT #306 also confirmed she did not wash or sanitize her hands when exiting the room. Review of the Isolation - Initiating Transmission-Based Precautions Policy dated February 2018 revealed Transmission-Based Precautions will be initiated when there is a reason to believe that a resident has a communicable infectious disease. Transmission-Based precautions may include Contract Precautions, Droplet Precautions, or Airborne Precautions. Protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. Post the appropriate notice on the room entrance door, or be aware that they must first see the nurse to obtain additional information about the situation before entering the room. Be sure that an adequate supply of antiseptic soap and paper towels are maintained din the room during the isolation period. 365209 Page 13 of 14 365209 03/18/2024 Majestic Care of Middletown LLC 6898 Hamilton Middletown Road Middletown, OH 45044

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, staff interview, and facility policy review, the facility failed to administer influenza vaccine timely. This affected one (#122) out of five residents reviewed for vaccinations. The facility census was 145. Residents Affected - Few Findings included: Review of the medical record for Resident #122 revealed an admission date of 03/31/23 with medical diagnoses of diabetes mellitus, dementia, hypertension, anxiety, and depression. Review of the medical record for Resident #122 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #122 had moderately impaired cognition and required moderate staff assistance with bathing, supervision with toileting hygiene, and was independent with transfers. Review of the medical record for Resident #122 revealed a consent to administer the influenza vaccine, dated and signed on 09/13/23. Review of the medical record for Resident #122 revealed a nurse's progress note, dated 03/12/24 at 12:08 P.M. stated Resident #122 verbally consented to receive the flu vaccine, administered in right arm with no adverse reactions. The nurse practitioner and floor nurse aware. Review of the medical record for Resident #122 revealed the March 2024 Medication Administration Record (MAR) which indicated Resident #122 received the influenza vaccine on 03/12/24. Interview on 03/18/24 at 2:35 P.M. with Infection Preventionist #91 confirmed Resident #122 did not receive her influenza vaccine until 03/12/24 even though she signed the consent in September 2023. Infection Preventionist #91 stated the facility identified the error after reviewing Resident #122's medical record and administered vaccine promptly. Review of the facility policy titled, Influenza Vaccine stated all residents and employees who have direct contact with residents would be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. This deficiency represents non-compliance investigated under Complaint Number OH00151159. 365209 Page 14 of 14