Health inspection·October 25, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure resident preferences regarding bathing were honored. This affected one (#398) of 28 residents sampled. The facility census was 143. Findings include: Review of the medical record for Resident #398 revealed an admission date of 10/02/22 with a diagnosis of malignant neoplasm of the prostate. Review of the Minimum Data Set (MDS) for Resident #398 dated 10/09/22 revealed resident was cognitively impaired and required physical assistance of one staff with bathing. Review of section F revealed the resident reported it was very important for him to choose between a tub bath, shower, and bed bath. Review of the care plan for Resident #398 dated 10/02/22 revealed resident was able to express preferences regarding his daily life. Interventions included: resident prefers to assist with his own personal care, resident prefers a shower in the morning. Review of bathing sheet for Resident #398 dated 10/04/22 revealed aide offered to give resident a bed bath, but resident refused said he wants a shower in the morning. Review of bathing sheets for Resident #398 dated 10/07/22 and 10/14/22 revealed resident received a bed bath. Review of bathing sheets for Resident #398 dated 10/11/22 and 10/18/22 revealed resident was bathed but the sheet does not specify what type of bath resident received. Interview on 10/18/22 at 8:45 A.M. with Resident #398 confirmed he had not received a shower since his admission to the facility on [DATE]. Resident #398 confirmed he preferred to take a shower in a shower chair and his preference was to shower in the mornings. Resident #398 confirmed he told staff this preference when he was admitted on [DATE] but he has only received bed baths. Interview on 10/20/22 at 11:39 A.M. with Registered Nurse (RN) #351 confirmed Resident #398's expressed preference upon admission was to receive showers in the morning. RN #351 further confirmed the facility had no record of Resident #398 receiving a shower since his admission to the facility. Page 1 of 15 365346 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0561 Review of the facility policy titled Activities of Daily Living (ADL's) undated revealed the facility would include the resident's preference when planning care when possible. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365346 Page 2 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with appropriate fingernail care. This affected one (#43) of 28 residents sampled. The facility census is 143. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed resident was admitted on [DATE] with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) for Resident #43 dated 07/14/22 revealed the resident was severely cognitively impaired and required extensive assistance of one staff with bathing and personal hygiene. Review of the care plan for Resident #43 dated 10/28/20 revealed resident had an activities of daily living (ADL) self-care deficit related to cognitive/communication challenges and requires total assistance with, toileting, dressing grooming and eating. Interventions include the following: provide total assistance with dressing and grooming, assist with bathing and showering, check resident's nail length and trim and clean on bath day as necessary, report any changes to the nurse. Review of the care plan for Resident #43 dated 04/03/22 revealed resident received hospice services related to a terminal prognosis/diagnosis of senile deterioration of the brain. Interventions included hospice aide was to provide services, activities of daily living (ADL) assistance four times weekly. Review of bathing records provided by the facility for Resident #43 for the previous two weeks revealed all bathing assistance was provided by the hospice aide. Review of bath records dated 09/30/22, 10/05/22, 10/07/22, 10/12/22, 10/14/22 revealed the hospice aide provided bathing assistance but it was noted that nail care was not provided. Observation on 10/17/22 at 10:52 A.M. revealed Resident #43's fingernails were long (extending approximately one quarter inch beyond the end of the nail) and had some jagged edges. Interview on 10/17/22 at 10:55 A.M. with State Tested Nursing Assistant (STNA) #310 confirmed Resident #43's fingernails were long (extending approximately one quarter inch beyond the end of the nail) and had some jagged edges. STNA #310 confirmed the hospice aides were responsible for nail care and should trim resident's fingernails the next time they came into the facility. Interview on 10/20/22 at 11:40 A.M. with Registered Nurse (RN) #351 confirmed the hospice aides provided bathing for Resident #43 but any staff could trim resident's fingernails as needed. Review of the facility policy titled Activities of Daily Living (ADL's) undated revealed the facility would ensure staff provided ADL assistance as needed to the residents in order to promote dignity and improve quality of life. 365346 Page 3 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

