Health inspection·March 13, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and dementia. A review of Resident #6's advanced directives in the hard chart of her medical records revealed she was a Do Not Resuscitate Comfort Care (DNR CC). The form was signed by the physician on 05/18/22. The DNR CC form indicated, after the State of Ohio DNR Protocol had been activated for a specific DNR CC patient, the protocol specified that emergency medical services and other health care workers were to do the following: They would suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care providers, such as hospice, home health, attending physician's, certified nurse practitioners, and clinical nurse specialists. They would not administer chest compressions, insert artificial airways, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance other than what was listed above, initiate resuscitative IV (intravenous), or initiate cardiac monitoring. The DNR CC was effective as soon as an authorized healthcare provider signed the form. A DNRCC-Arrest would not become effective until the patient/ resident experienced cardiac or respiratory arrest. Up until the time the patient/ resident experienced cardiac or respiratory arrest, they would receive all medical care necessary to treat any illness or injury, including intubation. They would be treated as any other medical patient. Should the patient/ resident experience cardiac or respiratory arrest during treatment, at that time the DNR protocol would be initiated and all resuscitative measures would stop. A review of Resident #6's physician's orders in the electronic medical record (EMR) revealed the resident had an order in place identifying her code status as being a DNRCC- Arrest. The order had been in place since 05/17/22. It was not until 03/12/24 (after the facility had been made aware of a discrepancy in another resident's code status) that the resident's code status order was changed to a DNR CC. The prior order for a DNRCC-Arrest was discontinued at that time to ensure the advanced directive in the hard chart of the resident's medical record matched the physician's order in the EMR. On 03/12/24 at 3:55 P.M., an interview with LPN #327 confirmed Resident #6's code status was not consistent between what was specified in her advanced directive in the hard chart of her medical record and what was specified under her physician's orders in the EMR. She confirmed the order had been changed in the EMR on 03/12/24 changing her code status from a DNRCC-Arrest to a DNR CC, after an issue with another resident's code status was identified and brought to their attention. Based on record review, staff interview and policy review, the facility failed to ensure accurate Page 1 of 16 365271 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few advanced directive information was present throughout the medical record. This affected three residents (#6, #28 and #32) of four residents reviewed for advanced directives. The facility census was 102. Findings Include: 1. Review of medical record revealed Resident #28 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unspecified asthma, respiratory failure, transient cerebral ischemic attack, abdominal aortic aneurysm, and heart failure. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of Resident #28's physician order, dated 08/15/23 identified Resident #28 was a Do Not Resuscitate Comfort Care (DNR-CC). Review of Resident #28's plan of care, dated 12/23/22 revealed Resident and Responsible Party had elected a DNR-CC code status. Review of Resident #28's paper medical record revealed a State of Ohio Do Not Resuscitate Comfort Care Arrest (DNR-CCA) signed and dated by Resident #28 and Physician on 08/16/23. Interview on 03/11/24 at 10:07 A.M. with Registered Nurse (RN) #228 confirmed Resident #28's electronic medical record identified Resident #28 was a DNR-CC and her paper record revealed she was a DNR-CCA. Further review of Resident #28's physician orders revealed Resident #28's code status order was updated on 03/11/24 at 11:24 A.M. to reflect Resident #28 was a DNR-CCA. 2. Review of medical record revealed Resident #32 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, Type two diabetes mellitus, acute systolic chronic heart failure, chronic kidney disease, and hypertension. Review of Resident #32's state operational MDS 3.0 assessment dated [DATE] revealed Resident #32 was cognitively impaired. Review of Resident #32's physician order, dated 11/23/21 identified Resident #32 was a Do Not Resuscitate Comfort Care Arrest (DNR-CCA). Review of Resident #32's plan of care, dated 11/23/21 revealed Resident and Responsible Party had elected a DNR-CCA code status. Review of Resident #32's paper medical record revealed a Do Not Resuscitate Comfort Care (DNR-CC) signed and dated by Resident #32's Physician on 05/02/23. Interview on 03/11/24 at 11:05 A.M. with Registered Nurse (RN) #338 confirmed Resident #32's electronic medical record identified Resident #32 was a DNR-CCA and her paper record revealed she was a DNR-CC. 365271 Page 2 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #32's physician orders revealed Resident #32's code status order was updated on 03/11/24 at 11:43 A.M. to reflect Resident #32 was a DNR-CC. Review of facility policy titled Advance Directives dated 11/16 revealed the do not resuscitate (DNR) code status order will be supported by a signed physician's order even in the presence of an advanced directive, living will or power of attorney. 