Health inspection·February 14, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to notify the physician of Resident #49's elevated temperature for two days. This affected one (Resident #49) of three residents reviewed for physician notification. The facility's census was 51. Findings include: Review of Resident #49's medical record revealed he was re-admitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was 101.3. On 01/26/23 at 2:37 P.M., Resident #49's body temperature was 101.9. On 01/27/23 at 7:45 A.M., Resident #49's body temperature was 101.3. On 01/27/23 at 9:54 A.M. Resident #49's body temperature was 99.8. On 01/27/23 at 2:45 P.M., Resident #49's body temperature was 104.0 degrees. Review of Resident #49's nursing progress notes from 01/25/23 to 01/27/23 revealed no documentation the physician was notified of elevated temperatures on 01/25/23 and 01/26/23. The physician was not notified until 01/27/23 when abnormal labs were received. Resident #49 was hospitalized on [DATE] and diagnosed with pneumonia. Review of the progress note dated 01/27/23 at 2:45 P.M. the facility obtained an order for 325 milligrams (mg) of Acetaminophen, give two tablets via percutaneous endoscopic gastrostomy (PEG) tube every six hours as needed for temperature. Further review revealed on 01/27/23 at 3:16 P.M. the physician was made aware of lab work indicating Resident #49 had an elevated white blood cell (WBC) count and Resident #49 had a temperature of 104 degrees. Interview on 02/07/23 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #49 experienced a change of condition on 01/25/23. The DON verified the facility failed to notify the physician of this change of condition and fever on 01/25/23 or 01/26/23. The physician was not notified until later in the day on 01/27/23 after Resident #49's temperature reached 104 degrees. Page 1 of 14 365595 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0580 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Change in Condition, dated 05/30/22 revealed the Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/mental/or emotional condition. Residents Affected - Few 365595 Page 2 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to provide activities to residents residing in the facility's Memory Care Unit (MCU). This affected three (Residents #25, #35, and #41) of three residents reviewed for activities. The facility's census was 51. Residents Affected - Few Findings included: 1. Review of Resident #25's medical records, revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbances, cerebrovascular disease, psychotic disorder with delusions due to known physiological condition, diabetes, hypertension, and diverticulosis of intestine. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had extensive cognitive impairment. His functional status is listed as extensive one to two person assist to totally dependent on staff for activities of daily living. Review of the care plan dated 07/30/21 revealed Resident #25's daily activity could be affected by admission, auditory deficits, cognitive deficit, decreased vision and general physical decline. Interventions included one on one (1:1) to be done three times a week by activity staff. Schedule activities to allow for limited energy, offer structured activity for intellectual stimulation, modify programs/goals as needed, encourage socialization with others with common interests, and assist resident to and from activities. 2. Review of Resident #35's medical record revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia, psychotic disorder with delusions, depressive and anxiety disorders, Alzheimer's Disease, chronic kidney disease, and diverticulosis of the intestine. Review of the quarterly MDS dated [DATE] revealed Resident #35 had severe cognitive impairment. Her functional status is listed as extensive one person assists for all activities of daily living. Review of the care plan dated 08/29/22 revealed Resident #35's daily activity could be affected by admission, auditory deficits, and cognitive deficit. Interventions included assist to and from activities, offer structured activity for intellectual stimulation, provide calendar of events, and divide tasks into segments allowing resident to work at own pace. 3. Review of Resident #41's medical record revealed resident was admitted to the facility on [DATE] with a diagnosis of dementia with behaviors, diabetes, cerebral infarction, hyperlipidemia, hypothyroidism, hypertension, repeated falls, and depression. Review of the MDS dated [DATE] revealed Resident #41 had extensive cognitive impairment. His functional status is listed as extensive one to two person assist for all activities of daily living except eating and he is a supervise set up only. Review of the care plan dated 12/13/22 revealed a