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 record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place per the resident's plan of care and failed to conduct thorough investigations to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #399 experienced repeated falls resulting in a laceration which required surgical repair. Additionally, the facility failed to ensure Resident #26 was provided with adequate supervision and assistance while toileting resulting in an avoidable fall which placed the resident at risk for more than minimal harm that did not result in actual harm to the resident. This affected two (#399 and #26) out of four residents reviewed for falls. The census was 143. Findings include: 1. Review of the medical record for Resident #399 revealed an admission date of 10/07/22 with a diagnosis of syncope and collapse. Review of the Minimum Data Set (MDS) for Resident #399 dated 10/11/22 revealed the MDS was in progress. Review of admission note for Resident #399 dated 10/07/22 revealed nurse received report from hospital that resident was a fall risk and resident was admitted with bruising to her lower extremities from previous falls. Review of the fall risk assessment for Resident #399 revealed resident was at high risk for falls. Review of the baseline care plan for Resident #399 dated 10/07/22 revealed resident was at risk for falls. Interventions included the following: anticipate and meet resident needs, be sure my call light is within reach and encourage me to use it for assistance as needed, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. keep needed items in reach, staff to offer toileting and peri-care to resident upon rising, before and after meals, at bedtime and as needed. Review of nurse progress note for Resident #399 dated 10/08/22 timed at 12:55 A.M. revealed staff found resident on the floor beside her bed sitting on her buttocks. Resident #399 said that she was trying to go to the bathroom. Resident #399 had on non-slip socks on her feet. Resident #399 had two scrapes on her back and complained of pain at the right hip. There was a knot on the back of resident's head. Staff assisted resident back to bed and applied ice to back of resident's head. Resident #399 was sent to the hospital for an evaluation due to fall. Review of hospital note for Resident #399 dated 10/08/22 revealed resident was evaluated at the hospital for the fall and returned to the facility on the same day. Review of nurse progress note for Resident #399 dated 10/11/22 timed at 1:00 A.M. revealed the resident was found on the floor at her doorway. Resident #399 said she tried to get her cane which was located at the end of her bed. Resident #399 said she fell and hit her head resulting in a laceration 365346 Page 4 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0689 Level of Harm - Actual harm Residents Affected - Few over the right eyebrow. Resident #399 was sent to the hospital for an evaluation. Recommendation to prevent further falls was put cane at the side of the resident's bed instead of next to the wall at the foot of the bed. Review of hospital note for Resident #399 dated 10/11/22 revealed the resident was admitted to the hospital and treated for recurrent falls and resident presented with a facial hematoma to the right forehead with a three-centimeter (cm) laceration which required surgical repair with four sutures. Resident #399 was also treated for a urinary tract infection (UTI) and was readmitted to the facility on [DATE]. Review of the nurse progress note for Resident #399 dated 10/13/22 revealed resident was readmitted to the facility following hospitalization related to fall on 10/11/22. Resident #399 had a laceration to right forehead above the right eye secured by four sutures and presented with diffuse bruising to the right side of her face. Review of the fall investigation for Resident #399 dated 10/17/22 timed at 1:20 P.M. completed per Registered Nurse (RN) #351 revealed the interdisciplinary team (IDT) met to review the fall from 10/11/22 for Resident #399. Resident #399 was found on floor in room sitting at her doorway and stated she was trying to get her cane. A laceration was noted to the resident's right eyebrow and the resident was transferred to the emergency room for evaluation. New intervention was to ask the physician to conduct a review of resident