365271 Page 3 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, review of an owner's manual/ technical specifications for a bed used for a resident, resident interview and staff interview, the facility failed to ensure a resident had an appropriate sized bed/ mattress to allow for proper positioning to accommodate his height and failed to identify and timely treat another resident who displayed signs of intense itching. This affected one (#65) of two residents reviewed for positioning and one (#198) of one resident reviewed for non-pressure skin conditions. Residents Affected - Few Findings include: 1. A review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity, a stage IV pressure ulcer to the right heel (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), and multiple contractures of the bilateral knees/ left hip/ left ankle. A review of Resident #65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. His height was recorded as being 80 inches (6'8) tall. A review of Resident #65's active care plans revealed he had a care plan in place for an alteration in mobility. The interventions included the need to assist the resident with bed mobility as needed. A review of Resident #65's physician's orders revealed he was to be on a pressure reduction mattress with a foot extender. That order had been in place since 09/26/23. They were also to encourage or assist the resident to elevate his heels while in bed. There were no physician's orders regarding any specialty bed being used such as a bariatric bed (larger bed for obese residents) or a bed/ mattress that accommodated his large size. On 03/11/24 at 9:25 A.M., an observation of Resident #65 noted him to be lying in bed in a supine position with the head of his bed elevated. The foot board to the bed had been removed and the mattress extended about four to five inches past the end of the bed frame. His head extended past the top of the mattress by about six to eight inches. His feet were slightly hanging over the end of the bed. There was a gray colored rectangular shaped cushion placed between the top edge of the mattress and the head board that was lower than the level of the mattress and did not fully fill the gap between the mattress and the headboard. There were two pillows that had been placed under the resident's head with one pillow over top of the gray cushion and the other pillow more directly under the resident's head. It did not provide good head/ neck support. The resident reported he needed a longer bed and was six foot eight inches tall. On 03/12/24 at 10:02 A.M., ongoing observations of Resident #65 noted him to remain in bed in a supine position with the head of the bed up. Maintenance Director #297 was asked to obtain measurements of the resident's bed frame and his mattress. The bed frame was noted to measure 88 inches and the mattress was measured to only be 80 inches long. He reported the bed the resident was in was a bariatric bed. He confirmed he had taken the foot board off the bed due to the resident's height. He acknowledged the mattress did not extend the full length of the bed frame and when the head of bed was raised the resident's heels were at the end of the bed and his head exceeded the end of the top of 365271 Page 4 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the mattress by about six to eight inches. He stated there were longer mattresses available to accommodate the length of the bed frame if the bed frame had been extended as the resident's was. On 03/12/24 at 10:05 A.M., further interview with Resident #65 revealed he had been in the facility for about six months now. He had been in and out of the hospital a couple of times, but had been in the same bed since he first arrived. He confirmed the mattress was not long enough to accommodate his size as he was 6'8 tall. He reported he had mentioned the bed was not big enough for him at different times in the past, but he was not provided a new bed or mattress that was accommodating to his size. He also felt it was obvious by looking at him that his mattress was not the proper size for him as they had to take off the footboard. He also stated his head often extended further than the top of the mattress did and they had to use the gray pad at the head of his bed to fill in the gap between the end of the mattress and the head board on his bed. He stated a king size bed was the only bed he comfortably fit in and when he used a queen size bed in the past he would have to lie diagonally so he would fit. He felt some of the discomfort he experienced could have been related to his positioning but could not be sure that was the cause. He was in a longer bed the few times he was hospitalized and reported that bed was really comfortable. The facility was asked to provide the owner's manual/ technical specifications for the bed Resident #65 currently had. A review of the bed specifications for the P903 bed revealed the overall length of the bed without the wall bumper could be adjusted from 87, 91 and 95 inches. The length of the mattress deck was 82.6 inches. Mattress lengths available included 80 inches, 84 inches, and 88 inches. After the facility was asked to provide the bed specifications on 03/11/24, they provided a purchase requisition and a purchase order request the morning of 03/12/24 showing they had contacted a medical supply company about getting a new bed/ mattress