plan in place for Resident's #41's daily activity could be affected by admission, cognitive deficit. Resident enjoyed the outdoors and talking to people. Interventions included assist to and from activities, assist with radio/television programs as needed, divide tasks into segments allowing resident to work at own pace, encourage feedback 365595 Page 3 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding activity schedule/calendar, encourage participation, and encourage socialization with others with common interests. Numerous observations on 02/06/23 and 02/07/23 at various times throughout the annual survey revealed MCU residents were sitting in front of a television with no activities and/or treatment and services for dementia being completed. Residents #25, #35, and #41 were not observed participating in any activities throughout the survey. Interview with the Activities Director #195 on 02/07/23 at 2:00 P.M. confirmed she was short an activity aide, therefore, activities for the MCU were not being completed. Activities Director #195 indicated the higher functioning residents on the MCU would attend the general activities in the common area. Review of the February 2023 activities calendar revealed no activities scheduled for the MCU. Review of the facility policy titled, Resident Rights, undated revealed residents have the right to maintain their highest practicable well-being. 365595 Page 4 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to respond to an acute change in condition, including an elevated temperature for Resident #49 in a timely manner. Actual harm occurred on 01/27/23 when Resident #49, who was in a persistent vegetative state and dependent on staff for all activity of daily living care, was transferred to hospital and admitted for treatment of pneumonia requiring intravenous (IV) antibiotics. The resident had been initially assessed to have an elevated temperature on 01/25/23 of 101.3 with no evidence of physician notification, comprehensive assessment or treatment. The resident was hospitalized until 02/02/23. The facility's census was 51. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed the resident was readmitted to the facility on [DATE]. Diagnoses included, diffuse traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Further review revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's progress note dated 01/14/23 revealed the resident was discharged to the hospital from the nursing facility related to a fever. On 01/14/23 the progress notes confirmed Resident #49 was admitted to the hospital with the diagnosis of systemic inflammatory response syndrome (SIMS). Resident #49 returned to the facility on [DATE]. Review of Resident #49's vital signs history revealed on 01/25/23 at 5:38 P.M., Resident #49's body temperature was elevated at 101.3 degrees Fahrenheit (F). On 01/26/23 at 2:37 P.M., Resident #49's body temperature was elevated at 101.9 F. On 01/27/23 at 7:45 A.M., Resident #49's body temperature was elevated at 101.3 F. On 01/27/23 at 9:54 A.M. Resident #49's body temperature was elevated at 99.8 F. On 01/27/23 at 2:45 P.M., Resident #49's body temperature was elevated at 104.0 degrees F. (Normal body temperature 97 to 99 degrees F) Further review of the nursing progress notes from 01/25/23 to 01/27/23 revealed no documentation the physician was notified of elevated temperatures on 01/25/23 or 01/26/23. The physician was not notified until 01/27/23 when abnormal labs were received. Further review of Resident #49's progress notes revealed on 01/27/23 at 2:45 P.M. the facility obtained an order for 325 milligrams (mg) of Acetaminophen, give two tablets via percutaneous endoscopic gastrostomy (PEG) tube every six hours as needed for temperature. At 3:18 P.M., the physician was notified of lab work indicating Resident #49 had an elevated white blood cell (WBC) count and Resident #49 also had a temperature of 104 degrees. On 01/27/23 at 11:11 P.M. the hospital was contacted and notified the facility Resident #49 was admitted to the hospital with a diagnosis of pneumonia. Review of the Medication Administration Record (MAR) for Resident #49 revealed on 01/27/23 at 2:45 P.M. the resident was administered Acetaminophen via PEG tube for a body temperature of 104. 