medications related to repeated falls. Review of the facility fall investigation dated 10/17/22 timed at 5:47 P.M. completed per RN #351 revealed the IDT met to review the fall from 10/08/22 for Resident #399. Resident #399 was found on the floor in her room beside her bed. Resident #399 stated she was attempting to use the bathroom. The new intervention was to keep resident's cane and walker within reach. Interview on 10/17/22 at 3:56 P.M. with RN #351 confirmed the fall investigation for Resident #399's fall on 10/08/22 did not include a root cause analysis regarding the cause of the fall and/or possible contributing factors. RN #351 confirmed the investigation did not indicate if care planned interventions were in place or not at the time of the fall. RN #351 confirmed Resident #399 did not sustain injuries in the fall on 10/08/22 and the IDT team put a new intervention in place following the fall on 10/08/22 which was to ensure resident's cane was within reach. Interview with RN #351 confirmed Resident #399 sustained a repeat fall on 10/11/22 in which she fell trying to reach her cane which was at the foot of resident's bed and not within reach as per the resident's updated plan of care. RN #351 confirmed Resident #399 was sent to the hospital on [DATE] and required sutures for a laceration to the forehead sustained during the fall on 10/11/22. RN #351 confirmed the fall investigation for the fall on 10/11/22 for Resident #399 did not include a root cause analysis regarding the cause of the fall and/or possible contributing factors. RN #351 confirmed the investigation did not indicate if care planned interventions were in place or not at the time of the fall. Observation on 10/18/22 at 8:51 A.M. of Resident #399 revealed resident had diffuse bruising to the right side of her face and a bandage over her right eyebrow. Interview on 10/18/22 at 8:51 A.M. with Resident #399 confirmed she had bruised her face when she fell the week before and that she had received stitches to her forehead following the fall. Interview on 10/19/22 at 11:11 A.M. with RN #351 and the Director of Nursing (DON) confirmed the facility had not completed any additional fall investigation for Resident #399's falls on 10/08/22 and 365346 Page 5 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0689 10/11/22. DON confirmed the investigations completed on 10/17/22 for the falls on 10/08/22 and 10/11/22 did not include a root cause analysis regarding the falls. Level of Harm - Actual harm Residents Affected - Few 2. Review of the medical record for Resident #26 revealed an admission date of 01/30/20 with a diagnosis of asthma. Review of the MDS for Resident #26 dated 10/05/22 revealed the resident was cognitively impaired and required extensive assistance of two staff with bed mobility, transfers, and toilet use. Review of fall risk assessment for Resident #26 dated 10/05/22 revealed resident was at risk for falls Review of the care plan for Resident #26 dated 09/14/22 revealed resident was at risk for falls related to antihypertensive medications, deconditioning, gait/balance problems, incontinence, psychoactive drug use, history of falls, poor safety awareness, getting my legs tangled in the blankets, sliding out of chair. Interventions included the following: provide safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, right assist bar as ordered, grab bar in bathroom, personal items within reach, offer to assist resident to bed after meals, therapy to evaluate and treat as ordered and as needed, staff to offer toileting and peri-care to resident routinely on rounds and as needed. Review of the care plan for Resident #26 dated 04/21/20 revealed resident had an activities of daily living (ADL) self-care and/or physical mobility performance deficit related to activity intolerance, impulsivity, fatigue, weakness, and history of cerebrovascular accident (CVA). Interventions included for toilet use resident required supervision to limited assistance with transfer using grab bars on the toilet and extensive assistance with incontinence care. Review of facility incident log for October 2022 revealed resident had an unwitnessed fall on 10/15/22. Review of nurse progress note for Resident #26 dated 10/17/22 revealed intervention for the resident's fall on 10/15/22 was as long as resident in room, aide must not leave resident unattended. Review of October 2022 monthly physician orders for Resident #26 revealed an order dated 10/17/22 for to cleanse left hand skin tear with normal saline, pat dry, apply xeroform, cover with gauze, wrap with Kerlix each day. Review of written statement per State Tested Nursing Assistant (STNA) #144 dated 10/15/22 revealed aide