Health inspection·March 12, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to ensure cognitive impaired residents were treated in a dignified manner while assisting them with eating their lunch. This affected five (Resident #14, #21, #27, #50 and #65) of seven residents observed during lunch in the westside dining room. The facility census was 81. Findings include: 1. Review of medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included heart failure and cerebrovascular accident transient. Review of the annual Minimum Data Set (MDS) assessment, dated 12/15/18, revealed Resident #14 had severely impaired cognitive deficits and required total dependence with activities of daily living. Review of medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included dementia and depression. Review of the quarterly MDS assessment, dated 01/01/19, revealed Resident #21 had moderately impaired cognitive deficits and required extensive assistance with activities of daily living. Review of medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included arthritis and dementia. Review of the quarterly MDS assessment, dated 01/05/19, revealed Resident #27 had moderately impaired cognitive deficits and required supervision with activities of daily living. Review of medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnoses included dementia, Parkinson's Disease, seizure disorder, anxiety and depression. Review of the quarterly MDS assessment, dated 01/19/19, revealed Resident #50 had severely impaired cognitive deficits and required extensive assistance with activities of daily living. Observations on 03/04/19 at 12:12 P.M., revealed State Tested Nurse Aide (STNA) #14 placed a food tray in front of Resident #27 as Resident #14, #21 and #50 sat at the table. Trays were delivered to other residents sitting in the dining room before delivering food trays to Resident #14, #21 and #50 whom sat with Resident #27. Resident #27 waited to eat her meal until Resident #14, #21 and #50 received their meal. At 12:26 P.M., revealed Residents #14, #21 and #50 received their meals. Interview on 03/04/19 at 12:26 P.M., revealed STNA #14 verified the findings. 2. Observation on 03/04/19 at 12:28 P.M., revealed STNA #14 was standing in between Resident #14 and Resident #50. STNA #14 was feeding the both of the residents while standing. STNA #14 confirmed Page 1 of 15 365327 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0550 the finding at the time of observation. Level of Harm - Minimal harm or potential for actual harm 3. Review of medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included anxiety and depression. Review of the quarterly MDS assessment, dated 01/31/19, revealed Resident #65 had moderately impaired cognitive deficits and required total dependence for activities of daily living. Residents Affected - Some Observation on 03/05/19 at 12:15 P.M., revealed Resident #65 was sitting in the dining room waiting on her lunch meal tray. There was a food tray sitting three feet across from Resident #65 and there was no one sitting at the empty table. Resident #27 was eating her meal and sitting at the table with Resident #65. Further observation on 03/05/19 at 12:50 P.M., revealed STNA #37 realized the tray sitting at the empty table belonged to Resident #65. STNA #37 gave tray to Resident #65. Surveyor requested meal tray food temperatures to be taken. The puree pork chops were at 125 Fahrenheit (F) and the milk was at 50 F. Interview on 03/05/19 at 1:00 P.M., revealed Dietary Manager (DM) #80 reported the tray has been sitting out for more than a half of hour and food was not at appropriate temperature. DM #80 warmed the food for Resident #65 and gave her another milk out of the refrigerator. 365327 Page 2 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, and record reviews, the facility failed to protect the health information of residents. This affected one resident (#40) of 81 residents observed during the annual survey. Residents Affected - Few Findings include: Observation on 03/07/19 at 8:26 A.M. revealed the laptop on top of the east wing medication cart for the far hallway was open and the medical record for Resident #40 was visible and accessible. Resident #40's photograph was located in the top left corner of the laptop and his medication administration record was exposed. There were three residents in the dining area of the east wing, and several residents ambulating in the hallway near the medication cart. Interview on 03/07/19 at 8:30 A.M. with Activity Director (AD) #122 verified that the laptop was open on the medication cart and Resident #40's photograph and electronic health record (EHR) were visible and accessible. Interview on 03/07/19 at 8:35 A.M. with Licensed Practical Nurse (LPN) #126 verified she was the nurse assigned to that medication cart and that she had accessed Resident #40's EHR on the laptop and left it open and accessible to other persons. LPN #126 stated she had worked at the facility 30 to 40 times and was aware of the privacy policies of the facility. Interview on 03/07/19 at 8:45 A.M. with Regional Clinical Coordinator (RCC) #64 verified Resident #40's EHR was open and accessible to other persons and education would be provided for the staff by the end of the day. 365327 Page 3 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident and staff interviews, the facility failed to maintain resident's room environment in a clean, sanitary and comfortable manner. This affected five (Resident #29, #34, #37, #53 and #231) of the 24 residents interviewed for environment. The facility census was 81. Findings include: 1. On 03/04/19 at 3:49 P.M., an observation of Resident #29 and #37's bathroom revealed the bathroom floors were sticky, underneath the toilet lid, towards the back was not clean, and a hole was observed on the wall in the resident's room between the two televisions. 