365595 Page 5 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0684 Review of the hospital documentation revealed Resident #49 was admitted to the hospital on [DATE] with health-care associated pneumonia. Resident #49 required intravenous (IV) antibiotics. Level of Harm - Actual harm Residents Affected - Few Review of Resident #49's progress notes revealed the resident returned to the facility from the hospital on [DATE]. Interview on 02/07/23 at 3:03 P.M. with the Director of Nursing (DON) confirmed Resident #49 experienced a change of condition of an elevated temperature on 01/25/23 and 01/26/23. The DON verified the facility failed to notify the physician of this change of condition and fever on 01/25/23 and 01/26/23. The physician was not notified until later in the day on 01/27/23 after Resident #49's temperature reached 104.0. The DON further verified Resident #49 required hospitalization. Review of the facility policy titled, Change in Condition, dated 05/30/22 revealed the Charge Nurse will notify the resident's Attending Physician or On-Call Physician where there has been a significant change in the resident's physical/mental/or emotional condition. 365595 Page 6 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the faciltiy failed to assess pressure ulcers on a weekly basis to include wound measurments and description of the wounds. This affected two (Residents #30 and #37) of four residents reviewed for pressure ulcers. The facility identified four (Residents #29, #30, #37, and #39) with pressure ulcers. The facility's census was 51. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 12/09/22. Diagnoses included neuromuscular dysfunction of bladder, gastroesophageal reflux disease, type II diabetes mellitus, seizures, major depressive disorder, and pressure ulcer of the sacral region (stage IV). Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 had impaired cognition. The resident required total assistance for all activities of daily living (ADLs), except bed mobility in which the resident required extensive assistance. The assessment indicated Resident #30 had a Stage IV pressure ulcer upon admission. Review of the admission assessment dated [DATE] for revealed Resident #30 had an area to the sacrum measuring 2 by 2 (measurement unit not identified on the assessment), with tunneling (wound has progressed to form pathways underneath the surface of the skin). Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #30 was at high risk for the development of pressure ulcers. Review of the plan of care dated 12/29/22 revealed Resident #30 was at risk for skin breakdown related to medical condition. Interventions included body audits as scheduled and as needed, low air loss mattress, and turning and repositioning every two hours. Review of the weekly skin assessments from 12/09/22 through 02/03/23 revealed the facility identified Resident #30 had a pressure ulcer to the scarum area, however the assessments did not include wound measurements or descriptions of the pressure ulcer. Further review of the medical record revealed Resident #30 went to a wound clinic once a month for review of the pressure ulcer. The facility provided wound clinic documentation from Resident #30's visits on 11/16/22, 12/14/22, and 01/11/23. The wound clinic documentation included extensive notes and measurements regarding the wound to the sacrum. With each visit, the wound to the sacrum appeared to stay stable related to measurements and descriptions provided. Interview on 02/08/23 at 2:18 P.M. with the Director of Nursing (DON) confirmed Resident #30 went to the wound clinic once monthly for treatment and assessment of the wound to her sacrum. The DON verified the facility staff was completing treatments to the wound as ordered by the clinic but was not assessing the wound regularly to include measurements or any changes in condition. The DON verified lack of documentation of wound measurements and wound descriptions in the residents medical record. 2. Review of the medical record for Resident #37 revealed an admission date of 01/18/22 with a hospitalization from 12/03/22 through 12/10/22. Diagnoses included vitamin D deficiency, major 365595 Page 7 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0686 depressive disorder, vascular dementia, type 2 diabetes mellitus, and peripheral vascular disease. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. The resident required total assistance from staff for toileting, locomotion on/off unit, and transfers. Resident #37 required extensive assistance from staff for bed mobility, dressing, eating, and personal hygiene. The assessment indicated the resident had one unstageable pressure ulcer upon admission. Residents Affected - Few Review of the admission assessment dated [DATE] for Resident #37 revealed the resident had many skin issues but had one pressure area to the left buttocks. No measurements were noted in the assessment. Review of the pressure ulcer risk assessment for Resident #37 dated 01/19/22 revealed the resident was at a very high risk for the development of pressure ulcers. Further review of the medical record revealed Resident #37 had a pressure ulcer to the coccyx being noted on 03/30/22. The facility would send the resident to the wound clinic monthly to review the pressure ulcer to the coccyx and other skin