assisted Resident #36 onto the toilet and left the resident unattended. Review of the statement revealed resident's call light was in reach and that resident's wheelchair was in the bathroom with her and was not locked. Resident #26 was found on the floor of the bathroom. The section of the statement for regarding footwear in place at the time of the fall was blank. The section of the statement regarding additional information to prevent future falls was blank. Observation on 10/17/22 at 2:15 P.M. of Resident #26 revealed her left arm was wrapped with Kerlix gauze. Interview on 10/19/22 at 1:19 P.M. with Registered Nurse (RN) #79 confirmed there was no note in Resident #26's medical record describing the circumstances of the fall. RN #79 confirmed there was a 365346 Page 6 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0689 Level of Harm - Actual harm Residents Affected - Few note in Resident #26's medical record dated 10/17/22 per RN #10 which referred to a fall on 10/15/22. RN #79 confirmed she knew Resident #26 had sustained a skin tear during the fall. RN #79 confirmed the facility had not completed a fall investigation of Resident #26's fall on 10/15/22 at the time of the interview. RN #79 confirmed the statement provided by the aide dated 10/15/22 revealed the aide had assisted resident onto to the toilet and left the resident unattended. RN #79 confirmed the facility had not yet completed an investigation regarding Resident #26's fall. RN #79 further confirmed Resident #26 required assistance of staff and should not be left unattended while on the toilet. Review of the facility policy titled Falls Management dated 12/03/19 revealed the IDT will meet to review the fall to determine if further interventions are needed. The care plan will be reviewed and dated to assure it has been updated to reflect the current needs of the resident to prevent a further fall. 365346 Page 7 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on record review, staff interview, and review of the facility policy, the facility failed to provide an adequate and timely response to a resident with suicidal ideation. This affected one (#366) of 28 residents sampled. The facility census was 143. Findings include: Review of the medical record for Resident #396 revealed an admission date of 09/07/22 with a diagnosis of acute pulmonary edema. Review of the Minimum Data Set (MDS) for Resident #396 dated 09/12/22 revealed the resident was cognitively intact and required extensive assistance of one to two staff with activities of daily living. Review of the nurse progress note for Resident #396 dated 09/08/22 revealed the resident verbalized suicidal ideation to the nurse. Resident #396 said he wanted morphine for his pain so he could die. The nurse noted Resident #396 was to have a psychological consult with the facility's psychologist. Review of the care plan for Resident #396 dated 09/12/22 revealed the resident had suicidal ideation's. Interventions included the following: administer medications as ordered and monitor for adverse drug reactions, document negative findings, allow resident time to express concerns and fears, approach and re-approach resident in a calm manner, discuss precipitating factors such as stress, recent losses, etc., encourage activities for resident, encourage resident to share feelings, encourage resident to stay in the common area, encourage relaxation techniques, encourage/assist resident to socialize with staff and other residents, interview resident and determine if resident has a plan to injure himself, keep the door of resident's room open unless care is being provided, psychological referral as needed, refer to social services, refer to spiritual services, remove potentially dangerous items from resident's bed room, monitor resident for suicide warning signs: hopelessness, expressing wanting to die, giving away belongings, comments about what it would be like to die in a specific way, preoccupation with death or suicide, suddenly making final arrangements-wills, funeral plans, insurance, provide resident with one on one interactions with reassurance. Review of October 2022 monthly physician orders for Resident #396 revealed an order dated 10/07/22 for the resident to have a psychological consult with the facility psychologist for voicing the desire to die. Review of the progress notes for Resident #396 dated 09/08/22 through 10/19/22 revealed the notes did not include follow up with resident regarding suicidal ideation's expressed on 09/08/22. Interview on 10/19/22 at 10:18 A.M. with Registered Nurse (RN) #351 confirmed she obtained an order on 10/07/22 for Resident #396 to have a psychological evaluation with the