2. On 03/04/19 at 4:51 P.M., an observation of Resident #34's bathroom revealed the bathroom toilet was stained with a brown ring around the inside of the toilet bowl. Interview on 03/04/19 at 5:00 P.M., revealed Resident #34 reported she hated the look of the toilet. She stated a person should not have to live like this. 3. On 03/04/19 at 6:18 P.M., an observation of Resident #231's room revealed the room was not swept and mopped. The trash can have no liner in it and Resident #231 was spitting in the trash can because she said the facility ran out of tissue. There was a box of empty tissue on resident's bed side table. 4. On 03/05/19 at 11:45 A.M., revealed Resident #53's light in the entrance of the room was not working. Interview on 03/07/19 at 3:30 P.M., revealed Housekeeping Director (HD) #93 verified Resident #29 and #37's bathroom needed cleaned and the whole in the wall in their room. The HD verified Resident #34's stained toilet, Resident #231's floors needed cleaned, there was no liner in the trash can and there was an empty box of tissues. The HD verified Resident #53's light in the room was not working. She reported there were no work orders received for the residents rooms. 365327 Page 4 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, coronary atherosclerosis due to calcified coronary lesion and chronic kidney disease. Review of the progress note, dated 01/24/19, revealed Resident #74 was transferred to the hospital per ambulance and per order of physician due to increasing abdominal pain. There was no evidence the resident or family were notified of the facility's bed hold notice and return policy, when the resident was transferred to the hospital. Review of the progress note, dated 02/25/19, revealed the night shift nurse was contacted by the hospital concerning Resident #74 being admitted to the hospital for gallstones and hypomagnesemia. There was no evidence the resident or family were notified of the facility's bed hold notice and return policy, when the resident was transferred to the hospital. Interview on 03/07/19 at 2:45 P.M. with Director of Social Services #109 confirmed the facility had not send out a bed hold notice and return policy to Resident #74 when the resident were transferred to the hospital on [DATE] and 02/25/19. Review of the facility's undated bed hold policy revealed the policy was to inform the resident or their legal representative after leaving the facility for hospitalization of the bed hold policy and notification. Based on record review, review of facility policy and staff interview, the facility failed to provide a bed hold notice to two (Resident #34 and #74) of four residents reviewed for hospitalization. This had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the record for Resident #34 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure and chronic respiratory failure. Review of the admission Minimum Data Set (MDS) assessment, dated 01/07/19, revealed the resident had moderate cognitive impairment. Review of the progress notes for Resident #34 revealed she was sent to the hospital on [DATE] due to chest pain and shortness of breath and returned to the facility on [DATE]. The resident's record was silent for any bed hold notice to the resident and/or resident's representative. During an interview with Corporate Registered Nurse #64 on 03/07/19 at 1:05 P.M., he verified no bed hold notice was given to Resident #34. 365327 Page 5 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive resident-centered care plan for Residents #11. This affected one (Resident #11) of 18 residents whose care plans were reviewed. The facility census was 81. Findings include: Record review of Resident #11 revealed he was admitted initially to the facility on [DATE] with recent readmission of 12/05/18. Diagnoses included glaucoma and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 12/13/18, revealed the resident was cognitively intact and the resident had adequate vision. Review of physician orders revealed the resident was receiving Latanoprost 0.005% eye drops for glaucoma. Review of Resident #11's care plan revealed it was silent to resident's glaucoma and eye drops related medications for glaucoma. Interview on 03/07/19 at 8:18 A.M. with Regional Clinical Consultant (RCC) #64 verified the resident's care plan was not person centered and does not reflect that he has glaucoma. 