for Resident #65. The purchase requisition was dated 03/11/24 and the purchase order was dated 03/12/24. There were three items on the purchase requisition and order for the amount of $1,588.00. The items had item numbers and there was a brief description of the items that included repairs and maintenance, supplies, and minor medical equipment. It did not specifically identify what items were ordered. An acknowledgement letter from the medical supply company for an order date of 03/11/24 revealed they would be providing the facility with an Infinity Bariatric Expandable Hi-Low Full Electric Low Bed that was 88 inches long and had a width that expanded from 36 inches to 42 inches to 48 inches with a 650 pound capacity. A head and foot board would be provided for an expandable bed. They were also going to send a 42 inch x 84 inch multi-layered pressure reduction mattress w/ firm perimeter and fire barrier with a 600 pound capacity. The order also included a 42 (width) x 6 (depth) x 4 (length) mattress extender. Total order amount came to $1,703.13 not counting freight charges. On 03/12/24 at 1:20 P.M., an interview with the facility's Administrator revealed they had contacted the medical supply company and had purchased a new bed frame and a longer mattress for Resident #65. They were just awaiting notification of a delivery date. She acknowledged the resident had been in the facility since 06/12/23 (about nine months now) and had been in the same bed that was not of proper size to accommodate his height. 2. A review of Resident #198's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult inset diabetes mellitus, anxiety, and peripheral vascular disease. He did not have any skin related diagnoses such as psoriasis, eczema, or dermatitis. 365271 Page 5 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #198's MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not noted to have displayed any behaviors or reject care during the seven days of the assessment period. His comprehensive care plans were still being developed. A review of Resident #198's physician's orders revealed the resident did not have any orders to receive any medications by mouth or topically for itching. He was not ordered any oral anti-histamines nor did he had any cortisone creams that could be applied for itching skin. A weekly skin only evaluation dated 03/12/24 revealed Resident #198's skin was assessed and he was only indicated to have had a pressure ulcer to his left heel. He was not indicated to have any rashes or any other skin issue at the time the assessment was completed. A review of Resident #198's progress notes revealed there were not any progress notes that identified the resident as having any skin problems such as rashes or complaints of itching. Progress notes were reviewed from the date of his admission on [DATE] to 03/13/24. On 03/10/24 at 4:07 P.M., an observation of Resident #198 noted him to be in his room in bed. He was noted to be scratching his arms. An interview with the resident at the time of the observation revealed his skin had been itching, but he did not receive anything for it. He stated he had been complaining but no one seemed to care. On 03/12/24 at 4:20 P.M., ongoing observations of Resident #198 during a treatment observation for his pressure ulcer noted him to continue to be scratching. He had multiple red scabbed areas on his right shin that he had scratched open and was also noted scratching his neck area during the treatment. LPN #327 noted him scratching and had asked the resident about his itching. He informed her that he had been itching for some time and did not know if it was medication related or caused by something else. He informed her that he had told multiple people about it, but nothing had been done to address his itching. She did inform the resident that she would contact the doctor to see if they could get something ordered to help with his itching. On 03/13/24 at 11:29 A.M., an interview with State Tested Nursing Assistant (STNA) #325 revealed she was the aide taking care of Resident #198 that day. She denied the resident complained much to her about anything. She denied she had seen the resident scratching and had not noted any rashes on him. She further denied he reported anything to her about him itching. On 03/13/24 at 11:31 A.M., an interview with LPN #262 revealed she had just left Resident #198's room after checking his blood glucose level. She was familiar with the resident and was the nurse that did his admission assessment when he was admitted to the facility on [DATE]. She denied she was aware of the resident having any complaints of itching and denied she had seen him scratching when she was in his room checking his blood sugar. She was informed the resident had been observed to be scratching since observations were initiated on the resident beginning 03/10/24. She was asked to go back into the resident's room and check his skin to see if he had any rashes present. She entered the resident's room and immediately noted the resident was scratching his right shoulder. She asked the resident if she could check the resident's skin and he complied. The nurse noted the resident had pinpoint scratch marks (scabbed areas) to his bilateral shoulders, down both his arms, and down the front of his right leg. The nurse asked the resident if he was aware of any allergies he had to medications or food. He denied that he did. She reported he was not like that when she assessed him upon admission. She recalled the resident had that issue when he was in the facility the first time and 365271 Page 6 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0684 thought they had Atarax and a Hydrocortisone cream they were using on him. She stated she would contact the physician and get something ordered to help with the resident's itching. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365271 Page 7 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used recorded on the pen. This affected three residents (Resident's #8, #43 and #197) who received insulin and resided on the second floor nursing unit. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 05/15/23 and diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus without complications and anxiety disorder. Review of Resident #8's physician orders dated 11/16/23 revealed Novolin 70/30 FlexPen subcutaneous suspension pen-injector (70-30) 100 units per milliliter (ml) (insulin NPH isophane and regular (human), inject 50 units subcutaneously one time a day for diabetes. 2. Review of Resident #43's medical record revealed an admission date of 05/10/23 and diagnoses included diabetes mellitus without complications, Parkinson's disease and dysphagia. Review of Resident #43's physician orders 07/06/23 revealed Levemir FlexPen subcutaneous solution pen-injector 100 units per ml (insulin detemir), inject 20 units subcutaneous two times a day related to type two diabetes mellitus without complications. 3. Review of Resident #197's medical record revealed an admission date of 10/16/23 and diagnoses included type two diabetes mellitus without complications, morbid obesity due to excess calories, congestive heart failure. Review of Resident #197's physician orders dated 02/28/24 revealed Lantus SoloStar 100 units per ml solution pen-injector, inject 70 units subcutaneously at bedtime related to type two diabetes mellitus without complications. Observation on 03/11/24 at 10:39 A.M. of Licensed Practical Nurse (LPN) #262 revealed she opened the top drawer of her medication cart, and checked the insulin pens of residents residing on the second floor nursing unit for dates when the insulin pens were first opened and used. Further observation revealed LPN #262 checked Resident #43's Levemir FlexPen 100 units per ml and noted there was no date the FlexPen was first opened and used written on it. Further review revealed LPN #262 checked the date on Resident #197's Lantus SoloStar 100 units per ml pen-injector and noted there was no date Resident #197's Lantus pen-injector was first opened and used written on it. Observation revealed LPN #262 checked the date on Resident #8's Novolin 70/30 insulin pen 100 units per ml and confirmed there was no date it was first opened and used written on it. Interview on 03/11/24 at 10:39 A.M. of the Director of Nursing (DON) confirmed Resident #8, #43 and #197's insulin pens did not have the date they were first opened and used written on the pens. The DON stated the insulin pens needed to be discarded and she would have the pharmacy send Resident's #8, #43 and #197 replacement insulin pens. The DON indicated Resident's #8, #43 and #197 would not be charged for the insulin pens, and the facility would pay to replace them. 365271 Page 8 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Administering Medications revised 04/2019 included medications were administered in a safe and timely manner, and as prescribed. The expiration or beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container. Insulin pens containing multiple doses of insulin were for single-resident use only. Residents Affected - Some 365271 Page 9 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, interview, observation, and policy review the facility failed to trend and identify infections/organism. The facility also failed to use proper hand hygiene and glove use during suprapubic catheter care. This had the potential to affect all 102 residents residing in the building for infections and one resident (#78) of one observed for catheter care. Residents Affected - Many Findings include: 1. Review of the infection control logs, and facility floor plans dated 10/2023 to 03/2024 revealed no evidence the facility was trending and identifying all infections/organism. The facility was utilizing floor plans to trend the infection. The October 2023 floor plan revealed the facility was trending genito- urinary (GU), gastro-intestinal (GI), skin, respiratory, eye, and others. Review of the October 2023 infection control log revealed there was two sepsis, one otitis media, one tonsillitis, three conjunctivitis, two clostridium difficile (C-diff), one methicillin resistant staphylococcus aureus (MRSA) one Vancomycin Resistant Enterococcus (VRE), four pneumonia, two cellulitis, two wound infection, one skin infection, and 10 Urinary Tract Infections (UTI) however the UTIs did not include the organisms. B. The November 2023 floor plan revealed the facility was trending GU, GI, skin, respiratory, eye, influenza A, and others. Review of the November 2023 infection control log revealed there was one osteomyelitis, two C-diff, two MRSA, one Extended Spectrum Beta Lactamase (ESBL), one enterovirus gastrointestinal, one otitis media, and six unknown infections. There were 22 influenza A, two bronchitis, eight pneumonia, and one upper respiratory infection tract infection. There were three cellulitis, three skin