concerns. Review of the plan of care dated 09/26/22 revealed Resident #37 had a longstanding pressure ulcer to the coccyx. Interventions included body audits as scheduled and as needed, low air loss mattress with bolsters, and maintaining wound vac to pressure ulcer as ordered. Review of the weekly skin assessments from 03/30/22 through 02/03/23 revealed the facility identified Resident #37 had a pressure ulcer to the coccyx area, however the assessments did not include wound measurements or descriptions of the pressure ulcer. Further review of the medical record revealed Resident #37 went to a wound clinic once a month for review of the pressure ulcer. The facility provided documentation from the wound clinic visits from March 2022 through February 2023. The wound clinic had extensive notes and measurements regarding the wound to the coccyx. With each visit, the wound to the coccyx appeared to stay stable but required a wound vac as a treatment in December 2022. Review of the physician orders for Resident #37 from March 2022 through February 2023 revealed orders for the treatment to the wound on the coccyx. Orders matched recommendations given by the wound clinic. Review of the Treatment Administration Record (TAR) from March 2022 through February 2023 for Resident #37 revealed facility staff documented treatments as completed. Interview on 02/08/23 at 2:20 P.M. with the Director of Nursing (DON) confirmed Resident #37 went to the wound clinic once monthly for treatment and assessment of the wound to his coccyx. The DON verified facility staff was completing treatments to the wound as ordered by the clinic but was not assessing the wound regularly to include measurements or any changes in condition. Review of the facility policy titled, Skin and Wound Care Program, dated 05/30/22 revealed the facility failed to follow their policy of monitoring the incidence and severity of pressure ulcers. 365595 Page 8 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure an ordered orthotic therapeutic device was applied to assist with a resident's contracture. This affected one (Resident #49) observed for application of therapeutic devices. The facility identified 25 residents with contractures. The facility's census was 51. Findings include: Review of Resident #49's medical record revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included traumatic brain injury, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, tracheostomy, gastrostomy, and persistent vegetive state. Review of Resident #49's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition related to his persistent vegetive state. Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of Resident #49's physician orders revealed an order dated 11/09/22 for staff to place right hand roll orthotic during the daytime shift, times six hours as tolerated for contraction management. Review of the Treatment Administration Record (TAR) for Resident #49 revealed the facility failed to apply the orthotic device to the right hand on 02/01/22 and 02/02/22. Observation on 02/06/23 at 10:40 A.M. revealed Resident #49 did not have the orthotic device in his right hand. Observations on 02/07/23 at 9:53 A.M. and 2:07 P.M. revealed Resident #49 did not have the orthotic device in his right hand. Interview on 02/07/23 at 2:07 P.M. with Registered Nurse (RN) #192 verified Resident #49 did not have his orthotic device in his contracted right hand as ordered. RN #49 stated she cannot say why the orthotic device was not placed and stated, We can put the orthotic device on him if you want? Additionally, RN #192 confirmed Resident #49's TAR was not signed off as providing the orthotic device on 02/01/23 and 02/02/23. 365595 Page 9 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide supervision and failed to implement interventions for a resident who smoked. This affected one (Resident #45) of five residents identified to smoke. The facility's census was 51. Findings include Medical record review for Resident #45 revealed an admission date of 06/11/21. Diagnoses included encephalopathy, seizures, polyarthritis, alcohol abuse, anxiety disorder, essential primary hypertension, pseudobulbar affect, major depressive disorder, alcohol abuse with alcohol induced psychotic disorder, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had severely impaired cognition. Resident #45 required extensive assistance from staff with bed mobility, transfers, dressing, locomotion on the unit, and toilet use. Resident #45 required limited assistance from staff with personal hygiene and eating. Review of Resident #45's most recent care plan revealed interventions and goals in place for smoking, with a target date of 03/22/23. Interventions included immediately notify nurse/administrator if resident was observed smoking unsupervised