365327 Page 6 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review and staff interview, the facility failed to timely revise the care plan for Resident #279 following a fall. This affected one (Resident #279) of one resident reviewed for falls. The facility census was 81. Findings include: Review of the record for Resident #279 revealed she was admitted to the facility on [DATE]. Diagnoses included sepsis, chronic kidney disease and urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment, dated 03/07/19, revealed she was severely impaired in decision making and was totally dependent on staff for bed mobility and transfers. Review of the nurse's progress note, dated 03/02/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room. Another nurse's progress note, dated 03/02/19, revealed Resident #279 returned to the facility from the hospital at 1:40 A.M. with sutures to a laceration on her nose. Review of physician orders, dated 03/02/19, revealed the resident to have a bariatric bed to allow room for increased safety when turning. Review of the resident's care plan revealed a fall care plan was initiated on 03/07/19, six days after a fall with injury occurred on 03/01/19. During an interview with the Administrator on 03/11/19 at 11:41 A.M., she verified the fall care plan for Resident #279 was not initiated until 03/07/19, six days after her fall with injury on 03/01/19. 365327 Page 7 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

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 and staff interview, the facility failed to follow the hospital discharge instructions for removing sutures. This affected one (Resident #279) of one resident reviewed for falls. The facility census was 81. Residents Affected - Few Findings include: Review of Resident #279's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis, diabetes mellitus, chronic kidney disease, dementia, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 03/07/19, revealed the resident was cognitively impaired and was totally dependent on two persons assistance for bed mobility. Review of the nurse's progress note, dated 03/02/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room. Another nurse's progress note, dated 03/02/19, revealed Resident #279 returned to the facility from the hospital at 1:40 A.M. with sutures to a laceration on her nose. Review of the hospital record for Resident #279, dated 03/01/19, revealed the resident was evaluated for a fall that had occurred at the facility, the resident received sutures to her nose related to the fall and was sent back to the facility with discharge instructions for the resident to have her sutures removed in five to seven days. Review of physician orders, dated 03/02/19, revealed an order to clean the laceration to resident's nose with mild soap and water one time a day after the first two days and then to apply antibiotic ointment after each cleaning and leave open to air until the area was healed. Observation of Resident #279 on 03/12/19 at 10:13 A.M. revealed the resident was resting in a wide bed and had sutures to the top of her nose. Interview with Licensed Practical Nurse (LPN) #129 on 03/12/19 at 4:17 P.M. confirmed Resident #279 returned to the facility on [DATE] at approximately 1:40 A.M. with sutures to her nose. Nurse #129 stated she thought the sutures to resident's nose were dissolvable. Interview with Director of Nursing (DON) on 03/12/19 at 4:11 P.M. confirmed the facility had not followed the hospital discharge instructions to remove the sutures to Resident #279's nose within five to seven days following resident's fall on 03/01/19. Further interview with the DON on 03/12/19 at 5:10 P.M. confirmed the facility had removed sutures to Resident #279's nose at approximately 5:00 P.M. on 03/12/19. 365327 Page 8 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

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** 2. Review of Resident #33's record revealed he was admitted to the facility on [DATE]. Diagnoses included disorders of lung, dementia with behavioral disturbance, phobic anxiety disorders, chronic kidney disease, alcohol dependence in remission, heat syncope, muscle weakness, and wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/19, revealed the resident had severe cognitive impairment and he required supervision with dressing and personal hygiene and was independent with eating, toileting, bed mobility and transfers. A review of the care plan for Resident #33 revealed he had the potential for injury related to smoking and the facility was to secure his cigarettes and lighter at the nurse's station. Review of the smoking assessment, dated 11/14/18, documented the need for supervision during smoking, the use of a smoking apron and the need for the facility to store his lighter and cigarettes. During an interview with the Director of Nursing on 03/06/19 at 2:18 P.M., she verified the smoking supplies for all residents per policy should be kept at the nursing station. During an interview with the Administrator on 03/06/19 at 2:20 P.M., she verified the smoking supplies for all residents per policy should be kept at the nursing station. During an observation and interview with Resident #33 on 03/06/19 at 3:12 P.M., he stated he kept his smoking supplies on him and smoked when he