infections, one cystitis, and eight UTI, however there was no evidence of the type of organisms. C. The December 2023 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others. Review of the December 2023 infection control log revealed there was one C-diff, one enterovirus gastrointestinal, four MRSA, seven unknown, 29 COVID, seven pneumonia, one bronchitis, two influenza A, three cellulitis, one skin infection, one cystitis, and 29 UTI, however no indication of the organism. D. The January 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other. Review of the January 2024 infection control log revealed one osteomyelitis, one strep throat, one periodontitis, one c-diff, three MRSA, one herpes zoster, one unknown infection, seven pneumonia, two bronchitis, five COVID, one skin infection, one cellulitis, and one wound infection. E. The February 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other. 365271 Page 10 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of February 2024 infection control log revealed one bacteremia, three osteomyelitis, two periodontitis, one strep throat, three conjunctivitis, one herpes zoster, two bronchitis, five bronchitis, four COVID, three skin infections, and 10 UTI's, however no indication of the organism. The March 2024 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others. Residents Affected - Many Review of March 2024 electronic infection control log revealed there was one bacteremia, one strep throat, one conjunctivitis, two unknown, one bronchitis, one cellulitis, one UTI. Review of March 2024 paper infection control log revealed on 400 hall there was one MRSA, one prophylactic for UTI, one unknown fever. The 200-hall had two UTI's, however no indication of the organism, one osteo, and one respiratory. The 300-hall had five UTI's without evidence of organisms, one dental prophylactic, one bacteremia, one strep throat, and one conjunctivitis. The electronic logs only included room number, date of infection onset, infection, signs and symptoms, status, pharmacy order, and comments. There was no indication if the infection was community or hospital acquired. Review of the facility policy titled Infection Prevention and Control Program (dated 05/12/23) revealed a system of surveillance would be utilized for prevention, identified, reporting, investigation, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individual providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The policy didn't include directive or guidance on completing the infection control log or trending infection. Interview on 03/13/24 at 9:30 A.M., with Licensed Practical Nurse (LPN) #286 confirmed she was trending infection by using a floor plan of the facility. The facility currently has three floors. The floor plan only includes the site of infection and not the infection/organism. The LPN confirmed if you looked at the floor plan there was no indication on which resident had MRSA since MRSA could be in several different body sites. The LPN confirmed the printed log did not indicate which logs were community or facility acquired nor did the UTI include the type of organism. The facility was looking into other alternatives to log infections due to there were identified issues. 2. Review of medical record for Resident #78 revealed an admission date of 01/06/24. Medical diagnoses included neuromuscular dysfunction of bladder, spinal stenosis, benign prostatic hyperplasia, and personal history of urinary tract infections. Review of Medicare Five Day Minimum Data Set (MDS) 3.0 dated 02/14/24 revealed Resident #78 had moderate cognitive impairment, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #78's care plan dated 01/09/23 revealed Resident #78 utilized urinary catheter related to neurogenic bladder. Review of physician orders for Resident #78 revealed an order dated 05/28/23 to cleanse supra pubic site with wound cleanser and apply antifungal cream and absorbent dressing daily. Observation of catheter care on 03/11/24 at 3:52 P.M. for Resident #78 revealed Registered Nurse 365271 Page 11 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (RN) #338 gathered supplies, knocked on door, entered resident's room, and had shut resident's door for privacy. RN #338 placed supplies on prepared bedside table. RN #338 washed hands and donned gloves removed soiled dressing around supra pubic catheter site, cleansed site with gauze pads soaked in wound cleanser, dried with clean dry gauze pads and with soiled gloves applied new split gauze dressing over supra pubic catheter site. RN #338 was not observed to doff gloves perform hand hygiene and don new gloves after removing soiled dressing and prior to applying new dressing. Interview on 03/11/24 at 4:00 P.M. with RN #338 confirmed gloves were not changed, and hand hygiene was not completed prior to applying clean dressing after soiled dressing was removed from Resident #78's supra pubic catheter site. Review of facility policy titled Personal Protective Equipment dated 07/10/23 revealed gloves were to be changed and hand hygiene was to be completed between clean and dirty tasks. 365271 Page 12 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0881 Implement a program that monitors antibiotic use. 