while in facility, remind visitors/resident to return cigarettes/lighters when returning from being out of the facility, staff to light cigarettes for resident during supervised smoking, provide and review a copy of the smoking policy and smoking schedule, and resident to smoke while supervised in the designated area. Review of Resident #45's smoking assessment dated [DATE] revealed Resident #45 required supervision during smoke breaks, was not able to light his own cigarette, and required the use of a smoking apron. Observation on 02/07/23 at 10:30 A.M. revealed Resident #45 was seated in the smoking room, alone, smoking a lit cigarette. Resident #45 was not wearing an apron, and no staff was present in the room or in the near vicinity to provide supervision. Subsequent interview with State Tested Nurse Aide (STNA) #168 verified Resident #45 required assistance with smoking and required a smoking apron. STNA #168 verified Resident #45 was seated in the designated smoking room, alone, with no supervision and no smoking apron applied. Resident #45 was smoking a lit cigarette. STNA #168 reported a staff member would have had to provide Resident #45 with the lit cigarette and left him alone because residents do not have access to smoking materials. Interview on 02/07/23 at 10:53 A.M. with the Administrator confirmed Resident #45 required supervision while smoking. The Administrator was unaware how Resident #45 ended up in the smoking room, smoking with no supervision or no smoking apron applied. The Administrator further reported she was unaware how Resident #45 could have gotten his cigarette lit. Interview on 02/07/23 at 11:30 A.M. with the Director of Nursing (DON) confirmed the facility identified STNA #169 as the aide who gave Resident #45 his cigarette, lit the cigarette, and left Resident #45 unsupervised to smoke on 02/07/23 at 10:30 A.M. The DON further confirmed STNA #169 did not utilize a smoking apron for Resident #45. 365595 Page 10 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Resident Smoking Policy, dated 01/20/23 revealed all tobacco products, matches, and lighters will be locked and stored at the nurse's stations and will be provided as needed. No resident shall be permitted to smoke unsupervised unless assessed as being independent. Residents Affected - Few 365595 Page 11 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

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 observations, staff interviews, and review of the facility policy, the facility failed to ensure proper storage of medications by ensuring expired medications were not being used. This affected six residents (#2, #4, #7, #15, #34, #155) who facility identified as receiving the expired medications from two medication carts and a medication storage room in the facility. The facility census was 51. Findings include: Observations and interviews on 01/07/23 from 10:20 A.M. to 11:00 A.M. of two facility medication carts (200 and 300 halls) and one medication storage room (200/300 halls) with Licensed Practical Nurse (LPN) #140 and Registered Nurse (RN) #192 revealed the following over the counter (OTC) expired medications: Certavite multivitamins expired 01/2023, Gerilanta expired 12/2022, and Claritin 10 milligrams (mg) expired 09/2022. LPN #140 and RN #192 confirmed the outdated medications were in the medication carts and the medication storage room. Review of the facility policy titled, Medication Storage, undated, revealed the facility failed to implement the policy. Medication with a preservative expires on the manufacture's expiration date unless otherwise indicated on the manufacturer's package insert. 365595 Page 12 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policies, the facility failed to maintain appropriate infection control techniques during tracheostomy (trach) care. This affected one resident (#49) of the two residents identified by the facility as requiring tracheostomy care. The facility also failed to utilize proper hand hygiene during wound care. This affected one Resident (#49) of the four residents identified with wounds and requiring dressing changes. The facility census was 51. Residents Affected - Few Findings include: 1. Review of Resident #49's medical record revealed resident was readmitted to the facility on [DATE]. His diagnoses included, but not limited to, diffuse traumatic brain injury (TBI), anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, trach dependent, and gastrostomy. Review of Resident #49's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed resident had impaired cognition. Further review of the MDS assessment revealed Resident #49 was totally dependent on staff with all areas of activities of daily living (ADLs). Review of the physician's orders dated 02/02/23 for Resident #49, revealed