wanted without staff supervision. He produced a pack of cigarettes and lighter from his coat pocket. He was wearing his coat at the time of the interview. During an observation and interview with Corporate Registered Nurse (RN) #64 on 03/06/19 at 3:55 P.M., revealed an observation of Resident #33's room and verified Resident #33 had cigarettes and lighter in his possession. RN #64 further verified Resident #33's had severe cognitive impairments, his care plan documented he needed to keep his supplies at the nursing station and the resident's smoking assessment documented he required supervision and a smoking apron to smoke. Based on record review, resident and staff interview, observation, and policy review, the facility failed to conduct an assessment to identify fall risk factors, implement interventions to prevent falls and failed to conduct a thorough fall investigation and a post-fall risk assessment for Resident #279. This resulted in actual harm for Resident #279 when the resident fell from her bed resulting in a laceration to her nose, which required emergent care and sutures. This affected one (#279) of one resident reviewed for falls. The facility also failed to ensure the environment was free of hazards and adequate supervision was provided for two residents. This affected two (Resident #4 and #33) of two residents reviewed for smoking. This had the potential to affect 25 residents the facility identified as residents who smoked. The facility census was 81. Findings include: 1. Review of Resident #279's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis, diabetes mellitus, chronic kidney disease, dementia, pressure ulcer of sacral region, and hypertension. 365327 Page 9 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0689 Review of the Minimum Data Set (MDS) assessment, dated 03/07/19, revealed the resident was cognitively impaired and was totally dependent on two persons assistance for bed mobility. Level of Harm - Actual harm Residents Affected - Few Review of the nurse's progress note, dated 03/01/19, revealed Resident #279 was found on the floor in her room next to her bed on 03/01/19 at 7:58 P.M. The resident was noted to have a laceration to her nose and there was blood on the resident's face and on the floor and the resident was sent to the hospital emergency room. Another nurse's progress note, dated 03/02/19, revealed Resident #279 returned to the facility from the hospital at 1:40 A.M. with sutures to a laceration on her nose. Review of the hospital record for Resident #279, dated 03/01/19, revealed the resident was evaluated for a fall that had occurred at the facility, the resident received sutures to her nose related to the fall and was sent back to the facility with discharge instructions for the resident to have her sutures removed in five to seven days. Review of physician orders, dated 03/02/19, revealed an order to clean the laceration to resident's nose with mild soap and water one time a day after the first two days and then to apply antibiotic ointment after each cleaning and leave open to air until the area was healed. There was also an order, dated 03/02/19, for a bariatric bed to allow room for increased safety when turning. Further review of the resident's record revealed it did not include a fall risk assessment upon admission or post-fall on 03/01/19. Review of the resident's fall care plan, dated 03/07/19, revealed the resident had an actual fall with injury on 03/01/19, a laceration to her nose with sutures. Interventions included providing the resident with a wide bed with a bariatric mattress for turning and positioning when in in bed. Review of the facility fall investigation for Resident #279 revealed the facility determined the root cause of the resident's fall on 03/01/19 to be that there did not seem to be enough room in bed for the resident to turn and that there was a safety risk of turning too far beyond edge of bed. Observation of Resident #279 on 03/12/19 at 10:13 A.M. revealed the resident was resting in a wide bed with a bariatric mattress. Resident had sutures to the top of her nose. Interview with Licensed Practical Nurse (LPN) #129 on 03/12/19 at 4:17 P.M. confirmed the nurse had found resident on the floor next to her bed with a laceration to her nose on 03/01/19 at approximately 7:58 P.M. The LPN further confirmed she assessed the resident and sent her to the hospital for evaluation. The LPN confirmed Resident #279 returned to the facility on [DATE] at approximately 1:40 A.M. with sutures to her nose. Interview with Director of Nursing (DON) on 03/12/19 at 11:47 A.M. confirmed the facility had not conducted a fall risk assessment to identify risk factors to prevent falls upon admission for Resident #279. The DON further confirmed the facility did not conduct a fall risk assessment following Resident #279's fall on 03/01/19. Further interview with the DON on 03/12/19 at 12:43 P.M. confirmed the facility's post fall investigation for Resident #279 following resident's fall on 03/01/19 did not include interviews with staff who had cared for resident prior to her being found on the floor on 03/01/19 at 7:58 P.M. Review of the facility's policy titled Assessing Falls