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 policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected four residents (#29, #30, #78, and #82) of five reviewed for infections. Residents Affected - Some Findings include: 1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, heart disease, and history of urinary tract infection (UTI). Review of Resident #82's nursing note dated 03/04/24 revealed the resident had complaints of dysuria. New order from physician for Macrobid 100 milligram (mg) twice daily for five days and Pyridium 100 mg three times a day for four days. Review of Resident #82's infection screening evaluation note dated 03/04/24 revealed the resident did not have an indwelling catheter and was afebrile. She had acute dysuria, and no other symptoms were noted. Review of Resident #82's infection note dated 03/05/24 revealed the resident had possible UTI. No diagnostic test was performed, and the resident was ordered antibiotic therapy of Macrobid 100 milligrams (mg) for five days. Review of Resident #82's antibiotic time out note dated 03/08/24 revealed on 03/04/24 the resident had complaints of dysuria and the hospice doctor placed the resident on antibiotics without obtaining urine. The resident had no complaints at this time. Per secure conversation with hospice doctor the resident needs to finish antibiotic as ordered due to history of recurrent UTI's. Interview on 03/13/24 at 9:37 A.M., with Licensed Practical Nurse (LPN) #286 confirmed the resident did not meet criteria for antibiotic treatment nor was urine collected to ensure an antibiotic was warranted and appropriate. The facility had identified concerns with facility staff not completing the proper paperwork, however hospice was not provided education on antibiotic stewardship program. 2. Record review revealed Resident #30 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including stage III kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, acute cystitis without hematuria, and heart disease. Review of Resident #30's physician telehealth note dated 03/10/24 revealed the resident had complaints of bladder distention and uncomfortable pressure. Requested a straight cath for comfort. The straight cath was obtained and 450 cc plus a full sample cup of urine was obtained. The urine was malodorous, muddy yellowish green with a lot of mucus and sediment. The resident sees a urologist regularly. The resident had vomited once at the beginning of the shift and had watery liquid stools twice this shift. The abdomen was soft per staff and didn't look distended. The assessment and plan included diagnoses of acute cystitis, diarrhea, nausea and vomiting, and history of recurrent UTI's. Plan to order Zyvox 600 mg for seven days and contact precautions until urine culture results. Check stool for C-diff and as needed Zofran 4mg four times a day. Review of Resident #30's health status note dated 03/10/24 revealed telehealth was contacted due to 365271 Page 13 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the resident having complaints of bladder distention and pressure. The resident also had nausea, vomiting, and diarrhea. New order for stat urinalysis for culture and sensitivity and stool sample for suspected c-diff, Zofran 4 mg every six hours and Zyvox 600 mg twice daily for five days for suspected UTI. The urine sample was taken to the lab for testing. Review of Resident #30's infection screening evaluation dated 03/10/24 revealed the resident was afebrile and had acute dysuria, costovertebral angle pain or tenderness, diarrhea, nausea, and vomiting. Review of Resident #30's infection note dated 03/11/24 revealed the resident urine was still pending. The resident was on Zyvox 600 mg twice a day for five days with no adverse reaction noted. The resident had no voiced complaints of pain or nausea and was afebrile. Interview on 03/13/24 at 9:48 A.M., with LPN #286 revealed the resident did not meet criteria for antibiotics, however the telehealth doctor started the resident on antibiotics with justification. The culture was still pending. The facility has not educated the telehealth doctors on the antibiotic stewardship program. 3. Record review revealed Resident #78 was originally admitted to the facility on [DATE] with diagnoses including type II diabetes, long term use of antibiotics, history of UTI's, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder, and suprapubic catheter for neurogenic bladder. Review of Resident #78's infection screening evaluation note dated 12/09/23 revealed the resident had supra-pubic tenderness and no other symptoms noted. Review of Resident #78's infection note dated 12/11/23 revealed the resident was ordered Cefdinir 300 mg twice a day until 12/12/23 for UTI. Review of Resident #78's antibiotic time out note dated 12/12/23 revealed the resident has returned from the emergency room with orders for antibiotics for three days for a UTI. The resident was not having any symptoms or signs of infection at this time. The resident supra-pubic catheter was draining clear yellow urine at this time. The antibiotic was completed today and doesn't require any further treatment. Review of Resident #78's medical record revealed no evidence of a urine culture. Review of Resident #78's infection screening evaluation dated 01/25/24 revealed the resident had an indwelling catheter and no symptoms. Review of Resident #78 infection note dated 01/27/24 revealed the resident was ordered Augmentin 500/125 mg twice daily for five days for UTI from the hospital. Review of Resident #78's antibiotic time out note dated 01/29/24 revealed the resident was re-admitted to the facility on [DATE] with intravenous antibiotics, however the order was changed to Augmentin by mouth on 01/26/24. The resident urine was dark colored. The physician was notified and wanted the antibiotic continued due to recurrent UTI's and hospitalization related to UTI. Review of Resident #78's medical record revealed no evidence of a urine culture. 