facility's psychologist after she reviewed the nurse progress note for Resident #396 dated 09/08/22. RN #351 confirmed Resident #396 had not yet been evaluated by the facility psychologist and could not offer a rationale for the delay in follow up. 365346 Page 8 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0742 Level of Harm - Minimal harm or potential for actual harm Interview on 10/19/22 at 10:20 A.M. with the Administrator confirmed Resident #396's medical record did not include documentation of follow up with resident per social services after he expressed suicidal ideation on 09/08/22. Administrator further confirmed the facility had no record of increased monitoring or evaluation of resident related to the incident on 09/08/22. Residents Affected - Few Review of the facility policy titled Suicide Prevention dated October 2013 revealed any resident exhibiting potential warning signs of suicidal ideation will be reported immediately to the Director of Nursing (DON) and the Administrator. A suicide risk care plan would be implemented immediately. Follow up would include frequent monitoring at a minimum. The Social Worker or designee will talk with the resident one on one asking specific questions about a suicide plan to determine the seriousness of the resident's intentions. Most people do talk about their suicide plan before they attempt to carry it out. Social Services will document daily progress notes regarding the progress and status of the resident. 365346 Page 9 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and review of facility documents and policy, the facility failed to ensure nurses administered insulin as ordered by the physician resulting in a significant medication error. This affected one (#62) of seven residents reviewed for medication administration. The facility census was 143. Residents Affected - Few Findings include: Review of the medical record for Resident #62 revealed an admission date of 08/03/22 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #62 dated 08/03/22 revealed the resident was cognitively impaired and required extensive assistance of staff with activities of daily living (ADL's.) Review of the care plan for Resident #62 dated 09/01/20 revealed resident had a diagnosis of diabetes mellitus (DM.). Interventions included the following: check resident's blood sugar as ordered by the doctor and report as needed, provide diabetes medication as ordered by the doctor, monitor/document for side effects and effectiveness. Review of the October 2022 monthly physician orders for Resident #62 revealed an order dated 04/23/21 for Levemir insulin inject 40 units subcutaneously at bedtime. The order did not include parameters or directions for withholding the insulin. Review of the September and October Medication Administration Records (MAR's) for Resident #62 revealed doses of evening doses of Levemir insulin were withheld/not administered on the following dates: 09/22/22, 09/26/22, 10/02/22, 10/07/22. Review of the nurse progress note per Registered Nurse (RN) #51 dated 09/22/22 revealed Resident #62's evening dose of Levemir insulin was withheld due to the resident's blood sugar was 90. Review of nurse progress note per RN #51 dated 09/26/22 revealed Resident #62's evening dose of Levemir insulin was withheld due to resident's blood sugar was 91. Review of nurse progress note per RN #51 dated 10/02/22 revealed Resident #62's evening dose of Levemir insulin was withheld due to resident's blood sugar was 71. Review of nurse progress note per RN #289 dated 10/07/22 revealed Resident #62's evening dose of Levemir insulin was withheld due to resident's blood sugar was 81. Review of facility coaching form dated 10/19/22 revealed the Director of Nursing (DON) provided education to RN #51 regarding withholding insulin for Resident #62. Review of the form revealed the nurse did not have a physician's order to withhold the medication nor did the nurse notify the physician after she withheld the medication. Further review of the form revealed nurse should notify the attending physician prior to withholding ordered medications. Interview on 10/19/22 at 3:28 P.M. with the DON confirmed RN #51 and RN #289 had documented withholding long-acting Levemir insulin as ordered for Resident #62 on 09/22/22, 09/26/22, 10/02/22, and 365346 Page 10 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/07/22. DON confirmed Resident #62's Levemir order did not include any parameters for withholding the medication. DON further confirmed Resident #62's medical record did not include documentation of physician notification of the withholding of insulin for Resident #62. Interview on 10/19/22 at 3:49 P.M. with RN #51 confirmed Resident #62's order for long-acting Levemir insulin did not include parameters for withholding the medication. RN #51 further confirmed she withheld Resident #62's insulin on 09/22/22, 09/26/22, and 10/02/22 based on the resident's blood sugar and her nursing judgment. RN #51 confirmed she did not notify the physician she withheld the medication. Review of the facility policy titled Insulin Administration dated 06/21/17 revealed insulin is a high-risk drug and warrants additional precautions for safe and effective administration. It is important that the nurse is familiar with the type of insulin prescribed. Notify the prescriber as appropriate if insulin is not administered as ordered. Levemir is a long-acting insulin with an onset of 1.1 to two hours with no significant peak. Duration for Levemir insulin is a mean of 7.6 to greater than 24 hours. Meal timing is not applicable to Levemir administration. This deficiency substantiates Complaint Number OH00136402. 365346 Page 11 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff secured resident's medications. This affected one (#142) of six residents observed for medication administration. The facility census was 143. Findings include: Review of the medical record for Resident #142 revealed an admission date of 09/23/22 with a diagnosis of hypertension (HTN.) Review of the October 2022 monthly physician orders for Resident #142 revealed an order dated 10/11/22 for resident to receive hydralazine once daily. Observation on 10/19/22 at 11:50 A.M. revealed there was a plastic cup with a tablet sitting unattended on top of the Transitional Care Unit (TCU) front medication cart. Interview on 10/19/22 at 11:54 A.M. with Registered Nurse (RN) #260 confirmed the tablet in the plastic cup was hydralazine which he had prepared for Resident #142 and left unattended while he was in the resident's room providing care. RN #260 confirmed medications should be secured at all times and should not be left unattended. Review of the facility policy titled Medication Storage dated 06/21/17 revealed medications should be stored safely and securely and should only be accessible to licensed and authorized personnel. 365346 Page 12 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility menus, observations, staff interview and policy review, the facility failed to provide puree food portions as planned by a Registered Dietitian. This had the potential to eight (#27, #14, #24, #73, #65, #35, #71,and #48) residents who received food from the [NAME] Hall kitchettes. The total facility census was 143. Findings include: Review of Registered Dietitian approved puree meal tickets dated 10/20/22 revealed a puree menu and portions of hotdog and bun eight ounces, (#8 scoop, doubled), corn of four ounces, mashed potatoes four ounces, (#8 scoop) and pudding four ounces. Observation on 10/20/22 at 12:15 P.M. of Magnolia steam table serving utensils revealed the residents received puree hotdog of four ounces, mash potatoes of #12 scoop. Interview on 10/120/22 of State Tested Nurse Aide, (STNA) # 157, who served the puree meal on the Magnolia unit, verified the residents received the incorrect portion of hotdog, (only one four ounce portion) and mashed potatoes. STNA #157 stated the correct scoops were not available. Observation on 10/20/22 at 12:20 P.M. of the [NAME] Garden steam table serving utensils revealed the residents received puree mash potato of a #6 scoop. A #20 scoop was used and not observed as a portion amount on a puree ticket. Interview on 10/20/22 at 12:20 P.M. STNA # 13 who served the puree meal on the [NAME] Garden unit, revealed the puree mash potato was the incorrect scoop and the #20 scoop size (1.75 to two ounces) was used and not on the puree menu. Observation on 10/20/22 at 122:30 P.M. of the [NAME] Lane steam table serving utensils revealed the resident's received hotdog of #12 scoop, and corn of #16 scoop (two to 2.5 ounces). Interview on 10/20/22 at 12:30 P.M., Diet Aide, (DA) # 376, who served the puree meal on the [NAME] Lane unit, verified the scoops used were smaller than the planned menu. DA #376 stated he used the scoops available and was unable to verify the printed number on the scoops for the surveyor. The facility confirmed the incorrect portion sizes had the potential to eight (#27, #14, #24, #73, #65, #35, #71,and #48) residents who received food from the [NAME] Hall kitchettes. Review of facility policy. Portion Control, dated 2021, revealed residents will receive the portions of food as outlined on the menu. 365346 Page 13 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced appropriate hand hygiene and appropriate personal protective equipment (PPE) doffing practices for residents with Coronavirus Disease 2019 (COVID-19). This affected one (#104) of four facility identified COVID-19 positive residents. The facility also failed to ensure nurses practiced appropriate hand hygiene during medication administration. This affected one (#395) of six residents observed for medication administration. The census was 143. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #407 revealed an admission date of 10/11/22 with a diagnosis of COVID-19. Review of the admitting orders for Resident #407 revealed an order dated 10/11/22 for COVID-19 isolation per facility protocol. Review of the medical record for Resident #104 revealed an admission date of 09/09/22 with a diagnosis of Alzheimer's disease. Review of the progress note for Resident #104 dated 10/12/22 revealed resident tested positive for COVID-19 and was placed in COVID-19 isolation per facility protocol. Observation on 10/17/22 at 12:30 P.M. revealed State Tested Nursing Assistant (STNA) #98 exited Resident #407's room wearing an N-95 mask, a face shield, and an isolation gown. Resident #407's room had a zippered barrier in the doorway. STNA #98 doffed the gown in waste receptacle outside Resident #407's room after he had rezipped the barrier to the room. STNA #98 then donned a gown from the isolation cart outside Resident #104's room and started unzipping the barrier to resident's room. Interview on 10/17/22 at 12:31 P.M. with STNA #98 confirmed he should have doffed the gown he was wearing in Resident #407's room before he exited the room, but he forgot so he doffed the gown in the waste receptacle outside the room. STNA #98 further confirmed he did not perform hand hygiene after doffing the gown he wore in Resident #407's room and donning a gown to wear into Resident #104's room. STNA #98 confirmed he did not think it was necessary to perform hand hygiene because he had washed his hands before he exited Resident #407's room. Observation on 10/17/22 at 12:32 P.M. with STNA #98 revealed he entered Resident #104's room to provide care and did not perform hand hygiene after handling the contaminated gown from Resident #407's room and donning a gown to enter Resident #104's room even after discussion with the surveyor. Interview on 10/17/22 at 12:40 P.M. with Registered Nurse (RN) #351 confirmed staff should doff gowns inside the COVID 19 isolation room and should perform hand hygiene after doffing PPE. Review of the facility policy titled Hand Hygiene dated 11/05/21 revealed hand hygiene should be performed after removing PPE. Review of Center for Disease Control (CDC) document titled PPE Sequence undated revealed healthcare workers should wash hands or use an alcohol- based hand-sanitizer immediately after removing PPE. 365346 Page 14 of 15 365346 10/25/2022 Otterbein Lebanon Retirement Community 585 North State Route 741 Lebanon, OH 45036

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of CDC document titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 undated revealed the following sequence is required when doffing PPE: remove gown, untie all ties (or unsnap all buttons), rolling the gown down is an acceptable approach, dispose in trash receptacle, healthcare personnel (HCP) may now exit patient room, perform hand hygiene. 2. Review of the medical record for Resident #395 revealed an admission date of 10/05/22 with a diagnosis of malignant neoplasm of the left kidney. Review of the October 2022 monthly physician orders for Resident #395 revealed an order dated 10/18/22 for Percocet 5-325 milligrams (oxycodone-acetaminophen) every four hours as needed for pain. Observation on 10/19/22 at 12:17 P.M. per RN #260 revealed nurse unlocked controlled substance compartment of the medication cart located in the lower portion of the cart and popped a Percocet tablet for Resident #395 into his hand and then dropped the tablet into a plastic medication cup sitting on top of the cart. Interview on 10/19/22 at 12:17 P.M. with RN #260 confirmed he had handled the medication keys and then touched Resident #395's Percocet tablet with his hands. RN #260 confirmed he was not supposed to touch resident's oral medication with his bare hands, but he was going to give the medication, because it was a controlled substance, and he didn't want to have to waste the medication. Observation on 10/19/22 at 12:30 P.M. with RN #260 revealed he administered the Percocet tablet to Resident #395. Review of the facility policy titled Medication Administration dated 11/09/21 revealed medications are administered per infection control standards of practice according to CDC and Centers for Medicare and Medicaid Services (CMS) guidelines. 365346 Page 15 of 15