and Their Causes, dated January 2019, revealed residents must be assessed upon admission and regularly afterward for potential risk of falls and 365327 Page 10 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0689 that all falls should be thoroughly investigated. Level of Harm - Actual harm 3. Review of Resident #4's medical record revealed an admission date of 08/09/18. Diagnoses included chronic atrial fibrillation, type two diabetes with diabetic neuropathy and alcoholic liver disease. Residents Affected - Few Review of the admission MDS assessment, dated 08/16/18, revealed the resident had no cognitive impairment and was independent to supervision for most activities of daily living (ADLs). Review of the resident's smoking assessment, dated 08/16/18, revealed the resident could smoke independently. Observation and interview on 03/04/19 at 10:45 A.M. with Resident #4 stated she keeps her cigarettes and lighters with her because when she leaves them at the nurses' station desk they disappear. Resident #4 pulled a red pack of cigarettes from her coat pocket with a lighter. Resident #4 stated she smokes when she wants and that her sister buys cigarettes and brings them in to her. Interview on 03/06/19 at 2:10 P.M. with the Director of Nursing (DON) revealed the residents keeping smoking materials at bedside was an ongoing challenge. The DON verified that by policy, residents were not to keep smoking materials at bedside, and must keep them at the nurse's station. The DON denied anyone reporting missing cigarettes when kept at nurse's station. Interview on 03/06/19 at 2:15 P.M. with the Administrator verified the policy states smoking materials were to be kept at the nurse's station and not at the bedside and denied that anyone reported missing cigarettes. Interview on 03/06/19 at 2:20 P.M. with Social Worker (SW) #109 verified the policy and stated the facility had just received locking bags to keep smoking materials in for each resident. SW #109 stated she would have the master key for each bag and the independent smokers would have their key. Review of the facility's policy titled Supervised and Independent Resident Smoking Policy, dated 02/01/19, revealed the facility shall establish and maintain safe resident smoking practices. It stated no resident shall hold on their person or in the room. This included cigarettes and lighters. 365327 Page 11 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

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, interviews, and facility policy review, the facility failed to ensure open vials of medication were properly labeled. This had the potential to affect 34 residents residing on the east wing. The facility census was 81. Findings include: Observation on 03/07/19 at 8:17 A.M. of the east wing medication room's medication refrigerator revealed two open vials of Sequiris Influenza vaccine with an expiration date of 06/30/19 which were not labeled with the date they were opened. In an interview on 03/07/19 at 8:17 A.M., Licensed Practical Nurse (LPN) #112 verified the two open vials of influenza vaccine were not labeled with the date they were opened. In an interview on 03/07/19 at 8:30 A.M., Regional Clinical Coordinator (RCC) #64 verified the two open vials of influenza vaccine were not labeled with the date they were opened and the facility policy stated to date them with the date opened. Review of the facility policy, titled Storage of Medications, dated 12/2018, revealed it did not address the labeling of opened medications. 365327 Page 12 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews and record reviews, the facility failed to ensure routine dental care and dentures were provided for residents. This affected one (Resident #47) of one residents reviewed for dental. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/12/18. Diagnoses included chronic kidney disease, vascular dementia and dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 07/10/1,9 revealed the resident had moderate cognitive impairment with behaviors of inattention, disorganized thinking, altered level of consciousness and there were no dental issues coded positively within the assessment for Resident #47. Review of Resident #47's physician orders, for 02/2019, revealed an order for a dental consult as necessary. Review of Resident #47's care plan, dated 02/12/18, revealed a focus of potential for or altered dental status related to poor oral hygiene with interventions of assistance with oral care as needed, notification of charge nurse of any chewing problems or complaints of oral discomfort, consultation with dentist/orthodontist if needed/requested by resident/family/physician, administration of medications as ordered, notification of physician/family of any dental problems noted, oral assessment as needed, and assessment for oral pain as necessary. Review of Resident #47's progress notes on 05/14/18 at 7:28 A.M. revealed a social service note regarding dental hygiene visit on 05/11/18 in which adult prophylaxis was performed which included toothette swab. The note also stated Resident #47 was edentulous and was waiting on dentures. Interview on 03/04/19 at 2:59 P.M. with Resident #47 