365271 Page 14 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #78's infection screening evaluation dated 03/06/24 revealed the resident had visible hematuria. Review of Resident #78's orders dated 03/07/24 revealed Bactrim DS 800-160 mg once a day prophylactic. Review of Resident #78 infection note dated 03/08/24 revealed the resident had possible UTI and was ordered Bactrim DS 800-160 mg twice daily for seven days. The urinalysis was pending. Review of Resident #78's urinalysis results dated 03/07/24 revealed the resident had plus four leukocytes and many bacteria. A culture was indicated. Review of Resident #78's urine culture results dated 03/09/24 revealed the organism was proteus mirabilis and resistant to Bactrim. There was a handwritten note to discontinue the Bactrim and start Keflex 500 mg every six hours for seven days. Review of Resident #78's orders dated 03/10/24 revealed Keflex 500 mg by mouth every six hours for UTI for seven days. Interview on 03/13/24 at 9:56 A.M. and 10:03 A.M., with LPN #286 confirmed the Resident was treated for an UTI on 12/09/23 and 01/25/24, however the urine culture was never obtained to ensure the resident received appropriate treatment for a UTI. The LPN confirmed on 03/05/24 the doctor was visiting and noted gross hematuria in the resident foley bag and ordered a urinalysis and started the resident on antibiotics prior to receiving the urine culture. Once the urine culture came back the antibiotic had to be changed due to the Bactrim being resistant against the organism. The LPN confirmed the resident did not meet criteria for antibiotic treatment on 12/09/23 and 01/25/24 and the resident was started on antibiotics on 03/06/24 before the culture returned. The physician should have waited for the culture to return. The physician has not been educated on the antibiotic stewardship program. 4. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia, history of UTI, and spinal stenosis. A. Review of Resident #29's health status note dated 02/16/24 revealed the resident returned form the emergency room with order for Keflex 500 mg twice daily for five days for UTI. Review of Resident #29's infection screening evaluation dated 02/17/24 revealed the resident had delirium, new onset confusion, and new onset functional decline. The resident did not meet criteria for antibiotic treatment. Review of Resident #29's antibiotic time out form dated 02/21/24 revealed the resident had gone to the emergency room on [DATE] due to being lethargic and functional decline and was diagnosed with UTI. The resident had two more days left on treatment and had no signs or symptoms of infection noted. The physician wanted antibiotic continued as ordered from the emergency room and if any signs and symptoms after completion of antibiotic to notify physician. Review of Resident #29's medical record revealed no evidence of a urine culture. Interview on 03/13/24 at 9:52 A.M., with LPN #286 revealed the resident did not meet criteria for 365271 Page 15 of 16 365271 03/13/2024 Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotic treatment, however the doctor wanted the antibiotic continued due to the resident had altered mental status. Review of Resident #29's health status note dated 03/02/24 revealed a family member came to the nurse's station requesting to have the resident temperature taken due to the resident was flushed. The resident temperature was 102.2 otherwise good. The doctor was notified, and new orders were received for laboratory testing and chest x-ray on Monday and to start Rocephin 1 gram (gm) IM for seven days. Review of Resident #29's Medication Administration Record (MAR) dated 03/2024 revealed the resident received Ceftriaxone Sodium Powder one gram IM for infection from 03/03/24 to 03/05/24. The order was originally 7 days. Review of the infection screen note dated 03/02/24 revealed the resident one single temperature greater than 102. The resident had no other noted symptoms. Review of Resident #29's health status note dated 03/05/24 revealed the resident had no signs or symptoms of infection and her labs were within normal limits and the chest x-ray was negative. The resident had only one temperature and all other temperatures were within normal limits. New orders to discontinue the Rocephin. Interview on 03/13/24 at 7:20 A.M. and 9:52 A.M., with LPN #286 confirmed the resident did not meet criteria for antibiotic treatment. Review of the facility policy and procedure titled Antibiotic Stewardship Program (dated 05/30/23) revealed it was the facility policy to implement and Antibiotic Stewardship Program as part of the facility overall infection prevention and control program. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Clinical justification for the use of an antibiotic beyond the initial duration ordered such as a review of laboratory reports/cultures in order to determine if the antibiotic remains indicated or of adjustments to therapy should be made. Education regarding the program would be provided at least annually to facility staff, prescribing practitioner, residents, and families. 365271 Page 16 of 16