resident was ordered to be suctioned as needed (PRN) via Yankuer (tool used to suction oropharyngeal secretions in order to prevent aspiration) or a 14 French suction catheter, trach care to be completed every night shift every three days and a trach tie holder changed every seven days. Review of the nurse's progress notes dated 02/03/23 for Resident #49, revealed trach care was given and residents inner cannula was changed without issues. Observation of trach care on 02/08/23 at 10:55 A.M. for Resident #49 revealed Licensed Practical Nurse (LPN) #179 removed the old stoma dressing on Resident #49's tracheostomy. Continued observations revealed LPN #179 washed his hands as resident appeared to be comfortable with his oxygen saturation being above 95 percent (%) (normal 96-100 %) and the resident had no signs of respiratory distress noted. Observations revealed LPN #179 opened the sterile trach kit and donned the sterile gloves from the kit. LPN #179 used his right hand (dominant hand) to grab sterile supplies from the trach kit and cleansed around resident's tracheostomy. Continued observations revealed LPN #179 used his contaminated gloved right hand to retrieve the new inner cannula from the kit and placed the new inner cannula into Resident #49's tracheostomy. Interview on 02/08/23 at 11:15 A.M. with LPN #179 confirmed he donned the sterile gloves, cleaned around Resident #49's stoma opening with his right hand then picked up the new sterile inner cannula and placed it in Resident #49's tracheostomy. Review of the facility document titled Competency Check Off for Tracheostomy Care, dated 01/24/21, revealed staff were to follow infection control procedures, as appropriate and tracheostomy care was a sterile procedure not a clean procedure, and follow sterile procedure when placing gloves on. 2. Review of Resident #49's medical record revealed resident was readmitted to the facility on [DATE]. His diagnoses included, but not limited to, diffuse TBI, anoxic brain damage, fracture of the thoracic vertebra, traumatic subdural hemorrhage, quadriplegia, trach dependent, and gastrostomy. 365595 Page 13 of 14 365595 02/14/2023 Momentous Health at Franklin 421 Mission Lane Franklin, OH 45005

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #49's most recent MDS 3.0 assessment dated [DATE], revealed resident had impaired cognition. Further review of the MDS assessment revealed Resident #49 was totally dependent on staff with all areas of ADLs. Review of the physician's orders dated 12/08/22 for Resident #49's revealed resident was ordered to have the open area on his right outer ankle cleansed with non-sterile saline, Mesalt (impregnated gauze for heavy wound drainage) applied, two by two (2 x 2) gauze applied, and island dressing (bordered gauze dressing for wounds with light to moderate drainage) applied every day on night shift. Review of the nurse's progress notes dated 02/08/23 for Resident #49, revealed resident had a treatment to his right outer right ankle. Notes indicated resident had a superficial, open area and no drainage or signs or symptoms of infection were noted. Observation on 02/08/23 at 11:10 A.M. of wound care for Resident #49, revealed LPN #179 washed his hands, applied gloves, and provided privacy for the treatment. Continued observations revealed LPN #179 removed the soiled dressing from the right outer ankle of the resident and changed gloves without cleansing his hands with hand sanitizer or soap and water. Continued observations revealed LPN #179 cleansed the wound with normal saline and applied the new dressing as ordered. Interview on 02/08/23 at 11:15 A.M. with LPN #179 confirmed he removed the soiled dressing, changed his gloves without cleansing his hands and completed the wound care to resident #49's outer ankle. Review of the facility policy titled, Infection Prevention Policy and Procedure, dated 10/2019, revealed hand hygiene prevents spread of pathogens such as bacteria and viruses which causes infections. Pathogens can contaminate hands of staff during direct contact with residents or contact with contaminated equipment and environmental surfaces. Failure to clean contaminated hands can result in spread of pathogens to residents, staff, and environmental surfaces. Employee must wash their hands 10 to 15 seconds using antimicrobial or non- antimicrobial soap. Before and after direct contact with residents, when hands are visibly dirty or soiled with blood or other body fluids, after contact with blood, body fluids, secretions, mucous materials or non- intact ski, after removing gloves, before eating and after using restroom, before donning sterile gloves, before preparing and handling medications, before handling clean or soiled dressings, and after contact with resident intact skin. 365595 Page 14 of 14