stated he had no teeth and wanted dentures. Interview on 03/05/19 at 11:17 A.M. with Social Worker (SW) #109 stated she did not know Resident #47 wanted dentures. Further interview on 03/06/19 at 2:36 P.M. with SW #109 revealed the previous dental company was supposed to deliver dentures to Resident #47 after the visit on 05/14/18 and verified Resident #47 had never received his dentures. SW #109 stated the company provided dental services at that time closed down in 11/2018. SW #109 stated the previous dental company did not bill correctly, didn't show up when they said they were going to be at facility, and it took one resident six months to get their dentures. SW #109 stated a new dental company will be at the facility on 03/25/19 and Resident #47 was already placed on the list to be seen for dentures. 365327 Page 13 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policy, review of manufacturer guidelines and staff interviews, the facility also failed to ensure glucometers used for multiple residents were sanitized properly. This had the potential to affect 18 (#3, #8, #11, #31, #34, #35, #39, #44, #49, #59, #63, #64, #70, #71, #72, #73, #74, and #378) of 81 residents within the facility who required the use of a glucometer. Residents Affected - Some Findings include: Observation on 03/05/19 at 7:36 A.M. of Licensed Practical Nurse (LPN) #1 revealed LPN #1 laid a glove box and a basket containing gauze pads, alcohol swabs, and lancets directly on Resident #3's bed. Upon obtaining Resident #3's blood sugar result, LPN #1 laid the contaminated glucometer in the basket with the clean glucometer supplies. LPN #1 then proceeded to Resident #13's room without washing or sanitizing her hands and without sanitizing the glucometer and proceeded to setup the materials to obtain Resident #13's blood sugar. With surveyor intervention, the LPN #1 was stopped from proceeding with the collection and asked LPN #1 to step outside the room. LPN #1 verified she did not sanitize the glucometer between residents and did not wash or sanitize her hands. LPN #1 stated She normally would sanitize the glucometer with sanitary wipes. She also stated the facility policy for cleaning glucometers between resident use, was to use the sanitary wipes in between residents and to clean her hands. LPN #1 stated the basket of clean glucometer supplies would have to be discarded because she had laid the glucometer in the basket. Interview on 03/05/19 at 8:00 A.M. of LPN #120 revealed her statement that she has worked previous shifts at the facility and her statement that she cleans the glucometers using alcohol swabs between resident use because it is a disinfectant. LPN #120 stated she was not aware of what the facility policy was regarding the cleaning of glucometers in between resident use. Observation on 03/05/19 at 8:05 A.M. of nursing students revealed cleaning of glucometer between residents with alcohol swabs. Interview on 03/05/19 at 8:07 A.M. of Nursing Instructor #110 stated this was her first term teaching students at this facility. NI #110 verified a sanitary wipe should be used to clean the glucometers between resident use but the facility was unable to locate any containers of sanitary wipes today. NI #110 stated she had talked to several nurses at the facility about the lack of sanitary wipes and proper sanitization of the glucometers. Interview on 03/05/19 at 8:15 A.M. with LPN #121 revealed sometimes there were wipes to clean the glucometers but verified there were times when the facility has not had sanitary wipes and has used alcohol swabs in the past. Interview on 03/05/19 at 9:00 A.M. with the Administrator and RCC #64 verified the glucometers should be cleaned according to policy and manufacturer's instructions and that cleaning the glucometers with alcohol pads was inappropriate. Observation on 03/05/19 at 10:00 A.M. of the central supply storage room on the west hall revealed eight containers of Sani-Wipes. Review of the facility's list of residents who utilize the facility's glucometers revealed Resident 365327 Page 14 of 15 365327 03/12/2019 Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #3, #8, #11, #31, #34, #35, #39, #44, #49, #59, #63, #64, #70, #71, #72, #73, #74, and #378 utilized the glucometers. Review of the undated facility policy, Policy and Procedure for Cleaning Glucometers, revealed the statement, all glucometers will be cleaned and disinfected using Clorox Bleach Wipes, Clorox Bleach Germicidal Wipes, Hydro Peroxide Wipes, Cavi Wipes, Super Sani Clothe Wipes, or equivalent. All glucometers that will be shared by multiple patients will be thoroughly wiped with disinfectant and allowed to air dry after every use and between every patient. Use a fresh wipe each time you clean a glucometer. Wipe all surfaces, top, bottom, and sides, avoiding the results window and electrical connection. Review of the Arkray manufacturer's instructions titled, Cleaning and Disinfecting Blood Glucose Meters, dated 10/14/10 revealed the statement, it was Arkray's policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test to avoid cross contamination issues. Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. 365327 Page 15 of 15